CONSCIOUSNESS

Assessment of altered conscious level in clinical practice

Rachel Palmer, Jessica Knight

he Glasgow Coma Scale (GCS) is an internationally recognized tool which assess the conscious level of a patient. It is siuiple to use, with ;i high degree of inter-rater reliability (Rowley and Fielding, 1991; Harnihill, 1996; Fairley and Cosgrove, 1999; Heron et al, 2((H: Teasdale, 2004). There are three components (eye opening, best verbal and motor response) which collectively create the GCS tool. These elements are considered to be relevant to conscious level. However, in the authors' experience there is lack of fundamental knowledge of the anatomical and physiological components of conscious level. This incomplete knowledge base has the potential for the neurological assessment to be misinterpreted. Healthcare professionals use a variety of assessment tools in clinical practice. It should also be noted that GCS is the primary tool used by healtli professionals to make repeated, rapid evaluations on the conscious level of the patient. One purpose of the GCS tool is to provide a common language for communication between nmltidisciplinary groups (Jennett, 1986). It was designed to reduce observer variability and to give comparison, allowing for analysis of trends over time. GCS is recognized as the *gold standard' assessment tool (Harrahill, 1996). Patients in any clinical setting may require assessment ot conscious level for a number of reasons, e.g. falls, unresponsiveness, post-anaesthesia or new admissions. Alteration of consciousness level may result from intra- or extra-cranial causes (Table /). Conversely, an altered conscious level can be further complicated by secondary insults to the central nervous system or from the deteriorating influences of extracranial factors listed in Table 1. Equally, impaired conscious level may compound many other medical conditions.

Abstract
This article vIl critically appraise the literature focusing on the use and application of the Glasgow Coma Scale (GCS). Historically the GCS tool was created in a 14-point format and later revised to a 15-point format. Critical analysis of this potentially confusing aspect wiU be explored. The GCS tool enables the healthcare practitioner to effectively monitor the level of consciousness. The authors believe that anatomical and physiological knowledge is required to competently interpret assessment of level of consciousness. The article will review the anatomical basis of consciousness and consider some of the issues of application of GCS in practice, including painful stimuli.
Key words: Glasgow Coma Scale Consciousness Early warning score

History of GCS GCS is an objective clinical scoring system for assessing changes in a patients' conscious level Quarez and Lyons, 1995). It has developed from the Coma Index into the GCS tool that is currently used in practice today (see Table 2).The Coma Index was developed as a research tool to monitor level of consciousness in severe head injury and provide objective measurement of function in comatose patients (Fischer and Mathieson, 2001). Prior to this development there was no national standardized assessment (Ingram, 1994). The original GCS was published in 1974 as a 14-point scale (see Table 2) and then revised two years later in to the 15-point system (Teasdale and Jennett, 1974; Teasdale, 1976; Jennett andTeasdale, 1977), The main purpose of the GCS tool is to

provide a common language to improve communication in reporting neurological findings among healthcare profes.sionals (Fischer and Mathieson. 2001;Aird and Mclntosh, 2004). It provides a visual trend and concise information about the patient's level of consciousness. The revised GCS (15 point) is the accepted version that has been conmionly utilized in practice for the last 30 years (NICE, 2003; Wiese, 2003). In the 15 GCS the additional point is from the inclusion of 'abnormal flexion' [Table 2). Teasdale (2004) never intended the 15-point scale to be adopted into general use, due to the issue of recognizing abnormal flexion as a deteriorating physiological sign found between normal flexion (withdrawal) and extension. The distinction between "abnormal' and 'normal'flexionwill only be made consistently by practitioners experienced in assessing neurological patients (Teasdale and Murray, 2000). However, the revised GCS has been adopted into general use as evidenced by the Advanced Trauma and Life Support (ATLS) protocols (American College of Surgeons, 1993; NICE, 2003). GCS is applicable for adolescents, as well as adults, and has been adapted for use in paediatrics. Fischer and Mathieson (2001) recognize that it is not suitable for use in children under the age of three years due to developmental issues.
Rachel Palmer is Lecturer Praitirioner and Jessica Kniglit is Lecturer it Nursing, School of Nursing it Midwifery. University of Soucliaiiipcon & Wessex, Neurological Centre, Soudiampton University Hospitals NHS Trust
Accepted for publication: August 2006

