Health Assessment

  1. What is the first question you would ask if a pt. complains of depression?
    • "Are you thinking about killing yourself?"
    • if so,
    • "What is your plan?"
    • Important to assess feasability and seriousness of plan.
  2. T/F Mental status is an objective assessment?
    F. It's both subjective and objective because it is inferred through an individual's behavior.
  3. When would you want to obtain a mental status assessment?
    • To obtain a baseline (family may need to help fill in gaps).
    • When there is a Behavior change
    • Brain lesions (trauma, tumor, brain attack)
    • Aphasia (secondary to brain damage)
    • Symptoms of psychiatric mental illness
    • A,B,C,T abnormalities:
    • Appearance
    • Behavior
    • Cognition
    • Thought processes
  4. Objective Data for the Mental Health Assessment
    • Appearance:
    • Posture
    • Body movements, are they smooth, easy, natural?
    • Dress, is it appropriate for their peer group?
    • Grooming and hygiene
    • Behavior:
    • LOC?
    • Facial expression, is it appropriate to setting/questions?
    • Speech, any dysphasia?
    • Mood and affect. Mood=general feelings about life, affect=feelings right now.
  5. What are the components of the minimental exam?
    • J= Judgment: What would you do if you saw someone collapse in the street?
    • O=Orientation: Name, location, date, time
    • M= Memory: 3 unrelated words at 1 & 5 minutes, recent & past events
    • A= Appearance: Posture, body movements, dress, grooming/hygiene
    • C= Calculation: Subtract serial sevens from 100
    • S= Speech: Quality, Rate, Articulation, Word choice
  6. What are some various levels of consciousness?
    • Alert and oriented: A,A,Ox4
    • Lethargic (somnolent): Drowsy, but responds to name, slow response, ↓spontaneous movements
    • Obtunded: Difficult to arouse, confused, needs constant stimulation
    • Stupor or semi-coma: Unconscious but able to arouse with pain, language impaired, +reflex activity
    • Coma: Unconscious, no response to pain
    • Acute confused state (delirium): clouded consciousness, incoherent, agitated, disoriented
  7. Delerium vs. Dimentia...
    • Delirium:
    • Acute onset
    • Young or old
    • Causes: infection, intoxication, withdrawal, hypoxia, F&E imbalance, post head trauma, postop

    • Dementia:
    • Gradual onset
    • More common in elderly
    • Causes: Alzheimer’s, Parkinson’s, CVA, HIV, head trauma
  8. Developemental considerations for Mental Status in Aging Adults
    • No decrease knowledge or vocabulary
    • Slowed response time
    • Decrease in recent memory
    • No change in remote memory
    • Multiple losses can affect mental status and cause disorientation, depression and disability.
  9. Who is most at risk for suicide?
    Men over 65 yrs.
Card Set
Health Assessment
Chapter 5