Glasgow Coma Scale (1)
The tool we use to assess the level of consciousness is the Glasgow Coma Scale (GCS). This tool is used at the bedside in conjunction with other clinical observations and it allows us to have a baseline and ongoing measurement of the level of consciousness (LOC) for our patients. The GCS has been in use in clinical practice for approximately forty years and is used universally around the world.
Using a universal assessment tool allows us as clinicians to quantify LOC of people in our care and produces a shared understanding of patients' conditions.
|Motor Response||Obeys commands||6|
|Localise to pain||5|
Using a coma scale to assess patient consciousness levels
VOL: 101, ISSUE: 25, PAGE NO: 38
Debra Fairley, MSc, Post Grad Cert, BSC, RGN, is critical care nurse consultant
Jake Timothy, FRCS, FRCS (SN), MBBS, EANS Part A, is consultant neurosurgeon; Juliette Cosgrove, Post Grad Dip, MA, BSc, RGN, is critical care nurse consultant; all at The Leeds Teaching Hospitals NHS Trust
Assessing a patient’s level of consciousness is an essential component of a neurological examination, which is usually performed alongside an assessment of pupil size and reaction, vital signs and focal neurological signs in the limbs.
The Glasgow coma scale, developed by Teasdale and Jennett (1974), is the most widely used assessment tool for measuring a patient’s level of consciousness. It is the method favoured by The Leeds Teaching Hospitals NHS Trust and this article outlines guidelines the trust has developed in order to standardise its practice and to minimise any possibility of misinterpretation.
Methods of evaluation
The Glasgow coma scale is based on three aspects of a patient’s behaviour - eye opening, verbal response and motor response (Table 1). A score is applied to each category and then added up to give an overall value ranging from 3 to 15. As well as calculating a total Glasgow coma score (GCS), a score for each of the three components must be calculated and recorded separately.
The original Glasgow coma scale included 14 points (Teasdale and Jennett, 1974). Two years later, its authors introduced a distinction between normal and abnormal flexion, increasing the ‘best motor response’ item by one point (Teasdale and Jennett, 1976). The extra point was introduced because the significance between flexion and abnormal flexion helped in assessing the patient’s prognosis.
The Leeds Teaching Hospitals NHS Trust uses the 15-point scale. A recent telephone survey of A&E hospitals revealed that some still use the older 14-point scale (Wiese, 2003).
Although neither scale is wrong, it is important that actual clinical response is communicated rather than simply giving a number. This enables nurses to work out the GCS whichever scale has been used.
The following are important points to note when assessing a patient’s level of consciousness using the Glasgow coma scale and calculating a GCS:
- The arms give a wider range of responses and, for this reason, are always observed using the Glasgow coma scale. Spinal reflexes may cause the arms or legs to flex briskly in response to pain and must not be interpreted as a response;
- Always record the best arm response. If the motor response is different on each side, the better response is used;
- Responses must be recorded on the patient observation chart in black ink. Changes in neurologic function, pupil response or GCS must be recorded in relevant nursing documentation including the date, time and signature;
- As the GCS is an assessment of consciousness level, it cannot be determined accurately in patients who are receiving anaesthetic agents. Where anaesthesia is being used, neurological assessment should focus on pupil responses;
- Some drugs may affect pupillary reaction and the effects of any prescribed medication must be considered when carrying out a pupil assessment;
- A GCS can still be determined in a patient who is sedated, although it must be noted that the score obtained might not be an accurate reflection of what the patient is capable of. In neurosurgical intensive care and high-dependency units, a patient’s GCS must be assessed at verbal handover or at the beginning of a shift by both nurses (at the same time) in order to avoid misinterpretation and facilitate continuity;
- When a patient with an impaired level of consciousness is transferred to another ward or department, such as recovery or ICU, a GCS must be assessed by both the nurse escorting the patient and the nurse receiving the patient (at the same time) in order to avoid misinterpretation and facilitate continuity of assessment;
- Although the Glasgow coma scale should be communicated using its individual components, a score from 3-15 may be used to summarise the scale. A deterioration of one point in the ‘motor response’ or one point in the ‘verbal response’ or an overall deterioration of two points is clinically significant and must be reported to medical staff.
