Cognition, Vision, Somatosensory Competency

Pain (Sharp/Dull)

A primitive protective measure, alerting the organism to potential danger. Materials Needed: Safety pin, paper clip (do not use safety pin if client presents skin breakdown, open wounds, or dry, cracked skin) Procedures: Occlude the patient's vision. Randomly apply the dull or sharp end of a safety pin or paper clip to the screening area. Apply the stimulus to the patient's face, upper arm, forearm, digits, bottom of the feet, and toes, in accordance with the dermatome chart. Apply the stimulus three times to a specific area. Ask the patient to indicate sharp or dull when the stimulus is felt. If sharp or dull verbalizations are not possible, the patient should respond with established alternative communication method. Document whether the patient presents with sensory loss along specific dermatome regions. Can the patient feel or identify sharp items or utensils when reaching into a kitchen drawer? Can the patient feel or identify a shoe placed on the wrong foot? Impairment if patient is unable to identify pain sensation when applied. A score of two out of three incorrect answers for three stimuli is indicative or impairment.

Planning

A scheme or method of acting, doing, preceding, making, etc., developed in advance Textbook: Planning is the ability to mentally conceptualize an event or activity that will occur in the future. It involves the ability to assess task demands, analyze and synchronize the components of a task, consider a range of options, and make a decision regarding the best course of action. Ask the client to make a grocery list, ask the client to budget paycheck, ask the client to plan a trip. See if the client can make a grocery list for a upcoming party of 30 people, see if the client can make a budget for the upcoming month with enough money to pay bills and additional costs, plan a vacation to the beach. Cognitive impairment may be indicated if the patient demonstrates difficulty planning a basic self-care task of two or three steps.

Contrast Sensitivity

Ability to detect subtle changes in contrast between the background and foreground. Ask a patient to fill a clear glass with water from a pitcher to within 1 inch from the rim of the glass. Ask the patient to sort a pile of white laundry. Ask the patient to distinguish blue, black, brown, and purple material. Observe a patient negotiate steps and curbs. Using different contrast settings on a kindle, see when the client is able to read the words. Ask patient to distinguish color, color code closet. Impairment indicated if the patient has difficulty determining the liquid level in a clear glass, requires additional lighting to perform tasks such as self-care and reading, and has difficulty distinguishing among (a) white, beige, and tan and (b) blue, black, purple, and brown. In addition if the patient demonstrates a hesitation when negotiating curbs or steps or trips.

Temperature (Hot/Cold)

Ability to distinguish various changes in temperature serves as a protective measure. Materials Needed: Test Tubes, Hot and Cold Water Procedures: Occlude patient's vision. Randomly apply test tubes containing hot and cold water. Apply the stimulus to the patient's face, upper arm, forearm, trunk, digits, lower extremities, bottoms of the feet, and toes, in accordance with the dermatome chart. Is the patient aware of changing water temperature when washing his or her hands? Can the patient feel heat emanating from an electric stove-top (without touching surface)? Can the patient detect the water temperature when stepping into the bathtub? Impairment if client unable to distinguish hot from cold, or if the patient is unable to recognize and accurately interpret temperature stimuli.

Proprioception

Ability to identify ones trunk and limbs in space when vision is occluded. Test 1: Occlude the patient's vision. Move the patient's shoulder of the involved extremity back and forth many times from flexion to extension ending by holding the arm in flexion. Ask the patient if their arm is up or down. Have them mimic the placement with their uninvolved arm. Test 2: Occlude the patient's vision. Move the patient's knee of the involved extremity back and forth many times from flexion to extension ending by holding the knee in flexion. Ask the patient if their knee is bent or straight. Have them mimic the placement with their uninvolved leg. Observe movement during ADL Impairment if patient is unable to state the positioning of the assessed joint or unable to reproduce the positioning with the uninvolved extremity.

