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Scales Flashcards

1
Q

MMSE (0-30)- Normal

A

25-30

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2
Q

MMSE (0-30)- mild cognitive impairment/ early stage of alzheimer’s disease

A

21-24

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3
Q

MMSE (0-30)- moderate/moderate alzheimers

A

10-20

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4
Q

MMSE (0-30)- Late/severe alzheimer’s disease

A

0-9

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5
Q

SLUM: 0-30 (Mental Status)
Normal

A

27-30

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6
Q

SLUM: 0-30 (Mental Status)
Mild Dementia

A

21-26

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7
Q

SLUM: 0-30 (Mental Status)
Dementia

A

0-20

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8
Q

What depression scales are there?

A

HAM D
PHQ-9
Beck

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9
Q

HAM-D (0-76)
Normal
*hint: HAM-Da Pig lives on 7543 E. Bacon ave.

A

0-7

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10
Q

HAM-D (0-76)
Mild

A

8-13

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11
Q

*HAM-D (0-76)
Moderate

A

14-18

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12
Q

HAM-D (0-76)
Severe

A

19-22

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13
Q

HAM-D (0-76)
Very severe

A

23-76

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14
Q

PHQ-9 (0-27)
Normal
*Hint: might as well call it PHQ 4)

A

0-4

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15
Q

PHQ-9 (0-27)
Mild

A

5-9

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16
Q

PHQ-9 (0-27)
Moderate

A

10-14

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17
Q

PHQ-9 (0-27)
Mod to severe

A

15-19

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18
Q

PHQ-9 (0-27)
Severe

A

20-27

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19
Q

Beck (0-63)
Normal
*Hint: Becka lives on 9910 23rd and southern

A

0-9

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20
Q

Beck (0-63)
Mild

A

10-18

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21
Q

*Beck (0-63)
Moderate

22
Q

Beck (0-63)
Severe

23
Q

What scales are used for anxiety?

24
Q

HAM A (0-56)
Mild
*Hint: AAA- Adolescent, Adult, and Anxiety

25
Q

*HAM A (0-56)
Moderate

26
Q

HAM A (0-56)
Severe

A

25 and above

27
Q

GAD 7 (0-23)
Normal

28
Q

GAD 7 (0-23)
Severe

29
Q

GAD 7 (0-23)
Mild

30
Q

*GAD 7 (0-23)
Moderate

31
Q

COWS- (0-36)
When to start treatment?
Hint: normal- young kids don’t do drugs but start when they are 7 yo.

A

No symptoms = 0-4
Start tx when 7 or higher

32
Q

COWS- (0-36)
Mild
What to medication should you give?
Hint: this medication can also be given at a certain age for impulsively and ADHD.

A

5-12
Clonidine

33
Q

*COWS- (0-36)
Moderate
What meds to give?

A

13-24
Buprenorphine or Suboxone

34
Q

COWS- (0-36)
Mod to severe
Hint: this is when adults will most likely do drugs.

35
Q

COWS- (0-36)
Severe

A

36 or higher

36
Q

CIWA (0-21)
When to start treatment?

A

0-9 no symptoms/minimal symptoms
Start treatment higher than 8.

37
Q

CIWA (0-21)
Mild

38
Q

*CIWA (0-21)
Moderate

39
Q

CIWA (0-21)
Severe

A

21 or higher

40
Q

CIWA- when you can start giving PRN meds

A

When the patient scores 8 or higher.

41
Q

CIWA- when to give scheduled meds and PRNs?

A

15 and above

42
Q

Main benzos for CIWA?

A

Diazepam (Valium) and Lorazepam (Ativan)

43
Q

Diazepam =

A

Longer half life

44
Q

Lorazepam =

A

Shorter half life.
Give if liver is compromised

45
Q

Where to refer patients on ETOH withdrawal to?

A

Refer to residential tx center

46
Q

What to do when a pregnant patient is having withdrawals?

A

Refer to residential TX center
*not report to CPS

47
Q

Scale = Mild anxiety/ depression

A

Either do therapy or nothing

48
Q

Scale = moderate anxiety/depression

A

Medications and/or therapy

49
Q

Pulse
Sweating
RestlessNess
Pupil size
Body aches
Running nose
Gi upset
Yawning
Tremors
Anxiety/irritability
Gooseflesh skin

A

COWS Scale components

50
Q

N/V
Tremors
Sweats
Anxiety
Agitation
Tactile disturbance
AH
HA
Orientation

A

Signs of CIWA components

51
Q

What are three medications to treat ETOH Disorder?

A
  1. Acamprosate
  2. Dissulfiram
  3. Naltrexone
52
Q

Acamprosate is metabolized by liver: True or false

PMHNP Boards (12 decks)

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