Chapter 2: Examine Level of Consciousness

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  1. Levels of Consciousness Exam
    • Determine orientation to person, place, and time (A & O x 3)
    • Determine response to stimuli
    • Determine level of consciousness (arousal)
    • Glasgow Coma Scale (GCS)
  2. Determine Response to Stimuli
    • Purposeful, non-purposeful, no response
    • Verbal, tactile, simple commands
    • Painful stimuli (pinch, pinprick)
  3. Alertness
    • Alert pt responds appropriately
    • Can open eyes, look at examiner, respond fully and appropriately to stimuli
  4. Lethargy
    • Pt appears drowsy
    • Can open eyes and look at examiner, responds to questions, but falls asleep easily
  5. Obtundation
    • Pt can open eyes and look at examiner
    • Responds slowly and is confused
    • Demonstrates decreased alertness and interest in environment
  6. Stupor
    • Pt can be aroused from sleep only with painful stimuli
    • Verbal responses are slow or absent
    • Pt returns to unresponsive state when stimuli are removed
    • Demonstrates minimal awareness of self and environment
  7. Coma
    • A state of unconsciousness from which pt cannot be aroused
    • Eyes remain closed
    • No response to external stimuli or environment
  8. Unresponsive Vigilance (Vegetative) State
    • State characterized by:
    • Return of sleep/wake cycles
    • Normalization of vegetative functions (respiration, HR, BP, digestion)
    • Lack of cognitive responsiveness (can be aroused but is unaware
  9. Persistent Vegetative State
    A state lasting > 1 year for TBI and > 3 months for anoxic brain injury
  10. Minimally Conscious State (MCS)
    State characterized by severely altered consciousness with minimal but definite evidence of self or environmental awareness
  11. Glasgow Coma Scale
    • Relates consciousness to 3 elements of response: eye opening, motor response, and verbal response
    • Scoring ranges from 3-15
    • Severe brain injury: 1-8
    • Moderate brain injury: 9-12
    • Minor brain injury: 13-15
Card Set:
Chapter 2: Examine Level of Consciousness
2015-03-08 22:31:05
Levels Consciousness Exam
NPTE: Chapter 2
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