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a. Lifestyle
b. Independence in ADL
c. Ability to take responsibility for his life (decision
making, cognitive function, etc.)
d. Ability to cope psychologically & emotionally with
stress
(ALL of 3 above is referring to the idea that rehabilitation begins on
admission)
1. Level of consciousness
a. controlled by reticular activating system (RAS)
1
(1) Assess orientation to:
4 spontaneously
3 on request
2 to pain stimuli
1 no opening
6 obeys a command
5 localizes a painful stimulus
4 normal flexion either arm
3 abnormal flexion of arm
2 extends arm to painful stimulus
2
1 no response
(The total GCS score is a sum of the numeric values assigned to each of the
three areas evaluated. The highest GCS score is 15 for a fully alert person, and
the lowest possible score is 3. A GCS score of 8 or less is generally indicative of
coma.)
a. size of pupils
b. Reaction to light
c. Eye Movement
a. light touch
3
b. deep pressure
c. pain
d. temperature
*ask to close eyes, compare for both sides
*ask pt. to differentiate between cold & warm water during bath
5. Motor Function
a. muscle size
(a) atrophy
(b) asymmetry
b. muscle tone
(a) flaccidity
(b) spasticity
(c) rigidity
c. muscle strength
d. reflexes
(1) gag
4
(a) stroke one side of the mucous membrane
of the post pharynx at a time
(b) should gag
(2) swallow
a. temperature
(1) controlled by the hypothalamus
(2) could be subnormal or elevated
(3) take rectally in unconscious pt
(4) stay with the pt while the thermometer is in place
(5) always record the route used
(6) assess every 30 minutes until normal
b. pulse
5
c. blood pressure
d. respirations