MENTAL STATUS ASSESSMENT

A. Appearance

• Posture Posture is erect and position is relax.

• Movement Body movements are voluntary, deliberate, coordinated and even.

• Dress Is appropriate for setting, season, age, gender and social group.

• Grooming and Hygiene Clean and well groomed.

B. Behavior

• Level of Consciousness The person is awake, alert, and aware of stimuli from

the environment and within self and responds appropriately to stimuli.

• Facial Expression Appropriate to situation.

• Speech Speaks effortlessly and shares conversation appropriately. Words are

clear and understandable.

• Mood and Affect Mood and affect are consistent to place and condition.

C. Cognitive Function

• Orientation Orientation to time, place, person.

• Attention Span Able to complete a thought without wandering. Able to follow

direction.

• Recent Memory Able to recall recent facts (Verifiable).

• Remote Memory Able to recall past events (Verifiable).

• New Learning Able to recall 4 unrelated words (after 5, 10, 30 minutes).

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D. Thought and Perception

• What the person says is sensible.

• What the person says is consistent and logical.

• The person is consistently aware of reality.

CRANIAL NERVE ASSESSMENT

A. Cranial Nerve I (Olfactory Nerve)

To test the adequacy of function of the olfactory nerve:

1. The client is asked to close his eyes and occlude one nares.

2. The examiner places aromatic and easily distinguishable substance close to

the client’s nose. (E.g. Coffee).

3. Ask the client to identify the odor

*** Each side is tested separately, ideally with two different substances.

1. Test the functioning of Cranial Nerve that innervates the facial structures.

Normal Finding:

The client is able to identify an odor on each side of the nose.

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B. Cranial Nerve II (Optic Nerve)

Testing for visual acuity and peripheral vision assesses the optic nerve.

Visual Acuity is tested using a Snellen chart for those who are illiterate and

unfamiliar with the western alphabet, the E chart, in which the letter E faces in

different directions maybe used. The chart has a standardized number at the end

of each line of letter; this number indicates the degree of visual acuity when

measured at a distance of 20 feet.

The numerator 20 is the distance in feet between the chart and the client or

the standard testing distance.

The denominator 20 is the distance from which the client eye can read the

lettering, which correspond to the number at the end of each letter line;

… therefore the larger the denominator the poorer the vision.

Measurement of 20/20 vision  is an indication of normal eye refraction and

optic pathway; while measurement of less than 20/20 vision is an indication of either

refraction error or some optic disorder.

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In testing visual acuity you may refer to the following:

1. The room used for his test should be well lighted.

2. A person who wears corrective lenses should be tested with and without them to

check for the adequacy of correction.

3. Only one eye should be tested at a time; the other eye should be covered by an

opaque card or eye cover, not with client’s fingers.

4. Make the client read the chart by pointing at a letter randomly at each line;

maybe started from largest to smallest or vice versa.

5. A person who can read the largest letter on the chart (20/20) should be checked if

they can perceive hand movement about 12 inches from their eyes, or if they can

perceive the light of the penlight directed to their eyes.

Peripheral Vision or Visual Field

The assessment of visual acuity is indicative of the functioning of the

macular area, the area of central vision. However it does not test the sensitivity of

the other areas of the retina, which perceive the more peripheral stimuli. The

Visual field confrontation test provides a rather gross measurement of peripheral

vision.

The performance of this test assumes that the examiner has normal visual fields,

since the client visual field is to be compared with the examiners.

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The following steps in conducting the test:

1. The examiner and the client sit or stand opposite each other, with the eyes at the

same horizontal level with a distance of 1.5-2 feet apart.

2. The client covers the eye with opaque card, and the examiner covers the eye that

is opposite to the client’s covered eye.

3. Instruct the client to stare directly at the examiner’s eye, while the examiner

stares at the client’s open eye. Neither looks out at the object approaching from

the periphery.

4. The examiner hold an object such as pencil or penlight, in his hand and gradually

moves if in from the periphery of both direction horizontally and from above and

below.

5. Normally the clients should see the object at the same time the examiner sees it.

The normal visual field is 180 degree.

C. CRANIAL NERVE III, IV, AND VI (Oculomotor, Trochlear, Abducens)

All the 3 Cranial nerve are tested at the same time by assessing the Extra Ocular

Movement (EOM) or the six cardinal position of gaze.

Following steps given;

1. Stand directly in front of the clients and hold a finger or a penlight about 1ft

from the client’s eyes.

