Disability assessment:

Top Tip!

During this point of assessment, we want to establish a patient’s conscious level and investigate potential reasons for an altered conscious state. A rapid change in the patient’s conscious level can be an indication of acute illness.

Assessment of conscious level

There are two tools that we use to assess conscious levels; ACVPU and the Glasgow Coma Scale (GCS).

Legend

  1. Alert: The patient is conscious, fully alert. Their eyes will be spontaneously open, they will respond to voice and be able to communicate. This includes patients who are asleep and remain alert when woken.

  2. Confusion: Recently added to the scale to distinguish between patients who have acute onset of confusion but would have otherwise scored ‘A’ on the AVPU scale.

    This patient may present as alert but will have a new onset of delirium or confusion. It is recommended that confusion is considered as new in the acutely ill patient until confirmed otherwise.

  3. Voice: The patient will make a response only when you talk to them. This may include any verbal response. Could be eye opening when spoken to or motor response when prompted by the assessor.

  4. Pain: The patient will respond to pain stimulus. Recognised methods for applying a low – level pain stimulus include squeezing the earlobe or trapezius muscle. The patient may illicit an eyes, voice or motor response to this painful stimulus.

  5. Unresponsive: The patient makes no response to painful stimulus.

The Glasgow Coma Scale

The Glasgow coma scale can be used as a more detailed assessment of conscious level. This scale is a practical way to assess impairment of conscious level in response to defined stimuli. The test measures three areas; eye response, verbal response and motor response. A patient can score between 3 and 15 on the scale.

When discussing a patient’s score it is most useful to break the number down into the categories. A GCS of 15/15 broken down into the categories would be written as E (eyes) 4 V (Verbal) 5 and M (Motor) 6.

Pupils

Pupillary assessment is a vital part of a neurological assessment. Changes in equality, reactivity to light and size may provide clues to explain a patient’s deterioration.

  • Pupils should be equal in size and round in shape, average size 2-5mm

  • Test reactivity to light (pupil should constrict) by shining a pen torch into each pupil, the opposite pupil should also react. Document as either brisk reaction, sluggish or no reaction

A dilated and non-reactive (fixed) pupil in an unconscious person can be a sign of increased intracranial pressure and herniation, causing pressure on the third cranial nerve. This is a medical emergency and should be investigated immediately.

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A dilated and non-reactive (fixed) pupil in an unconscious person can be a sign of increased intracranial pressure and herniation, causing pressure on the third cranial nerve. This is a medical emergency and should be investigated immediately. -

  • The movement and power of all four limbs should be assessed. A new weakness or change in sensation could represent a serious disease process such as stroke and needs further investigation.

  • Hypoglycaemia can cause a reduced level of consciousness. Therefore, it is important to check a blood sugar level during your assessment of disability.

  • This adds vital information to your assessment, as the source of pain may aide your diagnosis. Pain itself also has important physical and psychological consequences such as tachycardia, hypertension, restricted movement and inability to deep breathe.