Cognitive Assessment in Nursing

Cognitive/Sensory Assessment

• Assessing level of consciousness involves evaluating responses to verbal, light, and pain stimuli to detect alterations in mental status.
• Normal speech patterns are clear, well-paced, and coherent, and should be appropriate for the patient's educational and socioeconomic level.
• Observing general appearance, including hygiene and appropriateness of clothing to setting and weather, can help detect alterations in mental status.
• Asking direct questions related to person, place, and time helps measure patient's orientation to their immediate environment.
• Giving simple commands, such as opening and closing eyes or sticking out tongue, can help detect alterations in level of consciousness (LOC) and orientation.

Cranial Nerve Examination

• The examination involves assessing the function of the 12 cranial nerves, which innervate various structures in the head, neck, and trunk.
• Cranial nerve II (optic nerve) is tested by evaluating visual acuity, visual fields, pupillary light reflexes, and accommodation reflex.
• Cranial nerve III (oculomotor nerve) is assessed by evaluating pupil size and eye movements.
• Cranial nerve IV (trochlear nerve) is evaluated by assessing eye movements and convergence.
• Cranial nerve V (trigeminal nerve) is tested by evaluating both sensory and motor branches, including sensation and muscle function.
• Cranial nerve VI (abducens nerve) is assessed by evaluating the ability to abduct the eye.
• Cranial nerve VII (facial nerve) is tested by evaluating facial movements and sensation in the face.
• Cranial nerve VIII (vestibulocochlear nerve) is evaluated by assessing hearing and vestibular function, including nystagmus and balance.
• Cranial nerve IX (glossopharyngeal nerve) is tested by evaluating taste sensation on the back of the tongue and gag reflex.
• Cranial nerve X (vagus nerve) is assessed by evaluating swallowing and speech.
• Cranial nerve XI (accessory nerve) is evaluated by assessing shoulder and neck movements.
• Cranial nerve XII (hypoglossal nerve) is tested by evaluating tongue movement and speech.

Neurological Assessment

• Neurological assessments are essential in identifying and evaluating neurological disorders to determine the integrity and function of the nervous system.
• Sensory motor assessment and cranial nerve examination are two critical components of a neurological assessment.

Sensory Motor Assessment

• Sensory motor assessment evaluates the patient's ability to sense and interpret different stimuli and respond appropriately.
• Muscle strength and tone are assessed by asking the patient to perform various movements, such as clenching their teeth or pushing against resistance.
• Reflexes are automatic responses to specific stimuli, and examples include the knee-jerk reflex and the abdominal reflex.
• Coordination is evaluated by testing the patient's ability to perform complex movements, such as tapping their fingers or foot quickly.
• Sensation is assessed by testing the patient's ability to feel light touch, pinprick, vibration, and position sense.