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CONSCIOUSNESS, ALTERED

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PHYSICAL DATA

Vital signs
Neurological evaluation including any evidence
of motor weakness, facial weakness, listlessness,
substantial change in function
Signs or signs of acute infection (fever, chills,
etc. )
Explanation of present intestinal and bladder function
Any indicators of bruising or other injuries
Pain assessment (location, characteristics, severity, etc. )
Evaluate and obtain particulars of mood, behavior,
orientation, and alertness
Blood sugar level
O2 sats

HEALTH CARE BACKGROUND

Patient’s age and sex
All present medications, including any recent adjustments
Any history of severe or chronic psychiatric disorders
Any recent history of fall, head injury or injury
Conclusions from prior neurologic or psychiatric
consultations
All current diagnoses
Any recent laboratory or diagnostic test results, including
blood sugar if patient is a diabetic

Assess whether resident can comply with basic
instructions
Ask resident name, particular date/time, place
Evaluate the appropriateness of the verbal
responses
Measure clearness of speech
Observe change in degree of consciousness such
as:
Alert: conscious and responds appropriately
Lethargic: very tired, but arouses to
stimulation
Stuperous: not completely alert, but responds
to discomfort
Comatose: is entirely unresponsive to
stimuli
Glasgow Coma Scale (GCS) is a neurological
scale that aims to present a reliable, objective way
of recording the conscious state of a person for
initial, as well as future analysis.
GCS:

http: //www. strokecenter. org/trials/scales/

glasgow_coma. pdf.

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