Graphesthesia

Ability to interpret letters drawn on the palms surface. Procedures Instruct the patient that you are going to write letters on his or her hand using your fingertip. Write five letters on your patient's hand, one at a time. Ask the patient to identify each letter. Test uninvolved hand first. Repeat with involved hand Traced words onto client's hand and see if they can identify what word it was. Impairment indicated if client is unable to identify three out of five letters

Visual Tracking or Pursuits

Ability to lock onto and maintain function on a moving target across all visual fields. In a well illuminated room with minimal distraction, present the patient with a high contrast object such as an index car, orange ball, or item of personal relevance to the patient. Hold the object approximately 16 inches from the nose. Present the object in mid position to allow for visual fixation. Slowly move the object across the right visual field, toward the superior visual field, toward the inferior visual field, and to mid position. Slowly move the object diagonally into upper and lower visual fields. Observe the patient's ability to track movement of people within the room. Play a game of catch with the client to see if they can track the object. Impairment if patient unable to visually track objects across visual fields, if unable to coordinate the movement of both eyes simultaneously in the same direction or unable to isolate head from eye movements.

Visual Acuity- Near

Ability to read and perform near tasks such as needlepoint, buttoning, and writing. In a well illuminated room, place the patient in a sitting position. Provide the patient with a near visual acuity chart held 16 inches away from the eyes. Have the patient read top to bottom. Continue until the patient misses more than 50%of the line or reading speed is considerably decreased. Ask the patient to read a line of a standard size newspaper or magazine. Continue for one page Complains of blurry or fuzzy print. Is unable or has difficulty reading print. Complains of print being too faint or small. Complains of lighting issues. Blinks excessively. Rubs eyes. Changes the focal length of the reading material. Shifts the page position. Views out of corner of eye. Has difficulty performing fine motor tasks such as buttoning or cutting with scissors.

Stereognosis

Ability to recognize shapes, objects, and textures by touch, with vision occluded. Materials Needed: Six familiar objects (coin, pen, screw) Procedures Have the patient occlude both eyes. Select six familiar objects. Place one object at a time in the patient's involved hand. Begin with the uninvolved hand and be sure the patient is using thumb and fingers. Allow the patient to manipulate the object for five to ten seconds. Ask the patient to name the object being manipulated. Finding a pen in a book bag without looking. Finding keys in a purse without looking. Impairment is client is unable to identify object three or more objects without seeing them.

Anosognosia

An extensive neglect syndrome involving failure to recognize one's paralyzed limbs as one's own. Ask the patient to show you his or her affected upper extremity (ask him or her to show you the left or right arm). If the patient cannot or if the patient can show you only his or her unaffected upper extremity, anosognosia is indicated Take the patient's affected upper extremity and shake hands with that limb. Ask the patient whose hand you are shaking. If the patient cannot recognize that you are shaking hands with his or her affected upper extremity, anosognosia is indicated. Ask the patient to tap the affected leg with his or her unaffected hand. If the patient cannot tap his or her affected leg, anosognia is indicated. Show the patient a colored block. Tell the patient that you are going to put the block somewhere on her body. Place the block on the patient's unaffected thigh. Ask the patient to find the colored block, then repeat the procedure with the affected lower extremity. If the patient cannot find the block placed on the affected lower extremity, anosognosia is indicated. Observe client getting dressed. See if they are aware of their affected extremities. Look for awareness of all limbs.

Insight

An instance of apphrending the true nature of a thing. Test client's ability to demonstrate an understanding of one's own strengths and weaknesses, motivations, and behaviors. Ask the client to describe both personal strengths and weaknesses. Ask the client to write about a recent situation and how they reacted. Note whether the patient is aware of deficit areas.

Visual Acuity- Far

Associated with tasks such as driving, reading signage, discriminating faces and objects, and watching television. In a well-illuminated room, place the patient in a seated position. Provide the patient with a distance acuity chart. Set chart distance for 10 or 20 feet from the patient, depending on what chart is being tested. Occlude the patient's left eye with a patch and ask the patient to verbally identify the letters in the specified line. Have the patient read top to bottom and left to right. Continue until the patient misses more than 50% of the letters. Record acuity as the last line which the patient was successful and note the number of letters missed. Repeat with right eye occluded. Repeat with both eyes. Have the patient read signs and room numbers either through functional ambulation or from wheelchair level. Has difficulty reading signs. Havs difficulty identifying faces and objects. Has difficulty driving. Squints and blinks excessively. Adjusts reading material closer to eyes.

