NUR 2092 HEALTH ASSESSMENT EXAM 2 STUDY GUIDE VERSION 2
1. Delirium: (Acute Confusional State) potentially preventable in hospitalized persons.
Characterized by disorientation, disordered thinking and perceptions (illusions and
hallucinations), defective memory, agitation, inattention
Sudden, over hours to days
Causes: hypoglycemia, fever, dehydration, hypotension, infection, adverse drug
reaction, head injury, change in environment, pain, emotional distress, substance
abuse
Cognition: impaired memory, judgment, calculations, attention span, can
fluctuate day to day
Level of Consciousness: Altered
Activity Level: Can be increased or reduced; restlessness; behaviors may worsen
in evening (sundowners); sleep/wake cycle may be reversed
Emotional State: Rapid swings, can be fearful, anxious, suspicious, aggressive,
have hallucinations and/or delusions
Speech and Language: Rapid; inappropriate, incoherent, rambling
Prognosis: Reversible with proper and timely treatment
2. Dementia: a chronic progressive loss of cognitive and intellectual functions, although
perception and consciousness are intact. Characterized by disorientation, impaired
judgment, memory loss.
Onset: Slowly, over months
Causes: Alzheimer disease, vascular disease, HIV, neurological disease, chronic
alcoholism, head trauma
Cognition: Impaired memory, judgment, calculations, attention span, abstract
thinking, agnosia
Level of Consciousness: Not altered
Activity Level: Not altered; behaviors may worsen in evening (sundowners)
Emotional State: Flat; agitation
Speech and Language: Incoherent, slow (sometimes due to effort to find the right
words), rambling, repetitious
Prognosis: Not reversible; progressive
3. Suicide:
4. Mini-Mental State Exam (MMSE): used with caution with people with low education;
Requires paper and pencil; person must be able to write and have no vision impairment.
It is quick and easy with 11 questions and takes 5-10 min to administer. It will
demonstrate worsening or improvement. It concentrates only on cognitive functioning,
not mood or thought process. It is detector of organic disease; dementia and delirium
and to differentiate these from psychiatric mental illness. Max score is 30, normal will
score average 27; 24-30 indicates no cognitive impairment. Available only by copyright.
5. Denver II Screening: gives chance to interact with child to assess mental status;
designed to detect developmental delays
, 6. Mini-Cog: reliable, quick and easily available to screen for cognitive impairment in
older adults. Takes 3-5 min. Consists of a 3-item recall test and a clock-drawing test.
7. 4 Unrelated Words Test: tests the person’s ability to lay down new memories. It is a
highly sensitive and valid memory test. It avoids the danger of unverifiable material.
Pick words with semantic and phonetic diversity. Ask to repeat in 5 min, 10 min and at
30 min. Normal response for people younger than 60 is accurate 3-4 recall. People with
Alzheimer will score 0-1 words. Score can be low with anxiety and depression due to
inattention and distractibility.
8. Appearance, Behavior, Cognition, and Thought Processes (A, B,C,T): four main
headings of mental status assessment.
9. Physical Changes in Elderly:
Vision and Hearing changes may alter alertness and leave a person looking
confused. Always check sensory status before assessing any aspect of mental
status.
There is no decrease in knowledge; response time is slower because it takes brain
longer to process information and to react.
Recent memory is decreased
Hearing Problems: Consonants are high frequency sounds; older people have
difficulty hearing them. This produces frustration, suspicion, and social isolation,
and makes the person look confused.
Losses (loved ones, income…): can lead to despair and grief; can result in
disorientation, disability, or depression.
Orientation: many elderly persons experience social isolation, loss of structure, a
change in residence, or some short-term memory loss. You can consider them
oriented if they know generally where they are and the present period.
People in their 70’s will average 2-4 words in 5 min. They will improve at 10 and
30 min after being reminded by verbal ques.
10. Assessment Techniques:
Inspection: concentrated watching; it is close scrutiny first of whole and then
each body system.
Begins moment first meet and develop a general survey
Train yourself not to rush by holding hands behind back
Use person as his/her own control and compare right and left sides of the
body. Should be nearly symmetric
Requires good lighting, adequate exposure, and use of tools (penlight…)
Palpation: uses sense of touch to assess texture, temperature, moisture; organ
location and size; swelling, vibration or pulsation, rigidity or spasticity, crepitation,
presence of lumps or masses, and presence of tenderness or pain.
