Assessing Mental Status Ability to perceive and react to environmental stimuli is closely related to mental status. Adapting to a new environment requires learning through experience and possessing a cognitive awareness of the immediate surroundings. To respond to stimuli, motor neuron carry impulses to muscles to carry involuntary reflex action. Sensory impulses travelling to the cerebral cortex of the brain inform the person that this stimulus is potentially harmful.

Mental Assessment Consciousness – is the state in which individuals are aware of themselves and their relationship to their surroundings. Unconsciousness – is the state in which individuals are aware of themselves and their relationship to their surroundings. Level of consciousness range from fully conscious to non-responsive

Mental status Assessment Six – Item Cognitive Impairment Test ItemMaximum ErrorScoreWeightFinal Item Score 1. What year is it now? What month is it now? 13 Memory Phrase : repeat this phase after me: “John Brown, 42 Market Street, Chicago”. 3. About what time is it now? Count backward Say the month in reverse order Repeat the memory phrase 52

Mental Status Assessment Assign “O” for a correct score, and “1” for each incorrect score up to the maximum number of errors permitted. Multiply the item score by the item weight to obtain the final item score. The maximum total score possible is 28. A score of 10 or higher is significant and should be referred.

Glasgow Coma Scale Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. Patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale). GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS, and doctors as being applicable to all acute medical and trauma patients. In hospitals it is also used in monitoring chronic patients in intensive care.

Glasgow Coma Scale Interpretation Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35". Generally, brain injury is classified as: Severe, with GCS ≤ 8 Moderate, GCS Minor, GCS ≥ 13.

Glasgow Coma Scale (GCS) Glasgow Coma Scale The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the scores in three categories. For adults the scores are as follows: Eye Opening Response - Spontaneous--open with blinking at baseline 4 points - Opens to verbal command, speech, or shout 3 points - Opens to pain, not applied to face 2 points - None 1 point Verbal Response - Oriented 5 points - Confused conversation, but able to answer questions 4 points - Inappropriate responses, words discernible 3 points - - Incomprehensible speech 2 points - None 1 point Motor Response - Obeys commands for movement 6 points - Purposeful movement to painful stimulus 5 points - Withdraws from pain 4 points - Abnormal (spastic) flexion, decorticate posture 3 points - Extensor (rigid) response, decerebrate posture 2 points - None 1 point

Glasgow Coma Scale For children under 5, the verbal response criteria are adjusted as follow: SCORE 2 to 5 YRS O TO 23 Mos. 5 5 Appropriate words or phrases Smiles or coos 4 Inappropriate words Cries and consolable 3 Persistent cries and/or screams Persistent inappropriate crying &/or screaming 2 Grunts Grunts or is agitated or restless 1 No response No response

Pediatric Glasgow Coma Scale Best eye response: (E) 4 Eyes opening spontaneously 3 Eye opening to speech 2 Eye opening to pain 1 No eye opening Best verbal response: (V) 5 Smiles, oriented to sounds, follows objects, interacts. 4 Cries but consolable, inappropriate interactions. 3 Inconsistently inconsolable, moaning. 2 Inconsolable, agitated. 1 No verbal response. Best motor responses: (M) 6 Infant moves spontaneously or purposefully 5 Infant withdraws from touch 4 Infant withdraws from pain 3 Abnormal flexion to pain for an infant (decorticate response) 2 Extension to pain (decerebrate response) 1 No motor response

Cranial Nerve Assessment NerveNameFunction Test 1 Olfactory Smell Have pt. smell a familiar odor 2OpticVisual Acuity Visual Field Have pt. identify fingers Check peripheral vision 3OculomotorPupillary Reaction Shine Light in the eye 4TroclearEye Movement Follow finger without moving the head 5TrigeminalFacial Sensation Motor Function Touch the face Have pt. hold mouth open 6AbducensMotor Function Lateral Eye movements 7FacialMotor Function Sensory Smile, wrinkle face, puff cheeks Tastes 8AcousticHearing Balance Snap fingers by the ear Rhomberg's Test 9GlossopharyngealSwallowing and Voice Swallow and say "AH" 10VagusGag Reflex Use tongue depressor 11Spinal AccessoryNeck Motion Shoulder shrugging 12HypoglossalTongue Movement and Strength Stick out tongue apply resistance with a tongue depressor