mental & nutritional assessment

MENTAL STATUS ASSESSMENT
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STRUCTURE & FUNCTION:
1. EMOTIONAL (feeling)
2. COGNITIVE (knowing)

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STRESS SURROUNDING A TRAUMATIC
EVENT TIPS THIS BALANCE CAUSING A
BRIEF DYSFUNCTION.

MENTAL DISORDER
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ORGANIC:

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DUE TO A DISEASE
OF THE BRAIN,
DELIRIUM,
DEMENTIA,
ALCOHOL, DRUGS.

PSYCHIATRIC:
DUE TO ANXIETY
DISORDER, OR
SCHIZOPHRENIA

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

THE MENTAL STATUS
ASSESSMENT
DOCUMENTS A DYSFUNCTION &
DETERMINES HOW THAT DYSFUNCTION
AFFECTS SELF CARE IN EVERYDAY LIFE.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

MENTAL ASSESSMENT
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CONSCIOUSNESS

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LANGUAGE

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ABSTRACT
REASONING

MOOD & AFFECT

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THOUGHT PROCESS

ORIENTATION

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THOUGHT CONTENT

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ATTENTION

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PERCEPTIONS

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MEMORY

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Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

COMPONENTS OF THE MENTAL STATUS
EXAM

A--B--C--T
APPEARANCE—BEHAVIOR--COGNITION-THOUGHT PROCESSES

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

OBJECTIVE DATA:
APPEARANCE
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POSTURE ERECT/POSITION RELAXED

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BODY MOVEMENTS

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DRESS

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GROOMING AND HYGIENE

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

BEHAVIOR
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LEVEL OF CONSCIOUSNESS

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FACIAL EXPRESSION

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SPEECH

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PACE OF CONVERSATION

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CLEAR & UNDERSTANDABLE SPEECH

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MOOD & AFFECT

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

COGNITIVE FUNCTIONS
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ORIENTATION

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ATTENTION SPAN

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RECENT MEMORY

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REMOTE MEMORY

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NEW LEARNING: THE 4 UNRELATED WORDS
TEST
JUDGEMENT

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

THOUGHT PROCESSES &
PERCEPTIONS

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THOUGHT CONTENT: what they say should be consistent and logical.
PERCEPTIONS: they should be consistently aware of reality.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

SCREENINGS
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SCREEN FOR
ANXIETY
DISORDERS
SCREEN FOR
DEPRESSION
SCREEN FOR
SUICIDAL
THOUGHTS

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

DEVELOPMENTAL COMPETANCE
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INFANTS &
CHILDREN: covers behavioral, cognitive & psychosocial development.
THE AGING ADULT: follow the A-B-C-T guidelines as with younger adults but with a few added considerations. Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

ABNORMAL MENTAL FINDINGS
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COMMON:

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DEPRESSION= sad, gloomy, dejected; symptoms may occur with rainy weather; after a holiday or with illness; if it is temporary symptoms disappear quickly. UNCOMMON:
PERSEVERATION=
persistent repeating of verbal or motor response, even with varied stimuli.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

NUTRITIONAL ASSESSMENT
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WHAT IS
NUTRITIONAL
STATUS?
Refers to the degree of balance between nutrient intake & nutrient requirements.

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This balance is affected by factors such as physiological, psychosocial, developmental, cultural
& economic factors.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

3 STATES OF NUTRITION

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OPTIMAL NUTRITION

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UNDERNUTRITION

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OVERNUTRITION

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

PURPOSES & COMPONENTS OF
THE NUTRITIONAL ASSESSMENT

TECHNIQUES ARE NON-INVASIVE,
INEXPENSIVE AND EASY TO PERFORM.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

PURPOSE:
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To identify individuals who are malnourished or are at risk for malnourishment.
To provide data for designing a nutrition plan of care that will prevent malnutrition.
To establish baseline data for evaluating the efficacy of nutritional care.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

MALNUTRITION SCREENING
TOOL
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MST = was validated for use in adults in the acute care setting. Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

MINI NUTRITIONAL ASSESSMENT
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MNA= this was designed for use in older adults in long term care and community settings. Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

COMPRHENSIVE NURTITIONAL
ASSESSMENT
INDIVIDUALS IDENTIFIED AT RISK DURING A
SCREENING SHOULD THEN UNDERGO A
COMPREHENSIVE NURTITIONAL
ASSESSMENT WHICH INCLUDES DIETARY
HISTORY, CLINICAL INFORMATION, PHYSICAL
EXAMINATION & LAB TESTS.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

SUBJECTIVE GLOBAL
ASSESSMENT (SGA)
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Used to assess areas of deficiency found during the initial nutritional assessment.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

SUBJECTIVE DATA COLLECTION
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EATING PATTERNS

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USUAL WEIGHT

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CHANGES IN
APPETITE, SMELL,
TASTE, CHEWING
,SWALLOWING.

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RECENT SURGERY
OR TRAUMA
CHRONIC ILLNESS
NAUSEA,
VOMITING,
DIARRHEA,
CONSTIPATION

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

Subjective data collection,( cont.)
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FOOD ALLERGIES
OR INTOLERANCES
MEDICATIONS OR
NUTRITIONAL
SUPPLEMENTS
SELF-CARE
BEHAVIORS

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ALCOHOL OR
ILLEGAL DRUG USE
EXERCISE AND
ACTIVITY
PATTERNS
FAMILY HISTORY

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

Subjective data collection, (cont.)
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ADDITIONAL
HISTORY OBTAINED
FOR INFANTS AND
CHILDREN.
ADDITIONAL
HISTORY FOR
ADOLESCENTS

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ADDITIONAL
HISTORY FOR THE
PREGNANT
WOMAN.
ADDITIONAL
HISTORY FOR
AGING ADULT

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

OBJECTIVE DATA
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SKIN: smooth, no signs of rashes, bruising, flaking HAIR: shiny, firm, does not fall out easily, healthy scalp
EYES: corneas are clear, shiny; membranes are pink and moist; no sores at corners of eyelids ●

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LIPS: smooth, not chapped or swollen
TONGUE: red in appearance; not swollen or smooth, no lesions
GUMS: reddish-pink, firm, no swelling or bleeding Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

Subjective data (cont.)
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NAILS: smooth, pink

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MUSCULOSKELTAL: erect posture, no malformations, good muscle tone, can walk or run without pain

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NEUROLOGIC: normal reflexes, appropriate affect

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

NUTRITION & THE AGING ADULT
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OLDER ADULTS HAVE INCREASED RISK FOR
UNDERNUTRITION OR OVERNUTRITION.
NORMAL PHYSIOLOGIC CHANGES IN AGING
ADULTS THAT DIRECTLY AFFECT
NUTRITIONAL STATUS INCLUDE:
* Poor dentition

* Slowed GI motility

* Decreased visual acuity

* Decreased taste/smell

*Decreased saliva production

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

COMMON FINDING:
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OBESITY: due to caloric excess and refers to weight more than 20% above ideal body weight or body mass index of 30.0-39.9.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

FRIGHTENING STATISTICS !

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO

NOT SO COMMON FINDINGS
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MARASMUS (protein-calorie malnutrition) this is due to inadequate intake of protein and calories or prolonged starvation. Anorexia, bowel obstruction, cancer cachexia, and chronic illness are among the most common causes.

Jarvis, Carolyn. (2012). Physical Examination & Health Assessment. (6th ed.) St. Louis, MO