Scales and more Flashcards
Pfeiffer
Short Mental Status Questionnaire
10 questions. 8-10 wrong answers. severe
(Date, name, phone number who is the president etc)
The numbers are how many they got wrong on the questions
5-7 mod. intellectual impairment. 8-10 severe
Braden Pressure Injury Scale
The lower the number the higher the risk
Think LOW - FLOOR/Fall
Categories
Sensory 4
Moisture 4
Activity 4
Mobility Nutrition 4
Friction/Shear 3
23 is highest score
3-8 SEVERE RISK of Pressure injuries
Morse Fall Risk Scale
greater than
50 HIGH FALL RISK Think MORSE - MORE SCORE. MORE RISK
25-50 MODERATE FALL RISK
0-24 No Fall Risk
6 parameters
History of fall
Secondary DX
Ambulatory Aid (wheel chair, crutches, walker)
IV Access
Gait
Mental Status
GLASCOW COMA SCALE
THE LOWER THE SCORE
THE MORE SEVERE THE PATIENT IS.
SEVERE 0-8. Mod 8-12. Mild 13-15
MINI-MENTAL EXAM
Less than 20 cognitive impairment
SCALES
Pfeffer Mental Status Score - Cog impairment
Braden Pressure injury Scale - High Risk
Glasgow Coma Scale - Worst score
Mini-Mental Exam - Cog impairment
Edema - Worst
Morse Fall Risk - Highest Risk
LOW SCORE IS IMPAIRMENT
Braden Pressure High Risk 3-8/23
Glasgow Coma- Cog. Impairment 0-8 /16
MIni-Mental - Cog. Impairment - < 20
HIGH SCORE IS IMPAIRMENT (PEM)
Pfieffer Mini-Mental - Cog impairment 8-10 (wrong) /10 questions
Edema - +4 pitting (0-4
Morse Fall Risk - > 50 High Fall Risk
Respiratory Rates
Seniors. Adults
Seniors 16-25 Adults 12-20
5 Heart Sound Locations
All -Aorta
Patients - Pulmonic
Enjoy -Erbs
Taking -Tricuspid
Meds -Mitral
Where are S1 and S2 heard?
S1 - mitral and tricuspid valves closing = Lub. -Apex Bell
S2 - aortic and pulmonic closing - Dub - Base Diaphragm
What is Oligoria?
Less than 500 ml urine per day
What is dysuria?
Painful urination
