Neurological Exam: Level of Consciousness

If you’re learning how to do neuro checks, one of the most challenging aspects can be distinguishing level of consciousness. Often, this is the first thing to change when neurologic damage is occurring. But it’s very subtle and can be difficult to detect. 

Let’s go through each level of consciousness (LOC) that you’ll see and the main differences between them. 

Level of Consciousness

Before you speak, observe 

How awake and alert is the patient? When you walk into the room, do they hear you, turn their head, acknowledge you with speech when you announce yourself?

Or… do you have to say their name to wake them?  Or… do you have to shake their shoulder to get them to open their eyes?

Do they stay awake during the entire interaction? Note the amount of stimulation required for them to participate in the neuro check.

Now, let’s walk through each level of consciousness you may see. (Please note, we’re not talking about orientation or confusion levels here, just alertness level!)

Awake and alert

They awaken easily, and maintain that level of alertness throughout the interaction (this will probably be what you see the most). They can interact with you and those around them. 

If you walk into the room and they’re sleeping, they easily awaken with either verbal or very gently tactile stimulation. They easily chat and interact with you. They’re awake in between care. 

Lethargic 

This is more than just sleepy… this could be considered “severe drowsiness”. So, to wake them up, you need to use tactile stimulation (a gentle shake of the shoulder, tap on the chest) along with simultaneous verbal stimulation. They may fall asleep immediately after your interaction, or possibly during. 

How to distinguish sleepy versus lethargic 

Sometimes, it can be pretty difficult to tell if a patient is just tired. They likely have very legitimate reasons to be fatigued, as we are waking them often, giving meds, and they’re not in their normal sleep environment.

Here are some ideas of how to really wake someone up. If they are unable to shake off the fatigue for a few minutes to interact, likely we’ve got more going on.

Flip on all the bright lights, speak in a louder voice, and pull the cover back. Wake them, let them know you need them to stay awake for a chat to see how their brain is doing. If they’re merely sleepy and it’s not due to a brain issue, they should be able to awaken themselves enough to focus and to participate. But if they seem to be “overcome” by being tired, despite visual, tactile, and verbal stimulation… that’s a decreased level of consciousness that most likely cannot be attributed to simple fatigue. 

Obtunded 

This person is less interactive than the lethargic patient. This patient repeatedly falls asleep during your short interaction. They often require simultaneous verbal and tactile stimulation (speaking to them while firmly shaking their shoulder). They constantly sleep in between assessments or interactions. 

Stupor

A “stuporous” patient will only respond minimally to vigorous painful stimulation. To get them to respond (at all) you have to do a trapezius pinch (ouch!), supraorbital pressure (really ouch!), or sternal chest pressure (not cool!). Unfortunately, we have to elicit painful stimuli to see if their brain can interpret it. This provides us with valuable information as to how the brain is functioning. A patient whose LOC is this compromised may be on a ventilator because they’re not awake enough to maintain their own airway.

Unresponsive

You may hear people use the word “coma” here, but I highly discourage it. People tend to think obtunded or stuporous patients are comatose. Coma is a vague term. When your loved one is this neurologically compromised, we shouldn’t be vague. We need to be clear, and concise.

This patient does not respond to visual (because they cannot open their own eyes), verbal, tactile, or painful stimulation. This patient likely lacks essential basic reflexes. This patient must be on a ventilator, as they won’t be able to maintain their own airway and breathe on their own. 

It gets easier

While reading and hearing about this helps, what will be crucial is visually seeing patients who fall into these categories. What might be just as important is the actual one you select is being able to tell when your patient starts to decline. 

So, maybe at the beginning of the shift you weren’t sure if they were lethargic or not… but now, 4 hours later, you realize that they’re definitely not awake and alert, or lethargic. They’re falling asleep during the interaction, sleep between care, and require much more tactile stimulation to awaken. That’s the stuff you need to tell the provider, and do so promptly!

Levels of Consciousness Video:

More neuro nurse tips

• Neuro Assessment: How to Assess An Unconscious Neuro Patient Like a Neuro ICU Nurse
• Noticing Subtle Neuro Changes for Nurses
• Top Tips for New Neuro Nurses