MENTAL STATE Flashcards
in mental state, how do you assess for level of consciousness?
Ask them a general knowledge question (current and up to date).
Ask them today’s date.
List three (associated) objects and ask them to tell you the link.
Ask the patient to remember three random objects.
By asking these questions and talking to the patient you are able to assess their Level Of Consciousness (LOC)
what is the AVPU behaviour in adults
Alert (A): The adult is fully awake, responsive, and oriented to person, place, time, and situation. They can follow commands appropriately, maintain normal speech, and make eye contact.
Verbal (V): The adult is not fully alert but can respond to verbal stimuli. They may appear drowsy, confused, or disoriented. Their response to verbal cues may be delayed, and their speech may be slurred or inappropriate.
Pain (P): If there is no response to verbal stimuli, a painful stimulus is applied to elicit a response. This can involve applying pressure or a pinch to the nail bed or sternum. A purposeful movement, such as withdrawal or localization of the painful stimulus, or a vocalization indicates a pain response.
Unresponsive (U): If there is no response to verbal or painful stimuli, the adult is considered unresponsive. There is no purposeful movement, and they do not follow commands or vocalize.
what is AVPU behaviour in children?
Alert (A): the child is active and responds appropriately to SO and other external stimuli
Verbal (V): responds only when their name is called
Pain (P): responds only when painful stimuli are received, such as pinching the nail bed
Unresponsive (U): no response at all
There are several different movements you can make the patient do to assess CN VII.
They include:
Frown
Grin
Scrunch
Raise eyebrow(s)
Poke tongue out (CN XII)
We then ask the patient to swallow (CN X).
Next, we assess the sensation of the face, using a ________ we press in different areas of the face Using first the soft end and then the wooden end to ensure both fine and softer sensation is felt.
what areas of the face are pressed?
forehead
eye bags
checks
under the mouth (https://moodle.port.ac.uk/mod/book/view.php?id=2458800&chapterid=420232)
Eyes and vision
In this section, we are assessing several different nerves through a selection of tests.
Observations
A visual inspection checking for ______, ___________ and ___________
Visual acuity (___________)
Using the ___________check to see the patient’s vision over ____________ if using a handheld chart have the patient at _______ record the smallest line completed successfully.
Pupil function (____________)
Using the _____________ check both pupils for the following:
Pupils _____________and round AND ____________
Shine the torch into one eye then the other to check that it reacts then shine the torch into the eye and move the torch out to check that both eyes have reacted _____________
Ocular motility (___________)
Using both the ___________ test (CN IV) (move your index finger in towards the _________) to see if both eyes move inwards AND the __________ (CN VI) (keeping the patients head straight, have them to follow your finger as it moves out from the middle and draws a large H).
Visual field (CN II)
Check the patient field of vision by placing your hands behind them at the ___________level bring your hands forward whilst asking them to say stop when they can see your fingers. This is known as testing the fields by ______________.
Do the same from both below and above the temporal level.
Eyes and vision
In this section, we are assessing several different nerves through a selection of tests.
Observations
A visual inspection checking for symmetry, cellulitis and discharge
Visual acuity (CN II)
Using the Snellen chart check to see the patient’s vision over 20ft (6m) if using a handheld chart have the patient at 14ft record the smallest line completed successfully.
Pupil function (CN III)
Using the pen torch check both pupils for the following:
Pupils equal and round AND Reactive to Light
Shine the torch into one eye then the other to check that it reacts then shine the torch into the eye and move the torch out to check that both eyes have reacted the same.
Ocular motility (CN IV + VI)
Using both the convergence test (CN IV) (move your index finger in towards the patient’s nose) to see if both eyes move inwards AND the cardinal sign (CN VI) (keeping the patients head straight, have them to follow your finger as it moves out from the middle and draws a large H).
Visual field (CN II)
Check the patient field of vision by placing your hands behind them at the temporal level bring your hands forward whilst asking them to say stop when they can see your fingers. This is known as testing the fields by confrontation.
Do the same from both below and above the temporal level.
how is the Rinne test done?
what is the equipment used?
Place the vibrating 512Hz tuning fork against the patients mastoid bone (behind the ear) and ask the patient to tell you when they can no longer hear the sound then take the fork away and immediately hold in front of the ear and ask for them to tell you when they can no longer here the sound. Air conduction should be greater than bone conduction.
how is the Weber test done?
what is the equipment used?
Place the vibrating 256Hz (or 512Hz) tuning fork on the patient’s forehead equal distance from each ear the patient should hear the sound equally in both ears.
how is the Whisper test done?
Whisper a word at two distances away from one ear, whilst the other ear is blocked (by pressing on tragus).
