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Assess I: Cognitive and Perception
Terms in this set (94)
According to the U.S. Surgeon General, what is the definition of mental health?
"A state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change to cope with adversity"
What does the World Health Organization (WHO) states?
"There is no health without mental health... it is a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make contribution to his or her community... mental health is the foundation for wellbeing and effective functioning for an individual and for a community."
What are some common mental health disorders?
- Postpartum Depression
What is the nurse's role when assessing mental health?
Mental health assessment is within the context of patient's own culture
- Observation of the pt
- The pt's responses to the nurse's questions
It is Integral to any full medical or nursing examination.
Must be inferred from answers to questions and behaviors because it cannot be observed directly.
What history should be focused on for a mental health assessment?
Common symptoms of altered mental health
Homicide ideation and aggressive behavior
Altered mood and affect
What is included in the objective data portion of the mental assessment?
A - appearance
B - behavior
C - cognitive function, &
T - thought process
also the mini-mental status examination
How do you administer mini-mental cog exam?
(Mini-Cog Box 9.6)
1. Instruct the pt to remember and repeat 3 unrelated words.
2. Instruct the pt to draw the face of the clock, either on a blank sheet of paper or on a sheet with the clock circle already drawn in. Ask the pt to draw the numbers, then tell them to label a specific time.
3. Ask the pt to repeat the unrelated words again.
Why is it important for someone to have an appropriately functioning nervous system?
It is critical for all human endeavors
Exerts unconscious control over basic body function, such as respiration, temperature regulation, and movement coordination.
Enables very complex interactions with people and the environment.
What are the goals of a mental assessment?
To detect change in neurological status, particularly acute and life threatening alterations.
To localize the pathology.
How does a nurse make a mental medical diagnosis?
By identifying actual or potential health problems related to neurological dysfunction and assess the pts response to those problems.
What is normal posture and body movements?
Voluntary, deliberate, coordinated, smooth, even, and purposeful.
What is an example of a condition characterized by change in body movements or posture?
What is the physical appearance of a normally functioning person?
Clean, matching, hair neat, nails clean
When looking at physical appearance, why should you watch being judgmental?
- age changed if cold or hot
- teens dont care how they look
- homeless are not all dirty
Certain conditions can be identified by a change in:
- Level of Consciousness
- Facial expression
What is the normal Level of Consciousness characterized by?
Awake, alert, response appropriately
What are some things that can alter someones LOC?
- Lack of sleep
What is normal when assessing facial expressions?
Symmetry, and the appropriate expression for what was said or done.
What is abnormal when assessing facial expressions?
Non-symmetrical (suggesting stroke)
What is normal when assessing speech?
Normal tone with moderate pace, normal fluctuations, makes eye contact.
Moderate loudness, english fluent, clear and distinct.
What does a very loud voice indicate?
The person is hard of hearing
What does a very soft voice indicate?
The person is shy or doesn't like communication
What is something to look for when assessing speech?
What is normal orientation?
- oriented to self, place, and time.
*Consider situations that may alter this, if so, add current situation or surrounding (AAOx4)
What indicates a normal attention span?
When someone can follow conversation and events
What are some indications of an abnormal attention span?
- Short, brief
- Long for age
- 5 min attention span means easily distracted
- Cannot sit still for entire movie
- Elderly is about 15 minutes
- Not all children have a short attention span, not everyone is ADD or ADHD
What should you ask to assess Short Term Memory?
What they ate last night or current president
What should you ask to assess Long Term Memory?
What year they were born or where they grew up
How can conditions like a head injury, stroke, dementia, and alzheimer's alter someones memory?
- They may remember their past but not what they did 5 mins ago
- Head injury may remember the accident but not their ABCs from childhood
What is normal?
4 unrelated words
Normal can recall at 5, 10, 30 minute intervals
Mood and Affect:
What is normal?
mood is congruent with subject (happy, sad, mad)
- blank and flat can be caused by diseases
What should you assess when testing Cognitive Abilities and Mentation?
- Spatial Perception
- Higher Intellectual Functioning
How can you assess for normal Spatial Perception?
Have the pt comply simple drawings of objects.
What the are ways you can assess ones Higher Intellectual Functions?
1. Proverb Interpretation - Have the pt explain a common proverb, or have the pt finish a common proverb.
2. Abstract Reasoning - Have the pt solve a simple problem with rational reasoning.
3. Calculation - Have the pt solve a simple math problem.
What are some examples of Proverb Interpretation?
- Don't bite the hand that feeds the face
- You can't teach an old dog new tricks
- No news is _________ (good news)
- What does it mean to call the kettle black?