BntisK journal of Nursing. 2(Hiii, Vol 15. No 22

1255

An alternative perspective, as researched by Wijdicks et al (1998). is chat alert patients can have subtle neurological deterioration that may not be captured in current coma scales. The authors have experienced this perspective within the practice setting and agree that neurological practitioners can 'pick up' the early subtle factors that would not change the GCS score on documentation, e.g. patient slower to respond.

The Importance of consciousness

Many health professionals do not have a good understanding of the underlying mechanisnLs tliat produce altered levels of consciousness (Addison and Crawford, 1999; Shah, 1999; Waterhouse, 2005). There is confusion and ambiguity over the use of the term consciousness, with descriptors using a multitude ofverbs to define the continuum from consciousness to coma, e.g. confusion, rousable, inattentiveness, delirium, clouding of consciousness, drowsiness, stupor, unrousable, flat, unconsciousness, obtundation, vegative state or coma (Victor and Ropper, 2001; Goetz, 2003; Hickey, 2003). When asleep, there is a reduced level of consciousness due to the inhibition of direct perception of sensory stimuli. Sleep and coma can be differentiated by the fact that cerebral uptake does not decrease during sleep as it does in coma. Hence a sleeping person who is stimulated can be roused (Barker, 2002).

The GCS was developed to assess these components of consciousness (Teasdale and Murray. 2000). There are three properties of consciousness which can be individually assessed and form the basis of the GCS. These are: best eye opening (E), verbal (V) and motor (M) responses: E: arousal or wakefulness (best eye opening) V: alertness and awareness (orientation and verbal communication) M: motor activity, an aspect of arousal (e.g. obeying commands). Consciousness can only be descriptively approached by documentation of observations made at that point in time. Consciousness is subject to change; it can occur rapidly within seconds, minutes and hours or very slowly, over a period of days, weeks, months and years. Consciousness can be described in many ways (see Table 3). Critically it should be noted that 'impaired consciousness IS an expression of dysfunction in the brain as a whole' (Teasdale andjennett, 1974 p81). A more creative description of consciousness is 'our continuing stream of awareness of either our surroundings or our consequential thoughts' (Guyton and Hall, 2006 p723). Regardless of any number of philosophical and artistic interpretations of consciousness, the fact is, healthcare practitioners have to be able to make a critical and functional analysis of consciousness.

Table 1. Causes of altered consciousness

These can easily be divided into intracranial and extracrania causes, or rather central nervous system structural abnormalities and metabolic imbalances. Intracranliil Direct destaiction oF the anatomical structures by a disease or insult Space-occupying lesions Include: Tumour, haematoma, contusion or abscess which is literally taking up intracraniai space Head )n|ury Haemorrhagk events: Cerebral haemorrhage Subarrachnoid haemorrhage (SAH) Extradural haemorrhage (EDH) Subdural haemorrhage (SDH) Cerebrovascular accident (CVA) Seizures/epilepsy Infections Inflammation of the brain tissue can be caused by bacteria, viruses or fungi Extracranial The most common metabolic causes of altered LOC seen in a hospitalized population are hypoxia. hypoglycemia. and sedative drug overdose' (Hickey, 2003 pi62) Metabolic causes Hypo/hyperglycaemia Fluid/electrolyte imbalance Acid-base imbalance Respiratory invoivement Hypoxia Hypo/hypercapnia Cardiovascular instability Hypo/hypertension Sepsis, shock, and trauma Liver, renal and endocrine dysfunction Pharmacologicai agents, e.g.: Anaesthetic, sedatives and paralysing agents Opiate analgesics Anticonvulsants Antidepressants Recreational drugs and alcohol Multi-organ dysfunction

