Exam 2: Sensory and mental status assessment Flashcards
Frontal lobe
Personality, behavior, emotions, and intellectual function
Precentral gyrus of front lobe initiates
voluntary movement
parietal lobe’s post central gyrus is
primary center for sensation
Occipital lobe is the primary
visual receptor center
Temporal lobe behind the ear has th
primary auditory reception center
Wernicke’s area
Language comprehension (reception)
Broca’s area
motor speech (expression)
Wernicke’s are is located where?
temporal lobe
Broca’s are is located in the
frontal lobe
damage to specific cortical ares (wernicke/Broca)
- Impaired ability to understand/process language
- impaired ability to express
Spinal cord nervous tissue that occupies upper 2/3 of vertebral canal from
medulla to lumbar vertebrae L1 to L2
Left cerebral cortex receive sensory information from and control function to
Right side of the body
Spinal cord is the main highway that connects
brain to spinal nerves; mediates reflexes
Pathways of the CNS
Crossed representation
Organs in body that often have referred pain
Heart, liver, spleen
Sensation travels
In afferent fiber in peripheral nerve, through posterior (dorsal) root, and into the spinal cord
Neurological system intellectual function
memory knowledge abstract thinking association judgment
Neurological system 3 functions
Intellectual function
cranial nerve function
motor function
Neurological system motor function
Coordination of gross and fine motor function
integrates assessment of neurological system and musculoskeletal systems
walking, other gross, fine, movements
Balance
How to assess balance?
Romberg’s test
Reflexes are basic
defense mechanisms
How are reflexes involuntary?
quick reaction to painful or damaging situations
Reflexes help maintain
balance and muscle tone
4 types of reflexes
Deep tendon reflexes
superficial
visceral
pathologic
Example of deep tendon reflexes
Patellar or knee jerk
examples of superficial reflex
Corneal reflex, abdominal reflex
Example of visceral reflex
Pupillary response to light
example of Pathologic reflexes
babinski’s or extensor plantar reflex
5 deep tendon reflexes
Triceps Biceps Brachioradial patellar achilles
Reflex is graded from 0-5
0 - absent
1 - sluggish/diminished
2- active/expected
3 - slightly hyperactive/ more brisk than normal
4 - brisk, hyperactive with intermittent clonus associated with pathology
to elicit plantar reflex (babinski test)
stroke the lateral aspect of the sole form the heal to ball of foot, medially crossing the ball
– Upside down “J”
Negative babinski test =
it’s desired! plantar flexing/scunching is normal
Positive babinski indicates
this would be fanning of the toes
abnormal findings for anyone over age of 2
infant babinski
fanning of toes is normal for newborns - 2 years due to nervous system still developing
Reception
stimulation of receptor such as light, touch, or sound
Perception
integration and interpretation of stimuli
reaction
only the most important stimuli will elicit a reaction
sensory deficits
deficit in the normal function of sensory reception and perception
sensory deprivation
inadequate quality or quantity of stimulation
sensory overload
reception of multiple sensory stimuli and cannot disregard
sensory overload can cause
behavioral change; mood swings, agitation, restlessness
factors affecting sensory function
age meaningful stimuli amount of stimuli social interaction environmental factors cultural factor
assessment of sensation is through
the patients senses
During an assessment of sensation: mental status helps
paint the whole picture
physical assessment for assessment of sensation
neuro/HEENT, others PRN
environmental hazards for sensation
impaired senses increases risk
senses
Sight --- visual hearing ---- auditory touch --- tactile smell --- olfactory taste --- gustatory position and motion --- kinesthetic
sight assessment
visual acuity
hearing assessment
whisper test, audiometer, higher level
Smell assessment
differentiate scents w/ eyes closed
taste assessment
distinct flavors
touch assessment
pain temperatur light/firm/sharp/dull vibration position discrimination
discriminatory testing assess the
Ability of the cerebral cortex to interpret and integrate information
stereognosis
- ask patient to close eyes, place object in hand & ask to identify
- discriminate shape, size, weight, texture, & form of a familiar object by touching & manipulating it
- altered stereognosis may indicate a parietal lobe or sensory nerve tract dysfunction
Graphesthesia
- ability to discriminate outlines, numbers, words, or symbols traced on the skin
- if client cannot distinguish the number or letter, it may indicate parietal lobe lesion
dermatomes
areas of skin innervated by specific dorsal root nerves
location of spinal injury determines
area of altered function
dermatomes also used to assess
general skin sensation
Assessment NANDA for sensory
risk for injury risk for fall impaired socialization impaired verbal communication impaired mobility
mental statue is a
person’s emotional and cognitive functioning
mental and emotional status can be obtained through
interactions and questions
Formal mental and emotional assessment can help
pinpoint the problem and determine treatment plans
Orientation: Basic and quick assessment of cognitive status
