Exam 2: Sensory and mental status assessment Flashcards
(114 cards)
1
Q
Frontal lobe
A
Personality, behavior, emotions, and intellectual function
2
Q
Precentral gyrus of front lobe initiates
A
voluntary movement
3
Q
parietal lobe’s post central gyrus is
A
primary center for sensation
4
Q
Occipital lobe is the primary
A
visual receptor center
5
Q
Temporal lobe behind the ear has th
A
primary auditory reception center
6
Q
Wernicke’s area
A
Language comprehension (reception)
7
Q
Broca’s area
A
motor speech (expression)
8
Q
Wernicke’s are is located where?
A
temporal lobe
9
Q
Broca’s are is located in the
A
frontal lobe
10
Q
damage to specific cortical ares (wernicke/Broca)
A
- Impaired ability to understand/process language
- impaired ability to express
11
Q
Spinal cord nervous tissue that occupies upper 2/3 of vertebral canal from
A
medulla to lumbar vertebrae L1 to L2
12
Q
Left cerebral cortex receive sensory information from and control function to
A
Right side of the body
13
Q
Spinal cord is the main highway that connects
A
brain to spinal nerves; mediates reflexes
14
Q
Pathways of the CNS
A
Crossed representation
15
Q
Organs in body that often have referred pain
A
Heart, liver, spleen
16
Q
Sensation travels
A
In afferent fiber in peripheral nerve, through posterior (dorsal) root, and into the spinal cord
17
Q
Neurological system intellectual function
A
memory knowledge abstract thinking association judgment
18
Q
Neurological system 3 functions
A
Intellectual function
cranial nerve function
motor function
19
Q
Neurological system motor function
A
Coordination of gross and fine motor function
integrates assessment of neurological system and musculoskeletal systems
walking, other gross, fine, movements
Balance
20
Q
How to assess balance?
A
Romberg’s test
21
Q
Reflexes are basic
A
defense mechanisms
22
Q
How are reflexes involuntary?
A
quick reaction to painful or damaging situations
23
Q
Reflexes help maintain
A
balance and muscle tone
24
Q
4 types of reflexes
A
Deep tendon reflexes
superficial
visceral
pathologic
25
Example of deep tendon reflexes
Patellar or knee jerk
26
examples of superficial reflex
Corneal reflex, abdominal reflex
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Example of visceral reflex
Pupillary response to light
28
example of Pathologic reflexes
babinski's or extensor plantar reflex
29
5 deep tendon reflexes
```
Triceps
Biceps
Brachioradial
patellar
achilles
```
30
Reflex is graded from 0-5
0 - absent
1 - sluggish/diminished
2- active/expected
3 - slightly hyperactive/ more brisk than normal
4 - brisk, hyperactive with intermittent clonus associated with pathology
31
to elicit plantar reflex (babinski test)
stroke the lateral aspect of the sole form the heal to ball of foot, medially crossing the ball
-- Upside down "J"
32
Negative babinski test =
it's desired! plantar flexing/scunching is normal
33
Positive babinski indicates
this would be fanning of the toes
| abnormal findings for anyone over age of 2
34
infant babinski
fanning of toes is normal for newborns - 2 years due to nervous system still developing
35
Reception
stimulation of receptor such as light, touch, or sound
36
Perception
integration and interpretation of stimuli
37
reaction
only the most important stimuli will elicit a reaction
38
sensory deficits
deficit in the normal function of sensory reception and perception
39
sensory deprivation
inadequate quality or quantity of stimulation
40
sensory overload
reception of multiple sensory stimuli and cannot disregard
41
sensory overload can cause
behavioral change; mood swings, agitation, restlessness
42
factors affecting sensory function
```
age
meaningful stimuli
amount of stimuli
social interaction
environmental factors
cultural factor
```
43
assessment of sensation is through
the patients senses
44
During an assessment of sensation: mental status helps
paint the whole picture
45
physical assessment for assessment of sensation
neuro/HEENT, others PRN
46
environmental hazards for sensation
impaired senses increases risk
47
senses
```
Sight --- visual
hearing ---- auditory
touch --- tactile
smell --- olfactory
taste --- gustatory
position and motion --- kinesthetic
```
48
sight assessment
visual acuity
49
hearing assessment
whisper test, audiometer, higher level
50
Smell assessment
differentiate scents w/ eyes closed
51
taste assessment
distinct flavors
52
touch assessment
```
pain
temperatur
light/firm/sharp/dull
vibration
position
discrimination
```
53
discriminatory testing assess the
Ability of the cerebral cortex to interpret and integrate information
54
stereognosis
- ask patient to close eyes, place object in hand & ask to identify
- discriminate shape, size, weight, texture, & form of a familiar object by touching & manipulating it
- altered stereognosis may indicate a parietal lobe or sensory nerve tract dysfunction
55
Graphesthesia
- ability to discriminate outlines, numbers, words, or symbols traced on the skin
- if client cannot distinguish the number or letter, it may indicate parietal lobe lesion
56
dermatomes
areas of skin innervated by specific dorsal root nerves
57
location of spinal injury determines
area of altered function
58
dermatomes also used to assess
general skin sensation
59
Assessment NANDA for sensory
```
risk for injury
risk for fall
impaired socialization
impaired verbal communication
impaired mobility
```
60
mental statue is a
person's emotional and cognitive functioning
61
mental and emotional status can be obtained through
interactions and questions
62
Formal mental and emotional assessment can help
pinpoint the problem and determine treatment plans
