Week 6 Notes
• This week, the focus of exploration encompasses neurocognitive and
psychiatric disorders in maturing and older adults. Particular importance
is placed on common neurocognitive disorders, including Alzheimer's
disease, dementia, delirium,
cerebrovascular accident, and dizziness, and on common psychiatric
disorders including, depression, anxiety, and sleep/wake disorders.
Effectively diagnosing and managing these neurological and psychological
disorders is foundational to optimizing outcomes. Highly skilled family nurse
practitioners (FNPs) serve as change agents for these populations by
advancing health and narrowing health disparities.
Neurological Assessment
• Whether conducting a comprehensive or screening examination, the
neurological assessment can be organized into five categories:
• Mental status, speech, and language
o The mental status assessment includes the level of alertness, language
function,
memory, calculation, visuospatial processing, and abstract reasoning.
• Cranial nerves
Number Roman Numeral Name Function<
1 CNI Olfactory Smell
2 CNII Optic Vision
3 CNIII Oculomotor
GSM: 4 extrinsic eye muscles and levator palpebrae superioris.
GVM: pupillary sphincter
4 CNIV Trochlear Superior oblique
5 CNV Trigeminal (branches):
Ophthalmic Scalp, forehead and nose.
Maxillary Cheeks, lower eye lid, nasal mucosa, upper lip, upper teeth and palate.
Mandibular
GSS: anterior 2/3 tongue, skin over mandible and lower teeth.
SVM: muscles of mastication.
6 CNVI Abducens Lateral rectus
,Number Roman Numeral Name Function<
CNVII Facial
GSS: sensation to part of ext. ear.
SVS: taste from ant. 2/3 tongue, hard and soft palate.
SVM: muscles of facial expression.
GVM: lacrimal, submandibular, sublingual glands and mucous glands of mouth
and nose.
CNVIII Vestibulocochlear Hearing and balance
CNIX Glossopharyngeal
GSS: post. 1/3 tongue, ext. ear, and middle ear cavity.
GVS: carotid body and sinus.
SVS: taste from post. 1/3 tongue.
GVM: parotic gland.
SVM: stylopharyngeus
10 CNX Vagus
GSS: ext. ear, larynx and pharynx.
GVS: larynx, pharynx and, thoracic & abdominal viscera.
SVS: taste from epiglottis region of tongue
GVM: smooth muscles of pharynx, larynx and most of the GIT.
SVM: most muscles of pharynx and larynx.
11 CNXI Spinal accessory
GSM: trapezius and sternocleidomastoid.
SVM: a few fibers run with CNX to viscera.
12 CNXII Hypoglossal Intrinsic and extrinsic tongue muscles (except the palatoglossus).
, • Motor system
o When assessing overall motor function or motor function of a limb or the
trunk,
focus on body position, involuntary movements, characteristics of the
muscles (bulk, tone, and strength), and coordination. Muscle strength
is rated from 0 (indicating no muscle contraction detected) to 5
(indicating normal muscle strength with no evidence of fatigue with
active movement against full resistance).
• Sensory system
o When examining the sensory system, assess for sensation of pain and
temperature, position and vibration, light touch, and discrimination. If
there is sensory loss, assess if there is a pattern, if it is bilateral, and if
it is symmetric. The NP may use knowledge of dermatomes (areas of
skin that are innervated by the sensory root of a single spinal nerve)
to localize a lesion of the spinal cord.
• Reflexes
o Deep tendon reflexes should be interpreted only within the context of the
rest of
the neurologic examination. A reflex hammer is used to elicit muscle
reflexes. There are different uses of both the pointed end and the flat
end of a reflex hammer. For example, the pointed end is useful for
striking small areas, such as your finger as it overlies the biceps
tendon. Reflexes are rated from 0 indicating an absent reflex to 4
indicating very brisk with clonus. A wide range of normal reflex
responses exists; healthy people may have diminished reflexes, or
they may have brisk ones.
Mental Status Exam
• Level of Consciousness
o The Glasgow Coma Scale is a common tool used to assess a
client’s level of consciousness.
▪ Eye Opening Response
• Spontaneous - open with blinking at baseline - 4 points
• To verbal stimuli, command, speech - 3 points
• To pain only (not applied to face) - 2 points
• No response - 1 point
▪ Verbal Response
• Oriented - 5 points
• Confused conversation, but able to answer questions - 4
points
• Inappropriate words - 3 points
• Incomprehensible speech - 2 points
• No response - 1 point
▪ Motor Response
• Obeys commands for movement - 6 points
• Purposeful movement to painful stimulus - 5 points
• Withdraws in response - 4 points
• Flexion in response to pain (decorticate posturing) - 3 points
• Extenstion repsonse in response to pain (decerebrate
posturing) - 2 points
• No response - 1 points
o Score of 15 is the highest score possible
o Score equal to or less than 8 indicates the client is comatose
o Score equal to or less than 3 indicates the client is unresponsive
o
, • Appearance
o An individual’s appearance provides important clues about their mental
status. Activities of daily living (ADLs), including dressing and
grooming practices, may be some of the first behaviors impacted by
mental health issues. When an individual is severely depressed or
psychotic, they often present looking disheveled and with poor
hygiene. Assessment of appearance involves observing and
documenting posture, dress, grooming, and physical appearance
(including distinguishable markings such as scars or tattoos), facial
expressions, level of alertness, and attitudes.
