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mental & nutritional assessment

By nursedeb44 Jul 27, 2014 960 Words
MENTAL STATUS ASSESSMENT


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



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

MENTAL DISORDER


ORGANIC:



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


CONSCIOUSNESS



LANGUAGE



ABSTRACT
REASONING

MOOD & AFFECT



THOUGHT PROCESS

ORIENTATION



THOUGHT CONTENT



ATTENTION



PERCEPTIONS



MEMORY




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


POSTURE ERECT/POSITION RELAXED



BODY MOVEMENTS



DRESS



GROOMING AND HYGIENE

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

BEHAVIOR


LEVEL OF CONSCIOUSNESS



FACIAL EXPRESSION



SPEECH



PACE OF CONVERSATION



CLEAR & UNDERSTANDABLE SPEECH



MOOD & AFFECT

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

COGNITIVE FUNCTIONS


ORIENTATION



ATTENTION SPAN



RECENT MEMORY



REMOTE MEMORY





NEW LEARNING: THE 4 UNRELATED WORDS
TEST
JUDGEMENT

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

THOUGHT PROCESSES &
PERCEPTIONS





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






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




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


COMMON:



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


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



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



OPTIMAL NUTRITION



UNDERNUTRITION



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:






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


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


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)


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


EATING PATTERNS



USUAL WEIGHT







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



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.)






FOOD ALLERGIES
OR INTOLERANCES
MEDICATIONS OR
NUTRITIONAL
SUPPLEMENTS
SELF-CARE
BEHAVIORS







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.)




ADDITIONAL
HISTORY OBTAINED
FOR INFANTS AND
CHILDREN.
ADDITIONAL
HISTORY FOR
ADOLESCENTS





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






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







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.)


NAILS: smooth, pink



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



NEUROLOGIC: normal reflexes, appropriate affect

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

NUTRITION & THE AGING ADULT




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:


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


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

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