Levels of Consciousness
Client is responsive, opens eyes, responds to normal tone of voice
Alert
How to assess orientation
Ask client present time ( time, day, month), person ( who they are) & place (where they are at now).
APA’s professional reference book on mental health and brain-related conditions.
DSM-5 or DSM-5-TR
Assist w/ problem solving, crisis intervention, stress management
Counseling
Client unconscious with no response to painful stimuli
Comatose
Tool used to assess cognition
MMSE (Mini Mental Status Exam)
Nurses use to provide basis for appropriate nursing interventions.
North American Nursing Diagnosis Association (NANDA)
Teaching social and coping skills
Health teaching
Client able to open eyes & respond but drowsy and falls asleep readily.
Lethargic
How to assess immediate memory
Ask client to repeat series of numbers or objects.
Standardized tool to assess depression in geriatric patients
Geriatric Depression Scale
Assist w/ cessation of smoking & other substance use, monitor other health conditions.
Health promotion & maintenance
Client requires strenuous or painful stimuli to elicit brief response,
Stuporous
How to assess judgment
Based on answer to hypothetical such as what to do if a fire broke out in their room. (response should be logical).
Pain assessment tool for clients with Advanced Dementia
PAINAD scale (Memory trick: PAIN + AD for Advanced Dementia)
Process of assessment, planning, care coordination, and advocacy designed to meet comprehensive health needs.
Case Management
Serious, abnormal body positions that signal severe, life-threatening brain or spinal cord injury
Decorticate or Decerebrate ( more severe) Posturing.
How to assess ability to calculate
Have client count backwards by 7’s
Structured tool that providers use to check the social & emotional health of adolescents.
HEADSSS
Orient to physical setting, identify rules & boundaries , ensure safety, assist in appropriate activities
Milieu therapy