Topic 14 Flashcards
mental status
a person’s emotional and cognitive functioning
strikes a balance between good and bad days, allowing person to function socially and occupationally
mental disorder
an illness that affects a person’s thoughts, emotions, and behaviors
organic disorders
Due to brain disease of known specific organic cause (e.g., delirium, dementia, alcohol and drug intoxication and withdrawal)
psychiatric mental illness
organic etiology has not yet been established (e.g., anxiety disorder or schizophrenia)
when do you perform a full mental status examination
when any abnormality in affect or behavior is discovered and in certain situations
mental status: aging adult
o Older adulthood contains more potential for losses
o Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or depression
o Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of life
the four main headings of mental status assessment:
A-B-C-T
-Appearance
-Behavior
-Cognition
-Thought processes
aphasia
impairment of language ability secondary to brain damage
brain lesions
trauma, tumor, cerebrovascular accident or stroke
when is a full mental status examination necessary
-Patients whose initial screening suggests an anxiety disorder or depression
-Behavioral changes, such as memory loss, inappropriate social interaction
-Brain lesions
-Aphasia
-Symptoms of psychiatric mental illness, especially with acute onset
what things does the nurse ask about when determining the orientation of a client?
-time(day of the week, date, year, season)
-place(where person lives, address, phone number, present location, type of building, name of city and state)
-person(own name, age, who examiner is, type of worker)
attention span
ability to concentrate-noting completes a thought without wandering
assessing recent memory
Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency
confabulates
makes up plausible explanation for his actions without intention to deceive, to fill in gaps of memory loss
assessing remote memory
In the context of the interview, ask verifiable past events;
describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person
Remote memory is lost when
cortical storage area for that memory is damaged, such as in Alzheimer disease, dementia, or any disease that damages cerebral cortex
the four unrelated words test
Pick four words with semantic and phonetic diversity; ask person to remember the four words
have him or her repeat the words
Ask for the recall of four words at 5, 10, and 30 minutes
what is a normal response of the four unrelated words test for a person younger than 60
an accurate 3- or 4-word recall after 5, 10, and 30 minutes
assessing word comprehension
ask person to name object in room
assessing reading
ask person to read available print; be aware that reading is related to educational level
assessing writing
ask person to make up and write a sentence; note coherence, spelling, and parts of speech
thought processes
Way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts
thought content
what person says should be consistent and logical
perceptions
an awareness of objects through the five senses
When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess…
any possible risk of physical harm to himself or herself
when screening for suicidal thoughts, begin with..
more general questions; if you hear affirmative answers, continue with more specific probing questions
Mini-Mental State Exam (MMSE)
o Concentrates only on cognitive functioning, not on mood or thought processes
o 11 questions, 5 to 10 minutes to administer
the Mini-Mental State Exam (MMSE) can detect
dementia and delirium and differentiate from psychiatric mental illness
normal for the Mini-Mental State Exam (MMSE) is…
average 27;
scores between what numbers on the Mini-Mental State Exam (MMSE) indicare no cognitive impairment
scores between 24 and 30 indicate no cognitive impairment
what should be assessed before any aspect of mental status?
sensory status (vision and hearing changes)
Glasgow Coma Scale is useful in..
testing consciousness in aging persons in whom confusion is common
Mini-Cog
a reliable, quick, and easily available instrument to screen for cognitive impairment in healthy adults
-o Tests person’s executive function, including ability to plan, manage time, and organize activities, and working memory
what does a Mini-Cog consist of
o Consists of three-item recall test and clock-drawing test
what id normal for the mini-cog test
no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested
alert
awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.
Lethargic or Somnolent
Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased.
obtunded
(Transitional state between lethargy and stupor; some sources omit this level.) Sleeps most of time; difficult to arouse—needs loud shout or vigorous shake; acts confused when is aroused; converses in monosyllables; speech may be mumbled and incoherent; requires constant stimulation for even marginal cooperation.
Stupor or Semi-coma
Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists
coma
completely unconscious, no response to pain or to any external or internal stimuli
dysphonia
impairment or change in voice quality that affects the ability to speak or sing
Dysarthria
slow, slurred speech
global aphasia
affects receptive and expressive language skills (written and verbal) as well as auditory and visual comprehension
Broca’s aphasia
expressive language impairment - speaking and writing
Wernicke’s aphasia
receptive aphasia - difficult time understanding written and spoken language - speech lacks content or meaning
Delerium
confused thinking and reduced awareness of surroundings
Dementia
group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform ADL’s
depression
persistently depressed mood or loss of interest in activities that affects daily life
panic attack
a defined period of intense fear, anxiety, and dread accompanied by signs of dyspnea, choking, chest pain, increased heart rate, palpitations, nausea, and sweating.
agoraphobia
An irrational fear of being in places or situations where escape might be difficult.
specific phobia
a pattern of debilitating fear when faced with a particular object or situation.
social anxiety disorder
A persistent and irrational fear of being in social situations.
Generalized Anxiety Disorder (GAD):
A pattern of excessive worrying and morbid fear about anticipated “disasters” in the job, personal relationships, health, or finances.
Obessive-Compulsive Disorder (OCD)
A pattern of recurrent obsessions (intrusive, uncontrollable thoughts) and compulsions (repetitive ritualistic actions) done to decrease anxiety and prevent a catastrophe.
PTSD (Post Traumatic Stress Disorder)
This follows a traumatic event outside the range of usual human experience involving actual or threatened death.
