Sensory/Mental Status Assessment Flashcards
1
Q
frontal lobe
A
personality, behavior, emotions, and intellectual function
2
Q
precentral gyrus of the frontal lobe
A
initiates voluntary movement
3
Q
parietal lobe’s postcentral gyrus
A
primary center for sensation
4
Q
occipital lobe
A
primary visual receptor center
5
Q
temporal lobe
A
behind the ear, primary auditory reception center
6
Q
Wernicke’s area in temporal lobe
A
language comprehension (reception)
7
Q
Broca’s area in the frontal lobe
A
mediates motor speech (expression)
8
Q
Damage to specific cortical areas produces:
A
- corresponding loss of function
- impaired ability to understand/process language
- impaired ability to express
9
Q
spinal cord
A
nervous tissue that occupies upper 2/3 of vertebral canal from medulla to lumbar vertebrae L1 to L2
- main highway that connects the brain to spinal nerves
- mediates reflexes
10
Q
Left cerebral cortex receives sensory information from and controls the motor function of what side of the body?
A
right side
11
Q
Components of neurological system?
A
intellectual function (memory, knowledge, abstract thinking, association, judgment) and cranial nerve function
12
Q
motor function
A
- coordination of gross and fine motor functioning
-integrates assessment of neurological system and musculoskeletal systems - walking, other gross movements, fine motor movements
- balance
13
Q
What is a test to measure balance?
A
Romberg’s test
14
Q
reflexes
A
- basic defense mechanisms
- involuntary, quick reaction to painful or damaging situations
- helps maintain balance and muscle tone
15
Q
What are the 4 types of reflexes?
A
- deep tendon reflexes (knee jerk)
- superficial (ab/corneal reflex)
- visceral (pupillary response to light)
- pathologic (abnormal)
16
Q
deep tendon reflexes
A
- position (have patient relaxed and eyes closed)
- tap tendon briskly
- compare bilaterally
17
Q
Grading the deep tendon reflexes
A
0 = absent/no response
1 = sluggish/diminished response
2 = active/expected response
3 = slightly hyperactive/more brisk than normal; not necessarily pathologic
4 = brisk, hyperactive with intermittent clonus associated with pathology
18
Q
plantar reflex (Babinski)
A
- stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball
19
Q
negative Babinski
A
- desired
- plantar flexion/scrunching of the toes
20
Q
positive Babinski
A
- abnormal finding for anyone over the age of 2 years old
- extension/fanning of the toes
21
Q
reception
A
stimulation of a receptor such as light, touch, or sound
22
Q
perception
A
integration and interpretation of stimuli
23
Q
reaction
A
only the most important stimuli will elicit a reaction
24
Q
sensory deficits
A
deficit in the normal function of sensory reception and perception
25
sensory deprivation
inadequate quality or quantity of stimulation
26
sensory overload
- reception of multiple sensory stimuli and cannot disregard
- can cause behavioral changes: mood swings, agitation, restlessness
27
What are the factors affecting sensory function?
- age
- meaningful stimuli
- amount of stimuli
- social interaction
- environmental factors
- cultural factors
28
What are the senses?
- sight/visual
- hearing/auditory
- touch/tactile
- smell/olfactory
- taste/gustatory
- position and motion/kinesthetic
29
How to test sight?
visual acuity
30
How to test hearing?
whisper test, audiometer, higher level
31
How to test smell?
differentiate scents w/ eyes closed
32
How to test taste?
distinct flavors
33
How to test touch?
pain, temperature, light/firm/sharp/dull, vibration, position, discrimination
34
discriminatory testing
assess the ability of the cerebral cortex to interpret and integrate information
35
stereognosis
1. ask patient to close eyes, place object in hand, and ask to identify it
2. discriminate shape, size, weight, texture, and form of a familiar object by touching and manipulating it
3. altered stereognosis may indicate a parietal lobe or sensory nerve tract dysfunction
36
graphesthesia
- ability to discriminate outlines, numbers, words, or symbols traced on the skin
- if the client cannot distinguish the number or letter, it may indicate a parietal lobe lesion
37
dermatomes
- areas of skin innervated by specific dorsal root nerves
- location of spinal injury determines area of altered function
- assesses general skin sensation
38
mental status
person's emotional and cognitive functioning
39
What is the typical sequence of orientation loss?
time, then place
40
When is a comprehensive mental status exam is necessary?