Pupillary Light Response

Controls the amount of light entering the eye and allows us to adapt to illumination changes within the environment. Observe the pupil size of each eye in a well-lit room. Compare the size of both pupils. Note size in mm(normal=3). In a dimly lit room, hold a penlight approximately 4 inches from the patient's eye. Shine light into one eye for 2 seconds. Observe for rapid constriction and maintenance of stimulated pupil. Observe equal constriction of nonstimulated pupil. Normal pupillary construction from a light source is 1.5 mm in both eyes. Repeat on nonstimulated eye. Indicated if the pupil is greater or smaller than 3 mm or assymetrical, if the nonstimulated pupil does not constrict or constricts too slowly, or if pupil does not remain constricted.

Extraocular Range of Motion

Degree of range of motion present in each eye within all six cardinal planes In a well-illuminated room with minimal distractions, hold a brightly colored target approximately 16 inches from the bridge of the patient's nose. Slowly move the object in an arc laterally toward the patient's right shoulder and then slowly towards the left shoulder. Return the target to midposition. Move the target in an upward direction toward the top of the patient's head and then down toward the chin. Return to midposition. Move the target in an upward diagonal direction toward the upper right temporal area, then in a downward diagonal pattern toward the patient's right shoulder. Return to mid position. Repeat without occlusion of the eye. Impairment indicated if eye is unable to complete the full range of motion within the direction tested.

Topographical Orientation

Difficulty comprehending the relationship of one's location to another. Ask the patient to find his or her way back from the occupational therapy treatment setting to his or her hospital room. Ask the patient to find his or her way back from the occupational therapy treatment setting to the dining room or cafeteria, lobby, gift shop. See if the client is able to find way around different sections of a grocery store. Indicated if patient commonly becomes lost while trying to navigate around the treatment setting using verbal directions and/or a written or pictorial map.

Spatial Relations Dysfunction

Difficulty using concepts relating to positions, such as up/down, in/out, behind/in front of, and before/after. Instruct the patient to follow at least three of the following directions using the above terms: - Place the pencil on top of the box. Place the box inside the drawer. - Take the pot from underneath the sink and place it on the table. Put the bag of rice inside the pot. - Place the comb in front of the small free-standing mirror and place the hairbrush behind the mirror. - Put the bar of soap on top of the sink and place the hairbrush inside the medicine cabinet. - Place the soup can on top of the shelf of the cabinet and put the cereal box on the bottom shelf. Use terms relating to positions to help client get the ingredients to make a meal. See if they can follow directional terms. Indicated if the patient demonstrates difficulty carrying out two of three of these commands.

Depth Perception/Stereopsis Dysfunction

Inability to determine whether objects in the environment are near or far in relation to each other and in relation to the patient. Place several blocks of different sizes on a table in front of the patient. Ask the patient to identify which blocks are the farthest away, which blocks are closest, and which blocks are at mid-range between the farthest and closest blocks. Place the patient in front of a window. Ask him or her to identify which objects are closest to the building, which are farthest, and which are midrange. Set the table and see if the client can identify what plate, glass, and utensils are closest to them, which are farthest, and which are midrange. Impairment indicated if the patient is unable to accurately determine which blocks are closest, farthest, and midrange. Also indicated if the patient is unable to accurately determine which objects (outside the window) are closest to the building, which are farthest, and which are at mid-range.

