ORIENTATION PHASE MENTAL STATUS

Part I. Assess the level of consciousness.

✓ Introduce self and verify client’s identity a. Nasaan tayo ngayon?

b. Anong araw ngayon at oras (Date and Time)
(age and birthday).
✓ Explain the assessment procedure, ask for Observe appearance and Behavior.
cooperation, and inform the patient that you
a. Kumusta naman ang pagkakaupo mo ngayon,
will touch them.
komportable lang po ba kayo?
Part II. Observe mood, feelings, and expressions.
✓ Provide privacy a. Okay lang naman ba ang nararamdaman niyo
✓ Perform hand hygiene ngayon, may masakit ba?
✓ Wear gloves
Observe thought process and perception.
✓ Assist the patient to wear gown
a. Repeat after me:
HISTORY TAKING - 5 , 10 , 15, 20
- 20, 15, 10 , 5
Nakaka-experience ka ba ng headache, madalas na
pagsakit ng ulo? Observe cognitive abilities.
How about seizures? or nawawalan ng control sa a. 5 x 5 = 25
sarilina hindi namamalayan? b. 10 + 5 = 15
Nahihilo ka po ba? or feeling mo mawawalan ka ng
malay, matutumba?
Humihina po ba ang pang amoy at panlasa? CRANIAL NERVES
Cranial Nerve I. (olfactory)
Minsan ba nakakarinig ng ringing sa ears at or kaya
- clear nose using tissue paper.
humihina na ang pandinig niyo ma’am?
- close eyes, cover the other nose with a
Sa paningin or sa mata naman, may nagiging sagabal finger. anything they can smell
ba sa nakikita or kaya may pagbabago? - smell the calamansi and efficasent oil on
Kapag naman ganito pong may kausap ka, each nose and describe its smell.
nahihirapan ka bang maintindihan yung sinasabi sayo
or hindi ba nila naiinindihan yung mga sinasabi mo, Cranial Nerve II. (optic)
ma’am? - read Snellen chart.
Nahihirapan po ba sa pagsasalita at pakikipag-usap? - read a newspaper.
- test peripheral vision. (cover left & right
Sa paglunok naman, nahihirapan po ba? eye with cardboard then use a pen)

Cranial Nerve III. (oculomotor)

Sa pag control ng ihi at pagdumi, nahihirapan po ba?
Cranial Nerve IV. (trochlear)
Cranial Nerve VI. (abducens)
May nararamdaman po bang panghihina sa muscles
okaya ay hindi maigalaw? - check for pupil dilation.
- follow and look at the pen for H pattern.
Nagiging sobrang makakalimutin po ba tayo ma’am?
- look at the penlight then on me.

Nagkaroon na po ba ng head injury? Diagnosed ng Cranial Nerve V. (trigeminal)

sakit sa head?
- clench teeth, palpate temporal & mandibular.
May iniinom bang gamot? - pinch face with: ↓ then identify:
o paperclip (sharp)
o ballpen (light)
- touch the cornea with cotton tip.
Okay so before we start, gusto niyo po ba muna
uminom ng tubig or umihi? Cranial Nerve VII. (facial)

- smile, show teeth, pout, puff cheeks.

- raise eyebrows, close eyes tightly.
Cranial Nerve VIII. (auditory / vestibulocochlear) Test vibratory sensations.

- perform whisper test.

- T.fork on top of head.
- T.fork on mastoid process. (behind ear)

Cranial Nerve IX. (glossopharyngeal)

Cranial Nerve X. (vagus)

- observe uvula and soft palate.

- test for gag reflex
- check ability to swallow (water)

Cranial Nerve XI. (spinal accessory)

- raise the shoulders (trapezius muscles)

then test for resistance.
- turn the head on left & right.

Cranial Nerve XII. (hypoglossal)

- tongue out, move to left & right, up &

down.
- Use tongue depressor to move each side
against resistance of the tongue.
MOTOR AND CEREBELLAR SYSTEMS.
Test condition and movements of muscles.
- Move arms up and down.
- Move legs up and down.
- Hold arms up and push it down.
- Squeeze your two fingers by both hands.
- Fight resistance on behind of legs.
Test Balance.
- Ask the patient to walk.
- Ask patient to stand steadily with eyes
closed. (Romberg’s Test)
- Standing on one foot with eyes closed.
(left and right , one at a time)
Assess Coordination.
- Finger-to-nose test.
- Finger to nose and to the nurse’s finger.
- Fingers to hand.
- Heel down opposite shin.
SENSORY SYSTEM.
Test light touch, pain, and temp sensations.
*EYES CLOSED*
Test position sensations.
- Ask the client to close both eyes.
- Move the client’s toe in up and down.
- Ask the client to tell you the direction it is
moved.
Test tactile discrimination.
- Place the coin (1) then facemask (2) then
ask the client to identify it.
REFLEXES.
Test Deep tendon Reflexes.
Hit the following part using reflex hammer:
- Biceps
- Triceps
- Brachioradialis (anterior radial)
- Patellar (knee)
- Achilles (posterior tibial)
- Ankle clonus (move feet up)
Test Superficial Reflexes: Using tip of reflex hammer
- Plantar (stroke from down to up)
- Abdominal (stroke from up to down)
- Cremasteric reflex (applicable for male
only)
Test for meningeal irritation / inflammation.
- lay patient in a supine position and raise
the head.

- Ask the client to identify the area they
were touched upon testing the light touch
sensation with cotton.
- Next is for pain sensation. Use paperclip.
- Temp sensation. Identify whether hot or
cold touches the skin.
If the patient involuntarily flexes their hips and knees in
attempt to lessen traction forces to the meninges, the
patient may be positive to meningeal irritation or
meningitis.
Demo positive to Brudzinski’s test.