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Observe level of consciousness
Response to calling to client·s
name. If the client does not respond,
call the name louder. If necessary,
shake the client gently.
If the client still does not respond,
apply a painful stimulus.
Observe appearance and movement
p costure
p ÷ait
client alters position occasionally.
Alert & awake with eyes open
and looking at examiner; client
responds appropriately.
Relaxed, with shoulders back and
both feet stable
Smooth, coordinated movements;
Uncoordinated³staggering,shuffling,stumbling
Lethargy: Open eyes, answers questions,
and falls back asleep
Obtunded: opens eyes to loud voice, res-
ponds slowly with confusion, seems un-
aware of environment.
Stupor: awakens to vigorous to
unrepondsive asleep.
Coma: remains unrespondsive to all
stimuli; eyes stay closed. Client with
lesions of the corticospinal tract draws
hands up to chest (decorticate or abnor-
mal flexor posture) when stimulated.
Client with lesion of the diencephalon
midbrain, or pons extends arms and legs,
arches neck, and rotates hands and arms
internally (decerebrate or abnormal ex-
tensor posture) when stimulated.
Tense, rigid, slumped, asymmetrical posture.
slumped posture is seen with depression or
organic brain disease.
Jerky, uncoordinated; temors. Tics, fast or
slow movements are seen with
schizophrenia; tense fidgety, and restless
behavior in anxious patients.
 p Votor movements same as above
p |ress clothes fit and are appropriate Clothes extra large or small and inappropriate
for occasion and weather. For occasion. Inappropriate dress is seen with
depression, dementia, Alzheimer disease and
Schizophrenia.
p ygiene skin clean, nails clean & trimmed |irty, unshaven; dirty nails; foul odors. coor
ygiene is seen wirh depression, dementia,
Alzheimer disease, and schizophrenia; meti-
culous, finicky grooming in obsessive-
compulsive disorder.
p Facial expression good eye contact, smiles/frowns
appropriately. coor eye contact is seen in apathy is seen in
depression; masklike expression in parkinson·s
|isease; extreme anger or happiness in
anxious client.
p Speech Clear with moderate pace igh pitched; monotonal; hoarse; very soft or
weak. Slow, repetitive speech is present in
|epression or parkinson·s disease; loud and
rapid in manic phases, irregular,
uncoordinated speechin multiple sclerosis;
dysphonia in impairment of CN X; dysarthia
in cakinson or cerebellar disease; aphasia
in lesions of dominant hemisphere.

Observe mood by asking,

´how are you feeling?µ or
´what are your plans for
the future?µ

p Feelings ( vary from joy or Responds appropriately to topic Expresses feelings inappropriate to situation
anger) discussed; expresses feelings appro- (e.g. extreme anger or euphoria)
priate to situation

p Expressions expresses good feelings abour self, Expresses dissatisfaction with self, others,and
others, and life; verbalizes positive coping life in general; verbalizes negative coping
mechanisms (talking, support system, mechanisms ( use of alcohol, drugs, etc.);
counseling, exercise. Etc.) prolonged negative feelings seen with
 |epression; elation and high energy seen with
manic phases; excessive worry seen in
obsessive-compulsive disorders; eccentric
moods not relevant to situation are seen in
schizophrenia.

Observe thought process

and perception by ststing
´tell me your understanding
of your current health situationµ

p Clarity and content Expresses full and and free-flowing Expressed thoughts are jumbled, confusing, and
thoughts during interview. And not reality oriented.Repetition and express-
Ion of illogical thoughts are seen with
schizophrenia; rapid flight of ideas in manic
phases; irrational fears with phobias; delusions
seen with psychotic disordes, delirium, and
dementia; illusions seen with acute grief, stress
reactions, schizophrenia, and delirium;
hallucinations with organic brain disease or
psychotic illness.

p cerceptions follows directions accurately; is unable to follow through with directives;

perceptions realistic and consistent perceptions unrealistic and inconsistent with
with yours and others. Yours and others.

p Judgement answers to question are based on impaired judgment may be seen in organic brain
sound rationale syndrome, emotional disturbances, mental
retardation, or schizophrenia.
 Observe cognitive abilities
p Orientation³ask client
name, hour, date,season,
where he or she lives now.
p Length of concentration
p Vemory ²ask client ´what
did you eat today?µ (recent)
and ´when is your birthday?µ
(past)
p Abstract reasoning³ask client
to explain a proverb, eg, ´ a stitch
in time saves nine.µ
p Ability to make sound judgments
ask client question such as ´why
did you come to the hospital?µ or
´what did you do when you have
pain?µ
p Ability to identify similarities--
ask client questions such as
´how are birds and bees alike?µ
p Sensory perception and
coordination³ask client to
write name and draw the face
of a clock or copy simple figures
such as: circle, square, diamond, etc.
aware of self, others, place, time;
has address
listens to youand respond with full thoughts
correctlyanswers question s about current
day·s activities; recall significant past events.
explains proverb accurately
answers to questions based on sound
rationale.
Identifies similarities
writes name, draws clock and/or
simple figures.
unable to express where he or she is,time,and
who others are; does not follow instruction.
Reduced level of orientation is seen in organic
brain disorders.
Fidgets; does not listens attentively to you;
expresses incomplete thoughts. |istraction and
And inability to focus are noted with anxiety,fa-
tigue, attention deficit disorders, and altered
states due to drug or alcohol intoxication.
Unable to recall to recall any recent events with
|elirium, dementia, depression, and anxiety;
unable to recall past events with cerebral cortex
disorders.
Unable to give abstract meaning of proverb with
schizophrenia, mental retardation, delirium, or
|ementia.
Answers to questions are not based on sound
Rationale in organic brain syndrome, emotional
disturbances, mental retardation,or schizophrenia
Unable to identify similarity with schizophrenia,
mental retardation, delirium, or dementia.
|oes not write name or draw clock/figures accu-
Rately with mental retardation, dementia, or
parietal lobe dysfunction.