Mental Status Assessment
Cognition and Perception
Dr. Karen Hill
Definition of Mental Health U.S. Surgeon General “a state of successful performance of mental
function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity” (U.S. Department of Health and Human Services [USDHHS], 1999)
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 a contribution to his or her community…mental health is the foundation for wellbeing and effective functioning for an individual and for a community…” (WHO, 2007)
Common Disorders Depression
Postpartum Depression Schizophrenia Substance abuse Dementia, Alzheimer’s
Nurses Role Mental health assessment is within the context of the
patient’s own culture Based on Observation of the patient The patient’s responses to the nurse’s questions Integral to any full medical or nursing examination Must be inferred from answers to questions and
behaviors because it cannot be observed directly
Focused History on… Common symptoms of altered mental health Suicide ideation Homicide ideation and aggressive behavior Altered mood and affect Auditory hallucinations Visual hallucinations
Objective Data Assessment A (appearance) B (behavior) C (cognitive function) and T (thought process)
plus the mini-mental status examination
Introduction Intact, appropriately functioning nervous
system Is critical for all human endeavors Exerts unconscious control over basic body
functions, such as respiration, temperature regulation, and movement coordination
Enables very complex interactions with people and the environment
Assessment serves multiple purposes
Goals Detection of change in neurological status, particularly
acute and life-threatening alterations Localize pathology
Make a medical diagnosis Nurses perform neurological assessment to identify Actual or potential health problems related to
neurological dysfunction The patient’s response to those problems
Physical Appearance & Behavior Posture & Body movements
Voluntary, deliberate, coordinated, smooth, even
Purposeful or non-purposeful Certain conditions are characterized by
their change in body movements or posture Parkinson’s Disease
Dress, grooming and hygiene
Clean, matching, hair neat, nails clean Watch being judgemental
Age changes if cold or hot Teens don’t care how they look Homeless are not all dirty
Certain conditions can be identified by a change in this Depression
LOC= Awake, alert, response appropriately Box 22.2 Glasgow Coma Scale, page 660 ANY change in Level of Consciousness is caused by
something Drugs Anesthesia Lack of sleep Alcohol Disease
You DO NOT change your Level of Consciousness for a reason
If ALONE, without cause, is reason for Concern
Facial expression Symmetrical or non-symmetrical (stroke) Smile or frowning Appropriate for what was said or done
Speech Normal tone with moderate pace, normal
fluctuations, makes eye contact Moderate loudness, English fluent, Clear and
distinct Consider that their may be speech impediments Very loud (hard of hearing) Very soft (shy or doesn’t like to communicate)
Cognitive Abilities and Mentation Orientation – AAOX3
Oriented to self Oriented to place Oriented to time Consider situations that may alter this AAOX4 – add current situation or
surroundings You MUST ASK – don’t assume
Attention span – can follow conversation and events Short, brief Long for age 5 min., 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
Recent memory/Remote memory Can they remember short-term (what ate last
nite, current President) Can they remember long-term (year born,
where they grew up) Min-Mental stagus/Mini-Cog, page 669 Conditions like head injury, stroke, dementia and
Alzheimer’s can alter their memory May remember their past but not what they did 5 min.
ago Head Injury may remember the accident but not their
ABC’s from childhood
New learning 4 unrelated words test (Fun, carrot, ankle, loyalty) Recall at 5, 10, 30 minute intervals
Mood and affect- is congruent with subject Happy, Sad, Mad Blank, Flat – these can be caused by diseases
Cognitive Abilities & Mentation Spatial Perception
Can copy simple drawings of objects Higher intellectual functions
Proverb interpretation Don’t bite the hand that feeds the face You can’t teach an old dog new tricks No news is ________________ What does it mean to call the kettle black?
Abstract reasoning Calculation
Judgment Note their response to family situations,
interpersonal conflict, making decisions Ask direct questions Assess long-term goals
Normal is making good judgments and takes responsibility for own actions
Unrealistic or impulse decisions
Thought Processes and Perceptions Thought processes
Easy to follow, logical, coherent, relevant, goal directed, consistent and abstract
Logical, illogical, unrealistic Thought content
Consistent and logical Perceptions
Aware of reality, illusions, hallucinations
Suicidal Ideations SAD PERSONAS – suicide risk assessment See Box 9.4, page 191
Lethal Suicide – if they have tried it before
Nurse assesses for safety of patient and others Must report findings
Variations related to age: Infants Neuro exam should be done when the
infant is in a quiet alert state Observe spontaneous activity for symmetry
and smoothness of movement Sensory integrity
w/d all limbs to painful stimuli Deep tendon reflexes
+Babinski sign – normal until 16-24 mos. – see page 682
Evaluate muscle strength and tone
Variations related to age: Children Denver II
Developmental test, measures fine & gross motor, language and personal-social skills
Observe play for gait and fine motor coordination Deep tendon reflexes Behavioral checklist
Mood, play, school, friends & family relations Cognitive Psychological development Coping with environment Neurological soft signs
Denver Developmental Test
Look up Denver Dev. Screening http://www.google.com/images?
