Standardized Assessment Tools Flashcards
General Mental Health assessment tool name, setting of use, content
Patient Stress Questionnaire
Primary care- global behavioral health assessment
Assess: depression, anxiety, trauma, alcohol use
Depression: assessment tool name, setting of use, content
PHQ-9 Patient Health Questionnaire self ranking 9 signs/ symptoms over 2 weeks. scale 0-3- 3 indicates symptoms occur everyday. higher score indicates depression 1-4 minimal 5-9- mild 10-14- moderate 15-19 moderately severe 20-27 severe Max score 27 (=3x9), each score range increases by 5.
Anxiety disorders: assessment tool name, setting of use, content
Generalized Anxiety Disorder-7 (GAD-7)
self administered-ranks 7 signs/ symptoms over last 2 weeks, ,0-3 scale- 3 is everyday symptom
5-9 mild anxiety
10-14 moderate anxiety
15-21 severe anxiety
total score > 10 indicates probably diagnosis of generalized anxiety disorder
Drug and alcohol use: assessment tool name, setting of use, content
CAGE-AID- self report- screening tool to measure if further assessment needed for alcohol or drug use issues
C: have you ever felt that you ought to CUT down on your drinking or drug use
A: Have people ANNOYED you by criticisizng your drinking or drug use?
G: Have you ever felt GUILTY about your drinking or drug use?
E: Every you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (EYE OPENER)
2 or more yes answers need further assessment
Wong-Baker FACES Pain Rating Scale- format/ content
self assessment
rates pain by choosing among 6 faces- ranging from smiling to crying
Brief Pain Inventory (BPI) short form- format/ content
Uses: Chronic pain/ Chronic disease- cancer, OA, low back pain, or acute conditions- post-op pain
severity of pain and impact of pain on daily functions -self report
measures location of pain, pain medication usage and amount of pain relief
RAAS- Richmond Agitation Sedation Scale
10 point scale- assess level of anxiety, agitation and sedation- critical care \+4 to -5 score range \+4 combative -5 unarousable 0 alert and calm
CPOT- Critical Care Pain Observation Tool - format/ content
4 behavioral categories- facial expression, body movements, muscle tension, compliance with ventilator (intubation) or vocalization (extubated patients)
each category score 0-2
total score range 0-8
CAM-ICU- format/ content
critical care unit delirium assessment 4 features- acute onset of mental changes or fluctuating course inattention disorganized thinking altered level of consciousness perform every shift with ICU patient
Mini-Mental State Examination (MMSE)- format/ content, scoring
Delirium/ Dementia assessment- measures cognitive impairment
ORArL 2,3 RWD
11 components
Orientation to place AND time
Recognition- repeat 3 objects
attention- counting backwards by 7 from 100
recall- recall 3 objects 5 minutes later
Language
2- identify names of 2 objects
3- follow 3 step command- take paper in right hand, fold in half and place on the floor
Reading- read statement to yourself, do exactly what it says but do not say it aloud
Writing- write a sentence
Drawing -copy a design
Scoring- max 30
no cognitive impairment- 24-30 (average 27)
Delirium/ dementia (18-23 mild) 0-17 (severe)
clock drawing test- purpose, format, scoring
assess cognitive impairment
patient draws numbers in the circle to resemble the face and hands of a clock. make the clock show 10 after 11
score range 1-6, > 3 means cognitive deficit present
Geriatric Depression Scale
self report
can be used in cognitively intact individuals- mild to moderate impairment as well
15 yes/no questions. score > 5 suggests depression
Functional Assessment/ ADLs- format/ content, uses
Katz Index of ADL- Index of Independent Activities of Daily Living
- measure progression of illness, need for care and effectiveness of rehab/ and treatment
Assess 6 self care functions: bathing, dressing, toileting, transferring, continence and feeding
Get-up and Go Test- format/ content, uses
gait, immobility/ fall risk
Short test
Patient is asked to rise from chair, stand still, walk a short distance, turn around, and walk back to chair, turn around and sit in the chair.
scoring 1-5. score > 3 indicated risk of falling
3-6 mildly- severely abnormal
How to assess pain in dementia- scale, format/ content
Pain Assessment in advanced Dementia Scale
5 behaviors- breathing, negative vocalization, facial expression, body language, consolability
0-10, , 0= no pain, 7-10= severe pain
