1

Diagnostic Reasoning 431

When you hear the term “assessment”, what comes to mind? STRESS: Assessment of the whole person

Mental Health Assessment Mental status is a person’s emotional and cognitive functioning. Optimal functioning aims toward simultaneous life satisfaction in work, in caring relationships, and within the self.

The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, you can assess mental status through the context of the health history interview.

Keep in mind the four main headings of mental status assessment (A, B, C, T):  appearance  behavior  cognition  thought processes

Appearance  posture  body movements  dress  grooming and hygiene

Behavior  level of consciousness  facial expression  speech  mood and affect

Cognitive Functions  orientation  attention span  recent memory  remote memory  new learning - the four unrelated words test  additional testing for persons with aphasia (word comprehension, reading, writing)

Example of tool: Mini-Mental State Examination (Folstein) (Maximum score = 30, normal person = 27, <20 = dementia and delirium) 2

Thought processes and perceptions  thought process (Does this person make sense?)  thought content (What the person says should be consistent and logical)  perceptions (The person should be consistently aware of reality)  screen for suicidal thoughts (have you ever felt so blue you thought of hurting yourself? Do you feel like hurting yourself now? Do you have a plan to hurt yourself? What would happen if you were dead? How would other people react if you were dead?)

NOTE: A precise suicide plan to take place in the next 24-48 hours using a lethal method constitutes high risk!

(Example of tool for Depression: Beck Depression Inventory Scoring: 0-3 Minimal 4-6 Mild 7-9 Moderate 10-21 Severe)

There is also a Beck Anxiety Inventory 3

Cultural Assessment One aspect of a comprehensive health history concerns the collection of data related to culturally based beliefs and practices about health and illness

A cultural assessment refers to a systematic appraisal or examination of individuals, groups, and communities in relation to their cultural beliefs, values, and practices to determine explicit nursing needs and intervention practices within the cultural context of the people being evaluated.

Areas to be assessed:  brief history of the cultural group with which the person identifies  values orientation (regarding birth, death, health, illness, health care providers)  cultural sanctions and restrictions  language and communication  health-related beliefs and practices  parenting styles and role of family  sources of support beyond family  nutrition (dietary practices)  socioeconomic considerations organizations providing cultural support  educational background  religious affiliation  spiritual considerations

Be aware of community makeup

Use interpreter 4

Spiritual Assessment  Does the person have religious objects in the environment?  Does the person wear outer- or undergarments having religious significance?  Are get-well greeting cards religious in nature or from a religious representative?  Does the person appear to pray at certain times of the day or before meals?  Does the person make special dietary requests?  Does the person read religious magazines or books?  Does the person mention God (Allah, Buddha, Yahweh, or a synonym), prayer, faith, or other religious topics?  Is there an expression of anxiety or fear about pain, suffering, death?  Does the person prefer to interact with others or to remain alone? 5

Nutritional Assessment

Nutritional status refers to the degree of balance between nutrient intake and nutrient requirements.

This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic.

Immigrants commonly maintain traditional eating customs long after the language and manner of dress of an adopted country become routine. Occupation, class, religion, gender, and health awareness also have a great bearing on eating customs.

Terms: optimal nutritional status, undernutrition, overnutrition

Purposes of nutritional assessment are to 1. identify individuals who are malnourished or are at risk of developing malnutrition; 2. provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition; and 3. establish baseline data for evaluating the efficacy of nutritional care.

A comprehensive nutritional assessment is recommended for all individuals with confirmed nutritional risk, i.e., with one or more of the following risk factors: 1. weight < 80% or > 120% of ideal weight 2. history of unintentional weight loss > 4.5 Kg (10 lb) or > or = 10 % of usual weight 3. serum albumin concentration < 3.5 g/dl 4. total lymphocyte count < 1500 cells/mm3 5. history of illnesses, symptoms, or factors associated with nutritional depletion or inadequate nutrient intake or absorption.

In addition to the screening assessment parameters (height and weight), comprehensive nutritional assessment includes:  dietary history and intake information - 24-hour recall - Food frequency questionnaire - food diaries - direct observation of feeding and eating process

HISTORY QUESTIONS (Subjective data) - Eating patterns - Usual weight - Changes in appetite, taste, smell, or chewing, swallowing - recent surgery, trauma, burns, infection - chronic illnesses - vomiting, diarrhea, constipation - food allergies or intolerances - medications and/or nutritional supplements - self-care behaviors (meal prep, socioeconomic factors) 6

- alcohol or illegal drug use - exercise and activity patterns - family history

Additional questions for specific populations:

FOR INFANTS AND CHILDREN: - gestational nutrition - infant breast or bottle fed - child willing to eat what you prepare

FOR ADOLESCENT: - your present weight (dieting?, feeling fat?, vomit/laxatives/diuretics after eating?) - what snacks or fat foods do you like to eat - age first start menstruating (late if malnourished)

FOR PREGNANT FEMALE: - how many times have you been pregnant? - what foods prefer when pregnant?

FOR AGING ADULT: - how does your diet differ from when you were in your 40s and 50s?

 physical examination for clinical signs

- skin - hair - eyes - lips - tongue - gums - nails - musculoskeletal - neurologic

 anthropometric measures (the measurement and evaluation of growth, development, and body composition)

- body weight as a percentage of ideal body weight (current weight/ideal weight X 100) - 80-90% = mild malnutrition - 70-80% = moderate malnutrition - < 70% = severe malnutrition

- Percent usual body weight (current weight/usual weight X 100) - 85-95% = mild malnutrition - 75-84% = moderate malnutrition 7

- < 75% = severe malnutrition

- Recent weight change (usual weight - current weight / usual weight X 100)

- skinfold thickness: provides an estimate of body fat stores or the extent of obesity or undernutrition (measure at posterior upper arm, midway between acromion process of scapula and the olecranon process) measure with calipers and compare with standards

[TSF = triceps skin fold]

- mid-upper arm circumference (MAC): estimates skeletal muscle mass and fat stores

- others: - arm span or total arm length - frame size - body mass index (simple indicator of total body fat or obesity) - waist-to-hip ratio (assesses body fat distribution as indicator of health risk)

 laboratory tests - hemoglobin - hematocrit - cholesterol - triglycerides - total lymphocyte count (TLC) - skin testing - serum albumin - serum transferrin - nitrogen balance - creatinine-height index

To monitor nutritional status in malnourished individuals or in individuals at risk for malnutrition, serial measurements of nutritional assessment parameters are made at routine intervals.

At the minimum, weight, Hgb, Hct, serum albumin, and TLC should be evaluated weekly.

Because TSF (triceps skin fold) thickness, MAC, and arm muscle circumference measures change more slowly, data on these indicators may be collected biweekly or monthly.