Mental Status/Nutrition/BMI Flashcards
2 things you look for when assessing mental health
Level of Consciousness
Orientation – time,
place and person and
remote memory
• Normal voice – patient looks at you and responds fully and appropriately
Alert
• Speak to patient in loud voice; appears drowsy, opens eyes and looks at you, responds to questions and falls asleep
Lethargic
• Shake patient and speak in loud voice; opens eyes and looks at you but responds slowly and confused
Obtunded
Apply painful stimuli or shake vigorously; arouses from sleep only after painful stimuli
Stupor
Apply repeated painful stimuli; unarousable, no evident response
Coma
Coma Type-Arms flexed, plantar flexed, arms move towards core
Decorticate
Coma Type-One sided paralysis
Hemiplegia
Coma Type- Extended limbs
Decerebrate
Coma Type-No movement, completely flaccid
Vegetative
usually caused by acute illness or drug toxicity and is a temporary state
Delirium
Acute
Somnolent
Fully reversible when caught early
Fluctuates between lucidity and confusion
Delirium
- Measures eye, verbal and motor response in patients with traumatic brain injuries
- Lower scores indicate a higher impairment
Glasgow Coma Scale
Lowest-Highest score on Glasgow Coma Scale
3 (deep coma) to 15 (normal)
loss of voice; affects larynx or nerve supply
Aphonia
impairment in the voice, quality or pitch of the voice; hoarse or only able to whisper
Dysphonia
lack of muscle control; affects the lips and tongue
Dysarthria
can’t produce or understand language
Aphasia
- Receptive
- Fluent
- Rapid Speech
- Sentences lack meaning
- Speech totally incomprehensible
Wernicke’s aphasia
Wernicke’s aphasia originates in
• Posterior superior temporal lobe
• Can speak and enunciate clearly but the sentences make no sense. “Word salad”
Wernicke’s aphasia
- Expressive
- Nonfluent
- Slowed Speech
- Understands what is being said
- Struggles to speak
Broca’s aphasia
Broca’s aphasia originates in
• Posterior inferior frontal lobe
• Can understand speech but have a really hard time expressing the words
Broca’s aphasia
- Orientation and short-term memory
- 30 points; 24 is cutoff
- Screens for dementia
- Best for screening more severe cases of dementia
MMSE
- Most popular-easier to use
- Orientation, short term memory and executive decision making
- COGNITIVE CHANGE OVER TIME
- Screen for mild or early dementia
- 30 points; dementia 21-26
SLUMS
- Orientation, short term memory and executive decision making
- Visual/Spatial awareness
- 30 point scale; cutoff is 26
Montreal Cognitive Assessment
- Best for mild impairment; SPECIFICALLY distinguishes between dementia and Alzheimer’s
- Also has clock drawing test-critical thinking
Montreal Cognitive Assessment
- Short term memory and executive decision making
* Brief screening tool to differentiate patients with dementia from those without it
Mini Cog
- 3 minutes
* Includes a 3 item recall test and clock drawing test
Mini Cog
- Acute onset, disorganized thinking
* Delirium screening tool
CAM
Repeatedly asks the same questions
Becomes lost or disoriented in familiar places
Cannot follow directions
Is disoriented as to the date or time of day
Alzheimer’s
Doesn’t recognize and is confused about familiar people
Has difficulty with routine tasks such as paying bills
Neglects personal safety, hygiene, and nutrition
Alzheimer’s
Falling asleep Sleep during the night Waking up too early Sleeping too much Feeling sad Decreased or increased appetite Decreased or increased weight
Depression
Apparent State of Health Level of Consciousness Facial Expression Odors of the Body and Breath Dress, Grooming, and Personal Hygiene Posture, Gait, Motor Activity Speech Mood and Affect
General Survey
Name the vital signs (excluding pain) and normal ranges
- Temperature – oral 96.4 – 99.5°F
- Pulse – 60 – 100 beats/minute
- Respirations 12 – 20 breaths/minute
- Blood Pressure – 120/80
What’s the formula for waist to hip ratio, and what is normal for men and women?
Waist circumference
Hip circumference = waist to hip ratio
Females: less than or equal to 0.80
Males: less than or equal to 0.90
Normal waist circumference for men and women?
Female: less than or equal to 35 inches (88cm)
Male: less than or equal to 40 inches (102cm)
IBW % formula
Actual Weight x 100 = % IBW
IBW
Explain what each IBW % means
- Severe malnutrition: less then 70%
- Moderate malnutrition: 70 – 80%
- Possible malnutrition/Lean: 80 – 90%
- Overweight: 10% above IBW
- Obese: 20% above IBW
Body Frame formula
Height in cm
___________
Wrist circumference in cm
What are the small/medium/large body frame ranges for men and women
Body Frame Ranges
Large Medium Small
Men >10.4 10.4 – 9.6 <9.6
Women >10.9 10.9 – 9.9 <9.9
IBW formula for women?
o 100lbs for the first 5 feet + 5lbs for every inch
o -10% for small frame
o +10 for large frame
o Example: 5’ 6” = 100 + (56=30) = 130lbs for normal frame
o Small frame 1300.10 = 13 130 - 13 = 117lbs
o Large frame 130 + 13 = 143lbs
IBW formula for men?
o 106lbs for the first 5 feet + 6lbs for every inch
o -10% for small frame
o +10 for large frame
o Example: 5’ 9” = 106 + (69=54) = 160lbs for normal frame
o Small frame 1600.10 = 16 160 - 16 = 144lbs
o Large frame 160 + 16 = 176lbs
For Glasgow Coma Scale, what is range for vegetative state?
<3
Useful screening tool to facilitate assessment of depression in older adults
Geriatric Depression Scale
Tool used to measure the impact headaches have on your ability to function on the job.
Headache Impact Test