Assessing eye-opening response
If a patient’s eyes are closed as a result of swelling or because of facial fractures, this is recorded as ‘C’ on the chart. Eye opening is meaningless in these circumstances.
Spontaneous eye opening
It is important to exclude the possibility that a patient is asleep before proceeding to assess eye opening. Spontaneous eye opening is recorded when a patient is observed to be awake with her or his eyes open. This observation is made without any speech or touch. Spontaneous eye opening is allocated a score of four.
Eye opening to speech
If there is no spontaneous eye opening, eye opening to speech is recorded when a patient opens her or his eyes to loud, clear commands. Eye opening to speech is allocated a score of three.
Eye opening to pain
If there is no eye opening to loud clear commands, eye opening to pain can be assessed. This can be recorded if a patient opens her or his eyes to a painful stimulus - finger tip pressure and supraorbital ridge pressure are the two most commonly used methods.
While it could be argued that supraorbital ridge pressure could cause patients to grimace and keep their eyes closed, finger-tip pressure could lead to misinterpretation of the eye opening response due to other complicating factors such as hemiparesis and high spinal cord injury. Also, the response elicited by finger-tip pressure might be misinterpreted as a motor response, particularly when the problems associated with ‘localising’ and ‘withdrawing’ to pain are taken into account. Eye opening to pain is allocated a score of two.
A recording of ‘none’ should be made when no response to a painful stimulus is observed. A complete lack of eye opening is given a score of one.
A patient with flaccid ocular muscles may lie with her or his eyes open all the time. This is not a true arousal response and should be recorded as a ‘no eye opening’ response and allocated a score of one. Such a response should not be documented as spontaneous eye opening.
Assessing best verbal response
If a patient has an endotracheal tube or tracheostomy tube in situ, this is recorded as ‘T’ on the chart under ‘no response’ and allocated a score of one.
If a patient is dysphasic, best verbal response cannot be determined with accuracy. This is recorded as a ‘D’ on the chart under ‘no response’ and allocated a score of one.
To be classified as orientated, patients must be able to identify
:- Who they are;
- Where they are;
- The month or year.
All three components must be identified correctly for a patient to be classified as orientated. Such a patient is allocated a score of five.
A patient is classified as confused when one or more of the above questions are answered incorrectly. A patient who is confused is allocated a score of four.
A patient is classified as using inappropriate words when conversational exchange is absent, that is, she or he tends to use single words more than sentences. Swearing is also common. A patient who is using inappropriate words is allocated a score of three.
A patient is classified as using incomprehensible sounds when her or his words and speech cannot be identified.
A patient may be mumbling, groaning or screaming. A patient who is making incomprehensible sounds is allocated a score of two.
A recording of ‘none’ should be made when the patient does not respond verbally to verbal or physical stimuli. A lack of verbal response is allocated a score of one.
Assessing best motor response
A patient’s ability to obey commands is assessed by asking her or him to grip and let go of the assessor’s fingers (both sides should be assessed). The patient must grip and ungrip to discount a reflex action. If there is any doubt, the patient should be asked to raise her or his eyebrows. A patient who obeys the commands achieves a score of six.
Localising to pain
If the patient is unresponsive to verbal commands she or he should be assessed for response to a painful stimulus. It is important to differentiate between localising to pain and flexion to pain: localising is a purposeful response and an indication of better brain function; flexion is not seen as a purposeful response and may be a reflex action. Supraorbital ridge pressure is considered to be the most reliable and effective technique for distinguishing localising from flexion or abnormal flexion as the observed response to this method is less likely to be misinterpreted.