q=denver+developmental+screening+test+ii&oe=utf-8&rls=org.mozilla:en-US:official&client=firefox-a&um=1&ie=UTF-8&source=univ&sa=X&ei=Etl-TcTqH5SJ0QHv-6CHCQ&ved=0CDIQsAQ&biw=1024&bih=532
Neurological Soft Signs Controversial b/c do not always indicate pathology. They are nonfocal, functional neurological findings that often provide
subtle clues to an underlying CNS deficit or a neurological maturation delay. Children with multiple soft signs often have learning disabilities
Soft signs include but are not limited to: Short attention span Poor coordination of position Hypopactivity/Hyperactivity Impulsiveness Labile emotions Distractibility No demonstration of handedness Language and articulation problems
Variations related to age: Pregnancy Exam same as adult Deep tendon reflexes
Baseline evaluation should be done at initial prenatal visit
Preclampsia – exaggerated deep tendon reflexes
Variations related to age: Elderly Always assess sensory function first Allow more time for maneuvers of coordination
and movement Diminished sense of smell and taste Gait
Shuffle (flexion hip/knees) Tactile, vibratory and position sensation may be
diminished Deep tendon reflexes
Less brisk or absent Behavior
LOC: Glasgow Coma Scale- Box 22.2
Variations: Elderly Tinette Balance & Gait Assessment Tool
Used for older adults thought to be at risk for falls Cognitive Function
Orientation New learning: avg 2 of 4 words after 5 minutes. Will
improve with verbal cues. Set test:
verbal test to screen for dementia, name 10 items in four categories-fruits, animals, colors, towns
Max score = 40, dementia <15
Definitions – if not in book, use dictionary LOC - 5 terms, pg. 669, Table 22.3
Alert wakefulness, Confusion, Drowsiness, Stupor (Semi-coma), Coma
Speech disorders – Dysphonia, Dysarthria (pg. 670), Aphasia (pg 207),
dysphasia
Mood abnormalities – (pg. 206) Flat affect, depression, elation, euphoria, anxiety,
ambivalence
Thought process abnormalities– Illogical, Incoherent, Irrelevant, Wandering, Inconsistent
Health History - Neurologic Headaches Head injury Dizziness/vertigo, seizures, tremors Weakness, coordination, numbness or
tingling Difficulty swallowing, speaking Past history of stroke , spinal injury,
meningitis, congenitial defect, alcoholism Environmental hazards: insecticides,
organic solvents, lead, illegal drugs.
History Variations – Infants & Children Prenatal history – mother’s health,
medications taken, infections, exposure to rubella, CMV, toxemia, bleeding, history of trauma or stress, HTN, drug or alcohol use
Birth history – Apgar scores, gestational age, birth weight, presentation, use of instruments, prolonged or precipitous labor, fetal distress, head circumference
Respiratory status at birth – supplemental oxygen, resuscitation, ventilation, cyanosis, continuous apnea
Perfect score is 10/10Check it immediately after born and again in 5 minutes
Can change quickly
These five physical signs are graded as 0, 1 or 2 and a total score of less than 5 is an indication of possible neurological damage and the need for an emergency response to ensure that the newborn survives.
2/10 – very much in distress
Neonatal health – infections, seizures, irritability, sucking & swallowing (poorly coordinated?)