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 2. Instruct the client to follow the direction of the object held by the examiner

by eye movement only; that is without moving the neck.

3. The nurse moves the object in a clockwise direction hexagonally.

4. Instruct the client to fix his gaze momentarily on the extreme position in each

of the six cardinal gaze.

5. The examiner should watch for jerky movement of the eye (nystagmus).

6. Normally the clients can hold position and there should be no nystagmus.

D. Cranial Nerve V (Trigeminal)

This cranial nerve functions both sensory and motor.

Sensory Function;

• Ask the client to close eyes.

• Run cotton wisp over the fore head, cheek and jaw on both side of the face.

• Ask the client if he/she feel it, and where she feels it.

• Check for corneal reflex using cotton wisp.

• The normal response is blinking.

Motor Function

• Ask the client to chew or clench the jaw.

• The client should be able to clench with strengths and force.

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E. Cranial Nerve VII (Facial)

This cranial nerve function both sensory and motor.

Sensory Function

(This nerve innervates the anterior 2/3 of the tongue)

• Place sweet, sour, salty or bitter substances near the tip of the tongue.

• Normally, the client can identify the taste.

Motor Function

• Ask the client to smile, frown, raise eye brow, close lids, whistle, or puff the

cheeks.

Normal Finding:

• Shape maybe oval or rounded.

• Face is symmetrical

• No involuntary muscle movements

• Can move facial muscles at will

F. Cranial Nerve VIII (Vestibulocochlear Nerve)

Examination of the cranial nerve VIII involves testing for hearing acuity and balance.

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Hearing Acuity

A. Voice test

1. The examiner stands 2ft. On the sides of the ear to be tested.

2. Instruct the client to occlude the ear canal of the other ear.

3. The examiner then covers the mouth and using a soft-spoken voice whisper non-

sequential number (e.g. 3, 5, and 7) for the client to repeat.

4. Normally the client will be able to hear and repeat the number.

5. Repeat the procedure on the other ear.

B. Watch Test

1. Ask the client to close the eyes.

2. Place a mechanical watch 1-2 inches away the client’s ear.

3. Ask the client if he hears anything.

4. If the client says yes, the examiner should validate by asking at “What are you

hearing? On which sides?”

5. Repeat the procedure on the other ear

6. Normally the client can identify the sound and on which side was heard.

Tuning for test

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This test is useful in determining whether the client has a conductive hearing loss

(problem of external or middle ear) or a perceptive hearing loss (sensorineural).

There are 2 types of tuning for test being conducted.

1. Weber’s test – assesses bone conduction, this is a test of sound lateralization;

vibrating tuning fork is placed on the middle of the forehead or top of the skull.

Normal: hear sounds equally in both ears (No lateralization of sounds)

Conduction loss: a sound lateralizes to defective ear (Heard louder on defective ear)

as few extraneous sounds are carried through the external and middle ear.

Sensorineural loss – Sounds lateralize on better ear.

2. Rinne test – compares bone conduction with air conduction

a. vibrating tuning fork placed on the mastoid process,

b. Instruct client to inform the examiner when he no longer hears the

tuning fork sounding.

c. Position the tuning fork in front of the client’s ear canal when he no

longer hears it.

Normal: sounds should be heard when tuning fork is placed in front of the ear anal as

air conduction < bone conduction by 2:1 (positive Rinne test)

Conduction loss: sound is heard longer by one bone conduction than by air

conduction.

Sensorineural loss: Sound is heard longer by air conduction than by bone conduction.

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G. Cranial Nerve IX and X (Glossopharryngeal and Vagus Nerve)

1. Sensory Function:

*Mediate taste on the posterior one third of the tongue.

*Technically difficult to test.

2. Motor function:

• Depress the tongue with a tongue blade and note pharyngeal

movement as the person says “ahhhh” or yawns.

• The uvula and the soft palate should rise in the midline and the

tonsillar pillar should move medially.

• Touch the posterior pharyngeal wall with a tongue blade and note

the gag reflex.

• Note the voice of the client ( should be smooth and not strained)

H. Cranial Nerve XI (Spinal Accessory Nerve)

• Examine the stetamoid and the trapezius muscle for equal size. Check

equal strength by asking the person to rotate the head forcibly against

resistance applied to the side of the chain.

• Ask the client to shrug the shoulders against resistance.

I. Cranial Nerve XII (Hypoglossal Nerve)

• Inspect the tongue (there should be no tremors).

• Note the forward thrust in the midlines as the client protrudes the

tongue.