• Behavior
o Behavior refers to how the client presents themselves during the
examination. Assess eye contact, psychomotor activity (increased or
decreased), movements, mannerisms, stereotypies, or posturing. Be
sure to observe how the client responds to the exam. Are the
responses appropriate to the situation, or does the client become
defensive and use posturing? Is the client able to sit still or do they
feel compelled to pace the room? Be sure to observe the gait. Are the
movements coordinated, slowed, or excessive?
• Speech & Language
o Speech is an important diagnostic indicator. Assess general speech
qualities, including rate, rhythm, latency, volume, and content. Is the
speech fast or slow? Is the rhythm monotone or slurred? Are there
increased or decreased pauses between questions and answers? Is
the speech volume soft, regular, or loud? Speech patterns can be
diagnostic indicators of a mental health issue when considered
alongside other assessment findings. For example, an individual who
presents with extraordinarily rapid and pressured speech with
constant interruptions may be in a state of hypomania or mania. An
absence of speech is common in dementia, and nonsensical speech is
often associated with schizophrenia.
• Mood
o Mood is the client’s state of mind or predominant emotion and is
typically described in the client’s own words. Some clients will easily
describe their mood; others may require questions to help elicit mood
statements. Documentation of mood should be as specific as possible.
Stable is a good descriptor for someone whose mood is appropriate to
their current situation. Other words used to describe mood might
include sad, depressed, angry, irritable, anxious, depressed, or
euphoric. Affect is the emotional state observed by the provider.
Affect could be described as normal, flat, dysphoric, or euphoric.
• Thought & Perception
o Expected Findings include:
▪ Organized thoughts
▪ Logical flow of thoughts
▪ Thoughts reflect reality
o Unexpected Findings include:
▪ Suicidal/Homicidal ideations
▪ Intrusive or unwanted thoughts
▪ Delusions
▪ Hallucinations
▪ Flight of ideas
▪ Poverty of thought
▪
• This week, the focus of exploration encompasses neurocognitive and
psychiatric disorders in maturing and older adults. Particular importance
is placed on common neurocognitive disorders, including Alzheimer's
disease, dementia, delirium,
cerebrovascular accident, and dizziness, and on common psychiatric
disorders including, depression, anxiety, and sleep/wake disorders.
Effectively diagnosing and managing these neurological and psychological
disorders is foundational to optimizing outcomes. Highly skilled family nurse
practitioners (FNPs) serve as change agents for these populations by
advancing health and narrowing health disparities.
Neurological Assessment
• Whether conducting a comprehensive or screening examination, the
neurological assessment can be organized into five categories:
• Mental status, speech, and language
o The mental status assessment includes the level of alertness, language
function,
memory, calculation, visuospatial processing, and abstract reasoning.
• Cranial nerves
Number Roman Numeral Name Function<
1 CNI Olfactory Smell
2 CNII Optic Vision
3 CNIII Oculomotor
GSM: 4 extrinsic eye muscles and levator palpebrae superioris.
GVM: pupillary sphincter
4 CNIV Trochlear Superior oblique
5 CNV Trigeminal (branches):
Ophthalmic Scalp, forehead and nose.
Maxillary Cheeks, lower eye lid, nasal mucosa, upper lip, upper teeth and palate.
Mandibular
GSS: anterior 2/3 tongue, skin over mandible and lower teeth.
SVM: muscles of mastication.
6 CNVI Abducens Lateral rectus
,Number Roman Numeral Name Function<
CNVII Facial
GSS: sensation to part of ext. ear.
SVS: taste from ant. 2/3 tongue, hard and soft palate.
SVM: muscles of facial expression.
GVM: lacrimal, submandibular, sublingual glands and mucous glands of mouth
and nose.
CNVIII Vestibulocochlear Hearing and balance
CNIX Glossopharyngeal
GSS: post. 1/3 tongue, ext. ear, and middle ear cavity.
GVS: carotid body and sinus.
SVS: taste from post. 1/3 tongue.
GVM: parotic gland.
SVM: stylopharyngeus
10 CNX Vagus
GSS: ext. ear, larynx and pharynx.
GVS: larynx, pharynx and, thoracic & abdominal viscera.
SVS: taste from epiglottis region of tongue
GVM: smooth muscles of pharynx, larynx and most of the GIT.
SVM: most muscles of pharynx and larynx.