A painful stimulus is applied to the supraorbital ridge to stimulate the supraorbital nerve. In the presence of facial fractures or gross eye swelling, pinching the earlobe is more favourable than applying supraorbital ridge pressure.To be classified as localising to pain, a patient must move her or his hand to the point of stimulation, bringing the hand up beyond the chin and across the midline of the body. A patient who is localising to pain is allocated a score of five.
Normal flexion response
In a normal flexion response to pain, no localising to pain is seen. This is recorded when, in response to a painful stimulus, a patient bends her or his arms at the elbow. It is a rapid response (likened to withdrawing from touching something hot) and is associated with abduction of the shoulder. A patient who has a flexion response to pain is allocated a score of four.
Abnormal flexion is recorded when, in response to a painful stimulus, the patient’s elbow flexes. It is characterised by internal rotation and adduction of the shoulder and flexion of the elbow. It is a much slower response than normal flexion and may be accompanied by spastic wrist flexion. A patient who exhibits abnormal flexion to pain is allocated a score of three.
Extension to pain
Extension to pain is recorded when there is no abnormal flexion to painful stimulus. A patient presents with straightening of the elbow joint, adduction and internal rotation of the shoulder and inward rotation and spastic flexion of the wrist. A patient who has extension to pain is allocated a score of two.
No motor response is recorded when there is no response to a painful stimulus. No motor response is allocated a score of one.
Focal neurological observations are used to localise cerebral disease to a specific area of the brain. Evidence of focal abnormalities may or may not coexist with evidence of diffuse brain function. Pupil size and reaction to light are important neurological observations.
Normal pupils are round and equal in size. The average size is 2-5mm in diameter. A millimetre scale is used to estimate the size of each pupil.
The shape of each pupil should be recorded. Abnormal pupil shapes may be described as ovoid, keyhole or irregular.
Reaction to light
When light is shone into the eye the pupil should constrict immediately. The withdrawal of the light should produce an immediate and brisk dilation of the pupil.
This is called the direct light reflex. Introducing the light into one pupil should cause a similar constriction to occur simultaneously in the other pupil. When the light is withdrawn from one eye, the opposite pupil should dilate simultaneously. This response is called the consensual light reflex.
For the purpose of neurological assessment, the size and reaction of the pupils to bright light should be recorded as follows:
- If the pupil reacts briskly to light it is documented as ‘+’;
- If the pupil does not react to light it is documented as ‘-‘;
- If the pupil is sluggish in response when compared with the other pupil it is documented as ‘S’.
A sluggish pupil may be difficult to distinguish from a fixed pupil and may be an early focal sign of an expanding intracranial lesion and increased intracranial pressure.
A sluggish response to light in a previously reacting pupil is therefore a cause for concern and must be reported at once to medical staff.
For the purpose of neurological assessment the following steps should be followed:
- The pupils must be observed simultaneously to determine size and equality;
- A bright light should be shone into each eye to gauge how the pupils react and the result recorded. Any external light source should first be eliminated if possible;
- Pupil responses must always be monitored and recorded in the records of a sedated patient with neurological injury;
- The shape of the pupil should be assessed. An ovoid pupil could be an indication of intracranial hypertension.
Points to note
Important points to remember when assessing pupil response are:
- Pinpoint non-reactive pupils are seen with opiate overdose and pontine haemorrhage;
- The parasympathetic nerve fibres of the third cranial nerve (oculomotor nerve) control constriction of the pupil. Compression of this nerve will result in fixed, dilated pupils;
- Antimuscarinic drugs cause the pupils to dilate. For example, atropine sulphate eye drops, one per cent, has a duration of action of 7-12 days after topical application. The effects of intravenous atropine sulphate on the pupil are dose-related. Higher doses further dilate the pupil. Effects reverse when therapy is discontinued (McEvoy, 2004);
- Non-reactive pupils may also be caused by local damage;
- One dilated or fixed pupil may be an indication of an expanding or developing intracranial lesion, compressing the oculomotor nerve on the same side of the brain as the affected pupil.
