neuro, muscle, mental

mental status

-a pt’s current level of cognitive and emotional function

-thinking

-awareness

-behavior

-perception

mental disorder

-significant behavioral or psychological pattern associated with:

• -distress (a painful symptom)

• -disability (impaired functioning)

• -significant risk( risk of pain, disability, or death, or loss of a freedom)

organic disorders

-due to brain disease of known specific organic cause

-ex:

• -delirium

• -dementia

  • -alcohol & drug intoxication & withdrawal

delirium

-sudden onset (hrs to days)

-fluctuates throughout the day

-impaired attention, fluctuates

-impaired memory, poor recall

-caused by infection, meds, substances, hypoxia, metabolic

-reversible if cause is treated

dementia

-gradual (months to years)

-chronic, slowly progressing

-attention usually intact until late

-progressive short & long-term memory loss

-caused by neurodegenerative disease

-usually irreversible, progressive

depression

-variable, often weeks

-persistent; often worse in AM

-intact attention but poor concentration

-selective “I dont know” answers (memory)

-caused by grief, chronic illness, stress

-reversible w/ treatment

considerations in neuro

-labs

-chest imaging/EKG

-drug/alcohol screening

alcohol (ETOH)

-directly affects the brain. behavior, cognition, and pt safety

-alcohol related symptoms can mimic many neurological or psychiatric conditions

alcohol intoxication

-stroke

-head injury

-hypoglycemia

-dementia or delirium

-psychosis

alcohol withdrawal

-anxiety

-tremors

-hallucinations

-seizures

-delirium tremens (DT)

ETOH screening tools

-cage

-audit (alcohol use disorder identification test)

cage questionnaire

-have you ever felt the need to Cut down on drinking?

-have people Annoyed you by criticizing your drinking

-have you ever felt Guilty about your drinking?

-have you ever had a drink first thing in the morning to steady nerves or get rid of a hangover?

SBIRT

-identifies:

• -risky alcohol use

• -substance misuse

• -early addiction patterns

• -need for counseling

  • -readiness to change behavior

substance-related clues may include

-odor of alcohol or marijuana

-pinpoint or dilated pupils

-tremors

-slowed responses

-agitation

-inconsistent history

-mood lability

-impaired attention

-altered gait

-hallucinations

drugs that cause constricted pupils

-heroin

-morphine

-oxycodone

-fentanyl

-methadone

-codeine

-hydrocodone

drugs that cause red eyes

-marijuana

-cocaine or crack

-benzodiazepines

-depressants

drugs that cause dilated pupils

-amphetamines

-methamphetamines

-cocaine or crack

-hallucinogens

-opiates

-heroin

-marijuana

-speed

SBIRT meaning

-screening (do you smoke cigarettes or use other tobacco products?)

-brief

-intervention

-referral to

-treatment

subjective data

-suicidal ideations

-homicidal ideations

-memory changes

• -recent (few mins to days)

• -remote (months to years)

-insight- pts understanding

-judgement: pts explanation of decision making in hypotheical or real scenarios

-sleep disturbances

mental status

-cannot be scrutinized directly like the characteristics of skin or heart sounds

-functioning is inferred through

• -pts words

• -behaviors

• -self report

ASEPTIC assessment

-appearance & behavior

-speech

-emotion

-perception

-thought

-insignt

-cognition

mental status exam

-evaluates a pt’s psychological, emotional, behavioral, and cognitive functioning

appearance and behavior

-what the pt looks like physically

• -hygiene/grooming

• -clothing appropriateness

• -facial expression

• -posture

• -motor activity

• -apparent age

• -signs of distress

speech

-how the pt communicates verbally

• -rate

• -volume

• -clarity

• -fluency

• -tone

• -coherence

mood

-the pts subjective emotional state— how the pt says they feel internally

-usually described in the pts own words

affect

-the outward emotional expression observed by the nurse

-assessed by observing facial expressions, body language, tone of voice, and emotional responsiveness during the interaction

perception

-how the pt experiences reality

-hallucinations

-illusions

-depersonalization

-derealization

thought process

-how thoughts are organized

-logical

-organized

-tangential

-racing

-flight of ideas

thought content

-what the pt is thinking abt

-delusions

-obsessions

-suicidal ideation

-homicidal ideation

-paranoia

SAD PERSONS

-point for each

Sex (Male)

Age <19 or >45

Depression or hopelessness

Previous attempt or psychiatric care

Excessive alcohol or drug use

Rational thinking loss

Separated or Single

Organized plan

No social support

Sickness

low risk SAD PERSONS

0-4

medium risk SAD PERSONS

5-6

high risk SAD PERSONS

7-10

suicidal/homicidal ideation w/ a plan

-do not leave the pt alone

-notify the provider immediately

-initiate 1:1 observation & remove access to means

duty to warn/protect (Tarasoff)

-a credible, specific threat against an identifiable person must be reported

involuntary hold criteria

-danger to self

-danger to others

-grave disability

capacity vs competency

-capacity is a clinical judgement made by the provider

-competency is the legal determination made by a court

least restrictive environment

-restraints/ seclusion are a last resort, time-limited, and require an order

document objectively

-exact pt statements, actions taken, and who was notified

circumstantiality thought process

-overly detailed eventually gets to the point

tangentiality thought process

goes off-topic, never returns to answer the question

flight of ideas

-rapid, continuous shifting from one idea to another

-often pressured speech

loose associations

-illogical or unclear connections between thoughts.

derailment

complete loss of connection between ideas

word salad

random incoherent word/phrases

clang associations

words chosen for sound/rhyme, not meaning

perseveration

repetition of the same response despite new questions

thought blocking

-sudden stop in speech or train of thought

neologisms

-made up words with personal meaning

echolalia

-pathological repetition of another person’s words

insight

-does the pt understand their condition or behavior

-awareness and understanding of their condition, behaviors, thoughts or emotions

judgement

-can the pt make safe, appropriate decisions

cognition

-assessment of higher brain functioning

• orientation (person, place, time, situation)