63
Orientation: Basic and quick assessment of cognitive status
Person
Place
Time
Situation
64
if alert and oriented to person , place, and time is documented is
AOX3
65
Typical sequence of orientation loss is FIRST
time
- then place
- and only rarely --- to person
66
When a comprehensive mental status examination is necessary
- initial screening suggests anxiety or depression
- behavior changes: memory loss, inappropriate social interactions
- brain lesions: trauma, tumor, CVA/stroke
- Aphasia: Impairment of language ability
- S/S of psychiatric mental illness, especially with acute onset
67
Subjective data for mental status assessment
Medical history
medications
recent changes in: Senses, behaviors, cognition
OLDCART
68
Objective mental status assessment data
Level of consciousness
Behavior and appearance
language
69
Levels of consciousness
```
Alert
Lethargic
Obtunded
Stupor/semi- coma
Coma
```
70
Alert
Awake or readily aroused
71
Lethargic
not fully alert, drifts off to sleep when not stimulated
72
Obtunded
sleeps most of the time, difficult to arouse
73
Stupor/semi-coma
sleepy, limited/minimal response
74
coma
completely unconscious, minimal/no response to stimuli
75
What is standard assessment for anyone with altered level of consciousness? (LOC)
Glasgow coma scale
76
Glasgow coma scale assesses for
eye opening
verbal response
motor response
77
Behaviors and appearance
```
Signs of distress
Grooming and hygiene
Affect/Mood
Eye contact
Signs of patient abuse
Signs of substance abuse
Speech
posture
body movement
dress
```
78
Aphasia
Impaired/absent ability to speak, interpret, or understand language
79
expressive aphasia
difficulty expressing thoughts through words, spoken or written
80
Receptive aphasia
difficulty receiving/understanding language spoken or written
81
global aphasia
inability to understand language or communicate orally
82
high score of Glasgow coma scale
Good! the best
83
Low score of Glasgow coma scale
not very good
84
Intellectual function assessment
Memory: recent and remote
Knowledge: Level of understanding of what they should understand
Abstract thinking
Association: a dogs is to a poodle as a cat is to a siamese
Judgement: Able to make appropriate conclusions
----Developmentally/age appropriate
85
Mini mental state exam concentrates on
cognitive functioning not mood or thought processes
86
mini mental state exam is a good screening tool to detect
dementia and delirium and to differentiate these from psychiatric mental illness
87
Mini mental state exam is a numerical scale of 1-30, higher is
Better! (20-30 is normal)
88
Mini cog
Reliable, quick and available instrument to screen for cog impairment in healthy adults
89
Mini cog test consists of
three item recall test and clock-drawing test
90
Mini cog tests persons executive function like
ability to plan, manage time, and organize activities as well as working memory
91
during mini cog, those with no cognitive impairment or dementia
can recall three words
| draw a complete, round, closed circle w/ clock face number in correct sequence
92
In the contaxt of the interview for remote memory, ask
the person verifiable past events
93
remote memory is lost when
storage area for memory is damaged
ex) dementia or Alzheimer
94
recent memory assess in context of
interview by 24-hour diet recall or by asking time person arrived at agency
95
recent memory testing ask questions you can
corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss
96
developmental competence for infants and children
follow similar guidelines with consideration for developmental milestones
- - appearance
- - behaviors
- - cognition
- - thought processes
97
abnormalities for infant/children developmental competence
is often that they do not achieve expected milestone or are significantly delayed
98
for developmental care of aging adults check
sensory status, vision, and hearing BEFORE any aspect of mental status
99
age group that has the highest risk for sensory alterations
Aging adults
100
many aging persons experience
social isolation, loss of structure without job, change in residence, or some short-term memory loss
101
Aging persons may be considered oriented if they
know generally where they are and the present period
102
Aging adults correct orientation can be
correct year and month
| correct identification of the type of setting
103
three most common cognitive problems in adults
- Delirium
- Dementia
- Depression
104
acute care for patients with altered sensation
Orientation to the environment
communication
controlling sensory stimuli
safety measures
105
Restorative and continuing care for patients with altered sensation
same as acute care AND
- - maintaining healthy lifestyles
- - understanding sensory loss
- -socialization
- -promoting self care
106
Mini cog assess the
executive function
107
Only the ____ knows if sensory abilities are improved
patient !!!
108
Which of the 2 D's can be reversible
Delirium and Depression
109
Patients with Glasgow Coma Scale score of 7 or less are
considered in comatose
110
Patients with glasgow Coma Scale score of 8 or less are
considered to suffer form severe head injury
111
Behaviors and appearance assessment
```
Signs of distress
grooming and hygiene
affect/mood
eye contact
signs of patient abuse
signs of substance abuse
Speech
posture
body movements
dress
```
112
Mini mental state exam consists of
standard questions 5-10 minutes
113
Mini mental state exam is useful for both
Baseline and serial measurement
114
What is a common and easily misdiagnosed condition for elderly individuals
Confusion
