ADD-ONS / SCALES

• the test evaluates the quantitative aspect of consciousness and the level of psychomotor activity
  • it is most commonly used in mechanically ventilated patients to avoid both oversedation and undersedation
    
• timing is crucial; sedation should be reduced or discontinued 1-2 hours before testing
• start with observing the patient
  • patient is alert, in a normal state (0)
    
  • patient is hyperactive (score +1 to +4)
• if not alert, state the patient’s name and request to open their eyes and look at the speaker
  • patient awakens with sustained eye contact (score –1)
  • patient awakens with eye contact, but not sustained (score –2)
  • patient exhibits any movement in response to voice but no eye contact (score –3)
  • scores -1 to -3 indicate varying degrees of somnolence; the patient responds to verbal stimulation and may be further tested for delirium
• if the response to verbal stimulation is absent, physically stimulate the patient by shaking the shoulder and/or rubbing the sternum
  • any movement in response to physical stimulation (score –4)
  • no response to any form of stimulation (score –5)
  • scores -4 and -5 correspond to a profound disturbance of consciousness (sopor – coma) and preclude further testing for delirium