Degenerative conditions e.g. Alzheimers, demyelinatlon in multiple sclerosis Secondary insults: Cerebrai oedema/swelling Raised intracranial pressure Ischaemia. infarction or vasospasm Increases in cerebrospinal fluid causing hydrocephalus (Teasdale and |ennett, 1974; |ennett and Teasdale. 1977; Fielding and Rowley. 1990; Edwards. 2001 ; Barker. 2002; Hickey. 2003: McLeod, 2004; Lewis, 2005)

1256

British Journal i>f Nursing. 2(Xlii,Vol 1S. No 22

CONSCIOUSNESS
To do this the nurse needs to be aware that there are two distinct components: arousal and awareness. Although distinct they should always be considered as united (Hickey, 2003). As arousal and awareness are complex, a generalized overview follows. The first step in a GCS assessment is to test arousal. Arousal is a state or appearance of being awake which reflects activity of the reticular activating system (RAS), colloquially known as level of consciousness (LOG). It is often described as the degree to which a person is able to interact with their environment with a quality of vigilance (Barker, 2002; Goetz, 2003; Hickey, 2003). The RAS is part of the reticular formarion (RF) which is a group of interconnected neurons that runs through the brain stem (midbrain, pons and medulla oblongata) and into the thalamus, the relay station to the cerebral cortex. Disruption of these pathways will manifest in altered conscious level and the degree of dysfunction will be reflected in the GSC score. Arousal demonstrates interaction between the RF and cerebral hemispheres, e.g. motor response and speech. Loss of the midbrain component of RF results in loss of control of the cortex, which cannot be altered by external or internal stimuli (Goetz, 2003). The midbrain RAS receives input from every major somatic and sensory pathway. Thus, painful stimulus, as a last attempt, to arouse the patient is justified. Impairment of arousal is thought to be attributed to the distortion of the normal anatomical relationships of the cortex, diencephalon and midbrain. This can be created because of an interruption to the flow of information between the midbrain and cerebral cortex.The diencephalon is a conduit, but Goetz (2003) proposes that it has a more active role in the control of arousal, especially within the normal sleep-wake cycle. Critically, when assessing the arousal component of GCS several other examinations should also be considered to give a full neurological assessment see Table 4. Awareness refers to the content of consciousness, including cognitive function and reflects the activity of the cerebral cortex. The changes in the person will be in their mental and intellectual functions and in their emotional/mood state (Barker, 2002; Goetz, 2003; Hickey, 2003). There must be interaction between the cerebral cortex and the RF for the individual to be aware.

Table 2. Glasgow Coma Scale (GCS)

14 point GCS (Teasdale & (ennett, 1974) Best eye opening 4 3 2 1 5 4 3 2 1 5 4 3 2 1 Spontaneously To speech To pain None Orientated Confused Inappropriate Incom prehensi ble None Obeying Localizing Flexing Extending None 15 point GCS Dennett & Teasdale, 1977) 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 Spontaneously To speech To pain None Orientated Confused conversation Inappropriate words Incomprehensible sounds None Obeys Localizes Withdraws Abnormal flexion Extends None

Best verbal response

Best motor response

stimuli. This may be central or peripheral in nature and there is much debate within the literature as to best practice. Peripheral stitnuK A peripheral stimulus is interpreted via the peripheral nervous system (spinal nerves) and communicates with the central nervous system via the spinal cord to the brain. However, reflex activity may be the response. A reflex can be initiated when a stimulus is applied and sensory information is interpreted at a spinal level resulting in a motor response, via the reflex arc, e.g. knee jerk (Marieb, 2004). A reflex response does not provide relevant information for assessment of LOC. Nail bed pressure is an example of a peripheral stimulus. Teasdale (1975, 2004) advocates that nail bed stimuli is less painful than sternal rub (central stimuli). Yet direct pressure over the nail bed can cause damage to the capillary network under the nail bed resulting in bruising and potential loss of nail. Pressure can alternatively be applied to the side of the fmger nail distal to the last interphalangeal joint.