• memory

• attention/concentration

• calculation ability

• abstract thinking

depression screening

-PHQ-9

anxiety assessment

-GAD7

cognitive impairment assessment

-mini cog

involuntary movement assessment

-AIMS

CNS

-brain

-spinal cord

PNS

-nerve fibers outside brain & spinal cord

-12 pairs of cranial nerves, 31 pairs of spinal nerves & all of their branches

-carries sensory (afferent) messages to CNS from sensory receptors

-motor (efferent) messages from CNS to muscles and glands, as well as autonomic messages that govern internal organs & blood vessels

the nervous system controls

-consciousness

-movement

-sensation

-speech

-memory

-coordination

-behavior

-reflexes

-vital body function

cerebral cortex

-frontal lobe, parietal lobe, occipital lobe, temporal lobe

frontal lobe

-concerned w/ personality, behavior, emotions, & intellectual function

parietal lobe’s postcentral gyrus

-primary center for sensation

occipital lobe

-primary visual receptor center

temporal lobe

-behind ear

-primary auditory reception center, taste, and smell

cerebellum

-coiled structure located under occipital lobe concerned with coordination of voluntary movements, equilibrium, and muscle tone

-coordinates & smoothes muscle movements (gait)

• adjusts & corrects voluntary movements, but operates entirely below conscious level

reflexes

-basic defense mechanisms of nervous system

reflex arc

-involuntary, below level of conscious control permitting quick reaction to potentially painful or damaging situations

four types of reflexes

-deep tendon reflexes (myotatic), ex: knee jerk

-superficial e.g. corneal reflex, abdominal reflex

-visceral ex: pupillary response to light

-pathologic (abnormal). ex: Babinski’s reflex or extensor plantar reflex

dermatome

-circumscribed skin area supplied mainly from one spinal cord segment through particular nerve

useful landmark dermatomes

-thumb, middle finger, fifth finger are C6,C7 & C8

-Axilla- T1

-Nipple-T4

-umbilicus- T-10

-groin L1

-knee L4

neuromuscular

-refers to the interaction between the nervous system and the muscles

• how nerves control muscle movement & coordination

neuro-muscular related subjective data

-headache

-tremors

-numbness

-tingling

-weakness

-head injury

-seizures

-dizziness, vertigo

cranial nerve 1

-olfactory nerve

-sense of smell

-sensory nerve

cranial nerve II

-optic nerve

-test visual acuity & visual fields by confrontation

-use ophthalmoscope, examine ocular fundus to determine color, size & shape of optic disc

-sensory

Cranial nerves III, IV, & VI

-oculomotor, trochlear, & abducens

-palpebral fissures usually equal in width

-check pupils for size, regularity, equality, direct and consensual light reaction and accommodation

-assess extraocular movements by cardinal positions of gaze

-assess nystagmus

• pendular movement or jerk

-all are motor

opening between the upper and lower eyelids

palpebral fissures

cranial nerve V

-trigeminal nerve

-motor function: assess muscles of mastication by palpating temporal & masseter muscles as person clenches teeth

-sensory function: w/ person’s eyes closed, test light touch sensation by touching a cotton wisp to designated areas on person’s face: forehead, cheeks, and chin

-both

nystagmus

back-and-forth oscillation of eyes

cranial nerve VII

-facial nerve

-note mobility and facial symmetry as person responds to requests to smile

-both

cranial nerve VII

-vestibulocochlear nerve

-test hearing acuity by ability to hear normal conversation & by whisper voice test

cranial nerves IX & X

-glossopharyngeal & vagus nerves

-depress tongue w. tongue blade & note pharyngeal movements as person says “ahh” or yawns

• uvula and soft palate should rise in midline & tonsillar pillars should move medially

-touch posterior pharyngeal wall w/ tongue blade, and note gag reflex

-both

cranial nerve XI

-accessory nerve

-shrug shoulders against resistance

-motor

cranial nerve XII

-hypoglossal

-inspect tongue; no wasting or tremors should be present

-motor

motor strength

-can the pt move limbs against resistance

0 reflex grade

-no response

1+ reflex grade

-somewhat diminished; low normal

2+ reflex grade

-average; normal

3+ reflex grade

-brisker than average; possibly but not necessarily indicative of disease4

4+ reflex grade

-very brisk, hyperactive, w/ clonus (rhythmic oscillations between flexion & extension)

cerebellar function balance test

-gait: observe as a person walks 10-20 ft, turns, and returns to starting point

-heal to toe walking

-normal muscle tone

-mild resistance to passive movement

hypotonia

-decreased resistance

-limb feels floppy or loose

-seen in LMN lesions (spinal cord injury, early stages of stroke)

hypertonia

-increased resistance to movement

-common in UMN lesions (stroke, cerebral palsy)

spasticity

-velocity-dependent increase in tone

-more resistance w/ fast movement

-often due to corticospinal tract damage

rigidity

-constant resistance regardless of speed or direction

-common in parkinson’s disease

clonus

-rhythmic, involuntary muscle contractions in response to sudden stretch (ex at the ankle)

-indicates UMN lesion

UMN lesion

-upper motor neuron lesion

-neurons that start in the brain and travel down the spinal cord

-damage to brain or spinal cord

LMN lesion

-lower motor neuron damage

-nerve damage directly to the nerves that innervate the muscle

generalized seizures

-absence (Petit Mal)

-tonic-clonic (Grand Mal)

-tonic

-atonic

-clonic

-myoclonic