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Test of variation in physiological measures An early warning system ( EWS ), sometimes called a between-the-flags or track-and-trigger chart , is a clinical tool used in healthcare to anticipate patient deterioration by measuring the cumulative variation in observations, most often being patient vital signs and level of consciousness. [ 1 ]
The FOUR Score is a 17-point scale (with potential scores ranging from 0 - 16). Decreasing FOUR Score is associated with worsening level of consciousness. The FOUR Score assesses four domains of neurological function: eye responses, motor responses, brainstem reflexes, and breathing pattern.
The Confusion Assessment Method (CAM) is a diagnostic tool developed to allow physicians and nurses to identify delirium in the healthcare setting. [1] It was designed to be brief (less than 5 minutes to perform) and based on criteria from the third edition-revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).
GCS was initially used to assess level of consciousness after head injury and the scale is now used by first aid, EMS and doctors as being applicable to all acute medical and trauma patients. In hospital it is also used in chronic patient monitoring, in for instance, intensive care.
The AVPU scale (an acronym from "alert, verbal, pain, unresponsive") is a system by which a health care professional can measure and record a patient's level of consciousness. [1] It is mostly used in emergency medicine protocols, and within first aid .
Pain stimulus is a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli (such as shaking of the shoulders). [1]
Richmond Agitation-Sedation Scale (RASS) is a medical scale used to measure the agitation or sedation level of a person. It was developed with efforts of different practitioners, represented by physicians, nurses and pharmacists. [1] [2] The RASS can be used in all hospitalized patients to describe their level of alertness or agitation. [3]
The Glasgow Coma Scale [1] (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviours make up the three elements of the scale: eye, verbal, and motor.