Glasgow Coma Scale

tests trends in LOC

checks: eyes, verbal and motor
score range: 3-15 with 15 being normal
Glasgow Coma Scale: Eyes Ratings
4: sponataneous
3: loud voice
2: to pain
1: no response
Glasgow Coma Scale: Verbal Ratings
5: oriented
4: confused
3: inappropriate
2: incomprehensible
1: no response
Glasgow Coma Scale: Motor Ratings
6: obeys commands
5: localizes to pain
4: withdraws (flexion)
3: abnormal flexion posturing (decorticate)
2: extension posturing (decerberate)
1: no response
Glasgow Coma Scale: Instructor
you need to be able to break it all down to the instructor.
remember to tell your partner to do a motor command for the motor portion.

you need to say: "they reached a score of 15 which is in the normal range of the
Glasgow Coma Scale."
Content of Mentation Testing
1. testing if affect and mood are congruent
2. testing cognitive abilities
Content of Mentation Testing: affect
note whether her expressions seem CONGRUENT with your partners mood
Content of Mentation Testing: Cognitive
you are testing:
length of concentration
recent and remote memory
abstract reasoning and judgement
Content of Mentation Testing: Cognitive Testing
ask questions like:

where are you?

why are you here?
what is that on the wall?
what does "a bird in the hand...." mean?
Content of Mentation Testing: Instructor
say something like:
"her affect, feelings and expressions are congruent."
Cranial Nerve Order: Mnemonic
OLd OPie OCCasionally TRIes TRIGonometry And Feels VEry GLOSomy, VAGue And
HYPOactive
Cranial Nerve Sensory, Motor, Both Mnemonic
Some Say Marry Money But My Brother Says Big Business Makes Money
Cranial Nerve Assessment: #1 Olfactory
sensory
smell
test: patient closes eyes, occlude a nare and have them smell something and tell you
what it is
if they pass, say: "cranial nerve 1, is intact"
Cranial Nerve Assessment: #2 Optic
sensory
vision
test: snellen for distance vision, jaeger for near vision, confrontation
you will say, "cranial nerve 2, the optic nerve, is intact"
Cranial Nerve Assessment: #3, 4 and 6: Oculomotor, trochlear, abducens
all motor
movement of the eye and pupils ability to accommodate

Tests:
check 6 cardinal fields (rectangle and criss cross)
use your penlight to check how pupils react indiv/together
convergence

you will say: "all 6 cardinal fields are intact, nystagmus is not present, they are
PERRLA"

Make sure to tell the instructor you would test with the light pen in a lit and dark room
Cranial Nerve Assessment: #5 Trigeminal
Both
sensory = facial feeling
motor = clinching jaw

test sensory: with pt eyes closed, touch 6 places on their face with a cotton ball and
have them tell you where.
test motor: have them clinch jaws against your pressure to check if pressure is equal,
have them open their mouth with pressure from your hand, have them move jaw from
side to side.

Tell the instructor: " cranial nerve 5, the trigeminal nerve, is intact"
Cranial Nerve Assessment: #7 Facial
Both
sensory: anterior 2/3 of the tongue
motor: facial movement

test sensory: cant --> salty and sweet taste

test motor: puff cheeks, frown, smile raise eyebrows --> check for symmetry

make sure to tell the instructor that the facial nerve innervates the anterior 2/3 of the
tongue.
"cranial nerve 7, the facial nerve, is intact"
Cranial Nerve Assessment: #8 Acoustic/Vestibulocochlear
sensory
hearing/balance

test: whisper test

"cranial nerve 8, the acoustic nerve is intact"

Cranial Nerve Assessment: #9 Glossopharyngeal
both
sensory: posterior 1/3 of the tongue --> taste bitter, sour
motor: swallow

test sensory: cant

test motor: have them swallow

"cranial nerve 9, the glossopharyngeal nerve, is intact"

Cranial Nerve Assessment: #10 Vagus Nerve
both
sensory: indiscriminate taste
motor: swallow and gag reflex

test sensory: cant

test motor: you will have tested this with cranial nerve 9
you should also have them open their mouth and say AHH to check for uvula midline

so you might say: "cranial nerve 10, the vagus nerve, is intact."
Cranial Nerve Assessment: #11 Spinal Accessory
motor
movement of trapezius and sternocleidomastoid

test: have them shrug shoulders against resistance and have them move their head
from side to side against resistance

"cranial nerve 11, the spinal accessory nerve, is intact"

Cranial Nerve Assessment: #12 Hypoglossal
motor
tongue movement
test: have their patient stick out their tongue to check for midline and have them push
their tongue against their cheek to feel for strength

"cranial nerve 12, the hypoglossal nerve, is intact"

Motor Assessment: general info
tests strength, equality (if unequal test for tone)
compare bilaterally

"I'm going to be assessing her strength on a scale of 5/5"

Motor Assessment: 0-5 Scale
0: no contractile power
1: minimally movement/contraction
2: can move but not overcome gravity
3: can overcome gravity
4: fair --> not full
5: full strength
Motor Assessment: Deltoid
test: patient makes chicken wings, put pressure with hands on outer shoulder and have
them move it up

"her deltoids are 5/5, bilaterally"

Motor Assessment: Biceps
test: patient flexes biceps and pushes up against resistance of your hands

"her biceps are 5/5 bilaterally"

Motor Assessment: Triceps
test: still flexed, the patient pushes down against resistance of your hands

"her triceps are 5/5 bilaterally"

Motor Assessment: Hand Grips
test: have the patient squeeze your 2 fingers as hard as they can.

"her hand grip is 5/5, bilaterally"

Motor Assessment: Leg Extensor
test: have the patient extend their legs against your hands resistance on their shins,
both at the same time if you can.

"her leg extensors are 5/5, bilaterally"

Motor Assessment: Plantar/Dorsi flexors
test: with legs extended, have the patient point their toes against resistance of your
hands and then flex upwards against resistance.

"her plantar and dorsi flexors are 5/5, bilaterally."

Sensory System Assessment
tests discriminatory and superficial touch
Sensory System Assessment Testing
have your patient close their eyes
touch them with a Q-tip on 6 spots of the body making sure to touch 1 spot on the trunk.

make sure to tell the instructor that you have already done the face

say, " her discriminatory and superficial sensory system is intact"