The Glasgow coma scale provides a practical means of assessing a patient’s level of consciousness, which may then be recorded on an observation chart. However, users of the scale will require training to ensure a consistent approach in order to assess and record changing states of altered consciousness reliably.
The Leeds Teaching Hospitals NHS Trust’s clinical guidelines provide practitioners with practical guidance on how to carry out and interpret each of the three components of the scale in order to standardise practice. This in turn will minimise errors in communication and misinterpretation of clinical findings.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:
- Know the three aspects of patient behaviour upon which the Glasgow coma scale is based;
- Understand how to assess each of the three behaviours contained in the Glasgow coma scale;
- Be familiar with how to assess a patient’s pupil response;
- Understand the significance of altered response.
Use the following points to write a reflection for your PREP portfolio:
- Outline why this article is relevant to your place of work and your practice;
- Think about one of your patients who may have needed to be assessed using the Glasgow coma scale;
- Outline what you have learnt about assessing level of consciousness;
- Detail something new that you have learnt about using the Glasgow coma scale;
- Outline how you will use what you have learnt in your future practice.
NT ContributorSours: https://www.nursingtimes.net/archive/using-a-coma-scale-to-assess-patient-consciousness-levels-21-06-2005/
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Levels of Consciousness in Medicine
Level of consciousness (LOC) is a medical term for identifying how awake, alert, and aware of their surroundings someone is. It also describes the degree to which a person can respond to standard attempts to get his or her attention.
Consistent medical terms describing a person's level of consciousness help in communication between care providers, particularly when the level of consciousness fluctuates over time.
There are a variety of medical conditions and drugs that contribute to the level of a person's consciousness. Sometimes impaired consciousness is reversible, while other times it is not.
Normal Level of Consciousness
According to medical definitions, a normal level of consciousness means that a person is either awake or can be readily awakened from normal sleep. Terms include:
- Consciousness identifies a state in which a patient is awake, aware, alert, and responsive to stimuli.
- Unconsciousness identifies a state in which a patient has a deficit in awareness and responsiveness to stimuli (touch, light, sound). A person who is sleeping would not be considered unconscious, however, if waking up would result in normal consciousness.
Between these two extremes, there are several altered levels of consciousness, ranging from confusion to coma, each with its own definition.
A Neurological Explanation of Our Consciousness
Altered Level of Consciousness (ALOC)
Altered or abnormal levels of consciousness describe states in which a person either has decreased cognitive function or cannot be easily aroused. Most medical conditions affect the brain and impair consciousness when they become serious or life-threatening, and an altered state of consciousness usually signals a serious medical problem.
Often, an altered level of consciousness can deteriorate rapidly from one stage to the next, so it requires timely diagnosis and prompt treatment.
Confusion describes disorientation that makes it difficult to reason, to provide a medical history, or to participate in the medical examination. Causes include sleep deprivation, fever, medications, alcohol intoxication, recreational drug use, and postictal state (recovering from a seizure).
Delirium is a term used to describe an acute confusional state. It is characterized by impaired cognition.
In particular, attention, alteration of the sleep-wake cycle, hyperactivity (agitation), or hypoactivity (apathy), perceptual disturbances such as hallucinations (seeing things that are not there) or delusions (false beliefs), as well as by instability of heart rate and blood pressure may be seen in delirium.
Causes can include alcohol withdrawal, recreational drugs, medications, illness, organ failure, and severe infections.
Delirium Risks and Effects
Lethargy and Somnolence
Lethargy and somnolence describe severe drowsiness, listlessness, and apathy accompanied by reduced alertness. A lethargic patient often needs a gentle touch or verbal stimulation to initiate a response. Causes can include severe illnesses or infections, recreational drugs, and organ failure.
Obtundationis a reduction in alertness with slow responses to stimuli, requiring repeated stimulation to maintain attention, as well as having prolonged periods of sleep, and drowsiness between these periods. Causes can include poisoning, stroke, brain edema (swelling), sepsis (a blood infection), and advanced organ failure.