Alertness/Arousal

Fully aware and attentive Is the patient alert and aware of his or her surroundings? Do the patient's eyes open spontaneously when his or her name is called in a loud voice or when physically pinched? Does the client respond to their name appropriately? Does the client respond to touch? Can you tell me the color of my shirt? In stuporous state on unaware of environment. Should be alert and aware of surroundings

Light Touch

Function it to alert the individual to contact to the skin Occlude the patient's vision. Lightly stroke a small region of the patient's skin using a cotton swab or fingertip. Apply the stimulus to the patient's face, upper arm, forearm, fingers, and toes, in accordance with the dermatome chart. Apply the stimulus three times to a specific area. Ask the patient to indicate yes or no when the stimulus is felt If yes or no verbalizations are not possible, the patient should respond with the established alternative communication method. Document whether the patient presents with sensory loss along specific dermatome regions. Tactile Awareness: If you can feel it Tactile Localization: If you can identify where Can the patient feel the shirt material on his or her arm? Can the patient feel the sock sliding over his or her foot? Impairment indicated if the patient is unable to identify when the stimulus was applied. A score of two out of three incorrect answers indicates impairment

Figure-ground perception dysfunction

Inability to distinguish objects in the foreground from objects in the background. Ask the patient to pick out forks from a kitchen drawer with disorganized, multiple utensils. Ask the patient to find the white toothbrush, bar of white soap, and white washcloth as they sit against the background of a white bathroom sink. Ask the client to organize closet and see if they can arrange the clothing and pick out requested items. Indicated if the patient is unable to pick out more than half of the forks from the other utensils and is unable to easily find the white toothbrush, soap, and washcloth against the white background of the bathroom sink.

Visual Agnosia

Inability to identify and recognize familiar objects and people Show the patient several familiar items, one at a time (ex. Pencil, eyeglasses, hair-brush, keys, wristwatch) and ask to identify object. Bring the client into the bathroom and ask them to identify the tools to brush his or her teeth (ex. Toothbrush, toothpaste, floss) If the patient is experiencing word-finding difficulties, offer a choice of three answers. Visual agnosia indicated if patient is unable to name four out of five objects.

Right-Left Discrimination Dysfunction

Inability to accurately use the concepts of right and left. Ask the patient to point to his or her own right and left body parts. Ask the patient to follow your right-left commands as you give him or her right-left directions to walk around the treatment environment. See if client can follow right left directions while driving. Indicated if the patient confuses right and left three out of four times when pointing to right and left body parts. It is also indicated if the patient confuses right and left commands to walk around the treatment environment.

Prosopagnosia

Inability to identify familiar faces because the patient cannot perceive the unique expressions of facial muscles that make each human face different from another Show the patient photographs of familiar objects (ex. World leaders, celebrities, sport figures). Make sure the famous people shown are individuals whom the patient would recognize, that is, people from the patient's own era or culture. Show the patient photographs of familiar family members. Ask the patient to identify the names of the people in the photographs. If the patient is unable to think of the individuals' names, ask the patient what the famous people are known for. Or offer the patient a choice of three answers. If the patient is an expressive aphasic, allow him or he to nod "yes" in response to the correct answer. Hold a mirror in front of the patient's face. Ask the patient to identify the person reflected in the mirror. Or give the patient a photo of him or herself and ask the patient to identify the person shown. Attend a family event with the client and ask him or her to introduce you to family members. Indicated if the patient is unable to identify familiar family members, famous people, and/or him or herself as reflected in a mirror or photograph.

Unilateral Neglect

Inability to integrate and use perceptions from one side of the body/or one side of the environment Ask the patient to perform the following tasks: - Draw a clock. Note whether the patient neglected to fill in the numbers on the left side of the clock. - Draw a human figure. Note whether the patient drew only one-half of the body or left off limbs on one side of the body. Ask the patient to read a paragraph from a book or magazine page. Note whether the patient begins each sentence at the middle of the page and ignores the words to the left of the midline. Give the patient a page on which columns of letters appear. Instruct the patient to cross out all of the H's. Note whether the patient crossed out only the H's on the right half of the page and ignored those on the left half of the page. Observe the patient while eating. Note whether the patient attends to both sides of the plate or ignores the food on the left half of the plate and meal tray. Observe the patient during the morning grooming routine. Note whether the patient fails to shave one side of his face or bathe one half of his or her body. Observe the patient while dressing. Note whether the patient is able to dress both halves of his or her body or whether he or she dresses only one side. Ask the client to set the table for a meal and note if the left side of the table is attended to or not. Look for awareness of both sides of the environment.