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 • Ask the person to say “light, tight, dynamite”, the sounds lingual speech

(letters l, t, d) is clear.

TEST FOR CEREBELLAR FUNCTION

Balance test:

A. Tandem walking

• Ask the person to walk a straight line in a heel-to-toe fashion.

Tandem walking decreases the base of support and accentuates problem with

coordination. Normally, the person can walk straight and stay balanced. Inability

to tandem walk may indicate upper motor neuron lesion such as multiple sclerosis.

B. Romberg test

• Ask the person to stand up with feet together and arms at all side.

• Ask the client to close the eyes and to hold the position for about 20

seconds.

• Normally, a person can maintain posture and balance even with the

visual orienting information blocked, although slight swaying may occur.

Positive Romberg sign (loss of balance that occurs when closing the eyes)

occurs with cerebellar ataxia, loss of proprioception and loss of vestibular

function.

Coordination tests:

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A. Rapid alternating movements (RAM)

• Ask the person to pat the knees with both hands, patting alternately

with the dorsum and palmar surfaces of the hands.

• Start slowly then ask the client to do it faster.

• Ask the person to touch the thumb to each finger on the same hand,

starting with the index finger then reverse direction.

B. Finger-to- Finger test

• With person’s eyes open, ask the client to touch your finger then touch

his own nose repeatedly. After several times, move your finger to a different

spot.

C. Finger-to-Nose test

• Ask the client to touch the tip of his nose with his index finger,

alternating hands for several times.

SENSORY FUNCTION TESTS

A. Stereognosis – test the persons ability to recognized objects by feeling their

forms, sizes and weights,

• Ask the clients to close his eyes and identify an object that is placed in

his hand.

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 • Test a different object in each hand.

* Normally, a person will explore the object with the fingers and correctly name

it. Testing the left hand assesses right parietal lobe functioning. Astereognosis

occurs in sensory cortex lesions.

B. Graphestesia – Ability to read a number by having it traced on the skin.

• With the client’s eyes closed, use a blunt instruction to trace a number or a letter

on the palm.

• Ask the person to tell you what the number or letter is.

TESTING STRETCH OR DEEP TENDON REFLEXES

Four Point Scale for Grading Reflexes

4+ Hyperactive with clonus; indicative of disease.

3+ Brisker than average; may indicate disease.

2+ Average normal

1+ Diminished, low normal

0 No response

A. Biceps Reflex (C5 to C6)

Technique:

• Support the person’s forearmed; partially flex the person’s arm.

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• Place thumb on the biceps tendon and strike a blow on the thumb.

Normal Response:

• Contraction of the biceps and flexion of the forearm.

B. Triceps Reflex (C7 to C8)

Technique:

• Tell the person to relax the arm as the examiner suspends it by holding the upper

arm.

• Strike the triceps tendon directly just above the elbow.

Normal Response:

• Extension of the forearm.

C. Brachioradialis Reflex (C5 to C6)

Technique:

• Hold the person’s thumbs to suspend the forearms in relaxation.

• Strike the forearm directly 2-3cm above the radial styloid process.

Normal Response:

• Flexion and supination of the forearm.

D. Quadriceps Reflex “Knee Jerk” (L2 to L4)

Technique:

• Let the lower leg dangle freely to flex the knee and stretch the tendons.

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• Strike the tendon directly just below the patella.

Normal Response:

• Extension of the lower leg.

• Contraction of the quadriceps.

E. Achilles Reflex “Ankle Jerk” (L5 to S2)

Technique:

• Position with the knee flexed and hip externally rotated.

• Hold the foot in dorsiflexion.

• Strike the Achilles tendon directly

Normal Response:

• Foot plantar flexes against hand of the examiner.

TESTING SUPERFICIAL REFLEXES

A. Abdominal Reflex (T8 to T10)

Technique:

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• Have the person assumes a supine position, with the knee slightly bent.

• Use the handle end of the reflex hammer to stroke the skin.

• Stroke from the side of the abdomen towards the midline at both the upper and

lower abdominal level.

Normal Response:

Ipsilateral contraction of the abdominal muscle with an observed deviation of the

umbilical towards the strokes.

B. Plantar Reflex (L4 to S2)

Technique:

• Position the thigh in slight external rotation.

• With the reflex hammer, draw a light stroke up the lateral side of the sole of the

foot and inward across the ball of the foot (“Inverted J”).

Normal Response:

• Plantar flexion of all the toes and inversion and flexion of the forefoot.

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