![]() ![]() Scores are added from these three categories to assign a patient’s level of responsiveness. Three primary areas assessed in the GCS include eye opening, verbal response, and motor response. See Figure 6.9 for an image of the Glasgow Coma Scale. The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess and continually monitor a patient’s level of consciousness when damage has occurred, such as after a head injury or a cerebrovascular accident (stroke). Common screening tools used frequently by registered nurses to assess mental status include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale (NIHSS), and the Mini-Mental State Exam (MMSE). There are many screening tools that can be used to further objectively assess a patient’s mental status and cognitive impairment. To assess a patient’s orientation status, ask, “What is your name? Where are you? What day is it?” If the patient is unable to recall a specific date, it may be helpful to ask them the day of the week, the month, or the season to establish a baseline of their awareness level.Ī normal level of orientation is typically documented as, “Patient is alert and oriented to person, place, and time,” or by the shortened phrase, “Alert and oriented x 3.” If a patient is confused, an example of documentation is, “Patient is alert and oriented to self, but disoriented to time and place.” Level of consciousness is typically evaluated on admission to a facility to establish a patient’s baseline status and then frequently monitored every shift for changes in condition. Assessing a patient’s orientation to time, place, and person is a quick indicator of cognitive functioning. Level of consciousnessrefers to a patient’s level of arousal and alertness. , See the “General Survey Assessment” chapter for more information about an overall mental status assessment. Routine assessment of a patient’s mental status by registered nurses includes evaluating their level of consciousness, as well as their overall appearance, general behavior, affect and mood, general speech, and cognitive performance.
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