- initial screening suggests an anxiety or depression
- behavior changes: memory loss, inappropriate social interaction
- brain lesions: trauma, tumor, CVA/stroke
- aphasia: impairment of language ability
- S/S of psychiatric mental illness, especially with acute onset
41
subjective mental status assessment data
medical history, medications, recent changes in senses, behaviors, cognition, OLDCART
42
objective mental status assessment data
level of consciousness, behavior/appearance, language
43
level of consciousness
assess on a continuum: fully awake to nonresponsive
44
alert
awake or readily aroused
45
lethargic (somnolent)
not fully alert, drifts off to sleep when not stimulated
46
obtunded
sleeps most of the time, difficult to arouse
47
stupor/semi-coma
sleepy, limited/minimal response
48
coma
completely unconscious, minimal/no response to stimuli
49
Glasgow Coma Scale
standard assessment for anyone with altered LOC; assess for eyes opening, verbal response, motor response
50
Screening for suicidal thoughts
- when person expresses sadness, despair, hopelessness, or grief
- assess for any risk of physical harm to self
- begin with general questions
- if you hear affirmative answers, continue with more specific probing questions
51
aphasia
impaired/absent ability to speak, interpret, or understand language
52
expressive aphasia
difficulty expressing thoughts through words, spoken or written
53
receptive aphasia
difficulty receiving/understanding language, spoken or written
54
global aphasia
inability to understand language or communicate orally
55
intellectual function assessment
- memory: recent/remote
- knowledge: level of understanding of what they "should" understand
- abstract thinking
- association
- judgment
- developmentally/age appropriate
56
Mini-Mental State Exam
- concentrates on cognitive functioning, not mood or thought processes
- standard questions, 5-10 minutes to complete
- numerical scale of 1-30 (higher score is better; 20-30 normal)
- good tool to detect dementia and delirium
57
Mini-Cog
- reliable, quick, and available instrument to screen for cog impairment in healthy adults
- three-item recall test and clock drawing test
- tests person's executive function
- those with no cognitive impairment or dementia can recall the three words and draw the clock
58
executive function
ability to plan, manage time, and organize activities as well as work from memory
59
remote memory
- lost when storage area for the memory is damaged
- ask person verifiable past events
- Alzheimer's, dementia, any disease/trauma to cerebral cortex
60
recent memory
- assess in context of interview by 24-hour diet recall or by asking time person arrived
- ask questions you can corroborate to screen for occasional person who confabulates or make sup answers to fill in gaps of memory loss
61
Developmental competence in infants/children?
- abnormalities are more often that the child does not achieve expected milestone or are significantly delayed
- follow similar guidelines, with consideration for developmental milestones (appearance, behaviors, cognition, thought processes)
62
Developmental care of aging adults
- check sensory status, vision, and hearing BEFORE any aspect of mental status
- confusion is the most common and easily misdiagnosed
- highest risk for sensory alterations
63
What is the orientation of aging adults?
- many aging adults experience social isolation, loss of structure without a job, change in residence, or some short-term memory loss
- considered oriented if they know generally where they are the present period
- consider oriented to time if year and month are correctly states
- orientation to place is accepted with correct identification of the type of setting
64
What are the three most common cognitive problems in adults?
1. delirium (acute confusion)
2. dementia
3. depression
these problems often occur together
65
Acute care of patients with altered sensation
- orientation to the environment
- communication
- controlling sensory stimuli
- safety measures
66
Restorative and continuing care of patients with altered sensation
- orientation to the environment
- communication
- controlling sensory stimuli
- safety measures
- maintaining health lifestyles
- understanding sensory loss
- socialization
- promoting self-care
