HA PRELIMS WEEK 3

MENTAL STATUS

-            The client’s level of cognitive functioning (thinking, knowledge, problem-solving) and emotional functioning (feelings, mood, behaviors, stability).

MENTAL HEALTH

-            A state of well-being in which an individual realizes their own abilities, can cope with normal stresses of life, can work productively, and is able to contribute to their community.

ASSESSMENT OF MENTAL STATUS

-            The assessment is organized into four areas: Appearance, Behavior, Cognition, and Thought processes.

ALERT
LETHARGIC
OBTUNDED
STUPOR
COMA

LEVEL OF CONSCIOUSNESS

ALERT

Awake, oriented, responsive

LETHARGIC

Drowsy, drifts to sleep when not stimulated

OBTUNDED

Difficult to arouse (needs loud shout/shake), confused when awake

STUPOR

Semi-coma, responds only to persistent pain, withdraws from pain

COMA

Completely unconscious, no response to pain

GLASGOW COMA SCALE

-            Used for clients with Traumatic Brain Injury (TBI).

-            Score Range: 3 (Deep Coma) to 15 (Normal).

-            Coma: Score of 7 or less usually indicates coma.

-          It is a standardized tool used by healthcare professionals to objectively assess LOC. Although originally designed to predict recovery from head injury, it is now widely used in critical care and emergency settings.

EYE RESPONSE
VERBAL RESPONSE
MOTOR RESPONSE

CATEGORIES FOR GLASGOW COMA SCALE (GCS)

PAINFUL STIMULI

-            is used to assess the patient’s eye opening and best motor response when they do not respond to verbal commands or sound. The goal is to elicit the best possible response without causing tissue injury.

-            Painful stimuli are categorized as Central (applied to the core, primarily to assess cerebral cortex function for the Motor score) or Peripheral (applied to a limb, primarily for eye opening, though this practice is controversial).

CENTRAL STIMULI
PERIPHERAL STIMULI

2 TYPES OF PAINFUL STIMULUS

CENTRAL STIMULI

-            For Motor Response and Eye Opening

-            These techniques target cranial nerves or large muscle groups to elicit a maximum neurological response.

TECHNIQUE	STEP-BY-STEP APPLICATION	RATIONALE & PRECAUTIONS
Trapezius Squeeze (Pinch)	1. Grasp a large section of the trapezius muscle (on the patient’s shoulder, between the clavicle and shoulder joint). 2. Pinch and twist the muscle firmly between your thumb and fingers. 3. Gradually increase pressure for 10 to 20 seconds to elicit a response.	The resulting pain is transmitted via the Accessory Nerve (CN XI). Avoid in patients with a fractured clavicle or a cervical collar.
Supraorbital Pressure	1. Locate the small notch just under the inner edge of the eyebrow on the orbital rim (supraorbital notch). 2. Apply firm pressure with your thumb, pressing upward against the bone. 3. Gradually increase pressure for 10 to 20 seconds.	Stimulates the Supraorbital Nerve (branch of Cranial Nerve V). Avoid in patients with facial or orbital fractures.

TRAPEZIUS SQUEEZE
SUPRAORBITAL PRESSURE

2 TECHNIQUES FOR CENTRAL STIMULI

TRAPEZIUS SQUEEZE

1. Grasp a large section of the trapezius muscle (on the patient’s shoulder, between the clavicle and shoulder joint). 2. Pinch and twist the muscle firmly between your thumb and fingers. 3. Gradually increase pressure for 10 to 20 seconds to elicit a response.

The resulting pain is transmitted via the Accessory Nerve (CN XI). Avoid in patients with a fractured clavicle or a cervical collar.

SUPRAORBITAL PRESSURE

1. Locate the small notch just under the inner edge of the eyebrow on the orbital rim (supraorbital notch). 2. Apply firm pressure with your thumb, pressing upward against the bone. 3. Gradually increase pressure for 10 to 20 seconds.

