Assessing Consciousness

AVPU and Glasgow Coma

Scale
 Lesson objectives
Describe the common causes of a deteriorating
conscious level.
Describe how to assess a patient with a altered
conscious level using the Glasgow coma scale.
Describe the emergency management of a patient
with a decreasing conscious level.
 Rapid Assessment
A Alert
V responds to Voice
P responds to Pain
U Unresponsive
 Glasgow Coma Scale
Assesses patients neurological condition

Value range 3 to 15

3 totally comatose patient

15 fully alert patient

 Classification of Brain Injury
According to Glasgow Coma Scale
(GCS) (HICKEY 2003)

SEVERE
GCS 3-8

MODERATE
GCS 9-12

MILD
GCS 13-15
 Neurological chart
GCS top section

Temperature/BP/pulse/respiratory rate

Pupil size / reaction to light

Limb movement arms and legs

 Eye opening
Spontaneous =4

To speech =3

To pain =2

None =1
 Verbal response
Orientated =5

Disorientated =4

Monosyllabic =3

Incomprehensive =2

None =1
 Motor response
Obeys commands = 6

Localises pain = 5

Withdrawal to pain = 4

Flexion to pain = 3

Extension to pain = 2

None =1
Posturing
 Case 1
20 year old brought in by ambulance on
stretcher/spinal board.
Fell down flight of stairs in night club.
Head injury/laceration scalp.
Loss of consciousness(LOC) approx10-15 mins.
Not speaking but groaning to pain stimuli.
Eyes open to pain stimuli.
When squeeze fingernail attempts to flex arm
away from pain.
Signs of ???
 Signs of basal skull fracture
Blood or CSF from
nose or ear
Periorbital haematoma
Mastoid haematoma
(Battle's sign)
Haemotympanum
Radiological evidence
of
intra-cranial air
Radiological evidence
of fluid
levels in
sinuses
 Case 2
66 year old brought in by ambulance and police.
Sat in a wheelchair.
Found in city centre staggering and unsteady on his feet.
He collapsed whilst with police.
No known injuries.
No loss of consciousness.
Talking to you, confused answers to questions. Eyes
open, obeys commands.
What could be going on with this patient?
 Causes of a decreased
conscious level
Hypoxaemia Intracranial
Hypotension haemorrhage
Hypercapnia Cerebral infarction
Hypoglycaemia Intracranial infection
Drugs (sedatives,opiates, Hypothermia
overdoses,alcohol) Hyperthermia
Seizures Hypothyroidism
Head injury Hepatic
encephalopathy
Early Signs & Symptoms of
Raised ICP
Deterioration in level of consciousness
(LOC)
Confusion
Restlessness
Lethargy
Headache
Pupillary dysfunction
Motor & sensory deficits
Cranial nerve palsy
Transient Signs & Symptoms of
Raised ICP
Decreased LOC
Pupil abnormalities
Visual disturbance
Motor dysfunction
Headache & vomiting
Aphasia
Changes in respiratory pattern
Changes in vital signs
 Late Signs & Symptoms of
Raised ICP
Continueddeterioration in level of
consciousness

Hemiplegia,decortication &
decerebration

Alteration in vital signs

Raised ICP Management of Deteriorating
Conscious Level
Ensure the patients airway is patent
Give high concentration oxygen to ensure good cerebral
profusion
If ventilation is inadequate, provide assisted ventilation.
Ensure intravenous access and prescribe fluids as
necessary
Reverse any drug induced CNS depression.
Measure the blood glucose and treat if level is below
3mmol/l.
Place patient horizontally in the left lateral recovery
position.
 Summary
A decreased level of consciousness is common in acute
illness
Hypoxaemia,hypotension, hypoglycaemia are common
causes of coma
A decreased consciousness level may cause airway
obstruction and loss of protective airway reflexes

Failure to identify early signs and symptoms of raised

intracranial pressure puts the patient at great risk, and
opportunity for intervention may be lost
Potential if untreated a respiratory or cardiac arrest

Treatment of a deteriorating consciousness is focused on

care of the airway, breathing, circulation disability and
exposure
 References
Critical care education group, SUHT Oct 2004

Hickey. J. (2003) 5th Ed The Clinical Practice of

Neurological and Neurosurgical Nursing

Intranet Marsden Manual. Neurological observation

Mooney G (2003) Neurological observations. Nursing

times Vol 99/ No 17

Smith G (2003) Alert manual. University of Portsmouth

 Common causes of a
decreased conscious level.
Intracranial haemorrhage
Cerebral infarction
Intracranial infection
Hypothermia
Hyperthermia
Hypothyroidism
Hepatic encephalopathy
 3 parameters
Eye opening
Verbal response
Motor response
 Problems of decreased
conscious levels
Inabilityto protect airway loss of cough
and gag reflexes

Increased risk of aspiration

Skin damage

Corneal ulceration