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Mental and consciousness evaluation

LTC Nursing Assistant Trainer, October 23, 2008

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The resident’s level of consciousness and mental orientation are important indicators of neurological status.  A change in level of consciousness is the most important sign of neurological deterioration.

To assess level of consciousness and orientation:

• ask the resident his or her name. If the resident responds correctly, evaluate response to date/time, place, and situation. If response is appropriate, ask about season and year.
  • Disorientation commonly affects the resident’s knowledge of date first, followed by time, place, caregiver, and self.
• assess the quality of the verbal response. Evaluate the clarity of the resident’s speech and his or her ability to make him- or herself understood. Rambling responses suggest the resident is having problems with thought processes and organization.
• evaluate the resident’s ability to follow directions. Determine whether he or she can follow a simple command. Evaluate the resident’s ability to remain focused on the task.
• try painful stimuli if the resident does not respond to verbal stimuli. Assess for a response on both sides of the body to rule out monoplegia (paralysis of one limb).

This excerpt is from HCPro’s book, Clinical Documentation: An Essential Guide for Long-Term Care Nurses, written by Barbara Acello, RN, BSN

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