Different parts of hand:
Fingertips: best for fine tactile discrimination, as of skin texture,
swelling, pulsation and determining presence of lumps
A Grasping Action of fingers and thumb: to detect the position,
shape and consistency of an organ or mass
1. Delirium: (Acute Confusional State) potentially preventable in hospitalized persons.
Characterized by disorientation, disordered thinking and perceptions (illusions and
hallucinations), defective memory, agitation, inattention
Sudden, over hours to days
Causes: hypoglycemia, fever, dehydration, hypotension, infection, adverse drug
reaction, head injury, change in environment, pain, emotional distress, substance
abuse
Cognition: impaired memory, judgment, calculations, attention span, can
fluctuate day to day
Level of Consciousness: Altered
Activity Level: Can be increased or reduced; restlessness; behaviors may worsen
in evening (sundowners); sleep/wake cycle may be reversed
Emotional State: Rapid swings, can be fearful, anxious, suspicious, aggressive,
have hallucinations and/or delusions
Speech and Language: Rapid; inappropriate, incoherent, rambling
Prognosis: Reversible with proper and timely treatment
2. Dementia: a chronic progressive loss of cognitive and intellectual functions, although
perception and consciousness are intact. Characterized by disorientation, impaired
judgment, memory loss.
Onset: Slowly, over months
Causes: Alzheimer disease, vascular disease, HIV, neurological disease, chronic
alcoholism, head trauma
Cognition: Impaired memory, judgment, calculations, attention span, abstract
thinking, agnosia
Level of Consciousness: Not altered
Activity Level: Not altered; behaviors may worsen in evening (sundowners)
Emotional State: Flat; agitation
Speech and Language: Incoherent, slow (sometimes due to effort to find the right
words), rambling, repetitious
Prognosis: Not reversible; progressive
3. Suicide:
4. Mini-Mental State Exam (MMSE): used with caution with people with low education;
Requires paper and pencil; person must be able to write and have no vision impairment.
It is quick and easy with 11 questions and takes 5-10 min to administer. It will
demonstrate worsening or improvement. It concentrates only on cognitive functioning,
not mood or thought process. It is detector of organic disease; dementia and delirium
and to differentiate these from psychiatric mental illness. Max score is 30, normal will
score average 27; 24-30 indicates no cognitive impairment. Available only by copyright.
5. Denver II Screening: gives chance to interact with child to assess mental status;
designed to detect developmental delays
, 6. Mini-Cog: reliable, quick and easily available to screen for cognitive impairment in
older adults. Takes 3-5 min. Consists of a 3-item recall test and a clock-drawing test.
7. 4 Unrelated Words Test: tests the person’s ability to lay down new memories. It is a
highly sensitive and valid memory test. It avoids the danger of unverifiable material.
Pick words with semantic and phonetic diversity. Ask to repeat in 5 min, 10 min and at
30 min. Normal response for people younger than 60 is accurate 3-4 recall. People with
Alzheimer will score 0-1 words. Score can be low with anxiety and depression due to
inattention and distractibility.
8. Appearance, Behavior, Cognition, and Thought Processes (A, B,C,T): four main
headings of mental status assessment.
9. Physical Changes in Elderly:
Vision and Hearing changes may alter alertness and leave a person looking
confused. Always check sensory status before assessing any aspect of mental
status.
There is no decrease in knowledge; response time is slower because it takes brain
longer to process information and to react.
Recent memory is decreased
Hearing Problems: Consonants are high frequency sounds; older people have
difficulty hearing them. This produces frustration, suspicion, and social isolation,
and makes the person look confused.
Losses (loved ones, income…): can lead to despair and grief; can result in
disorientation, disability, or depression.
Orientation: many elderly persons experience social isolation, loss of structure, a
change in residence, or some short-term memory loss. You can consider them
oriented if they know generally where they are and the present period.
People in their 70’s will average 2-4 words in 5 min. They will improve at 10 and
30 min after being reminded by verbal ques.
10. Assessment Techniques:
Inspection: concentrated watching; it is close scrutiny first of whole and then
each body system.
Begins moment first meet and develop a general survey
Train yourself not to rush by holding hands behind back
Use person as his/her own control and compare right and left sides of the
body. Should be nearly symmetric
Requires good lighting, adequate exposure, and use of tools (penlight…)
Palpation: uses sense of touch to assess texture, temperature, moisture; organ
location and size; swelling, vibration or pulsation, rigidity or spasticity, crepitation,
presence of lumps or masses, and presence of tenderness or pain.
Different parts of hand:
Fingertips: best for fine tactile discrimination, as of skin texture,
swelling, pulsation and determining presence of lumps
A Grasping Action of fingers and thumb: to detect the position,
shape and consistency of an organ or mass
