How do you describe an adult patient's sensorium?

How to Describe a Patient's Sensorium

Describe a patient's sensorium by documenting their level of consciousness (wakefulness/arousal) and content of consciousness (awareness of self and environment), using standardized terminology ranging from alert to coma, supplemented by validated assessment tools when appropriate.

Core Components of Sensorium Assessment

The term "sensorium" refers to the state of a patient's consciousness, which has two fundamental dimensions that must be evaluated 1, 2:

• Level of consciousness (arousal/wakefulness): The degree of alertness and responsiveness to stimuli, mediated by the ascending reticular activating system in the brainstem and thalamus 3, 2
• Content of consciousness (awareness): The patient's awareness of self and environment, their cognitive function, and ability to process information 1, 2

Standardized Descriptive Terms

Use these hierarchical terms to describe level of consciousness, progressing from normal to most impaired 3:

• Alert: Normal wakefulness with full awareness of self and environment 1
• Somnolent/Lethargic: Drowsy but easily arousable to normal alertness with minimal stimulation 3
• Obtundation: Decreased alertness with tendency to fall asleep, requires moderate stimulation to arouse 3
• Stupor: Arousable only with vigorous or painful stimulation, returns to unresponsive state when stimulation ceases 3
• Coma: Unarousable unresponsiveness to all stimuli 3

Validated Assessment Tools

For acute neurological conditions (especially stroke), use the NIH Stroke Scale (NIHSS) Item 1a (Level of Consciousness), which provides standardized scoring from 0 (alert) to 3 (coma) 4, 5.

For critically ill patients who cannot self-report, behavioral assessment is essential 6:

• Behavioral Pain Scale (BPS) for intubated patients 6
• Critical-Care Pain Observation Tool (CPOT) for all ICU patients 6
• Numerical Rating Scale (0-10) for patients who can communicate 6

Comprehensive Neurological Examination

Beyond describing consciousness level, document associated findings 4:

• Cognitive function: Attention, memory, executive function, language 4
• Sensory function: Vision, hearing, tactile sensation 4
• Motor function: Strength, coordination, gait 4
• Cranial nerve function: Especially pupillary responses, eye movements 4

For patients with cognitive impairment, use validated screening tools like the Montreal Cognitive Assessment (MoCA) or Brief Interview for Mental Status rather than subjective descriptions 4, 7.

Documentation Best Practices

Avoid vague terms and instead provide specific observations 1:

• Document the exact stimuli required to arouse the patient (verbal, tactile, painful)
• Describe the quality and appropriateness of responses (purposeful vs. non-purposeful movements)
• Note fluctuations in consciousness level over time
• Record specific deficits in cognitive domains (attention, memory, language) rather than global terms like "confused"

Common Pitfalls to Avoid

Do not use subjective terms like "lethargic" without specifying the stimulus required for arousal and the quality of response 1. This leads to inconsistent assessments between providers.

Do not assume patients with severe motor deficits lack awareness—up to 40% of patients with disorders of consciousness may be misdiagnosed based on behavioral assessment alone 8. Consider that cognitive function may be present despite inability to demonstrate it behaviorally 8.

Do not attribute altered sensorium to "normal aging" or dismiss subtle changes—these represent pathology requiring investigation 7.

For patients with sensory impairments (hearing loss, vision loss), document these separately as they affect your ability to assess consciousness content but not the consciousness level itself 4.