Central srimuli
A central stimulus is applied to body areas where it is not possible for a reflex response.This includes: Trapezius muscle squeeze Supraorbital notch pressure Jaw angle pressure Sternal rub Sternal rub should be comidered with caution because this soft tissue area bruises easily. Commonly this stimulus is applied with the knuckles; trauma can be lessened by using a flat open hand (barker, 2002). Clearly supraorbital and jaw angle pressure may not be appropriate in the suspected or proven facial trauma. Supraorbital pressure is also contradicted in the presence of glaucoma and can also result in bradycardia (Barker, 2002). Response to noxious or painful stimuli implies that the neuronal pathways within the RAS connecting to sensory and motor pathways are still functioning to some extent (Price, 2002; McLeod, 2004). A central stimulus is generally

Discussion of theory/practice Implications

During neurological assessment, using the GCS tool, if a verbal or tactile stimulus does not illicit a response from the patient, there will be a need to apply noxious or painfial

Table 3. Definitions of consciousness

1. A state of general awareness of oneself, as well as a state of responsiveness to an environment with the ability to adapt to the external milieu (Barker. 2002) 2. A dynamic state, subject to change 3. Resulting from integrated activities of numerous neural structures including the reticular formation (Hickey. 2003; Bader and Littiejohns. 2004)

Unash Journal of Nursing. 2(I6.Vul 15. No 22

1257

advocated in the first instance (Woodward, 1997; Addison and Crawford. 1999; Shah. 1999; McLeod, 2004) as it can produce an overall body responso (Barker, 2002). Bader and Litdejohns (2004) recognize that a central stimulus is more reliable than peripheral, A peripheral stimulus is useful in assessing individual limbs. There is debate in the literature over best practice in central stimulus, with sonic advocating cither a trapezius muscle squeeze, supraorbital pressure or jaw angle pressure (Woodward, 1997; Addison and Crawford, 1999; Shah, 1999). Addison and Crawford (1999) argue that trapezius muscle squeeze is not a form of central stimulus as it may generate a spinal reflex. This is based upon the premise that only the upper portion of the trapezius muscle is innervated by the spinal accessory (cranial nerve XI). and the lower portion via the cervical spinal nerves C3, 4. 5 (Tortora and Grabowski, 1993; Nolan. 1996; Martini et al, 2001). The physical response by the patient to the central stimulus enables interpretation of the degree of neurological dysfunction and structures involved. Trapezius squeeze may be more difficult to perform on large or obese patients (Barker, 2002). Painful stimuh applied supraorbitally or to the jaw angle may result in grimacing and eye closure as a natural response (Teasdale, 1974) and hence, not useful to demonstrating eye opening response. Anecdotally, the authors have beard of other inappropriate painful stimuli, such as a nipple and testicular squeeze, which is clearly not recommended for practice. When a noxious or painful stimulus is applied to a patient who subsequently responds, the patient is not comatose, as this demonstrates a degree of cortical funccion,The arousal response can be classified into physiological levels of dysflinction and are summarized in the motor components of the GCS (see Table 2), Abnormal flexion and extension represent abnormal movements/posturing. The terms decorticate and decerebrate rigidity are also referred to in the literature. Decorticate rigidity is abnormal flexion and indicates interruption of the

