Health Assessment, part 3: Levels of Consciousness and Orientation, Glasgow Coma Scale

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Health Assessment - Nursing Flashcards

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Hi. I'm Meris, and in this video, I'm going to be covering content from our health assessment deck, including information about how to assess a patient's level of consciousness, level of orientation, and how to score them according to the Glasgow Coma Scale. I'm going to be following along using our health assessment flashcards. If you already have a set of your own, I'd invite you to follow along with me. And if you want to grab a set for yourself, you can find them on our website, LevelUpRN.com. All right. Let's go ahead and get started. So first up, we are going to be talking about assessing a patient's level of consciousness. And their level of consciousness refers to how alert they are, so how easy to rouse are they? The normal finding is for them to be alert. So let's review kind of the different levels of consciousness. So being alert means that they are awake, their eyes open spontaneously. Keep in mind that being awake and having my eyes open spontaneously does not mean that I am oriented, and we will talk about that in a moment. And we're going in descending order, so starting with the most conscious to the least conscious. The next level is lethargic, and a patient who is lethargic is one who's extremely drowsy. They may be able to be woken up by speaking to them, but they can fall back to sleep if they're not being stimulated. So as soon as you stop talking, they drift back to sleep. An obtunded patient is one who is very difficult to rouse. So they might need vigorous shaking or shouting, and they've got to be constantly stimulated in order to cooperate. Now, a patient who is stuporous, so think of them as being in a stupor. Stuporous patients respond only to vigorous shaking or painful stimuli. So that would be someone where I have to really do a deep sternal rub on them for them to respond, or if I put a lot of pressure on their nail bed using a pen that they might open their eyes in response to that. A patient who is comatose, however, that someone who is in a coma, these patients are completely unconscious. They are unresponsive to pain, so it does not matter how much I rub their sternum or push on their nails, or there's all kinds of other different painful stimuli, they are not going to respond to that stimulation, and they may also be abnormally posturing.

There are two types of abnormal posture you need to be aware of, decorticate and decerebrate. And you can see right here that we do have a cool chicken memory hint right here for you because in decorticate posturing, the patient's arms are going to be flexed and rotated inwards and their legs are going to be extended and rotated outwards. But this is what I want you to think of in decorticate posturing. And our trick to remember this is that in decorticate posturing, you protect your core, so my arms are brought in to protect my core. Now, decerebrate posturing, which is considered to be the worse of the two, this is where my head is arched back and my arms and legs are extended. So your patient who's arched back abnormally and they've got their arms and legs extended, they're not protecting their core. They have that abnormal extension of their head and neck. That is a decerebrate posturing. Either way, this type of posturing is abnormal, and it is not a great sign, but you do need to be familiar with both of those.

Now, let's talk about levels of orientation. Like I said, you can be completely alert. You can be awake. I am sitting up and I'm talking to you and I am not oriented because orientation gives us insight to the patient's cognitive functioning. So a normal average person in their normal average day is going to be oriented times 4, meaning that they are oriented to person, place, time, and situation. It is possible for me to be oriented to just one of those or to two of those or to none of them. And you will need to chart, you will need to be able to state what your patient's level of orientation is. So for a person, we're going to just ask the very simple question of, "Tell me your name," or, "What is your name?" When you are asking questions for orientation, I want to caution you not to say, "Can you tell me? Can you tell me your name?" They might say, "Yeah." "Okay, well, what is your name?" So don't ask them if they can answer the question. Ask them the question directly, "What is your name?" That's going to tell you if they are oriented to person. Now, to place is, "Where are we right now?" And sometimes I have patients, as an ER nurse, who might not know where they are right now in terms of which specific hospital they're at because the ambulance took them, and they don't really have a say in it. So you might get somebody who says, "I don't know." Try asking then, "What kind of a building is this?" If they can say, "Oh, it's a hospital," okay, then they're oriented to place.

And then time. So we're going to ask the patient to correctly identify either the day, the month, the year, or the season. So usually I just go with, "What year is it?" And if we have any kind of issue with that, then I might go with, "What season is it outside?" Because personally, you could ask me what day it is today, I may or may not be able to tell you correctly, but I can answer your other questions about time. So if your patient struggles, don't just write it off as, "Oh, they're not oriented." Ask another question in a slightly different way. And then lastly, event or situation. You can ask a couple of different questions. "Who is the president?" is one to kind of just globally assess their understanding of event or situation. Another good one is, "Can you tell me what brought you to the hospital today? Why are you here today?" If they say, "Well, I don't know. And I just woke up and I was here," maybe we're not oriented to situation. Or if they say, "Well, I was in a car accident," okay, we know what's going on.

So now I want to talk to you about the Glasgow Coma Scale, and this is a very important scale that I use in my daily career as an ER trauma nurse. And essentially what it is, it's a scale that's used to assess a patient's extent of consciousness based on three subcategories. This is very commonly used for patients who have sustained some sort of head trauma, but you can do this on any patient, and we do it on essentially all of our patients at the ER. So the three components of the GCS, Glasgow Coma Scale: eye-opening, verbal response, and motor response. And I'll let you take a look in your own time at the actual components and how you would receive those different breakdowns of points, but here's what I want to get across to you, that the maximum and what we consider to be the most normal score is 15. Meaning that you are scoring the top number of points in all three categories, remembering that it's eye-opening, verbal response, and motor response, and there are 4, 5, and 6 points respectively in those categories. And this is so unbelievably important, the minimum score is a 3. So the wall behind me has a GCS of 3. This table has a GCS of 3. There is no GCS of 0 or 1. It's not possible because the minimum score is that you earn 1 point in each category for a total of 3 points.

Now, what's the point here? Why do we care about this? Well, lots of reasons. It helps us to assess, like I said, that patient's extent of consciousness. Is it getting better? Is it getting worse? Is it what we call labile when it kind of goes up and down? It's really fluctuating. But also, there's something super duper critically important. You know what I'm going to say. Learn it. Love it. Get a necklace that says it. If your patient has a GCS that is less than 8, this means that they cannot protect their own airway, and we need to think about intervening. Now, there's one slight caveat here that I would like to say is that some of your patients may have an artificial airway already. Maybe your patients have a baseline GCS of 6 or 7, and they have a tracheostomy. I'm not freaking out that I got to intervene because we already have the airway protected, okay? But in a patient who comes to me in the emergency room out there living their lives and then something happens and now their GCS is 3 to 7, I know we need to intervene and help them to protect their airway. So our cool chicken hint here, and this is what you will hear every medical provider in the world say, if their GCS is less than 8, you're going to have to intubate. Less than 8, intubate, okay? So if my patient has a GCS of 6 or 7, I am concerned that they cannot maintain their own airway.

All right. I'm going to test your knowledge of some key facts I provided in this video using my quiz questions. What is the highest and lowest possible score a patient can receive on the Glasgow Coma Scale? 15 is the highest possible score, which is considered normal, and 3 is the lowest possible score. How should the nurse describe a patient who is extremely drowsy but can be awakened by speaking to them? This patient would be considered lethargic. What are the three components of the GCS, the Glasgow Coma Scale? The three components of the GCS are eye-opening, verbal response, and motor response. All right. That is it for this video. I really hope you found that review helpful. If you have a great way to remember things, I definitely want to hear it, so please leave me a comment, and I know that other students want to hear the things that you've come up with to help you recall this information as well. You're doing a really great job, and I'm super proud of you. Thanks for studying with me.