How do you assess ones Judgment, or ability to make decisions?
1. Record their response to:
- Family situations (EX: how do you feel about your parents divorce?)
- Interpersonal conflict (Ex: How would you handle a bully at your school?)
- Making decisions (Ex: Before you make a decision, what do you think about?)
2. Ask direct questions: (Yes or No)
3. Assess long-term goals
When assessing Judgment, what is normal? What is Abnormal?
Normal - Making good judgments and takes responsibility for own actions.
Abnormal - Unrealistic or impulse decisions.
When assessing ones Thought Process...
- What is normal?
- What are the 3 types of thought processes one can have?
Normal - Easy to follow, logical, coherent, relevant, goal directed, consistent and abstract.
1. Logical (normal)
When assessing ones Thought Content (what they think about), what is normal?
Consistent and logical
When assessing ones Perception, what is normal?
Being aware of reality, and being able to differentiate between reality, illusions, and hallucinations.
What is the Suicide Risk Assessment called?
What is the SAD PERSONAS risk assessment?
S - Sex
A - Age
D - Depression
P - Previous attempt
E - Ethanol abuse
R - Rational thought process
S - Social support slacking
O - Organized Plan
N - No spouse
A - Assess to lethal means
S - Sickness
What is considered Lethal Suicide?
When the pt has attempted suicide before.
What is important nursing roles when assessing Suicide?
To assess for SAFETY of patient and others.
*NURSE MUST REPORT ALL FINDING.
Cognitive Assessment Variations: Infants
1. Neuro exam should be done when the infant is in a quiet alert state.
2. Observe infants spontaneous activity for symmetry and smoothness of movement.
3. Sensory Integrity:
- Infant withdrawals all limbs to painful stimuli.
4. Deep Tendon Reflexes:
- Positive Babinski Sing (fanning) is normal up to 16-24 months (pg 713)
5. Evaluate Muscle Strength & Tone.
Cognitive Assessment Variations: Children
1. Denver II:
- Developmental test that measures fine and gross motor, language, and personal-social skills.
2. Observe play for gait and fine motor coordination.
3. Deep Tendon Reflex
4. Behavioral checklist:
- Family Relations
6. Psychological Development
7. Coping with environment
8. Neurological soft signs
What are Neurological Soft Signs?
They are non-focal, functional neurological findings that often provide subtle clues to an underlying CNS deficit or a neurological maturation delay. Children with multiples soft signs often have learning disabilities.
What are some examples of Soft Signs?
- short attention span
- poor coordination of position
- labile emotions
- no demonstration of handedness (right or left)
- language and articulation poor
Cognitive Assessment Variations: Pregnancy
1. Deep Tendon Reflex
- Baseline evaluation should be done at initial prenatal visit.
- Preclampsia: Exaggerated deep tendon reflex
Cognitive Assessment Variations: Elderly
1. Always assess sensory function first.
2. Allow more time for maneuvers of coordination and movement.
3. Diminished sense of smell and taste.
- They may shuffle because of poor flexion of the hips and knees.
5. Tactile, vibratory, and position sensation may be diminished.
6. Deep tendon reflexes:
- Absent or less brisk
- LOC: Glasgow Coma Scale (box 24.2)
8. Tinette Balance & Gait Assessment Tool:
- Used for older adults who are thought to be at risk for falls.
9. Cognitive Function:
- New Learning: Average of 2/4 words after 5 mins and improves with verbal clues.
10. Set Test:
- Verbal test to screen for dementia.
What is the Set Test and how is it given? What is the scoring?
It tests for dementia.
Ask the pt to name 10 items in 4 different categories. (fruit, animals, colors, towns)
Max score is 40.
Dementia results in a score less than 15.
Name and define the 5 terms regarding Level of Consciousness. (p. 669)
1. Alert Wakefulness - Pt appreciates the environment and responds quickly to stimuli.
2. Confusion - Pt is disoriented to time, place, or person; has shortened attention span; shows poor memory; or has difficultly following commands.
3. Drowsiness - Pt responds to stimuli appropriately but with delay and slowness; may respond to some but not all (also described as lethargy or obtunded state).
4. Stupor (semi-coma) - Pt is unresponsive and can be aroused only briefly by vigorous, repeated stimulation.
5. Coma - Pt is unresponsive and generally cannot be aroused.
Name and define the 4 terms regarding Speech Disorders. (p. 664; 207)
1. Dysphonia - difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.
2. Dysarthria - difficult or unclear articulation of speech that is otherwise linguistically normal.
3. Aphasia - Partial or total loss of the ability to express self through language or to understand the verbal communication of another person.
