The AVPU Scale

The AVPU scale is a tool to assess a patient’s brain function and perfusion. The medical
fraternity uses the scale to record and assess a patient’s level of consciousness and
responsiveness.

Healthcare providers, including nurses, doctors, EMTs, and paramedics, use the AVPU scale to
measure, record, and monitor brain function in patients.

The scale was developed as a simpler way to assess patient response during first aid and in
emergency medicine protocol. It’s a simplified form of the Glasgow Coma Scale … uses four
outcomes down to the standard 13 outcomes.

An AVPU scale assessment uses three measures – eyes, voice, and motor skills – and records the
best response of the three traits.

There are four possible outcomes on the AVPU scale … facilitate rapid assessment and response
in an emergency.

You should apply the scale sequentially … deductively moving from best to worst to save time
while ensuring accuracy.

Here’s a quick rundown of the AVPU Scale:

 Alert: The patient is aware of your presence, the environment, and can follow
commands.
 Verbally Responsive: The patient responses … in some form when you talk to them
 Painfully Responsive: The patient responds when you apply a painful stimulus … may
move, cry, or moan from the pain.
 Unresponsive: The patient doesn’t respond to your voice or pain application.
Now that you understand the gist of the AVPU scale … let’s take a detailed look at each of the
possible outcomes.

Alert

An alert patient might be slightly confused but fully awake and can identify people, and react to
external environmental stimuli.

The patient might be alert and confused, alert and lethargic, alert and disoriented, or alert and
oriented. The descriptors are crucial in describing the patient’s mental status.

You can evaluate the patient’s orientation state by asking them to answer simple questions such
as:

 What’s your name?

 Do you know where you are?
 Where are you now?
 What date is it?
 What time is it?

Avoid the no or yes questions when testing a patient for alertness. Questions that require the
patient to detail the answers are preferable since they lend themselves to the alert state scale.

The scale runs from 1 to 4, and a patient is rated on their ability to give specific answers.

A patient is alert if they:

 Fully awake and spontaneously opened their eyes

 Respond to environmental and voice stimuli
 Seem oriented to a degree or completely

Verbally Responsive

A patient who didn’t seem awake or oriented may respond to verbal stimulation … and respond
to your questions.

The patient may seem asleep but will respond … in some form … when you talk to them. The
verbal response has three components – eyes, voice, or motor responses.

The patient may open their eyes if you ask a question to test their alertness. They may grunt or
mumble a response or slightly move a limb following the voice prompt.

Common questions include, “are you okay?” “can you tell me what happened?” “can you hear
me?”.
It’s crucial that you note the responses as appropriate or inappropriate as it is indicative of the
patient’s orientation.

Note, however … if a patient responds to verbal stimuli and stays awake, they’re considered
alert.

You can’t classify a patient as verbally stimulated if they:

 Are alert
 Can answer sample history questions
 Describe their primary problem
 Make an informed decision to refuse care

A patient is verbally stimulated if they:

 Not fully awake and only reacts to verbal stimulation

 Show verbal orientation to a normal or loud voice
 Have appropriate or inappropriate answers to questions
 Respond in a normal voice

Painfully Responsive

If a patient isn’t orientated and doesn’t react to verbal stimuli, you can check if they’re
responsive to pain. I know, purposely causing a patient’s trauma … sounds ominous, but it really
isn’t.

A pain stimulus – peripheral or central pain stimulus – is a gentle and harmless way of eliciting a
reaction from a patient.

 Peripheral pain stimulus is simple and entails applying pressure to the patient’s hand or
shoulder, or pinching their ear.
 Central pain stimulus involves a sternum rub and is the most painful stimulus used by
paramedics and EMTs. It involves vigorously rubbing the patient’s sternum with
knuckles of a closed fist.

Depending on the amount of pressure applied … a sternal rub can be excruciating and can result
in bruising. It’s often taught in various martial art disciplines as a self-defense tactic.

If the patient opens their eyes, mumbles, or moves, they’re responsive to pain stimuli.

Interpreting Pain Stimulus

You can classify the patient’s movements when reacting to pain into various categories.

