Cognition and/or Mental/ Emotional Status (affective)

Intellect

a gift to replicate the mind in many forms for use according to purpose.

Cognitive or thought

process of knowing and interacting with the world.

Cognitive Development

evaluated by the attainment of language skills, intelligence and the ability to follow instructions.

Memory Problems (neurodegeneration and post-traumatic amnesia)

Became apparent in individuals who experienced traumatic brain injuries (TBIs).

Or effect of head or brain (trauma or disease).

Dementia

Deterioration in cognitive function beyond what might be expected from the usual consequences of biological aging.

Alzheimer’s Disease

leading cause of elderly dementia.

TOMM40

Processes material that may form amyloid plaque.

Depression

– most common mental health problem worldwide.

- more woman than man.

- Common among older children and teenagers.

Mood and Emotional State

Ask client to identify an event or incident that fostered the change in mood or emotional state.

orientation to time

what orientation is lost first?

orientation to person

what orientation is lost last?

Concentration Test

checking for Client’s ability to focus and stay attentive to you during the interview.

Test Immediate Memory

→Repeat series of digits (non-sequential).

→Increase the number of digits until the client fails to repeat the series correctly.

→Start again but have client repeat it backwards.

Test Recent Memory

Ask client to recall recent events of the day.

→Ask to name a nurse, doctor, or information from the recent interview.

→Provide 3 facts to recall

→Ask client to repeat all three later on in the interview.

Test Remote Memory

Ask client to describe a previous illness, surgery, birthday, or anniversary.

test of thought Content and Process

•

AM 1:

→Explore unusual or unpleasant thoughts.

→Assess logic, relevance, organization, and coherence.

•AM 2:

→ Ask client to define familiar words such as “apple”, “ocean”, and playground”.

one-step command

“Touch your nose with your right hand”

3-step command

“Take this piece of paper in your right hand. Fold it in half. Put paper on the table”

Praxis

Ask patient to use a pen, toothbrush, or comb.

Visual Perception and Constructional Ability

→ Present and object and have client identify size, shape, color, or size.

•

AM 2:

→ Ask client to draw the face of clock or copy figures.

Judgement

Requires comparing and evaluating facts and ideas to understand relationship and form conclusions.

→ Ask client “why did you seek healthcare?” or “what would you of if you become ill at home?”

Abstract reasoning

• It is the ability to evaluate situations and to decide upon a realistic course of action.

• The plans should reflect the reality of the client’s health, psychological stability, family situation, and obligation.

→ Ask the client a proverb and ask what it means.

Olfactory

ask client to close eyes.

→Occlude each nostril sequentially and present a smell specimen.

•Instruct client to gently sniff or blow if necessary.

Optic (Sensory

Function: vision and visual fields (visual acuity)

Optic (Sensory

AM 1:

→

Read Snellen’s, Rosenbaum’s, or Jaeger’s chart.

→

Check visual fields by confrontation

→

Conduct an ophthalmoscopic examination.

•

AM 2: (If tools are not available)

→

Have client read a newspaper (from headlines to smaller print).

Oculomotor (motor)

Function: Extraocular Movement (EOM)

Oculomotor (motor)

→

Assess six ocular movements (6 cardinal fields of gaze).

→

Assess pupil’s reactions by instructing the client to follow your fingers with their eyes using ‘H” or “N” or wagon-wheel pattern.

Oculomotor (motor)

Movement of the sphincter of the pupil; movement of ciliary muscles of the lens.

Trochlear

Function: Extraocular movement

•

Moves the eyeball downward and laterally.

→

Assess six ocular movements.

Trigeminal

Function: Sensation of Cornea

→

Approach from behind

→

Client looks upward

→

Touch latera sclerae to elicit blink reflex.

Trigeminal

→Touch cotton, or cotton wisp on the three areas:

–Forehead

–Cheeks

–Jaw

→Compare to opposite side of face.

→Use sharp and dull ends of a broken tongue blade.

→Alternate between the sharp point and the dull end

Trigeminal

→

Touch cotton, or cotton wisp on the three areas:

–

Forehead

–

Cheeks

–

Jaw

→

Compare to opposite side of face.

→

Use sharp and dull ends of a broken tongue blade.

→

Alternate between the sharp point and the dull end

Trigeminal

AM 1:

→

Have client clench the jaw and move it from side to side.

→

Palpate the temporal and masseter muscles (note strength and equality).

o

AM 2:

→

Have client grind teeth and open mouth against resistance.

Abducens

Function: Extraocular movement (EOM) moves eyeball laterally.

→

Assess directions of gaze.

Facial

→

Ask client to perform facial movements:

–

Smile

–

Wrinkle forehead

–

Raising the eyebrows

–

Purse lips

–

Puff out cheeks

–

Close tightly against resistance

•

AM 2: Sensory

→

Ask client to identify various taste placed on the tip and the side of the tongue.