Stuporis a level of impaired consciousness in which a person only minimally responds to vigorous stimulation, such as pinching the toe or shining a light in the eyes. Causes can include stroke, drug overdose, lack of oxygen, brain edema, and myocardial infarction (heart attack).
Coma is a state of unresponsiveness, even to stimuli. A person in a coma may lack a gag reflex (gagging in response to a tongue depressor placed at the back of the throat) or a pupillary response (pupils normally constrict in response to light).
It is caused by severely diminished brain function, usually due to extreme blood loss, organ failure, or brain damage.
What It Really Means to Be in a Coma
The causes of these altered states of consciousness may overlap. For example, the early stages of brain edema or organ failure can cause confusion but can advance rapidly through the stages of lethargy, obtundation, stupor, and coma.
Classifications of Coma
The states of coma and stupor may also be subdivided into levels or classifications that further clarify a person's degree of unresponsiveness. Several systems have been developed in order to standardize these classifications, which improves communication among healthcare providers and also aids in research.
The most commonly used classification systems are the Grady Coma Scale and the Glasgow Coma Scale:
- The Grady Coma Scale rates a coma in grades from I to V. The grades are determined based on a person's state of awareness and response to stimuli, such as response to the person's name being called, light pain, and deep pain. Grade I indicates confusion, while V indicates no response to stimuli (coma).
- The Glasgow Coma Scale uses a score to identify the level of consciousness, from 1 to 15, with 15 being a normal state of consciousness. This scale takes into account verbal, motor, and eye responses to stimuli in determining the overall score.
A Word From Verywell
There are also psychological terms used to describe consciousness (fully aware of one's intentions), in contrast to the subconscious (often describes deeper intentions), and preconscious (related to memory).
There are also several other theories and definitions of consciousness describing stages of sleep, levels of self-awareness, and the relationship between humans and matter. While all of these definitions are certainly valid, they are not used to define medical states of consciousness.
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Huntley A. Documenting level of consciousness. Nursing. 2008;38(8):63-64. doi:10.1097/01.NURSE.0000327505.69608.35
Tufts Medical Center. Altered level of consciousness.
Cleveland Clinic. Delirium. Updated November 9, 2016.
Maiese K. Overview of coma and impaired consciousness. Merck Manual Professional Version. Updated June 2019.
Opara JA, Małecka E, Szczygiel J. Clinimetric measurement in traumatic brain injuries. J Med Life. 2014;7(2):124-127.
Reith FCM, Lingsma HF, Gabbe BJ, Lecky FE, Roberts I, Maas AIR. Differential effects of the Glasgow Coma Scale Score and its components: An analysis of 54,069 patients with traumatic brain injury. Injury. 2017;48(9):1932-1943. doi:10.1016/j.injury.2017.05.038
Vasilevskis EE, Chandrasekhar R, Holtze CH, et al. The cost of ICU delirium and coma in the intensive care unit patient. Med Care. 2018;56(10):890-897.
Neurological assessment 1 – Assessing level of consciousness
This article, the first in a four-part series on neurological assessment, describes assessment of level of consciousness.
Click here to download the PDF of this article, with graphics included
Phil Jevon, PGCE, BSc, RGN, is resuscitation officer/clinical skills lead, honorary clinical lecturer, Manor Hospital, Walsall.
Neurological assessment is essential in the assessment of the acutely ill patient (NICE, 2007; Resuscitation Council UK, 2006). As a problem with airway, breathing or circulation can lead to altered level of consciousness, initial priorities include ensuring a clear airway, and adequate breathing and circulation.
Consciousness is defined as the state of being aware of physical events or mental concepts. Conscious patients are awake and responsive to their surroundings (Marcovitch, 2005).
The level of consciousness has been described as the degree of arousal and awareness. A manifestation of altered consciousness implies an underlying brain dysfunction. Its onset may be sudden, for example following an acute head injury, or it may occur more gradually, such as in hypoglycaemia.