 Alert: The patient is temporarily alert … and may ask why you’re hurting them.
  Localizing pain: Localizing indicates the patient is aware of where the pain is coming
from … and will attempt to stop you from hurting them. For instance, a patient may use
the other hand to stop you from pinching their nail bed.
 Withdrawing: The patient may pull their hand or finger away from you as you pinch
their nail bed.
 Decorticate: The patient may flex their arms and legs inwards … towards their core.
Flexion indicates a major problem with the brain.
 Decerebrate: The patient may extend both arms and legs with the palms pointing
downwards while the head is bent backward.

A patient is pain stimulated if they:

 Respond only to pain stimuli

 Moan or withdraw from the pain
 Make a sound or move their eyes due to the pain
 Respond by a voluntary or involuntary flexion or extension of their limbs.

Unresponsive

Also noted as unconscious, this outcome refers to a patient who is unresponsive to stimulus. The
patient remains flaccid and doesn’t respond to voice or pain stimulation.

The patient doesn’t make any movements or produce any sounds, intelligent or otherwise.

However, it’s critical to differentiate whether the patient is completely unresponsive or

unconscious but responsive to stimuli.

About the AVPU Scale

The AVPU is a consciousness evaluation system that checks a patient’s responsiveness to
stimuli. It was designed as a simpler and faster alternative to Glasgow Coma Scale, which uses a
13-point scale.

The AVPU system focuses on eye, voice, and motor skills to classify patients into one of four
possible outcomes – Alert and oriented, Verbally responsive, Pain responsive, and Unconscious.

Any outcome below A (Alert and oriented) calls for immediate medical attention.

Trauma and acute illnesses are the primary causes of decreased consciousness. Decreasing
consciousness may lead to airway obstruction and a decline in protective airway reflexes.

Rapid intervention is necessary to decrease the risk of respiratory failure and cardiac arrest.

If the patient is unconscious, you should check their vital signs. Also, ensure there are no
obstructions in the airways and place them in a recovery position.
Patients with an oxygen saturation that’s below 94% do require oxygen supplementation.

How to Use the AVPU Scale

Assessing an injured person’s level of consciousness is critical … the AVPU scale helps you get
this done quickly. The scale simplifies the ability to determine a patient’s level of responsiveness
during an emergency.

For patients that are alert … but have altered mental status, their focused history and a physical
examination can help you determine why.

During my practice, I have found that such patients exhibit symptoms of stroke, low blood
pressure, or a narcotics overdose. A quick look at their sample history questions or OPQRST
history helps to clear the air.

For patients with an outcome AVPU below A …, there’s an urgency to establish the cause and
provide treatment. For instance, unconscious patients lack control over their airways.

Determining the cause improves your ability to provide the best treatment … and increases the
patient’s chances of recovery.

AVPU assessment is critical for trauma victims during transportation. The paramedics constantly
monitor AVPU … alongside the patient’s vital to determine their progress. A patient can be
classified as improving, responding to treatment, or worsening.

Significance of AVPU Assessment

D in the ABCDE assessment stands for disability … a problem with a patient’s neurological
function resulting in a disability. In this context, disability relates to consciousness … self and
environmental awareness.

In a medical setting, changes in consciousness levels mirror changes in the patient’s neurological
status. It’s a timely and reliable way to assess a patient’s neurological status.

Typically, your consciousness is controlled by two major parts of the brain.

The reticular activating system (RAS) has diverse functions, including controlling sleep, eating,
sex, and walking. However, its primary function is to control consciousness.

It controls wakefulness and our ability to focus. It also helps to filter repeated stimuli to keep
your senses from being overwhelmed.

The cerebral cortex is the most sophisticated part of our brain … and it’s responsible for
cognition. It’s divided into the left and right and is also responsible for perception, thought, and
speech.
The cerebral cortex is divided into four lobes … each with specific functions. Frontal lobes
control motor functions, impulses, memory, and language … and are highly vulnerable to injury.

Causes of Altered Mental Status

 Direct destruction: The anatomical structures of the consciousness are directly impacted
by traumatic injury, infection, stroke, and more.
 Substrate alterations: Injuries and other metabolic causes might alter the energy
substance the brain needs to function correctly.
 Intoxication: Toxic effects from drugs and alcohol impair brain function.

