Physical Assessment: Neurological System Flashcards
Neurological System
controls or affects the function of all body systems -allows interaction with the external world Basic Functions: >cognition >emotion >memory >sensation + perception >regulation of homeostais
Mental Status Assessment
-patients appearance
-general behavior
-ability to speak clearly + response to questions
>any alterations could indicate and altered mental state
Areas Assessed with a Mental Status Assessment
- cognitive status
- orientation
- memory
- level of consciousness
- abstract thinking
- information processing
- decision making
- mood
Level of Consciousness
- arousal: response to stimuli
- orientation: time, place, person
ICU Psychosis
psychotic episodes, classically occurring in coronary care patients, occurring within 24 hours after entering the ICU inpatients with no previous history of psychosis; related to sleep deprivation, over-stimulation in ICU and time spent
Cognitive Orientation
ability to identify person, place and time accurately
-referred to as levels of awareness
Indicators of Cognitive Orientation
- identifies self + significant others
- identifies correct day, month, year
- identifies correct season
- identifies significant current event
- identifies where they are
Indicators for recalling recent memory
ex:
- what did you eat for breakfast? or
- who brought you to the hospital?
Indicators for recalling remote memory
ex: When is your birthday?
- when is your wedding anniversary?
- where were you born?
Indicators for Immediate Memory?
ex: ask to repeat a series of numbers
ex: say names of 3 unrelated objects. About 5 minutes later ask the patient to recall the words
Information Processing
ability to acquire, organize, and use information
Indicators of ability to process information
- identifies common objects
- reads + understands a short sentence or paragraph
- verbalizes a coherent message
- exhibits organized thought process
- exhibits logical thought processes
- explains similarity or dissimilarity between 2 items
- adds or subtracts several numbers
Mood
refers to a persons enduring and prevailing emotional state >Common terms to describe mood: -affect -labile -flat affect
Mood: Affect
the outward expression of a persons emotional state
Mood: Labile
rapid fluctuating or changing mood
Mood: Flat Affect
- lack of emotional response
- lack of change in facial expression
- flat voice tones
Orientation
refers to clients awareness of time, place, and person
“A, A, + O x3”
Reflexes
automatic responses
Deep Tendon Reflexes (DTRs)
automatic responses that do not require conscious thought from the brain
Deep Tendon Reflexes: Graded Scale
0= no response detected \+1= diminished response \+2= response normal \+3= response somewhat stronger than normal \+4= response hyperactive with clonus (involuntary contractions that continue after the first contraction is elicited by the hammer)
Level of Consciousness (LOC)
includes arousal and orientation >arousal may range from alert to deeply comatose -alert -lethargic -stupor -comatose AVPU A=alert V= verbal stimuli P= Painful stimuli U= unresponsive
Lethargic
- appears drowsy
- easily drifts off to sleep
Stupor
requires vigorous stimulation before responding
Comatose
does not respond to verbal or painful stimuli
Mental Status Changes to expect in Older Adults
- severe changes + sudden loss of cognitive function = physical or mental illness
- information processing speed, abstraction, and mental flexibility may decline with old age
- ability to divide, switch, or maintain sustained attention may decline with old age
- long-term memory remains stable while short-term memory exhibits more age-related changes
- accumulation of practical experience or wisdom, continues until end of life
