Nursing assessment principles and practice

Nursing Tools and Strategies to Assess Cognition and Confusion

A patient's cognitive ability can negatively impact their quality of life. With this in mind, Aird and McIntosh (2004) effectively describe the ambiguous nature of the term "confusion." They also clearly discuss several cognitive assessment methods, their use, and some drawbacks to the most popular methods. However, the authors don't make the connection between these two topics, relating how the ambiguous nature of "confusion" could impact these assessment methods.

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This paper reviews Aird and McIntosh's article "Nursing tools and strategies to assess cognition and confusion, " published in the British Journal of Nursing, in 2004. The authors discuss the implications for the nursing practice, regarding a nurse's bedside assessment of a patient's mental state. A patient's cognitive status is often not adequately assessed, despite the fact that a deficit in cognitive ability may impact all levels of their activities of living. To better understand the possible subtle differences in a patient's mental state, Aird and McIntosh (2004) explore the differences between confusion and cognition and describe several cognitive assessment tools.

Summary:

Aird and McIntosh (2004) note that oftentimes nurses use the term "confused" when describing a patient's mental state. Not only is this term ambiguous, but it also its meaning is highly dependent on the person using the term. When a patient, of any population, is presented with neurological dysfunction, their physical problems often overshadow their cognitive deficits, due to the fact the physical symptoms are measurable and observable. However, mental impairment may actually contribute to a patient's severity of physical impairment. In fact, mental illness can damage a patient in ways physical illness cannot, including altering the patient's interaction with their environment as well as their ability to communicate and maintain relationships. For this reason, nurses must have astute observational skills to detect their patient's discrete and continually changing problems.

Aird and McIntosh (2004) briefly overview Simpson's research conducted in 1994. The sample included doctors, registered nurses, psychiatric nurses, and patients, and he found that there was a wide discrepancy in what the term "confusion" meant. Yeaw and Abdate's 1993 study was also cited by the authors, which noted that the term "confused" included a large group of amorphous symptoms. These authors concluded that the focus of assessment should be how this ambiguous confusion affected the patient's ability to function.

Thinking, remembering, perception, and organizing information are all components of cognition. Aird and McIntosh (2004) surmise that cognitive function is necessary for a multitude of functions, including language, abstract reasoning, visuospatial ability, set shifting, attention and mental tracking, and memory. Cognition is also an integral part of awareness of self and one's environment. Citing Merluzzi, Aird and McIntosh conclude that cognitive assessment, from a clinical perspective, does not have to only include neuropsychological assessment or intelligence testing. Although intelligence testing is an important part of cognitive functioning, it can instead be included in a more formal neuropsychological testing. Mental status, however, can have a profound negative effect on cognitive assessment. With a strong correlation between anxiety and test performance, anxiety can degrade behavioral performance, which causes increased intrusive thinking and increased anxiety, which results in further degradation of performance.

Holden, according to Aird and McIntosh (2004), offers a simple and effective assessment method. A patient is given a magazine or newspaper and functions can be assessed, such as memory, picture recognition, comprehension, speech, attention, apraxias, presence of unilateral neglect, and the ability to read. Pat Barker used the serving of afternoon tee in much the same manner. As new patients went about the process of making their cup of tea, many neurological functions could be assessed without formal testing.

The Glasgow Coma Scale (GCS) is one of the most widely used and best known neurological assessment tools. Introduced in 1974, GCS provides a simple and uniform assessment of a patient's level of consciousness. Aird and McIntosh (2004) cite Teasdale as stating the GCS is superior to technological monitoring. It measures three modes of behavior: verbal response, eye opening, and motor response, with each graded on a scale of increasing dysfunction. These scores are then combined to determine a consciousness level. However, Aird and McIntosh cite Segatore and Way as considering the psychometric properties of GCS to be weak, because it lacks the subtleties needed to appropriately detail patients who have discrete disturbances of intellectual function.

The MiniMental Status Examination (MMSE) is one of the most commonly referred to assessment tools. It was developed to assess psychiatric patients' cognitive abilities. It is used particularly in elderly care settings, according to Aird and McIntosh (2004). The MMSE measures attention, orientation, calculation, registration, recall, use of language, and the ability to follow a three-part command. Eleven open-ended questions are used to evaluate the person's recall, orientation and ability to follow simple visuospatial commands. Although it is not used to diagnose cognitive problems, the MMSE is used to confirm or rule out cognitive impairment.

Evaluation:

The article effectively describes several cognitive assessment tools. In addition to describing their features and benefits, the authors also point out some of the limitations of these tools. The ambiguous nature of the term "confused" is also discussed quite throughly, with some previous research briefly overviewed to provide support for this theory. However, despite these areas where the authors have done well, they missed the mark on several critical areas.

First, the abstract and introduction of the article leads the reader to believe the article is going to be focused on the differences between confusion and cognition. However, a majority of the article discusses different cognitive assessment tools. Although the ambiguity in the term "confusion" could be discussed as it relates to these tools, the authors never make this connection. Instead, it's as if they are having two different discussions within their article. This is what would have interested me far more, then the handling of them as two disparate topics.