AVPU as an Assessment Tool

Nurses often perform a neurological assessment to gauge a patient’s neurological status.
Especially if the patient has a history of loss of consciousness, impaired consciousness … or a
high risk of deteriorating consciousness.

A typical neurological assessment entails a quick review of the patient’s state on the AVPU
scale. You’ll also check the pupil size and reaction, sensory and motor function, and vital signs.

Checking for responsiveness is a top priority when assessing a patient under your care. Check if
the patient is breathing and has an open airway and adequate blood circulation.

Following an accident, a medical professional should determine if the patient has lost
consciousness at any point … and if they’re likely to deteriorate.

Mastering the AVPU scale lets you breeze through the D section of the ABCDE assessment. It’s
a quick and efficient way to assess a patient’s level of consciousness and responsiveness.

Clinical Significance of AVPU Scale

First Aid and Emergency Care

The AVPU scale is a quick and efficient way to detect a patient’s altered mental status (AMS).
It’s critical during first aid and pre-hospital care since any outcome below “A” is classified as
abnormal.

Such results prompts the medic to conduct further assessment or embark on definitive care. EMS
crew follow a low AVPU score with a GCS assessment when responding to an accident.

Initially, AVPU was critical in the primary survey of trauma patients. Declining mental status is
often indicative of a poor supply of oxygenated blood to the brain.

Hospital Care and Long-term Care

Altered mental status is … among the best death predictors in inpatient care. The healthcare
fraternity … including nurses, use the AVPU scale to assess patients with a higher risk of
developing an abnormal level of consciousness.

AVPU is a core part of the Rapid Response Activation Criterion and Early warning scores.

Detecting changes in a patient’s physiological status helps detect and correct potentially life-
threatening issues during a hospital stay.

Patients in nursing homes or long-term care facilities may have an AVPU baseline that’s below
A. Terminal conditions and age-related issues such as Alzheimer’s are known to impact a
patient’s responsiveness.

While helpful … the AVPU scale isn’t ideal for the continued neurological observation of
patients.

Airways Protection

The AVPU scale is critical in helping healthcare professionals manage risks relating to
inspiration and airway management.

Patients with a P or U score usually have impaired or absent gag reflexes … they’re unable to
control their airways.

Following an outcome that’s less than A … healthcare providers should consider initiating
airway protection. Timely intervention helps avoid a compromised airway or aspiration.

A low AVPU score corresponds to scoring an 8 or lower on the GCS … which triggers airway
protection.

Nursing

As primary caregivers, nurses frequently use the AVPU scoring system. Undoubtedly, mastering
the AVPU scale is critical to your success as a nurse.

Any drop in a patient’s consciousness level should galvanize you to alert the managing clinician.

Limitations of the AVPU Scale

An AVPU scale is one of the numerous scales used to assess a patient’s mental status. The
Glasgow Coma Scale (GSC) Richmond Sedation and Agitation Scale (RASS)is popular …
and is considered the most effective.

Since AVPU is a simplified version of the GCS, it’s somewhat inferior to both.
The GCS and RASS scales supersede AVPU in predicting mortality in admitted patients.

They lend themselves to routing tracking … which improves the ability to detect patients with
deteriorating clinical health.

Like AVPU, the ACDU scale uses a 4-point rating … but is better suited to the routine
assessment of severely ill patients.

The ACDU scale uses alertness, confusion, downiness, and unresponsiveness to assess a
patient’s mental state.

The ACDU values are more evenly distributed when compared to GCS. That underpins the
scale’s ability to detect declining conscious levels in critically ill patients quickly.

Lastly, the Simplified Motor Score (SMS) scores patients on a 3-point scale. It assesses a
patient’s ability to obey commands, localize pain, and withdraw from pain.

The SMS scale is a staple in the pre-hospital and critical care setting for patients with possible
brain trauma. It’s the most efficient way to assess patients for altered loss of consciousness in
trauma and non-trauma patients.

GCS Vs. AVPU Scale

The AVPU is commonly used alongside GCS as part of the loss of conscious assessment. It’s
used to note the best response a patient maintains.

Compared to GCS, the AVPU scale has one significant drawback … the inability to provide
long-term neurological status follow-up.

GSC

AVPU

13- 15

Alert

9 – 12

Verbal response

4–8

Pain response

3
Unresponsive