4. Dysphasia - language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage.
Name and define the 6 terms regarding Mood Abnormalities. (p. 218)
1. Flat Affect - No emotional tone or reaction.
2. Depression - Feeling characterized by sadness, dejection, helplessness, hopelessness, worthlessness, and gloom.
3. Elation - High degree of confidence, boastfulness, uncritical optimism, and joy accompanied by feelings of grandeur.
4. Euphoria - Excessive sense of emotional and physical well-being inappropriate to the actual situation or environmental stimuli.
5. Anxiety - A feeling of apprehension or worry, especially about the future.
6. Ambivalence - Having two opposing feelings or emotions at the same time.
Name and define the 5 terms regarding Thought Process abnormalities. (p. 219)
1. Illogical - Lacking sense or clear, sound reasoning.
2. Incoherent - Not making any sense.
3. Irrelevant - Not connected with or relevant to something.
4. Wandering - Traveling aimlessly from place to place; itinerant.
5. Inconsistent - Not staying the same throughout.
What is important information to gain during a Neurological Health History?
- Head Injury
- Dizziness/vertigo, seizures, tremors
- Weakness, coordination, numbness or tingling
- Difficulty swallowing or speaking
- Past history of stroke, spinal injury, meningitis, congenital defect, alcoholism
- Environmental hazards: insecticides, organic solvents, lead, illegal drugs
What are 7 important types of information to obtain when asking a Neurological Health History on infants and children.
1. Prenatal History
2. Birth History
3. Respiratory status at birth
4. Neonatal Health
5. Cognitive and Perectional History
6. Exposure to lead
7. Family History
What information should be obtained when asking about Prenatal History?
- The mother's health
- Medications taken
- Exposure to rubella
- History of trauma or stress
- Drug or alcohol abuse
What information should be obtained when asking about Birth History?
- Apgar scores
- Gestational age
- Birth weight
- Use of instruments
- Prolonged or precipitous labor
- Fetal distress
- Head circumfrence
What is the Apgar test, and how is it scored?
A test for babies immediately after birth and again in 5 mins, because it can change quickly.
A - Appearance (skin color)
P - Pulse (heart rate)
G - Grimace Response (reflex)
A - Activity (muscle tone)
R - Respiration (breathing rate and effort)
Each physical sigh is scored on a scale from 0-2. A perfect score is 10/10.
A score of less than 5 indicates possible neurological damage and the need for an emergency response to ensure that the newborn survives.
A 2/10 means very much distress.
What does FTT mean?
Failure to thrive
What information should be obtained when asking about Respiratory Status at Birth?
- if supplemental oxygen was needed
- if baby was resuscitated
- if ventilation was needed
- presented signs of cyanosis
- if baby has continuous apnea
What information should be obtained when asking about Neonatal health?
- poorly coordinated sucking and swallowing
What information should be obtained when asking about cognitive and perceptional infant history?
- developmental milestones
- learning roblems
What information should be obtained when asking about infant/children's family history?
- cerebral palsy
- muscular dystrophy
- cystic fibrosis
What information is important to gather when performing a neurological assessment on an Aging Adult?
- Inability to perform ADLs
- Social withdrawal
- Pattern of increased stumbling or falling, change in gait
- Memory changes, confusion
- Vision or hearing changes
- Fecal or urinary incontinence
- Transient neurologic deficits (possible TIA) *TIA is a ministroke
How do you assess the Motor System?
Inspect and Palpate Muscles
What should be documented when assessing the Motor System?
- size, strength, tone, ROM
- Strength recorded as 0-5/5 (4-5/5 is normal)
- Involuntary movements (tic, tremor)
- Muscles have bulk and tone (normal)
How do you grade muscle strength of movement on a scale from 0 to 5+.
0 : No muscle contraction
1 : Barely detectable, flicker
2 : Active movement with gravity eliminated
3 : Active movement against gravity
4 : Active movement against some resistance
5 : Active movement against full resistance
What should you assess regarding Cerebral Function?
Balance and Coordination
What are the 3 way to test balance?
1. Observe gait
2. Romberg test (pt stands with eyes closed)
3. Shallow knee bend or hop in place
What are the ways to assess coordination and skilled movements?
- Rapid Alternating Movements (RAM)
- thumb to each finger
- finger to finger
- finger to nose
- heel to shin
What is normal documentation when assessing Cerebral Function?
- Walks smoothly without swaying
- Gait is smooth with opposite swing of arms
- Romberg Test is 'maintains position without opening the eyes'
- Coordination of movements correct (good)
How do you assess the sensory system?
