Help describing patient orientation

[Affsana]

I'm a student and had a cognitively impaired patient in restraints. This patient has difficulty communicating and didn't reply when I asked her name but she did say hospital when I asked if she knew where she was. She also communicated her elimination needs and pain. I put alert and oriented. What has me perplexed is that she kept pulling at her medical equipment (the reason for the restraints) and so my instructor said someone alert & oriented wouldn't do that but can't someone be alert & oriented & still resist treatment? Thank you.

[Jill2Shay]

There are levels to A&O. Alert means they're awake and will respond to you. I learned three levels of orientation: person, place and purpose. I would document 'alert and oriented to place'

[SoldierNurse22, BSN, RN]

Alert and oriented has a couple different layers of meaning.

"Alert" meaning that a patient is awake--they are conscious of their surroundings. This does not necessarily mean they are aware of where they are or even who they are.

That's where "oriented" comes in. Oriented refers to person--"Ma'am, can you tell me your name?"; place--"Mrs. Smith, do you know where you are?"; and time--"Mrs. Smith, do you know what year it is?" There are different ways to assess orientation, but the above questions are common ones used.

Yes, a patient who is A&Ox3 (they are alert and oriented to all 3 indicators of orientation) can be resistant to treatment. If a fully aware/autonomous patient is resisting treatment, we give them the option to opt out "against medical advice" or AMA.

It sounds like this patient has cognitive impairments that are known. Often times, patients like that will not understand restraints, even when they are placed in them for their own safety.

[mwlude]

As stated above, you are referring to the "A and O status" of this patient. commonly taught as Alert and oriented to person, place, time and event. who they are, where they are, what time (day, month, year, president?)it is and what the heck is happening or has happended to them. i dont usually report A and O status as A+O x 1 or 2 or 3 because thats almost meaningless. I always report WHAT they are oriented to. "the patient is alert and oriented to self only." saying "alert and oriented times one" leaves room for interpretation and as you can see...everyone learned it differently so my "alert and oriented times one" wont necessarily be my cross shifts "alert and oriented times one".

[nurseprnRN, BSN, RN]

You can never go wrong using plain English to describe things; no one will think you stupid for saying it clearly as opposed to using jargon or abbreviations that can be misunderstood.

So: don't say your patient ambulates, verbalizes, and is oriented times two.

Say your patient walks, talks, and knows her name and that she is in the hospital but not why.