11 CNXI Spinal accessory
GSM: trapezius and sternocleidomastoid.
SVM: a few fibers run with CNX to viscera.
12 CNXII Hypoglossal Intrinsic and extrinsic tongue muscles (except the palatoglossus).
, • Motor system
o When assessing overall motor function or motor function of a limb or the
trunk,
focus on body position, involuntary movements, characteristics of the
muscles (bulk, tone, and strength), and coordination. Muscle strength
is rated from 0 (indicating no muscle contraction detected) to 5
(indicating normal muscle strength with no evidence of fatigue with
active movement against full resistance).
• Sensory system
o When examining the sensory system, assess for sensation of pain and
temperature, position and vibration, light touch, and discrimination. If
there is sensory loss, assess if there is a pattern, if it is bilateral, and if
it is symmetric. The NP may use knowledge of dermatomes (areas of
skin that are innervated by the sensory root of a single spinal nerve)
to localize a lesion of the spinal cord.
• Reflexes
o Deep tendon reflexes should be interpreted only within the context of the
rest of
the neurologic examination. A reflex hammer is used to elicit muscle
reflexes. There are different uses of both the pointed end and the flat
end of a reflex hammer. For example, the pointed end is useful for
striking small areas, such as your finger as it overlies the biceps
tendon. Reflexes are rated from 0 indicating an absent reflex to 4
indicating very brisk with clonus. A wide range of normal reflex
responses exists; healthy people may have diminished reflexes, or
they may have brisk ones.
Mental Status Exam
• Level of Consciousness
o The Glasgow Coma Scale is a common tool used to assess a
client’s level of consciousness.
▪ Eye Opening Response
• Spontaneous - open with blinking at baseline - 4 points
• To verbal stimuli, command, speech - 3 points
• To pain only (not applied to face) - 2 points
• No response - 1 point
▪ Verbal Response
• Oriented - 5 points
• Confused conversation, but able to answer questions - 4
points
• Inappropriate words - 3 points
• Incomprehensible speech - 2 points
• No response - 1 point
▪ Motor Response
• Obeys commands for movement - 6 points
• Purposeful movement to painful stimulus - 5 points
• Withdraws in response - 4 points
• Flexion in response to pain (decorticate posturing) - 3 points
• Extenstion repsonse in response to pain (decerebrate
posturing) - 2 points
• No response - 1 points
o Score of 15 is the highest score possible
o Score equal to or less than 8 indicates the client is comatose
o Score equal to or less than 3 indicates the client is unresponsive
o
, • Appearance
o An individual’s appearance provides important clues about their mental
status. Activities of daily living (ADLs), including dressing and
grooming practices, may be some of the first behaviors impacted by
mental health issues. When an individual is severely depressed or
psychotic, they often present looking disheveled and with poor
hygiene. Assessment of appearance involves observing and
documenting posture, dress, grooming, and physical appearance
(including distinguishable markings such as scars or tattoos), facial
expressions, level of alertness, and attitudes.
• Behavior
o Behavior refers to how the client presents themselves during the
examination. Assess eye contact, psychomotor activity (increased or
decreased), movements, mannerisms, stereotypies, or posturing. Be
sure to observe how the client responds to the exam. Are the
responses appropriate to the situation, or does the client become
defensive and use posturing? Is the client able to sit still or do they
feel compelled to pace the room? Be sure to observe the gait. Are the
movements coordinated, slowed, or excessive?
• Speech & Language
o Speech is an important diagnostic indicator. Assess general speech
qualities, including rate, rhythm, latency, volume, and content. Is the
speech fast or slow? Is the rhythm monotone or slurred? Are there
increased or decreased pauses between questions and answers? Is
the speech volume soft, regular, or loud? Speech patterns can be
diagnostic indicators of a mental health issue when considered
alongside other assessment findings. For example, an individual who
presents with extraordinarily rapid and pressured speech with
constant interruptions may be in a state of hypomania or mania. An
absence of speech is common in dementia, and nonsensical speech is
often associated with schizophrenia.
• Mood
o Mood is the client’s state of mind or predominant emotion and is
typically described in the client’s own words. Some clients will easily
describe their mood; others may require questions to help elicit mood
statements. Documentation of mood should be as specific as possible.
Stable is a good descriptor for someone whose mood is appropriate to
their current situation. Other words used to describe mood might
include sad, depressed, angry, irritable, anxious, depressed, or
euphoric. Affect is the emotional state observed by the provider.
Affect could be described as normal, flat, dysphoric, or euphoric.
• Thought & Perception
o Expected Findings include:
▪ Organized thoughts
▪ Logical flow of thoughts
▪ Thoughts reflect reality
o Unexpected Findings include:
▪ Suicidal/Homicidal ideations
▪ Intrusive or unwanted thoughts
▪ Delusions
▪ Hallucinations
▪ Flight of ideas
▪ Poverty of thought
▪