Person
Place
Time
Situation
if alert and oriented to person , place, and time is documented is
AOX3
Typical sequence of orientation loss is FIRST
time
- then place
- and only rarely — to person
When a comprehensive mental status examination is necessary
- initial screening suggests anxiety or depression
- behavior changes: memory loss, inappropriate social interactions
- brain lesions: trauma, tumor, CVA/stroke
- Aphasia: Impairment of language ability
- S/S of psychiatric mental illness, especially with acute onset
Subjective data for mental status assessment
Medical history
medications
recent changes in: Senses, behaviors, cognition
OLDCART
Objective mental status assessment data
Level of consciousness
Behavior and appearance
language
Levels of consciousness
Alert Lethargic Obtunded Stupor/semi- coma Coma
Alert
Awake or readily aroused
Lethargic
not fully alert, drifts off to sleep when not stimulated
Obtunded
sleeps most of the time, difficult to arouse
Stupor/semi-coma
sleepy, limited/minimal response
coma
completely unconscious, minimal/no response to stimuli
What is standard assessment for anyone with altered level of consciousness? (LOC)
Glasgow coma scale
Glasgow coma scale assesses for
eye opening
verbal response
motor response
Behaviors and appearance
Signs of distress Grooming and hygiene Affect/Mood Eye contact Signs of patient abuse Signs of substance abuse Speech posture body movement dress
Aphasia
Impaired/absent ability to speak, interpret, or understand language
expressive aphasia
difficulty expressing thoughts through words, spoken or written
Receptive aphasia
difficulty receiving/understanding language spoken or written
global aphasia
inability to understand language or communicate orally
high score of Glasgow coma scale
Good! the best
Low score of Glasgow coma scale
not very good
Intellectual function assessment
Memory: recent and remote
Knowledge: Level of understanding of what they should understand
Abstract thinking
Association: a dogs is to a poodle as a cat is to a siamese
Judgement: Able to make appropriate conclusions
—-Developmentally/age appropriate
Mini mental state exam concentrates on
cognitive functioning not mood or thought processes
mini mental state exam is a good screening tool to detect
dementia and delirium and to differentiate these from psychiatric mental illness
Mini mental state exam is a numerical scale of 1-30, higher is
Better! (20-30 is normal)
Mini cog
Reliable, quick and available instrument to screen for cog impairment in healthy adults
Mini cog test consists of
three item recall test and clock-drawing test
Mini cog tests persons executive function like
ability to plan, manage time, and organize activities as well as working memory
during mini cog, those with no cognitive impairment or dementia
can recall three words
draw a complete, round, closed circle w/ clock face number in correct sequence
In the contaxt of the interview for remote memory, ask
the person verifiable past events
remote memory is lost when
storage area for memory is damaged
ex) dementia or Alzheimer
recent memory assess in context of
interview by 24-hour diet recall or by asking time person arrived at agency
recent memory testing ask questions you can
corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss
developmental competence for infants and children
follow similar guidelines with consideration for developmental milestones
- appearance
- behaviors
- cognition
- thought processes
abnormalities for infant/children developmental competence
is often that they do not achieve expected milestone or are significantly delayed
for developmental care of aging adults check
sensory status, vision, and hearing BEFORE any aspect of mental status
age group that has the highest risk for sensory alterations
Aging adults
many aging persons experience
social isolation, loss of structure without job, change in residence, or some short-term memory loss
Aging persons may be considered oriented if they
know generally where they are and the present period
Aging adults correct orientation can be
correct year and month
correct identification of the type of setting
three most common cognitive problems in adults
- Delirium
- Dementia
- Depression
acute care for patients with altered sensation
Orientation to the environment
communication
controlling sensory stimuli
safety measures
Restorative and continuing care for patients with altered sensation
same as acute care AND
- maintaining healthy lifestyles
- understanding sensory loss
- -socialization
- -promoting self care
Mini cog assess the
executive function
Only the ____ knows if sensory abilities are improved
patient !!!
Which of the 2 D’s can be reversible
Delirium and Depression
Patients with Glasgow Coma Scale score of 7 or less are
considered in comatose
Patients with glasgow Coma Scale score of 8 or less are
considered to suffer form severe head injury
Behaviors and appearance assessment
Signs of distress grooming and hygiene affect/mood eye contact signs of patient abuse signs of substance abuse Speech posture body movements dress
Mini mental state exam consists of
standard questions 5-10 minutes
Mini mental state exam is useful for both
Baseline and serial measurement
What is a common and easily misdiagnosed condition for elderly individuals
Confusion