corticospinal tract in the brain stem. This motor posturing implies malfunction, not necessarily destruction of these areas. Decerbrate rigidity is extension and retlects disturbance of the midbrain or pons (Bader and Litdejohns, 2004). Both reflect the loss of higher motor control functions. As discussed earlier, this is due to the complex nature of defining normal/abnormal flexion and extension that a sound knowledge of anatomical and physiological structures is required to accurately apply GCS assessment. Inconsistency in Application GCS can be used inappropriately and inconsistendy by healthcare professionals and needs reinforcement (Rowley and Fielding. 1991; Ellis and Cavanagh, t992;Teasdale and Murray. 2000). "Consistency in the application of the GCS is found to be essential to ensure that the tool is a valid indicator of the patient's clinical condition' (Fischer and Matbieson, 2001 p53). It is recognized that education and training in the use of the GCS tool is required to ensure optimal neurological assessment. Bassi et al (1999) concluded that doctors have difficulty utilizing the GCS when converting a patient's clinical condition into a score. However inter-rater reliability is high in professionals who are experienced in assessing patients with neurological deficits (Harrahill, 1996; Fairley and Cosgrove, 1999; Heron et al. 2001;Teasdale 2004). The GCS tool "claims to be valid and reliable in the repeated observations of the level of consciousness which can be accurately recorded and universally understood' (Fairley and Cosgrove, 1999 p 276), However Segatore and Way (1992) are in a minority who criticize the reliability and validity of the GCS tool and believe that it enjoys an unwarranteil privileged position in a clinical context. Sternbach (2000) critically reviewed alternative tools and concluded that although GCS has drawbacks, it remains the most universally accepted conscious level scale. GCS assessment, underpins clinical decision making in regards to effective and prompt interventions in the patient with an altered conscious level. Identification of the GCS tool and its format (14 or 15 point) in clinical settings is critical to safe patient management, in reviewing the literature it is clear that the 15-point GCS tool should be utilized,This may require some retraining, but also the continuing education of all the multi-professional team to ensure its safe application and interpretation. Assessment, application and training issues In the last decade alternative assessment tools have emerged, such as AVPU (alert, responds to voice, pain or unresponsive). This has been in response to the critical care agenda and the recognition of the 'at-risk patient' who may be acutely ill or deteriorating. AVPU has a simple structure which is easy to apply and has been incorporated into the Early Warning Score (EWS), This is in recognition of the fact that altered conscious levels are present in many deteriorating patients (Schein et al, 1990; Goldhill et al. 1999, 2001). Healthcare professionals need to be confident in their ability to assess and interpret results of a patient's level of consciousness. Practitioners should reniember the point made by McNarry and Goldhill (2004 ) that no other simple tool should replace GCS in the evaluation of a critically ill patient.

Table 4. Anatomical basis of assessment

Assessments Patient's ambient state Pupillary size and response to light Eye movements Observations e.g. awake, asieep Constriction and consensual response Anatomical structures Reticular activating system (RAS) Occulomotor cranial nerve (CN III)

Respirations

Motor examination

Conjugation, both eyes Occulomotor, abducens and trochlear cranial nerves moving simultaneously and in the same direction (CN III. IV and VI) Respiratory centres: Breathing patterns (rate, depth and rhythm) The pons contains the pneumotaxic area (rate) and the apneustic area (length of respiration) The medulla contains ventral respiratory groups (rhythm) Limb power: Motor cortex in frontal lobe and efferent (motor) pathways Arms Legs