Three most frequently abused prescription opioid pain relievers were products using the following:
-Oxycodone
-Hydrocodone
-Methadone
Prescription Drug Abuse occurs when.
an individual takes medication that was prescribed for someone else or takes medication in a manner that is different from that prescribed
Older adults have numerous characteristics that increase risk of alcohol use including:
o Liver metabolism and kidney functioning decrease,
(increases availability of alcohol in blood for longer periods)
o Less tissue mass means increased alcohol concentration in blood
o multiple medications that can interact adversely with alcohol
o Drinking alcohol increases risk of falls, depression, and gastrointestinal problems
If patient is currently intoxicated or going through substance withdrawal, collecting any history data is..
difficult and unreliable
R-R-R-R
o Risk of bodily harm: drinking and driving, operating machinery, swimming?
o Relationship trouble: family or friends?
o Role failure: interference with home, work, or school obligations?
o Run-ins with law: arrests or other legal problems?”
AUDIT tool will help
detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders
AUDIT covers three domains:
o Alcohol consumption
o Drinking behavior or dependence
o Adverse consequences from alcohol
AUDIT-C
Shorter version of AUDIT for acute and critical care units
- screening test for heavy drinking and/or active abuse
Score: 3 or above = heavy or at-risk drinking
CAGE questionnaire
cut down, annoyed, guilty, eye opener
Screening women for alcohol problems
TWEAK questions help identify at-risk drinking in women, especially pregnant women
TWEAK
-Tolerance: how many drinks can you hold? Or how many drinks does it take to make you feel high?
-Worry: have close friends or relatives complained about your drinking?
-Eye-opener: do you sometimes take a drink in morning when you first get up?
-Amnesia: has a friend or family member told you about things you said but could not remember?
-Kut down: do you sometimes feel the need to cut down?
SMAST-G questionnaire
for older adults who report social or regular drinking of any amount of alcohol. low risk response is 0 or 1 point. (10 questions)
what is the most commonly used biochemical marker of alcohol drinking
Serum protein, gamma glutamyl transferase (GGT)
Breath alcohol analysis (Breathalizer)
detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized
blood alcohol concentration (BAC)
the basis for a legal interpretation of drinking
CIWA-Ar Tool for assessment of withdrawal
o Nausea vomiting
o Tremor
o Paroxysmal sweats
o Anxiety
o Agitation
o Tactile disturbances
o Auditory disturbances
o Visual disturbances
o Headache
o Orientation and clouding of sensorium
Intoxication
Ingestion of substance produces maladaptive behavioral changes because of effects on the central nervous system
abuse
Daily use needed to function, inability to stop, impaired social and occupational functioning, recurrent use when it is physically hazardous, substance-related legal problems
dependence
Physiologic dependence on substance
tolerance
Requires increased amount of substance to produce same effect
withdrawal
Cessation of substance produces syndrome of physiologic symptoms
Intimate partner violence defined by the Centers for Disease Control and Prevention
-Physical or sexual violence, use of physical force, or threat of such violence
-Psychological or emotional abuse or coercive tactics after/prior physical violence between persons: Spouses, nonmarital partners, former spouses
as mandatory reporters of abuse you need only have
Suspicion that elder abuse and/or neglect may have occurred in order to generate a call to the authorities
Physical abuse
violent acts that result or could result in injury, pain, impairment, or disease
Physical neglect
failure of family or caregiver to provide basic goods and services such as food, shelter, health care, and medications
Psychological abuse
behaviors that result in mental anguish
Psychological neglect
failure to provide basic social stimulation
Financial abuse
intentional misuse of elderly person’s financial and material resources
Financial neglect
failure to use elderly person’s assets to provide needed services
Complications from injuries or bleeding from trauma
changes in circulatory homeostasis and fluctuations in blood pressure and pulse, shock, and death
Infections can progress to
generalized sepsis, then death in immunocompromised aging patients
Assault, or stress leading up to or following assault, can contribute to
cardiac complications
STIs and related complications for younger women are present in
older sexually assaulted women
Abuse of the elderly often is coupled with
neglect
Caregivers caring for elderly persons may struggle with their own severe physical and cognitive health challenges leading to
caregiver role strain
Routine, universal screening for IPV means the following
Asking every woman at every health care encounter if she has been abused by a husband, boyfriend, or other intimate partner or ex-partner
Alerts women that questions about domestic violence are coming and makes sure they
know they are not being singled out for these questions
If a woman answers yes to any of the Abuse Assessment Screen (AAS) questions, then ask questions to
assess how recent and how serious the abuse was
Important components of physical examination of known survivor of IPV or elder abuse include the following:
Complete head-to-toe visual examination, especially if patient is receiving health services for reported abuse
Health evaluations for known or suspected elder abuse and neglect should include baseline laboratory tests, including:
-complete blood count with platelet level,
-basic blood chemistries,
-serum liver function tests,
-coagulation panel,
-urinalysis
Danger Assessment (DA)
The more yes answers, the more serious the danger of the woman’s situation
IPV Factors among Ethnic and Racial Minorities: Legal Regulations
-societal stressors
-Legal regulations
-Lack of access
-Cultural values and gender roles
Documentation of IPV, child abuse, and elder abuse must include the following:
o Detailed, nonbiased progress notes
o Use of injury maps
o Photographic documentation in health record
o Other aspects of abuse history, including reports of past abusive incidents, can be paraphrased with use of partial direct quotations
o Written documentation of histories of IPV and elder abuse needs to be verbatim but within reason
o Critical to document exceptionally poignant statements made by victim that identify perpetrator and severe threats of harm made by perpetrator
