ADVANCED HEALTH ASSESSMENT - Comprehensive Final Exam

ADVANCED HEALTH ASSESSMENT - Comprehensive Final Exam COMPONENTS OF MENTAL STATUS EXAM INCLUDE: A-B-C-T APPEARANCE; posture, body movements, dress, grooming and hygiene BEHAVIOR; LOC, Facial expression, speech, mood and affect COGNITION; address, phone#, etc. date?, attention span, recent and remote memory, new learning THOUGHT PROCESS; perceptions, should be logical and consistent this person make sense? how do people treat you?, do you feel you are being watched, followed or controlled? have you heard your name when alone? Things to Consider When Assessing Older Adults mental status include: - ANSWER-Ask about chronic illness and how they are managing? Sensory impairments? Polypharmacy (med list again!) Social isolation Physiological issue - Delirium vs. Dementia - UTI - Sundowners ___________________ screens for Anxiety - ANSWER-GAD- 7 questions to ask for depression or suicidal ideations: - ANSWERDepression: Over the past two weeks, have you fell down, depressed or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? Suicidal: Have you ever felt so blue you thought of hurting yourself? Do you have a plan to hurt yourself? How would you do it? ***Must not ignore any talk of suicide*** When is a full mental status exam necessary? - ANSWER-* Patients whose initial screening suggests an anxiety disorder or depression * Behavioral changes: such as memory loss, inappropriate social interaction * Brain lesions: trauma, tumor, cerebrovascular accident or stroke * Aphasia: impairment of language ability secondary to brain damage * Symptoms- of psychiatric mental illness especially with acute onset ________________ Screens for Alcoholism. - ANSWER-CAGE: Score 2 or greater highly significant * Have you ever felt you should CUT down on your drinking? * Have people ANNOYED you by criticizing your drinking? * Have you ever felt bad or GUILTY about your drinking? * Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (EYE OPENER) Delirium VS Dementia VS Depression: Onset course duration consciousness attention psychomotor changes reversibility - ANSWER-Delirium ** Dementia ** Depression: ========================================== O: Acute insidious Acute or insidious C: Fluctuating Progressive May be chronic D: Hrs to wks Mos to yrs Mos to yrs C: Altered Usually clear clear A: Impaired Normal unless May be decreased severe dementia P: increased often normal may be slowed in decreased severe cases R: usually irreversible usually