1258

Untish JoiiniaJ ol" Nursing, 201)6,Vol 15. No 22

CONSCIOUSNESS
It should also be noted during a.ssessment of conscious level, that some other conditions, such as a spinal cord injury, may skew or complicate the results. Clinical experience is clearly a significant factor as is appropriate knowledge and training. Training should include practice examples for interpretation and discussion, focusing on known ditTicult aspects of assessment such as: Verbal - misinterpretations can occur as some may assume th.!t swearing could be considered as inappropriate words Motor - as previously discussed, abnormal flexion and extension are difficult for healthcarc professionals to recognize if they have no experience of motor neurological deficits. Experienced observers may identify more subtle changes, which may not alter the GCS score at the point of assessment. At this point the healthcare professional should increase the frequency of assessments and involve the wider muitidisciplinary team.
Goldhill D R , Worthington L. Mulcahy A. Tarling M, Sunnier AF (1999) The padent-at-risk team: idendfy-ing and maiiaguig seriously ill ward patients. Anaesilwsia 54: 853-60 Goidhill DK (21K)t)The cridcally ill: following your N4EWS. (Editonal) Quarterly ./.V/rrf 94: 507-10 H,irra!iiU M (19%) Glasgow Coim Scale: a quick review. / Btieig Nim Feb: 81-3 Heron R, Davie A. Gillies R, Couriey M (2(X11) [nterrator reliability of the Glasgow Coma Scale sct>ring among nurses in sub-specialities of critical can.'. -41I.VI Oil Cfin'14(3): 100-5 Hickey JV (2iJ03) Vic Clinical Pnxti of Nairologicd and .\'eurosiirgical Nursii^ 5tl] edn. Lijipincott, Philadelphia Ingram N ( 1994) Knowleclgi' and level of consciousness: applicadon to nursing pracdce.j.4i/ N'lirs 20: Hl-^ JeiHiet B (1986) Altered Conscious[iess and Coma. In: Cmckh;itv A. Hatwanl R. HotFJT eds. Nfurosiiigery.Tlic Srientifu- SiUiV of Cliniail IkMi: Blackwell Science. (").\-foid: 117-26 Jennett B. Teasdale G (1977) Aspects of coma after ovea- lie.d injuu', Liiuvi AprU 23: 878-81 Juarez VJ. Lyons M (1<)95) Interrater relaibility of the Glaa^jw C^ma Scale. _/ Neurom Nurs 27(5): 283-6 LeuHs SL (2005) Field Guide to the Neuroloffc Examination. Lippincott Wanis & Wilkins. Philadelphia Marieb EN. Hoehn K (2(K)4) Human Anatomy and Pli}'siolog}\ 7th edn. Pearson/ Benjamin Cummiiigs, San FrancLsco Martini FH. Ober WC, Garrison CW. Welch K. Hutchings R T (2(X)1) Ftindiimenrals ofAnatomy and Pliysioli'gY 5th edn. Prendce-Hall. New Jersey McLeod A (2(KI4) Intra and extracranial causes of alteradoii EI level of consciousness. BrJ Niirs 13(7): 354-61 N4cNarry AR Goldhill D R (2(X)4) Simple bedside assessment of ievel of consdoiisness: comparison t)f two simple .issessment scales with the Glasgow Coma Scale. .'iiiii'.fic.i 59: 3-17 Nadoiial Institute for Health and t;iinical Excellence (2(X)3) Head Injiir)-:Triage, Asseisnicni, Imvstigtion and EaHy Management of Head Injury in Infants, Children and Adults. NK"E. London Noian MF (1<96) Introduction to the Neurohigicat Examination. FA Davis, Philadelphia P r i t e T (2(X)2) Paintiil stimuli and the Glasi^ow Coma Scale. Nurs Crit Can- 7(1): 19-23 Rowley G. Fitldir^ K (l'Wl) Reliability and accuracy of the Gla^ow Coma Scale with expt-rienced and inexperienced users. Ltncct 337: 535-8 Schein R M . Hazday N. Pena M et al (19'X) Clinical antecedents to in-hospital canLipiilmonary :!nst. Chest 98(6): 1388-92 Segatore M, Way c: (1992) The Gbs^t.'ow Coma Scale: dme tor change. Heart anrf Ljifi 21(6): 548-57 Shah S (]'J99) Neurological assessment. Nurs Stand 13(22): 4'.-56 Sterribach CiL (2(KX))The GUsgiiw G o n u Sc.ile.J ameig Med 19(1): 67-71 Siibbe CP, Kruger M. Rudiertird H Gemmel L (2(Xll)'Validadon of a modied Early Warning Score m liedical admissions. QJ Med 94: 521 - 6 Teasdale G (1975) Acute impairment of brain fiincdon - hAssessing'coiiscioiK level'. ,V((w7j'Hi('iJune 12: 914-7 Teasdale GM (197()) Assessment of head injuries. BrJAnaesth 48: 761-6 Teasdale GM (2(K)4) Tlie Glmgow Coma Scale - JO Yean On. Neurotrautna Symposium. Leeds Teasdale GM, Jennett B (1974) Assessment of die coma and impaired con.sciousness: a practical scale. Luvet 2: 814 Teasdale GM. Murray L (2000) Revisiting the Glasgow Coma Scale and Conia Score, if wi'wn' Care Med 26: 1.53-4 Tortora GJ, Grabowski SR (1993) himples of .Anatomy and Physiology 7th edn. Harper C!olli[is College Publishers. New York Victor M. Ropper AH (2(H)1) AdaniK and Victor's Principles ofNeurokw. McGrawHill. N..-W York Waterhouse C (2005) The Gla;^iw Coma Scale and other neurological observations. Niirs Stand 19(33): .56-64 Watson M. Hom S. i.:urj (1W2) Searching for signs of revival. PrvfNunc 7(10): 6703 Wiese MF- (2(M)3) Different versions of the Gla^ow Coma Seile: telephone survey IMJ 327: 782-3 Wijdicks EFM. Kokinen E, O'Brien PC (1998) Measurement of impaired consciousness in the neumlogical intea^ve care unit: a new test. / Neiircl Neurosiiig and Psychiatry 64: 117-9 Woodward S (1997) Practical procedures for nurses No 5.1. Neurolt^cal bservjrins I.Glasgow Goma Scale.NURTm93(45 Suppl): 1-2

