GLASGOW COMA SCALE – Purpose, Description of the GCS, Equipment, Procedure, Eye Open, Best Motor Response, Verbal Response and Interpretation
The Glasgow Coma Scale (GCS) is an assessment tool designed to note trends in a client’s response to stimuli
The Glasgow Coma Scale can be used as an effective assessment tool. In order to achieve a clear and objective evaluation of the patient’s neurological status
The Glasgow Coma Scale is a standardized scoring system used to assess level of consciousness in a patient
PURPOSE
- To monitor level of consciousness in any patient who has altered sensorium
- To monitor patient with suspected or confirmed brain injury
DESCRIPTION OF THE GCS
Glasgow Coma Scale has three aspects of the patient’s behaviors are observed and recorded, eye opening, verbal responses and motor responses to a verbal command or painful stimulus. These assessments are further subdivided into different levels of response
EQUIPMENT
- Glasgow Coma Scale proform
- Knee hammer
- Pen torch
PROCEDURE
- Keep the patient in comfortable position
- Score responses in GCS sheet
- Add total score at bottom of sheet during each assessment
- Assess pupils, limb movements and vital signs for completion of procedure
- Document accurately and report for changes if any
EYE OPEN
- Spontaneously – 4
- To speech – 3
- Topain – 2
- No response – 1
BEST MOTOR RESPONSE
- Obeys – 6
- Localizes pain – 5
- Withdraws – 4
- Abnormal flexion – 3
- Extends – 2
- None – 1
VERBAL RESPONSE
- Oriented – 5
- Confused
- Conservation – 4
- Inappropriate words – 3
- Incomprehensible
- Sounds – 2
- None – 1
- Total 3-15
INTERPRETATION
- Each response is given a number (high for normal and low for impaired)
- The summation of these figures gives an indication of the severity of coma and a possible prediction of outcome
- The lowest score is 3 and the highest is 15
- In general, a score of 4 or 5 indicates the patient is deeply comatose
- A score of 6 to 10 shows intermediate disturbance of consciousness
- A score of more than 10 approaches a more conscious state