Causes of altered consciousness
A range of situations can lead to altered consciousness. These include: profound hypoxaemia; hypercapnia; cerebral hypoperfusion; stroke; convulsions; hypoglycaemia; recent administration of sedatives or analgesic drugs; drug overdose; subarachnoid haemorrhage; and alcohol intoxication (Resuscitation Council UK, 2006; Wyatt et al, 2006).
The Resuscitation Council UK (2006) recommends the ABCDE approach:
Evaluating ‘disability’ involves assessing the level of consciousness (using the AVPU scale), pupillary assessment, and sometimes the Glasgow Coma Scale. Staff caring for a patient with a head injury admitted for observation should all be able to assess:
- Respiratory rate; heart rate; temperature; blood pressure; blood oxygen saturation;
- Glasgow Coma Scale (GCS);
- Pupil size and reactivity;
- Limb movements (NICE, 2007).
Level of consciousness
It is not possible to directly assess the level of consciousness - it can only be assessed by observing the patient’s behavioural response to different stimuli.
During the initial rapid assessment of the critically ill patient, it is helpful to use the AVPU scale, with an examination of the pupils; the GCS should be used in the full assessment (Smith, 2003). NICE (2007) recommends using GCS to assess all patients with head injuries.
Before assessment, ascertain the patient’s acuity of hearing, medical history and any indications that may affect level of consciousness.
The AVPU scale is a quick and easy method to assess level of consciousness. It is ideal in the initial rapid ABCDE assessment:
- Responds to voice;
- Responds to pain;
- Unconscious (RCUK, 2006).
AVPU is incorporated into many early-warning score systems for critically ill patients, as it is simpler tool than GCS, but is not suitable for long-term observation.
- Explain the procedure to the patient.
- Assess the level of consciousness using the AVPU scale; if fully awake and talking to you, they are A (alert). If they respond but appear confused, try to establish whether this is a new or a long-standing problem; causes of recent onset confusion include neurological pathology and hypoxia.
- If the patient is not fully awake, check if they respond to your voice, for example by opening their eyes, speaking or moving; if they do, they are V (responds to voice).
- If the patient does not respond to voice, administer a painful stimulus such as a trapezium squeeze (Fig 1) and check for a response (eye opening, verbal such as moaning, or movement); if there is a response, they are P (responds to pain). Those who do not respond are U (unresponsive).
- Record the AVPU reading on the patient’s observation chart (Fig 2).
- The patient may need to be in the lateral position to help keep the airway patent; oxygen may need to be administered (Fig 3).
- Try to establish a cause of altered consciousness. Check the medical history and presenting complaint. Check for a medical alert bracelet or similar (Fig 4). Check the medication chart (Fig 5) as some medications can affect consciousness.
- To further establish the cause, perform bedside glucose assessment to exclude hypoglycaemia and hyperglyaemia (Fig 6). Check for evidence of alcohol intake, such as a smell on the breath. Check for signs of a head injury.
Marcovitch, H. (2005) Black’s Medical Dictionary. London: Black.
NICE (2007) Head injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. www.nice.org.uk
Resuscitation Council (UK) (2006) Advanced Life Support. www.resus.org.uk
Smith, G. (2003) ALERT Acute Life-Threatening Events Recognition
and Treatment. Portsmouth: University of Portsmouth.
Wyatt, J. et al (2006) Oxford Handbook of Emergency Medicine. Oxford: Oxford University Press.
NT ContributorSours: https://www.nursingtimes.net/clinical-archive/neurology/neurological-assessment-1-assessing-level-of-consciousness-08-07-2008/
Of consciousness nursing documentation level
When documenting your patient’s level of consciousness, you’ll notice you have a LOT of options to choose from. Your patient can be alert, confused, in a coma and anything in between. Knowing the difference between each level of consciousness will help you chart accurately and communicate your patient’s condition with precision. The different levels of consciousness are:
- Alert: awake and responsive
- Confused: note that confusion can occur anywhere along this spectrum and is not always present prior to the patient becoming somnolent, lethargic, etc… It is possible to have a patient who is somnolent or even lethargic and still oriented.