- compare sensations on symmetric parts of the body
- decreased sensation to sensitive areas (map borders)
- Spinothalamic tract
- Posterior column tract
What is assessed regarding the Spinothalamic Tract, and how is it documented?
1. Pain: Tongue blade broken in half.
- Pain sensation is intact bilaterally
2. Temperature: Test only if pain or touch is abnormal
3. Touch skin with warm or cool water or objects.
- Temperature sensation is intact bilaterally
4. Light Touch: Cotton swab.
- Patient correctly identifies light touch.
What is assessed regarding the Posterior Column Tract, and how is it documented?
1. Kinesthesia (Position)
2. You move their extremities and or joints and they identify the movement.
Documentation: Motion and position sense are intact.
What is Tactile Discrimination? What are the 3 main tactile discrimination tests?
3. Two-point discrimination
Stereognosis: How do you assess it? What is normal?
Tell the pt to close eyes, place random object in pt's hand and ask to identify.
Normal: Pt correctly identifies object.
Graphesthesia: How do you assess it? What is normal?
Tell pt to close eyes, trace a number 1-9 on hand and ask to identify number.
Normal: Pt correctly identifies number.
Two Point Discrimination: How do you assess it? What is normal?
Ask the pt to distinguish between 2 simultaneous pin pricks.
Normal: Pt feels one touch at 3-8 mm.
What are other ways to assess tactile discrimination?
1. Simultaneously touch both sides of the body
- normal: Sensations felt on both sides
2. Point location - touch the pt and tell them to point where you touched them.
What does Deep Tendon Reflexes indicate?
intact spinal column
How are Deep Tendon Reflexes graded?
A 4 point scale:
4+ Very brisk
3+ Brisker than average
Name the 6 spots to test for Deep Tendon Reflex. Where are these spots and what tip of the instrument do you use?
- Pointed tip
6. Plantar (Babinski)
For Infants, what are variations regarding the Motor System?
Smooth and symmetrical movements
- Denver II for gross and fine motor coordination
- Muscle Tone
* Extremities are symmetrically folded inward, hips slightly abducted, fists are tightly flexed.
* Breech babies do not have flexion in lower extremities, frog position.
* Landau reflex - raises head and arches back
For Infants, what are variations regarding the Sensory System?
Hypoesthesia (loss of sensation)
Normal - Respond by crying or withdrawal
For Infants, what are variations regarding reflexes?
- Rooting: 3-4 months
- Sucking: 10-12 months
- Palmar Grasp: 3-4 months
- Plantar grasp: 8-10 months
- Positive Babinski until age 2
- Tonic neck (fencing position) occurs form 2-6 months
- Moro reflex - startle reflex
- Placing Reflex - Hold under arms, top of foot touches underside of table, baby flexes him and knee, then extends hip to place foot on table. (4 days after birth)
- Stepping Reflex - disappears before voluntary walking
What should be assessed during a Neurological Screening for a healthy patient? (7 bullets)
- Vital signs (temp, pulse, resp, bp, pulse ox)
- Motor (strength, pronator drift, strength, balance, and coordination)
- Sensory (Gross assessment of limbs and face)
- Pupillary reaction
What are the 15 questions to ask when assessing geriatric depression?
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay home, rather than going out and doing things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?
How is geriatric depression scored?
Each answer indication depression equals 1 point.
A score higher than 5 points is suggestive of depression, and should warn a follow up comprehensive assessment.
A score higher than 10 points is almost always indicative of depression.
What are the 12 common neurological symptoms?
- Headache or other pain
- Weakness of single limb or one side of the body
- Generalized weakness
- Involuntary movements or tremors
- Difficulty with balance, coordination, or gait
- Dizziness or vertigo
- Difficulty swallowing
- Change in intellectual ability
- Difficulty with expression or comprehension of speech/language
- Alteration in touch, taste, or smell
- Loss or blurring of vision in one or both eyes, diplopia (double vision)
- Hearing loss or tinnitis
What are the 5 types of stimulation that can be used when assessing LOC? Give an example for each.
1. Spontaneous - Entering the room and observe arousal.
2. Normal Voice - State pts name and ask him or her to open eyes.
3. Loud Voice - Use loud voice if no response to normal voice.
4. Tactile (touch) - Touch pts shoulder or arm lightly.
5. Noxious (paint) - Apply nail bed pressure to illicit pain response, telling pt you will be applying pain.
Dementia is more common in ____ ____.
What are some cues that a pt may have dementia?
- Seems disoriented
- Is a poor historian
- Defers to a family member to answer questions directed to pt
- Repeatedly and apparently unintentionally fails to follow instructions
- Has difficulty finding the right words or uses inappropriate or incomprehensible words
- Has difficulty following conversation
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