Procedures - Conscious Level Assessment

Question 1

Assessment

Answer 1

Perform 5 moments of hand hygiene

Check doctor’s order in treatment notes to assess the need for monitoring of conscious level and the frequency

Know the indications for CLC

Patient assessment

Identify medical conditions that may affect conscious level

Review and note previous conscious level monitoring timing and record

Question 2

Indications for CLC

Answer 2

Hypoxia

Metabolic imbalance such as hypoglycaemia

Falls or trauma to the head

Unresponsiveness

Neurological disease process e.g. stroke, brain tumours, epilepsy

New admission to form a baseline assessment

Question 3

Medical conditions that can affect CLC assessment

Answer 3

• periorbital swelling/maxillofacial injuries
• glaucoma/ cataract/ eye disorders
• difficulty in hearing
• sedation and/or analgesia prescribed (if any)
• alcohol intoxication
• dysphasia/aphasia
• tracheostomy/ intubated
• high spinal injuries/ paralysis

Question 4

Planning and preparatory

Answer 4

Perform 5 moments of hand hygiene

Patient Identification – Use 2 patient’s identifier and check ID band

Explain purpose and indication of performing assessment of Conscious Level (CL) to the patient

Seek permission to assess him/her

Prepare requisites:
- pen torch (check for bright light)
- stethoscope
- sphygmomanometer
- thermometer
- nursing watch
Prepare environment to ensure privacy, safety and conducive for assessment

Question 5

Implementation - Eye Opening

Answer 5

Approach patient and observe for spontaneous eyes opening (It is a measure of arousal rather than patient’s awareness to surroundings).

Note that GCS assessment commences the moment the nurse approaches the patient’s bedside.

Call patient (without touching him/her) if there is no
spontaneous eye opening

Call louder if still no eyes opening (patient could have hearing difficulty especially elderly patient)

If still no eye opening, apply painful stimuli:
i) pressure on lateral outer aspect of the 2nd or 3rd
interphalangeal joint on third or fourth finger as shown or nailbed if eyes remain close

OR

ii) trapezius squeeze if eyes remain close

OR

iii) pressure over the supra-orbital notch/ridge using the thumb if eyes still remain close

Indicate “X” on the CLC as follows:
4: for spontaneous eye opening
3: for eyes opening to speech
2: for eyes opening to painful stimuli
1: for none
Document ‘C’ if eyes is closed due to swelling or surgery

Question 6

Implementation - Best verbal response

Answer 6

Assess best verbal response by asking for the patient for:

[1] His/Her Name
[2] Current place/location
[3] Current time of the day, month and year

Indicate “X” on the CLC as follows:
5: for orientated
4: for confused (if not able to answer correctly any of the questions above)
3: for inappropriate words
2: for incomprehensible sounds
1: for none

Document ‘T’ if patient has tracheostomy or ETT;
Document ‘D’ if patient has dysphagia

Question 7

Implementation - Best motor response

Answer 7

Assess all limbs by asking patient (limb by limb) to obey 2 simple instructions:
1. Can you raise your Rt hand and push against my (nurse) hands?

OR

2. Can you raise your Rt hand and touch your nose?

Repeat instruction for Lt hand and repeat for lower limbs (Rt leg and Lt leg)

If patient has spinal cord injury, ask patient to stick out his/her tongue and put it back.

If patient is able to obey, score ‘6’

Indicate “X” on the CLC as follows:
6: for Obeys commands
5: for Localise pain, moving limb to attempt to remove painful stimuli
4: for Flexion to pain; withdraw from stimuli
3: for Abnormal flexion or Decortication (flexes elbow and wrist while extending lower legs to pain)
2: for Extension to pain or Decerebration (extend upper and lower extremities to pain)
1: for none

(Record best motor response from upper limbs and lower limbs)

Question 8

Vital signs

Answer 8

Assess patient’s: HR/PR/RR/Temp/SpO2

Note: Monitoring of the five vital signs are crucial in detecting increased intracranial pressure.

↑Temp indicate S&S of infection/sepsis/meningitis

Question 9

Pupil size and reaction

Answer 9

Shine the pen torch from the outer cantus to the inner cantus of each eye;

Note: the reaction of the pupil and equality of both pupil;

If patient is unable to open his/her eyes, lift the eyelid gently using your thumb before shining with the pen torch;

Indicate the pupil size and reaction after shining the pen torch;

Document ‘I’ for irregular pupils OR ‘NT” if patient’s eyes cannot be opened due to swelling or surgery;

Indicate the pupillary reaction on the CLC as follows:
‘B’ for brisk
‘S’ for sluggish
‘F’ for fixed
‘C’ for closed due to swelling/surgery

Question 10

Motor strength

Answer 10

Instruct patient to raise his/her upper limbs and resists you as you press down on his/her upper limbs;

Repeat same assessment for lower limbs;

Record separately if there is difference between Rt and Lt sides

Indicate “X” on the CLC as follows:
5: for able to overcome gravity and maximum resistance
4: for able to overcome mild to moderate resistance
3: for able to lift up the arm but unable to overcome the
resistance (>anti-gravity strength)
2: for able to moves along the non-gravity surface but unable to lift up (<anti-gravity strength)
1: for visible muscle movement/muscle contraction
0: for no movement

Question 11

Evaluation and documentation

Answer 11

Evaluate the outcomes with senior staff to confirm if there is any deviation from previous assessment.

Ensure documentation is charted timely and accurately
Any decrease of GCS score ≥2 suggests possible underlying neurological deterioration and must be reported to the doctor in charge. Thus, it is always important to refer to the GCS baseline of patient.

Record on the right chart belonging to the right patient and in the correct column at the right time