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