- Somnolent: sleepy
- Lethargic: very drowsy, falls asleep in between care
- Obtunded: difficult to arouse
- Stuporous: very difficult to arouse
- Unresponsive/Coma: unarousable
Describing your patient’s LOC correctly is especially important when there are acute changes in condition. For example, I had a patient recently who was stuporous upon arrival to the ICU, but quickly became unresponsive, requiring immediate intervention in order to keep the patient safe. Had I not known how to describe this patient’s level of consciousness using standardized language, there could have been a huge miscommunication between me and the MD. So, let’s go through a quick example using an entirely fictitious patient. Ready?
In report you learn the following about your patient: 56 year old female with CKD stage 4, CHF, DM2, and hyperlipidemia. BIBA yesterday for SOB, currently on 6L oxygen. BP 110/68, HR 77, O2 sat 94%, afebrile. Urine output minimal overnight at 20 ml/hr, dark and concentrated. Chemistry panel shows mild hyperkalemia, elevated BUN and Creatinine, mildly anemic with Hbg 9.2 and WBC WDL.
At the time of your initial assessment at 0800, you note that the patient opens her eyes spontaneously and responds to questions though not all her answers make sense. She will follow simple one-step commands, but when you ask her to do more than one thing at a time, she does not always follow through. You ask your patient where she is right now and she answers “in my living room.” At this time, your patient is ALERT and CONFUSED.
At 0900, you bring in your patient’s medications. She wakes easily to voice but yawns a few times and states she just wants to sleep. At this point your patient is SOMNOLENT.
At 1000, you go in to help your patient get repositioned when you notice she opens eyes only to voice or stimulation (not spontaneously) . She follows some basic commands, and is slow to respond. She drifts off again once no longer stimulated. Your patient is now LETHARGIC.
At 1200, your patient is more difficult to arouse. Her responses are delayed and minimal. She does not appear to fully wake when stimulated and she immediately goes back to sleep when not stimulated. When she does answer questions, she mumbles and is clearly confused. At this time she is OBTUNDED.
By 1300, your patient can only be aroused by vigorous and repeated stimulation. When the stimulation stops she immediately lapses back into her unresponsive state. The only vocalizations she makes are moans. She is now in a STUPOR.
At 1400, your patient is unarousable to any stimulation, even vigorous and painful stimuli. At this point she is UNRESPONSIVE or COMATOSE.
Of course, you’ve been updating the MD on your patient’s changes in LOC all morning, and you have both ensured that the appropriate interventions have been instituted. In a case with patient with renal disease, you will often see them have decreasing levels of consciousness as their pH drops secondary to their metabolic acidosis. With a patient like this, you might anticipate the MD ordering an ABG at some point…don’t be surprised if it comes back acidotic. Typically what happens is the patient will receive dialysis and as things start to come back into balance the patient becomes more alert (assuming they don’t have any other underlying physiologic derangements such as sepsis.)
The other common situation this occurs in is COPD exacerbation. The pH will decrease as the CO2 increases. As the CO2 rises, the patient becomes more and more comatose…usually we can pull the patient out of it with BIPAP, but in extreme cases they may be intubated. You’ll see this over and over and over again…especially if you work in a medical ICU or telemetry unit.
This whole topic of consciousness is so incredibly interesting, especially as it relates to anesthesia. If you’re interested in getting your CRNA someday, you might find this article fascinating…I know I certainly did! Enjoy!
Are you starting nursing school soon or struggling and trying to adjust? Then you’ll LOVE my free guide 20 Secrets of Successful Nursing Students.
Get this on audio in Podcast Episode 98.