Color Agnosia

Inability to remember the appropriate colors for specific objects. Ask the patient to name the correct color for the following objects (do not present the actual object but rather only state the object's name): an apple, an ocean, a fire engine, a stick of butter, coffee. Determine whether the patient is able to accurately identify the color of the named objects. Present the patient with several objects, two of which are inaccurately colored. For example, present the patient with several pieces of plastic fruit, two of which are the wrong colors and ask the patient to identify which objects are incorrectly colored. Show the client different color clothing and see if they can identify what color it is. Indicated if the patient is unable to identify the correct color for named objects and is unable to identify which shown objects are incorrectly colored.

Immediate Recall (Short Term Memory)

Information retained in the brain that is retrievable over a brief span of time. Ask the patient about events that occurred in the past 24 to 48 hours. MMSE: Ask the client to repeat three words that are given to them such as apple, cat, sweater. What did you have for dinner last night? Did you have an visitors today? Who were they? What time did you wake up? What nurse did you see last? Cognitive impairment if client cannot answer more than half of the questions.

Long Term Memory (Declarative)

Information retrievable over a long period of time. Ask the client at least four of the following questions: What year were you born? Where did you grow up? What are the names of your children and what is the name of your spouse? What is your mother's maiden name? What year did you graduate from school? Where did you grow up? What are your parent's names? What state were you born in? What year did you graduate high school? Cognitive impairment indicated if the patient cannot answer more than two of the four questions.

Visual Scanning or Saccades

Quick, precise eye movements that are made during visual scanning or a visual search. In a well-illuminated room with minimal distractions, place the patient in a seated position. Sit opposite the patient. Hold two brightly colored targets of different colors 6-8 inches apart and approximately 12-16 inches from the patient. Ask the patient to hold head still and look from one object to the other when told to. While the patient is fixating on the stated color, move the other target up or down. Direct the patient to fixate on the newly positioned target. Assess midline, superior, inferior, and right and left quadrants. See if client is able to read a recipe. Have the client scan a crowded room for a specific object or person. If patient demonstrates understanding or overshooting between targets, shifting into all fields of gaze, nystagmus, and/or the inability to isolate head or eye movement.

Ocular Alignment

Required to achieve visual fusion. Corneal Reflection In a well-illuminated room, observe both eyes for alignment deviations. Eyes may be skewed in an inward, upward, or horizontal direction compared to the other eye. Lower the lighting within the room to allow for use of a penlight. Hold the penlight approximately 12 inches from the bridge of the patient's nose. Shine the light on the bridge of the nose. Compare the position of the corneal reflex in each pupil. Cover Test Ask client to cover eye while looking at distant object and record whether client moves uncovered eye to track object. Impairment if one or both eyes are deviated during general observation or the pupillary reflex is not equal in both eyes.

Blink Reflex

Semi-autonomic closing of the eye to protect from damage. Have the client stand behind a screen that is see through and throw a cotton ball towards their eye. Their blink reflex should be activated. Note if they did not blink.

Sensory Extinction

Simultaneous stimulation allows one to perceive touch on both sides of the body. This sensory function allows individuals to integrate different types of movement and to use bimanual manipulation during all aspects of ADL tasks. Extinction occurs when the patient can identify the area of stimulation of the involved extremity when touched alone but cannot identify the area of stimulation of the involved extremity when simultaneously touched on the same region of both extremities. Materials Needed: Finger or back of pen Procedures: Touch the patient on the dorsal surface of the involved hand. Ask the patient to indicate what body region has been touched. Touch the patient on the dorsal surface of the uninvolved hand. Ask the patient to identify on what body region they are being touched. Touch the dorsal surface of both hands simultaneously. Ask the patient to identify what body region has been touched. Extinction occurs when the patient cannot distinguish what area on the involved extremity has been touched. A person will not feel their clothes after wearing them for a long period of time. Impairment if client can identify the area of stimulation on both extremities.