Stimulates the Supraorbital Nerve (branch of Cranial Nerve V). Avoid in patients with facial or orbital fractures.

PERIPHERAL STIMULI

-            Often used for Eye Opening, sometimes Motor.

TECHNIQUE	STEP-BY-STEP APPLICATION	RATIONALE & PRECAUTIONS
Fingertip Pressure / Digital Compression	1. Apply pressure to the side of the second or third finger joint (interphalangeal joint). Note: The use of a pen pressed to the nail bed is a less favored, older method. 2. Gradually increase pressure for approximately 10 seconds.	Recommended by the GCS revision for assessing eye-opening response. It is important to note the response of the opposite hand for the motor score (M5: Localizing to pain, if the hand crosses the midline to remove the stimulus).

FINGERTIP PRESSURE OR DIGITAL COMPRESSION

1. Apply pressure to the side of the second or third finger joint (interphalangeal joint). Note: The use of a pen pressed to the nail bed is a less favored, older method. 2. Gradually increase pressure for approximately 10 seconds.

Recommended by the GCS revision for assessing eye-opening response. It is important to note the response of the opposite hand for the motor score (M5: Localizing to pain, if the hand crosses the midline to remove the stimulus).

EYE RESPONSE

EYE	DESCRIPTION	EXPLANATION
E4 – Spontaneous	Eyes open on their own	The patient’s eyes are open without any stimulus. This is the normal state for an awake person.
E3 – To Speech	Eyes open to verbal command	The patient’s eyes are closed but open when spoken to (e.g., “Mr. Smith, open your eyes”).
E2 – To Pain	Eyes open to painful stimulus	The patient’s eyes only open in response to pain (e.g., sternal rub, trapezius squeeze).
E1 – No Response	No eye opening	The patient’s eyes remain closed despite verbal commands and painful stimuli.

VERBAL RESPONSE

VERBAL	DESCRIPTION	EXPLANATION
V5 – Oriented	Appropriate, oriented speech	The patient is fully oriented and correctly answers questions about Person, Place, and Time.
V4 – Confused	Confused but coherent speech	The patient speaks in full sentences, but responses are incorrect or disoriented (e.g., “Where are you?” — “I’m at the beach.”).
V3 – Inappropriate Words	Random, inappropriate words	The patient uses recognizable words, but they are random, not in sentences, and do not make sense (e.g., “dog… blue… table…”).
V2 – Incomprehensible Sounds	Non-verbal sounds only	The patient produces moaning, groaning, or crying, with no understandable words.
V1 – No Response	No verbal output	The patient makes no verbal sounds, even after painful stimulus.

MOTOR RESPONSE

MOTOR	DESCRIPTION	EXPLANATION
M6 – Obeys Commands	Purposeful, commanded movement	The patient follows simple commands, including two-step commands (e.g., “Squeeze my fingers,” “Wiggle your toes”).
M5 – Localizes Pain	Purposeful movement to pain	The patient intentionally moves toward the painful stimulus to remove it (e.g., grabbing your hand during a sternal rub).
M4 – Withdraws from Pain	Non-purposeful withdrawal	The patient pulls away from pain, but the movement is not directed at the source of the stimulus.
M3 – Abnormal Flexion (Decorticate)	Flexion to pain	In response to pain, the arms flex inward toward the chest (“to the core”), while the legs extend. Indicates severe brain damage above the midbrain.
M2 – Abnormal Extension (Decerebrate)	Extension to pain	In response to pain, the arms and legs extend stiffly outward, with wrists flexed. Indicates more severe damage, usually at the brainstem level.
M1 – No Response	No motor response	The patient is flaccid and shows no motor response, even to painful stimuli.