6.4 Assessing Mental Status
Open Resources for Nursing (Open RN)
Routine assessment of a patient’s mental status by registered nurses includes evaluating their level of consciousness, as well as their overall appearance, general behavior, affect and mood, general speech, and cognitive performance., See the “General Survey Assessment” chapter for more information about an overall mental status assessment.
Level of Consciousness
refers to a patient’s level of arousal and alertness. Assessing a patient’s orientation to time, place, and person is a quick indicator of cognitive functioning. Level of consciousness is typically evaluated on admission to a facility to establish a patient’s baseline status and then frequently monitored every shift for changes in condition. To assess a patient’s orientation status, ask, “Can you tell me your name? Where are you? What day is it?” If the patient is unable to recall a specific date, it may be helpful to ask them the day of the week, the month, or the season to establish a baseline of their awareness level.
A normal level of orientation is typically documented as, “Patient is alert and oriented to person, place, and time,” or by the shortened phrase, “Alert and oriented x 3.” If a patient is confused, an example of documentation is, “Patient is alert and oriented to self, but disoriented to time and place.”
There are many screening tools that can be used to further objectively assess a patient’s mental status and cognitive impairment. Common screening tools used frequently by registered nurses to assess mental status include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale (NIHSS), and the Mini-Mental State Exam (MMSE).
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess and continually monitor a patient’s level of consciousness when damage has occurred, such as after a head injury or a cerebrovascular accident (stroke). See Figure 6.9 for an image of the Glasgow Coma Scale. Three primary areas assessed in the GCS include eye opening, verbal response, and motor response. Scores are added from these three categories to assign a patient’s level of responsiveness. Scores ranging from 15 or higher are classified as the best response, less than 8 is classified as , and 3 or less is classified as unresponsive.
National Institutes of Health Stroke Scale
The National Institutes of Health Stroke Scale (NIHSS) is a standardized tool that is commonly used to assess patients suspected of experiencing an acute cerebrovascular accident (i.e., stroke). The three most predictive findings that occur during an acute stroke are facial drooping, arm drift/weakness, and abnormal speech. Use the following hyperlink to view the stroke scale.
A commonly used mnemonic regarding assessment of individuals suspected of experiencing a stroke is “BEFAST.” BEFAST stands for Balance, Eyes, Face, Arm, and Speech Test.
- B: Does the person have a sudden loss of balance?
- E: Has the person lost vision in one or both eyes?
- F: Does the person’s face look uneven?
- A: Is one arm weak or numb?
- S: Is the person’s speech slurred? Are they having trouble speaking or seem confused?
- T: Time to call for assistance immediately
View the NIH Stroke Scale at the National Institutes of Health.
Mini-Mental Status Exam
The Mini-Mental Status Exam (MMSE) is commonly used to assess a patient’s cognitive status when there is a concern of cognitive impairment. The MMSE is sensitive and specific in detecting delirium and dementia in patients at a general hospital and in residents of long-term care facilities. Delirium is acute, reversible confusion that can be caused by several medical conditions such as fever, infection, and lack of oxygenation. Dementia is chronic, irreversible confusion and memory loss that impacts functioning in everyday life.
Prior to administering the MMSE, ensure the patient is wearing their glasses and/or hearing aids, if needed. A patient can score up to 30 points by accurately responding and following directions given by the examiner. A score of 24-30 indicates no cognitive impairment, 18-23 indicates mild cognitive impairment, and a score less than 18 indicates severe cognitive impairment. See Figure 6.10 for an image of one of the questions on the MMSE regarding interlocking pentagons.
Visit the following website for more information about the Mini-Mental Status Exam.
Oxford Medical Education
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Documenting level of consciousness
- 1 Emory Healthcare, Atlanta, GA, USA.
- Consciousness Disorders / diagnosis*
- Documentation / methods*
- Glasgow Coma Scale
- Neurologic Examination / methods*
- Neurologic Examination / nursing
- Nursing Assessment / methods*
- Nursing Records*