Practice Recommendations: Cognition/Perception/Language

Recommendation	Level of Evidence
8.0 Nurses in all practice settings should screen clients for alterations in cognitive, perceptual and language function that may impair safety, using validated tools (such as the Modified Mini-Mental Status Examination and the Line Bisection Test – appendix F of the Stroke Assessment Nursing BPG). This screening should be completed as follows: Within 48 hours of regaining consciousness: Arousal, alertness and orientation; Language (comprehensive and expressive deficits); and Visual neglect In addition, when planning for discharge: Attention; Memory (immediate and delayed recall) Abstraction; Spatial orientation; and Apraxia. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.	IV

Recommendation

Level of Evidence

8.0 Nurses in all practice settings should screen clients for alterations in cognitive, perceptual and language function that may impair safety, using validated tools (such as the Modified Mini-Mental Status Examination and the Line Bisection Test – appendix F of the Stroke Assessment Nursing BPG).

This screening should be completed as follows:

Within 48 hours of regaining consciousness:

Arousal, alertness and orientation;
Language (comprehensive and expressive deficits); and
Visual neglect

In addition, when planning for discharge:

Attention;
Memory (immediate and delayed recall)
Abstraction;
Spatial orientation; and
Apraxia.

In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

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Algorithm for Cognitive Screening in Stroke Clients

See the appendix of the Stroke Assessment Nursing BPG for the specified scales

Note:

Client needs to be alert to participate in the cognitive screen.
With changes in medical status and/or environment, a reassessment of the client’s cognition is warranted.

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Reference:
The Stroke Canada Optimization of Rehabilitation by Evidence (SCORE) Project Team (February 2005). Post-stroke Evidence-based Recommendations for Upper Extremity, Lower Extremity and Risk Assessment of Pressure Ulcers, Dysphagia,Falls, Cognition and Depression. Toronto: SCORE.

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