Delayed Recall (Retention)

The ability to remember something after a period of rest or distraction. MOCA/MMSE: Give client a list of words and have them repeat it back to you 3-5 minutes later. Read a short grocery list to the client. After a certain amount of time ask them if they remember the items on the list. Client should be able to retain information for a certain period of time. Note if the client needs cues to recall the words given to them.

Abstraction or Abstract Thinking

The act of considering something as a general quality or characteristic apart from concrete realities, specific objects, or actual instances EFPT: State two different items and ask patient to state a similarity Say orange and banana. Patient should reply with a similarity between the two such a fruit Look for display of concrete thought, the tendency to interpret events and language by literal meaning. Occurs when there is damage to the frontal lobe.

Initiation and Completion (or Termination) of Task

The advent of motor activity that commences a task. The inhibition of motor performance drive by the knowledge that the task is finished. EFPT: Ask client to begin a task and see if they can complete it independently or if they need assistance. Client should be able to initiate ADL independently or with minimal cues and set up. Present the client with ingredients for a peanut butter and jelly sandwich. Ask the client what they would do with all the ingredients, see if they need more cues to start the task. Client should be able to terminate ADL independently or with minimal cues. Cognitive impairment indicated if patient does not initiate task or initiates task but then drifts into an inactive state and fails to fully prepare the sandwich. Also if patient is unable to terminate the task independently such as making multiple sandwiches that are not needed.

Sequencing of Task

The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step. EFPT: Assign client a task and see if they are able to complete the steps in the correct order Ask the patient to performa at least three of the following tasks: count forward and backward, count forward and backward by 7s, state the months of the year in sequence, describe the steps of laundry, demonstrate the steps of ordering a pizza. Ask the client to make pasta. See if they know to boil water first, then pour pasta, and take off stove when done. The individual carries out the steps in an appropriate order, attends to each step appropriately, and can switch attention from one step to the next Cognitive impairment indicated if patient inaccurately sequences two of the three tasks.

Judgment and Safety

The employment of reason and decision-making capabilities to intentionally avoid physically, emotionally, or financially dangerous situations EFPT: Ask the client to perform a task, watch to see if it is done safely. Textbook: Is the patient a safety risk to themselves and to others? Is the patient impulsive? Does the patient understand simple emergency procedures to use if an accident occurs? Describe at least four of the following emergency situations and ask the patient to determine what they would do: - You are asleep in your room at home. The smoke alarm goes off. - You lose your keys and are locked out of the house. - You are home alone. You fall and are unable to move your leg and are in great pain. - You are preparing dinner. High flames begin to come from the pan on the stove. - You are in a large shopping mall and become separated from the person you came with and are lost. Ask the client to bake cookies. Watch to make sure they use an oven mitt and remember to turn off the oven once cookies are removed. Ask how client would prepare for an upcoming storm or what they would do if they saw someone fall and get injured at the park. The individual exhibits an awareness of danger by actively avoiding or preventing the creation of a dangerous situation. Safety may be compromised if the patient demonstrates any of the above behaviors or is unable to offer an appropriate solution for any of the indicated emergency situations.

Simultagnosia

The inability to interpret a visual stimulus as a whole. Show the patient photographs of detailed scenes (ex. Farm with animals or crops, zoo, city street, inside a grocery store) Ask the patient to describe the scene in detail. Or take the patient to a window and ask him or her to describe the scene outside the window. Bring the client to a park, grocery store, mall, etc and ask them to describe what they see. Indicated if the patient is unable to understand the scene as a whole or attempts to fill in the parts he or she cannot interpret through confabulation.

Organization (Managing) Time and Space

The physical arrangement of the environment, tools, and materials to facilitate efficient and effective performance of steps. EFPT: Participant retrieves items needed before starting a task. If paying bills, client gets the necessary items to complete the task: pen, checkbook, bills, envelope, stamp. The individual correctly retrieves and uses the items that are necessary for the task.

