CATEGORY	SCORE	RESPONSE
Eye opening	4	Spontaneous: eyes open spontaneously without stimulation
	3	To speech: eyes open with verbal stimulation but not necessarily to command
	2	To pain: eyes open with noxious stimuli
	1	None: no eye opening regardless of stimulation
Verbal response	5	Oriented: accurate information about person, place, time, reason for hospitalization, and personal data
	4	Confused: answers not appropriate to question but use of language is correct
	3	Inappropriate words: disorganized, random speech, no sustained conversation
	2	Incomprehensible sounds: moans, groans, and incomprehensible mumbles
	1	None: no verbalization despite stimulation
Best motor response	6	Obeys commands: performs simple tasks on command; able to repeat performance
	5	Localizes to pain: organized attempt to localize to remove painful stimuli
	4	Withdraws from pain: withdraws extremity from source of painful stimuli
	3	Abnormal flexion: decorticate posturing spontaneously or in response to noxious stimuli
	2	Extension: decerebrate posturing spontaneously or in response to noxious stimuli
	1	None: no response to noxious stimuli; flaccid

Data from Urden, L. D., Stacy, K. M., & Lough, M. E. (2010). Critical care nursing: Diagnosis and management (6th ed.). St. Louis, MO: Mosby.

Another tool in assessing level of consciousness is the Full Outline of UnResponsiveness (FOUR) score of neurologic assessment.^2,³ FOUR score (Table 25-2) was developed by neurologists at the Mayo Clinic as an alternative to the GCS in assessing and monitoring patients. Some practitioners believe that it is easier to use and provides more detailed information about the patient’s level of consciousness. FOUR score assesses eye, motor, brainstem, and respiratory function and assigns a score of 0 to 4 in each category. The lower the score, the more serious the patient’s condition. FOUR score does not assess a patient’s verbal abilities.

TABLE 25-2 FULL OUTLINE OF UNRESPONSIVENESS SCORE

Neurologic assessments should be trended to monitor for deterioration and for response to interventions.

Mental Status Exam

The most commonly used tool to assess cognitive function is the Mini-Mental State Examination (MMSE). Cognitive testing is focused on evaluating memory, ability to calculate, language, visuospatial skills, and degrees of alertness. It does not assess mood or thought processes and patients with mild dementia may be able to compensate.

Components of the Mini-Mental State Examination

• Orientation (order in which orientation is lost: time, then place, and finally person).

• Registration and memory: Name three unrelated items to the patient and ask him or her to state them back.

• Foundation of knowledge: Ask the patient what is on the national news.

• Attention span and calculation: For example, have the patient subtract backwards by 7 from 100.

• Naming: Show the patient an object and have him or her name it.

• Repetition: Have the patient repeat a statement.

• Comprehension: Give the patient simple directions to follow and see if he or she is able to follow the directions.

• Reading: Tell the patient to read a directive statement and then do what the statement says. For example, “Raise your hand.”

• Writing.

• Drawing.

Cranial Nerve Assessment

Table 25-3 lists the cranial nerves and their functions. See Chapter 36, Head Trauma, for more information.

TABLE 25-3 CRANIAL NERVES AND THEIR FUNCTION

NUMBER	NAME	FUNCTION
I	Olfactory	Smell
II	Optic	Vision
III	Oculomotor	Elevate upper lid, papillary constriction, most extraocular movements
IV	Trochlear	Downward, inward movement of the eye
V	Trigeminal	Chewing, clenching of the jaw, lateral jaw movement, corneal reflexes, face sensation
VI	Abducens	Lateral eye deviation
VII	Facial	Facial motor, taste, lacrimation, salivation
VIII	Vestibulocochlear	Equilibrium, hearing
IX	Glossopharyngeal	Swallowing, gag reflex, taste on posterior tongue
X	Vagus	Swallowing, gag reflex, abdominal viscera, phonation
XI	Spinal accessory	Head and shoulder movement
XII	Hypoglossal	Tongue movement

Selected Emergencies

Unconsciousness

Unconsciousness is defined as a lack of awareness of self or of anything surrounding oneself, despite application of various stimuli. Assessment of the patient who is unconscious or who has an altered level of consciousness must be done concurrently with emergent interventions for airway, breathing, and circulation. Causes of unconsciousness can be categorized as structural, metabolic, toxic, or psychiatric (Table 25-4).

TABLE 25-4 DIFFERENTIAL DIAGNOSIS FOR COMA

CATEGORY	DIFFERENTIAL DIAGNOSIS
Structural	Abscess, aneurysm, hematoma, hemorrhage, inflammation (i.e., meningitis, encephalitis), subarachnoid hemorrhage, stroke, trauma, tumor
Metabolic	Cardiopulmonary arrest, decreased cardiac output, elevated serum ammonia, fluid or electrolyte imbalance, hepatitis, hepatic dysfunction, hypoglycemia, hypothermia, hypothyroidism, seizure, vitamin deficiencies
Toxicity	Alcohol, anticholinergics, benzodiazepines, carbon monoxide, cyanide, opiates, salicylates, sedatives, tricyclic antidepressants, gamma hydroxybutyrate (GHB)
Psychiatric	Hysteria, malignant catatonia, psychogenic unresponsiveness