NURS 201: Exam 4
Cut down - Have you thought you ought
to CUT down your drinking?
Annoyed - Have people ANNOYED you
criticizing your drinking?
What is the CAGE assessment? Guilty - Have you ever felt GUILTY about
your drinking?
Eye Opener - Have you ever had a drink
first thing in the morning to steady to your
nerves or get rid of a hangover?
What does CAGE stand for? cut down, annoyed, guilty, eye opener
What is CAGE used for? to assess alcohol abuse
What is MMSE? mini mental status exam
What is MMSE used for? For screening cognitive function
- Standard set of 11 questions, requires
only 5 to
10 minutes to administer
- Both initial and serial measurement, so
worsening or improvement of cognition
What do you do for MMSE?
over time
- Good to detect dementia and delirium
and to differentiate these from psychi-
atric mental
illness
- Normal mental status average 27
What is the scoring for MMSE? - Scores between 24
and 30 indicate no cognitive impairment
What is the PHQ-9? a depression assessment tool
What is the GAD-7? anxiety screening tool
What are the two screening tools usually
PHQ-9 and GAD-7
used together?
minimal 5-9
mild 10-14
moderate 15-19
severe >20
, NURS 201: Exam 4
What is the scoring for PHQ-9?
mild 5
moderate 10
severe 15
A score >8 may identify pts. with GAD
What is the scoring for GAD-7?
What is GAD? generalized anxiety disorder
What is the main categories of mental
ABCT
status exam?
appearance, behavior, cognition, thought
What does ABCT stand for?
process
posture, body movements, dress, groom-
Appearance includes?
ing and hygiene
LOC, facial expression, speech, mood
Behavior includes?
and affect
orientation, attention span, memory, new
Cognitive function includes?
learning, 4-word recall
logical; perception (hallucinations, ob-
Thought process includes?
sessions)
- 3rd leading cause of death in 15-24 yr
What are the risk factors for suicide? olds
- Males higher risk
How/when to assess for suicide?
, NURS 201: Exam 4
- When the person expresses feelings of
sadness, hopelessness, despair, or grief,
it is important to assess any possible risk
of physical harm to himself or herself
- Begin with more general questions; if
you hear affirmative answers, continue
with more specific probing questions
Alert
Lethargic (or somnolent)
What are the different levels of con- Obtunded
sciousness? Stupor or Semi-Coma
Coma
Delirium
What is alert classified as? awake and easily arousable - oriented x3
difficult to arouse, drowsy, thinking slow
What is lethargic classified as?
but appropriate
sleeps most of the time, confused when
What is obtunded classified as?
aroused, speech mumbled
What is stupor or semi-coma classified responds only to vigorous shake or pain
as? non verbal except for moans ect
completely unconscious, no response to
What is coma classified as?
pain
awake but extremely confused, may be
What is delirium classified as? violent, incoherent speech, inattentive,
hallucinations
expressive/nonaffluent aphasia, can't ex-
press words but can understand lan-
guage, usually one word answers
What is Broca's aphasia?
What is Wernicke's aphasia?
Cut down - Have you thought you ought
to CUT down your drinking?
Annoyed - Have people ANNOYED you
criticizing your drinking?
What is the CAGE assessment? Guilty - Have you ever felt GUILTY about
your drinking?
Eye Opener - Have you ever had a drink
first thing in the morning to steady to your
nerves or get rid of a hangover?
What does CAGE stand for? cut down, annoyed, guilty, eye opener
What is CAGE used for? to assess alcohol abuse
What is MMSE? mini mental status exam
What is MMSE used for? For screening cognitive function
- Standard set of 11 questions, requires
only 5 to
10 minutes to administer
- Both initial and serial measurement, so
worsening or improvement of cognition
What do you do for MMSE?
over time
- Good to detect dementia and delirium
and to differentiate these from psychi-
atric mental
illness
- Normal mental status average 27
What is the scoring for MMSE? - Scores between 24
and 30 indicate no cognitive impairment
What is the PHQ-9? a depression assessment tool
What is the GAD-7? anxiety screening tool
What are the two screening tools usually
PHQ-9 and GAD-7
used together?
minimal 5-9
mild 10-14
moderate 15-19
severe >20
, NURS 201: Exam 4
What is the scoring for PHQ-9?
mild 5
moderate 10
severe 15
A score >8 may identify pts. with GAD
What is the scoring for GAD-7?
What is GAD? generalized anxiety disorder
What is the main categories of mental
ABCT
status exam?
appearance, behavior, cognition, thought
What does ABCT stand for?
process
posture, body movements, dress, groom-
Appearance includes?
ing and hygiene
LOC, facial expression, speech, mood
Behavior includes?
and affect
orientation, attention span, memory, new
Cognitive function includes?
learning, 4-word recall
logical; perception (hallucinations, ob-
Thought process includes?
sessions)
- 3rd leading cause of death in 15-24 yr
What are the risk factors for suicide? olds
- Males higher risk
How/when to assess for suicide?
, NURS 201: Exam 4
- When the person expresses feelings of
sadness, hopelessness, despair, or grief,
it is important to assess any possible risk
of physical harm to himself or herself
- Begin with more general questions; if
you hear affirmative answers, continue
with more specific probing questions
Alert
Lethargic (or somnolent)
What are the different levels of con- Obtunded
sciousness? Stupor or Semi-Coma
Coma
Delirium
What is alert classified as? awake and easily arousable - oriented x3
difficult to arouse, drowsy, thinking slow
What is lethargic classified as?
but appropriate
sleeps most of the time, confused when
What is obtunded classified as?
aroused, speech mumbled
What is stupor or semi-coma classified responds only to vigorous shake or pain
as? non verbal except for moans ect
completely unconscious, no response to
What is coma classified as?
pain
awake but extremely confused, may be
What is delirium classified as? violent, incoherent speech, inattentive,
hallucinations
expressive/nonaffluent aphasia, can't ex-
press words but can understand lan-
guage, usually one word answers
What is Broca's aphasia?
What is Wernicke's aphasia?
