Assessing Level of Consciousness

Level of Consciousness (LOC)

• Assess alertness: Determine if the patient is awake and oriented to person, place, and time.
• Evaluate facial expressions and speech: Look for signs of frowning, grimacing, and clarity of speech.
• Notice eye contact: Reduced eye contact may have cultural implications.

Posture, Gait, and Motor Activity

• Observe posture: Is the patient sitting upright or slouched?
• Assess gait: Note if the patient walks with a straight posture or uses assistive devices like walkers or canes.
• Monitor motor activity: Evaluate frequency of position changes and overall mobility.

Skin Color and Lesions

• Ensure skin color is consistent with the patient’s ethnicity.
• Check for odors on the body or breath, noting any prominent odors.

Dress, Grooming, and Hygiene

• Evaluate suitability of clothing: Is it appropriate for the season? Examine the condition of clothing and shoes.
• Look for signs of distress: Indicators may include guarded postures or labored breathing.

Data Collection

• Subjective Data: Gather symptoms based on patient’s reports, history, and review of systems (PMH, PSH, family, and personal history).
• Objective Data: Collect signs through observations, physical exams, vital signs, and lab/test results.

Review of Systems (ROS)

• ROS gathers information about the patient's health concerns and symptoms across body systems.
• Identifies specific symptoms prompting healthcare visits and evaluates normal vs. abnormal functions.

OLDCART-M Framework

• Onset: Determine when symptoms began.
• Location: Identify where symptoms are felt and if they radiate.
• Duration: Assess the length and frequency of symptoms.

Vital Signs

• Temperature: Normal range is 36.5 - 37.5°C (97.6 - 99.6°F).
  • Abnormalities include hypothermia (<36°C), febrile (>38°C), and hyperthermia (>39°C).
• Heart Rate: Normal is 60 - 100 bpm; abnormal includes bradycardia (<60 bpm) and tachycardia (>100 bpm).
  • Check apical pulse at the 5th intercostal space midclavicular line.
• Pulse Oximetry: Normal O2 levels are 92-100%; below 90% is abnormal.
  • Measurement locations include fingertips and earlobes.

Pain Perception

• Approach pain assessment with care, especially for patients with a history of adverse experiences (ACEs).

Healthy People 2030

• Framework for identifying health risk factors and addressing clinical issues in the U.S.
• Goals focus on improving individual and community health, promoting health, and preventing disease.

Disparities in Healthcare

• Racial and ethnic minorities face higher chronic disease rates and premature death.
• Transgender individuals have a significantly increased risk of suicide attempts.
• Persistent racial disparities in maternal mortality and chronic disease prevalence for specific ethnic groups.

Diversity Awareness

• Recognition and appreciation of diverse health-seeking behaviors across different patient populations.

Generalization and Implicit Bias

• Generalization serves as a starting point for understanding trends; individual assessment is critical.
• Implicit bias influences judgment and behavior; self-awareness is essential in delivering equitable care.

Cultural Assessment Considerations

• Inquire about cultural identity, language preferences, and beliefs impacting health care.
• Understand the family structure and decision-making processes in the context of healthcare decisions.

Spirituality and Religion

• Spirituality encompasses personal beliefs and is broader than organized religion.
• Assess spiritual distress and consider rituals or beliefs regarding end-of-life care.
• Engage patients in discussions about their spiritual needs and preferences during hospitalization.