Conclusion
Healthcare professionals require an understanding of the anatonucal and physiological basis of consciousness and possible causes of altered level of consciousness. Level of consciousness can change rapidly within minutes or hours. It should be remembered that the GCS 15-point format, while a simple and standardized system, is only one parameter; other factors such as vital signs, pupil size/response to light, and intracranial pressure, will be important in clinical decisions. It is essential that appropriate observations are instigated, whether this is AVPU or GCS, to assess neurological trends which will inform clinical decisions. Practitioners must recognize when to escalate assessment from AVPU to GCS. Healthcare professionals develop an evolving 'index of suspicion' based upon their knowledge and previous experience. The experienced practitioner has a deeper understanding ot the neurological system based on practical experience coupled with further education and training. It is the clinical and educational view of the authors that assessment of conscious level should be used by all healthcare protessionals as easily as routine vital signs observations. DB

AirdT. Mclmosh M (2(KW) Nursing tools and strategics to assess ct^iitioii and fonfosion. BrJ .\'urs 13(10): 621-> Adtiison C:. CraAford B {1999) Not bad. just niisunderstood. Nurs Times 95(43): .S2-3 American College of SuigeoiB (1993} ATLS Advanced Trauma Life Support Prc^mm for Physicians, lastmaor Manual, 5th edn. American College of Surgeons. Chicaj^ Holder MK, Litdejohas LR (eds) (2(.H)4) AANN Core Cuniailum Jbr .Mmmitie Nuriiig 4th edil. Sauiiders. St Louis Barker E (2(X)2) Ncuiosfute Nursing: A Spectrum of Care 2nd edn. Mosby, St Louis Bassi S. uxton A, Punt JA, O'Reilly G (1999) Glaj^ow C o n u Scale: a help or luoderance. BrJ \'cuhX'uis 13(5): 526-39 EdvvMTiK SI. (2(101) Using the Glasgow Coina Scale: imalysis jnd liinitadons. DrJ.\'iin 10(2):'2-]ll] Eilis A, Cavamgh SJ (1992) AspecB of neurosuigifal assessment using the Casgow Coma Scale, luicnsife Crit Caw Nun 8: 94-9 Fairky D. Cosgrove J (1999) tla^ow Coma Scale: improving nursing pracrice tliruugh clinical i-fiectiveness. Niirs Crit Care 4(6): 276-9 Fielding K, kowle>' G (1990) Reliability of assessments by .skilled observers using the (ilisgiiw Coma Scale. AuiiJ.-{dv Nun 7(4): 13-7 Fischer J. M.ichieson C (2(X)])'The history of the Glasgow Coma Scale: implications for pracce. Crii Care Nurs Q 23(4): 52-8 Frjwley P (99()) Neuroit^cal Observations. NursTimis 86(35): 29-34 Goetz C C (2(X)3) 'Itwibook ([ Clinical Neurolfy 2nd edn. Saundeir.. Philadelphia Ciuyton AC. Hall JE (21KJ6) Textbook of Medical Physiology l l t h edn. Elsevier Saunders, PliiUdeiphia

KEY POINTS I Patients may present in a range of different settings requiring neurological assessment, commonly due to extracranial causes. I Practitioners require an understanding of the related anatomy and physiology to competently interpret Glasgow Coma Score assessment results. I There are a range of different techniques for applying painful stimuli, the choice of which will depend upon the response that you are trying to elicit.

BriiLslijuunial of Nursing. 2nil(). Vol 15, No 22

1259