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
What is complementary and alternative medicine (CAM)? what is integrative medicine?
CAM- focus on whole person, physical emotional mental and spiritual health
ex. natural products, herbs, vitamins, minerals, probiotics, yoga, chiropractic, meditation, massage therapy, acupuncture, tai chi, qi gong, healing touch, hypnotherapy, music, light therapy, traditional Chinese medicine, homeopathy, naturopathy
Integrative medicine- combines conventional and complementary approaches- chronic pain- mindfulness and pharmacologic therapy combined