Balance, seizures, developmental milestones, learning problems
Exposure to lead Family history: Seizures, Cerebral Palsy,
Muscular Dystrophy, Cystic Fibrosis
History Variations: Aging Adult Inability to perform ADL’s Social withdrawal Pattern of increased stumbling or falling, change
in gait Dizziness Memory changes, confusion Tremors Vision or hearing changes LOC Fecal or urinary incontinence Transient neurologic deficits (possibly TIA’s)
The Cranial Nerves (page 672-673) I - Olfactory
Smell II – Optic
Visual acuity, visual fields Examine ocular fundus for color, size, and shape of optic
disc III - Oculomotor
Pupillary reaction Eyelid elevation Most EOM – 6 cardinal gazes
Cranial Nerves IV – Trochlear
Downward and inward eye movement V – Trigeminal
Jaw movement Sensation to eyes, corneal reflex Sensation of touch, pain, and temperature to face
VI – Abducens Lateral eye movement
Cranial Nerves VII – Facial
Facial movement Taste – anterior 2/3 of tongue
VIII – Acoustic Hearing and equilibrium
IX – Glossopharyngeal Voluntary muscles for swallowing and phonation Sensation of nasopharynx, gag reflex Taste posterior 1/3 of tongue Secretion of salivary glands Carotid reflex
Cranial Nerves X – Vagus
Voluntary muscles of phonation and swallowing Sensation behind ear and part of ear canal Secretion of digestive enzymes, peristalsis, and carotid reflex Involuntary action of heart, lungs and digestive tract
XI – Spinal Accessory Sternomastoid and trapezius muscles, size and strength Turn head, shrug shoulders
XII – Hypoglossal Tongue movement, lingual sounds Have pt. say “light, tight, dynamite”
Cranial Nerves O – On O – Old O – Olympus T – Towering T – Tops A – A F – Fin A – And G – German V – Von S – Sum H - Hocks
What is normal and most common PERRLA (see Table 24.9 for abnormal) EOMs intact Positive gag and corneal reflex Facial strength +4/4 with intact sensation
bilaterally
Motor System Inspect and palpate muscles
Size, strength, tone, ROM Strength recorded as 0-5/5 with4-5/5 normal – page
674 Involuntary movements (tic, tremor)
Muscles have bulk and tone
Cerebral Function Balance tests (will not do)
Observe gait Romberg test (stand with eyes closed) – page
675 Shallow knee bend or hop in place
Coordination and skilled movements Rapid alternating movements (RAM) Thumb to each finger Finger to finger Finger to nose Heel to shin
What is normal 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)
Sensory system Compare sensations on symmetric parts of the
body Decreased sensation to sensitive areas (map
borders)
Spinothalamic tract (eyes closed) Pain- tongue blade broken in half
Pain Sensation is intact bilaterally Temperature- Test only if pain or touch is
abnormal Touch skin with warm or cool water or objects
Temperature sensation is intactbilaterally Light touch – cotton swab
Patient correctly identifies light touch
Sensory system Posterior column tract
Position (kinesthesia) – You move extremities or toe of joint and they
identifies these movements Motion and position sense are intact
Tactile Discrimination (fine touch) Stereognosis- eyes closed identify objects
held Graphesthesia- identify traced number in
palm Two-point discrimination-ability to
distinguish two simultaneous pin pricks (will not do) More sensitive on fingertips, less on
upper arms, thighs, and back More discrimination distally than
centrally
Extinction- Simultaneously touch both sides of the body Point location-point where touched
Sensations are felt on both sides
See Terms for LOC applying stimulation Page 68, Table 22.2
Deep Tendon Reflexes Intact spinal column 4-point scale: Page 680 4+ - Very brisk
3+ - Brisker than average 2+ - Normal 1+ - Diminished 0 - Absent
Reflexes Biceps Triceps Brachioradialis Quadriceps Archilles Plantar (Babinski’s) Present, absent or equivocal (difficult to
determine) Positive babinski’s = fanning of toes
Variations: Infants (Birth to 12 mths)
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
Variations - Infants Sensory system
Hypoesthesia, respond by crying or withdrawal
Reflexes Page 700, Table 22.13 Rooting - 3-4 months Sucking - 10-12 mths Palmar grasp - 3-4 mths
Plantar grasp - 8-10 mths Babinski’s (positive Babinski’s until age 2) Tonic neck (fencing position) occurs from 2-6 mths Moro reflex - startle reflex Placing reflex - hold under arms, top of foot touches
underside of table, baby flexes hip and knee, then extends hip, to place foot on table - 4 days p birth
Stepping reflex - disappears before voluntary walking
Page references Neurological Screening in Healthy Pt. (See
Box 22.4) Geriatric Depression Scale (see Box 9.4) Common Neurological Symptoms – page 63
Assessment of Dementia, Confusion, Delirium, and Depression Dementia is more common in older adults Delirium generally has an underlying medical
cause Some cues that the patient may have dementia
include the following Seems disoriented Is a “poor historian”
Defers to a family member to answer questions directed to the patient
Repeatedly and apparently unintentionally fails to follow instructions
Has difficulty finding the right words or uses inappropriate or incomprehensible words
Has difficulty following conversations
Top Related