MILD HEAD INJURY
MODERATE HEAD INJURY
SEVERE HEAD INJURY
DEEP COMA

GCS SCORING INTERPRETATION

MILD HEAD INJURY

13-15 GCS

Patient is alert and oriented or may have minor confusion or memory loss

• Frequent neurologic checks (every 1–2 hours) to detect LOC changes • Re-orient to person, place, and time as needed • Implement safety precautions (side rails up, call bell within reach)

MODERATE HEAD INJURY

9-12 GCS

Patient is significantly lethargic or obtunded; at risk for deterioration

• More frequent neurologic checks (every 30–60 minutes) • Maintain airway readiness (keep suction and oral airway at bedside) • Enforce strict fall and safety precautions • Notify physician immediately of any decline in GCS

SEVERE HEAD INJURY

Less Than or Equal to 8 GCS

Critical red flag; score ≤ 8 defines coma and inability to protect airway

• Priority: Prepare for intubation and assist with endotracheal intubation • Maintain ventilation and sedation as ordered • Perform comprehensive neurologic checks (including pupillary response) every 15–30 minutes • Protect patient: eye care, ROM exercises, turn/reposition every 2 hours

DEEP COMA

3 GCS

Lowest possible score; indicates total unresponsiveness, often linked to brain death

• Provide full ventilatory and hemodynamic support (manage ventilator, titrate vasopressors) • Protect extremities and joints; maintain full passive ROM • Coordinate with healthcare team regarding prognosis and brain death testing • Provide clear updates and emotional support to the family

ORIENTATION

Awareness of Time, Place, and Person

Ask the patient the date/time, current location, and their name

CONCENTRATION

Ability to focus and follow commands

Give a multi-step command (e.g., “Pick up the paper, fold it, and place it on the table”)

RECENT MEMORY

Recall of recent events

Ask: “What did you have for breakfast?”

REMOTE MEMORY

Recall of past personal information

Ask: “When is your birthday?” or “What was your first job?”

ABSTRACT REASONING

Ability to think abstractly and interpret meaning

Ask the meaning of proverbs (e.g., “A rolling stone gathers no moss”)

DELIRIUM

Rapid, acute onset (hours to days).

Fluctuating (“sundowning” – worse at night).

Hours to weeks.

Often reversible (treat the infection/drug cause).

Impaired/Fluctuating.

Impaired immediate and recent memory.

DEMENTIA

Slow, insidious onset (months to years).

Progressive and chronic.

Months to years.

Generally irreversible.

Usually normal until late stages.

Impaired recent memory first, then remote.

CAGE QUESTIONNAIRE

-            Used to screen for alcohol dependence. A “Yes” to 2 or more suggests a problem.

1.     Have you ever felt you should Cut down on your drinking?

2.     Have people Annoyed you by criticizing your drinking?

3.     Have you ever felt bad or Guilty about your drinking?

4.     Have you ever had a Drink First Thing in the morning to steady your nerves (Eye-Opener).

VIOLENCE

-            The intentional use of physical force or power threatened or actual, against oneself, another person, or against a group or community.

-            Effects of Violence:

o   Physical: Injuries, chronic pain, STIs, unwanted pregnancy, death, restraining a person.

o   Psychological: Depression, PTSD, anxiety, suicide, substance abuse.

o   Economic: controlling resources.

INTIMATE PARTNER VIOLENCE
CHILD ABUSE
ELDER MISTREATMENT

MOST AT RISK CATEGORIES FOR VIOLENCE

HITS TOOL

Violence Assessment Tool
-            Score >10 indicates risk:

o   “How often does your partner physically hurt you?”

o   “Insult or talk down to you?”

o   “Threaten you with harm?”

o   “Scream or curse at you?”

INCONSISTENT HISTORY

1.     The explanation of the injury does not match the physical findings.

SCALD BURNS
BRUISES SHAPED LIKE OBJECTS
CIGARETTE BURNS
BITE MARKS

Patterned Injuries

BRUISING STAGES

1.     Bruises in various stages of healing (yellow, green, purple) suggest repeated injury over time.

SHAKEN BABY SYNDROME

1.     Retinal hemorrhages (bleeding in back of eyes) and subdural hematomas without external head trauma.