–

Sugar (sweet)

–

Salt, calamansi juice (sour)

–

Quinine or coffee (bitter)

Gross Hearing Acuity Test

assess the client’s response to normal voice tones.

•

AM 1:

→

Observe the response to normal voice tones.

•

AM 2:

→

Rub fingers next to either ear.

Voice-Whisper Test

•

AM 1:

→

Start with ear that has better hearing.

→

Stand 1-2 ft away from open ear.

→

Ask client to occlude one of his ears with finger and rubbing tragus in a circular motion.

→

Cover mouth (so the client will not see your lips when whispering)

→

Quietly exhale before whispering.

→

Whisper a two-syllable words or combination of three letters or numbers.

→

Have client repeat whispered words.

→

Repeat test using different sentence or combination of words.

→

If necessary: gradually increase voice intensity until the client correctly repeats what is whispered.

Watch Tick Test

- determines client’s ability to hear high-pitched sounds and screen for high-tone hearing loss.

•

AM 1:

→

Occlude one ear.

→

Be out of the client’s sight.

→

Place a ticking watch

→

Start at about 18 inches away from the ear

→

Compare with a person with normal hearing.

•

AM 2:

→

Hold it as close to the open ear and slowly move it away until the client stats they can no longer hear ticking (usually about 5 inches [13cm])

→

Repeat with other ear.

Weber’s Test

test for laterization or unilateral hearing loss

→

Hold tunning for (512Hz) at its base

→

Tap lightly against heel of the palm.

→

Place vibrating fork at midsagittal line or forehead, on top of the head at the midline, or in form of teeth.

→

Ask client if sound is hear better in one ear or same un both ears.

→

Test if client reports diminished or lost hearing in one ear.

Conductive deficit

e.g., wax in the external canal.

Rinne’s Test

- test for air and bone conduction.

- helps distinguish whether the client hears better by air or bone conduction.

→

place vibrating fork on mastoid (1 to 2cm [1/2in] from meatus)

→

ask client to give signal if vibration is no longer felt.

→

Note the duration of time in seconds.

Conduction

passage of sound from outside to the level of CN VIII

- transmission of sound through the external canal and middle ears.

Sensorineural

from CN VIII to the brain.

Mixed

combination of conduction and sensorineural loss.

Conductive hearing loss

tone is laterized to affected ear.

Sensorineural hearing loss

lateralized to unaffected ear.

Cold Caloric Test or Vestibulo-ocular reflex test

irrigate the external ear canal with ice-cold water.

- Doctors can test your brainstem function by putting warm or cold water (or air) into your ear canal using a syringe. This affects the nearby horizontal semicircular canal in your inner ear, which helps control balance and eye movements.

COLD

fast eye movement to the Opposite side

WARM

fast eye movement to the Same side

Glossopharyngeal

Function: Swallowing, gag reflex, tongue movement, and taste (posterior tongue).

•

Testes together with CN X.

•

AM 1: Motor

→

Ask client to swallow

→

Ask client to move tongue from side to side and up and down/

•

AM 2: Sensory

→

Use cotton-tipped applicator on posterior tongue, posterior pharynx, or uvula while client says “aah” to elicit gag reflex.

→

Apply taste of posterior 1/3 tongue for identification.

Vagus

The wanderer

•

Function: sensation and contraction of the pharynx, sensation of larynx, symmetric movement of vocal cords, symmetric movement of soft palate. Movement and secretion of thoracic and abdominal viscera.

•

Tested together with CN IV.

•

AM 1: Motor

→

Assess client’s speech or voice for hoarseness.

→

Ask client to drink small amount fo water and check for swallow.

•

AM 2: Sensory

→

Depress a tongue blade on the posterior tongue to elicit gag reflex.

→

Have client say “aah”

→

Observe for the symmetric rise of uvula and soft palate.

Spinal Accessory

Function: head movement, shrugging of shoulder (movement of sternocleidomastoid and trapezius muscle).

→

Turn head to the right then to the left.

→

Right ears to the right shoulder and left ear to left shoulder (do not raise shoulder).

→

Palpate and note the strength of sternocleidomastoid muscles while client turns head to side with and without resistance from your hand.

→

Attempt to return client’s head to midline position.

→

Repeat

→

Palpate and note the strength of trapezius muscle while the client shrugs shoulders without and and with resistance.

Hypoglossal

Movement/protrusion of the tongue

•

AM 1:

→

Ask the client to protrude the tongue at midline, then retract.

→

Move it to the sides of the beck with tongue.

→

Provide resistance by pressing on or two fingers on client’s outer cheeck.

→

Repeat on the other side.

•

AM 2:

→

Have the client say “d, 1, n, t” or a phrase containing these letters