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NERVOUS SYSTEM

281

•

Does the pariem have an altered sleep pattern?

•

What is the handedness of the patient? (Handedness is a predicror of brain [language] dominance.)

Observation

Data that can be gathered from close or distant observation of the

patient include the following:

•

Level of alertness, arousal, distress, or the need for restraint

•

Body position

•

Head, trunk, and extremity posture, including movement patterns

•

Amount and quality of active movement

•

Amount and quality of interaction with the environment or

family members

•

Degree of ease or difficulty with activities of daily living

•

Presence of involuntary movements, such as tremor

•

Eye movement(s)

•

Presence of hemibody or hemispace neglect

•

Presence of muscle atrophy

•

Respiratory rate and pattern

Clinical Tip

The therapist should correlate these observations with

other information from the chart review and other health

care team members ro determine (1) if the diagnosis is consistent with the physical presentation, (2) what rypes of

commands or tone of voice to use, (3) how much assistance is needed, and (4) how to prioritize the portions of the physical therapy evaluation.

282 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Mental Status Exam;natioll

The mental status examination includes assessment of level of consciousness, cognition, emotional state, and speech and language ability.

Level of Consciousness

COlIsc;ouslless consists of arousal and the awareness of self and

environment, including the ability to interact appropriately in

response to any normal stimulus' Coma is often considered the

opposite of consciousness. Table 4- 1 0 describes the different States

of consciousness. Evaluating a patient's level of consciollsness is

important because it serves as a baseline ro monitor stability,

Table 4-10. Normal and Abnormal States of Consciousness

Alerr

Completely awake.

Aware of all stimuli.

Able to interact meaningfully with clinician.

Lethargic or

Arousal with stimuli.

somnolent

Falls to sleep when nor stimulared.

Decreased awareness.

Loss of train of thought.

Obtundent

Difficult to arouse.

Requires constant stimulation for all activities.

Confused.

Stuporous

Arousal only with vigorous stimulation.

Unable to complete mental Status examination because

responses are usually incomprehensible words.

Coma

Unarousable.

Nonverbal.

Delirium

State of disorientation marked by irritability or agitation,

suspicion and fear, and misperception of stimuli.

Patient demonstrates offensive, loud, and talkative

behaviors.

Dementia

Alteration in mental processes secondary to organic disease

that is nor accompanied by a change in arousal.

Sources: Data from RL Strub, FW Black (cds). Mcntal Status Examination in Neurolo!,'Y

(2nd cd). Philadelphia: FA Davis, 1985; and F Plum, J Posner (cds). The Diagnosis of

Scupor and Coma (3rd cd). Phil3delphia: FA Davis, 1980.

NERVOUS SYSTEM 283

improvement, or decline in the patient's condition. It also helps

determine the severity and prognosis of neurologic insult or disease state, thus directing the medical plan of care.

Clinical Tip

•

Level of consciousness is often vaguely described in

medical charts; therefore, be specific when documenting

a patient's mental status. Describe [he intensity of stimulus needed to arouse the patient, the patient's best

response, and the patient's response to the removal of

the srimulus.9

•

Changes in body position, especially the transition from

a recumbent position to sitting upright, often stimulate

increased alertness. Other stimuli to increase alertness

include daylight, radio or television sound, or a cold cloth

on the forehead.

•

Use a progressive intensity of stimuli to arouse a patient

with decreased alertness or level of consciollsness. For

example, call the patient's name in a normal tone of voice

before using a loud tone of voice, or tap the patient'S

shoulder before rubbing the shoulder.

• Time of day, fatigue, and side effects of medication

are factors that can calise variable levels of alertness or

participation in physical therapy. The documentation of

these factors is important for communication among the

health care team and for the rehabilitation screening

process.

•

A & 0 x 3 is a common abbreviation for alert and

oriented to person, place, and time. The number may be

modified to reflect the patient'S orientation (e.g., A & 0

x I [selfl).

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is a widely accepted measure of level

of consciousness and responsiveness and is described in Table 4-:1 1 .

The GCS evaluates best eye opening (E), motor response (M), and

verbal response (V). To determine a patient'S overall GCS, add each