Selective/Alternating Attention

The process by which a person can selectively pick out one message from a mixture of messages occurring simultaneously. Is the client able to follow instructions from the therapist while an outside conversation is occurring? See if the client can sustain attention with other distractions in the room. Bring client to the food court and see if they can answer questions in this environment. Is the client distracted by other conversations or is the client able to attend and focus on the therapist? Cognitive impairment if client needs redirection of the task or is easily/constantly distracted

Kinesthesis

The sense by which position, weight, and movement are perceived Test with proprioception but tell them to move opposite extremity at the same time moving testing extremity Observe them in the kitchen. Ask them to stir a pot with one hand and another pot with the other hand. Impairment if client unaware of where joints are moving in space.

Visual Field

The space one is able to see when looking straight ahead. Confrontation Test In a well-illuminated room, place the patient in a seated position. Sit opposite the patient at approximately 1 meter. Occlude the patient's right eye with an eye patch. Instruct the patient to fixate on the therapist's left eye. Place both arms behind the patient's head out of the patient's field of view. Slowly bring one arm into the patient's field of view, wiggling only one finger. Present the target four times. Test the superior, left, and right visual fields, and the inferior visual field. Instruct the patient to say "now" or raise his or her hand when he or she first sees the wiggling finger. Repeat with the left eye occluded. Functional Observation: Observe the patient move through a crowded environment either from wheelchair level or via ambulation. Have the patient read a paragraph or standard size newsprint. Have the patient address an envelope. Have the patient scan the therapy closet for specific items. Observe the patient perform a morning ADL task, such as grooming or dressing. Observe body position. Impairment indicated if unable to or demonstrates delay in identifying the stimulus in the presented visual field, collides with obstacles within one of the visual fields, demonstrates abbreviated visual scanning in any of the visual fields, omits words or letters when reading, demonstrates skewed/drifted writing, visually searches only half of environment, presents with postural deviations to the right or left, or complains of feeling off balance.

Vergence

The turning motion of the eyeballs towards or away from each other. Align fovea of both eyes with targets. Present object in front of patient and bring it forwards and backwards and see if they can follow it. Record the breaking point. Present patient with a pen and bring it forward and backward. If the client experiences double vision and is unable to bring the image into the same line of site.

Accommodation Reflex

Three step process involving a change in the thickness of the lens, convergence of the eyes, and pupillary constriction. Screening 1: In a well-illuminated room, place the patient in a seated position. Sit opposite the patient. Present the patient with a bright target held approximately 20 inches from the eyes. Slowly move the target toward the bridge of the nose as the patient is told to fixate on the moving target. Measure the distance when the patient states that he or she is no longer able to focus clearly on the target. Screening 2: Have the patient fixate on a distant object approximately 2 feet away. Present a bright object within 12 inches from the bridge of the patient's nose. Ask the patient to look at the distant object and then the near object. Repeat five times. Ask the patient whether either the near or distant object is difficult to bring into focus. Does the patient complain of blurred vision during the oral hygiene, cosmetic application, and shaving mpairment if eyes fail to converge equally, pupillary construction is delayed or absent, or the patient is unable to maintain clear acuity within 4-5 inches from the bridge of his nose.

Orientation

To adjust to relation to surroundings, circumstances, facts, etc Does the patient remember his or her name? Does the patient know that he or she is in the hospital? Does he or she know what season of the year it is? MOCA: The therapist asks the client the date. Can cue for a complete answer by asking more specific questions such as what year, month, day of the week MMSE: Ask questions to see if the client is oriented to time and place What is your name? Where do you live? Do you know what time of day it is? Do you know what the date is? Do you know what season it is? Patient unable to state accurately what season, time of day, location, name

Focused/Sustained Attention

To concentrate on a central point Is the client able to attend to a repetitive task for a certain amount of time? Read client a list of words and ask them to recite them back to you. Observe client playing a game of chess. Have the client watch a video clip of a football game and see if they can count how many times the football is passed. Patient should be able to perform assigned task for a certain period of time.

Vestibulocular Reflex

When the head moves, the vestibuloocular reflex responds with an eye movement that is equal in magnitude but opposite in direction Examiner holds the patient's head and moves it back and forth and then does a sudden jerk. The patient is unable to stabilize one or both of his or her eyes when sharp movement of the head occurs.