Mindanao State University – Iligan Institute of Technology College of Nursing GLASGOW COMA SCALE

Purpose

Special Considerations
1.
2.
Cultural Considerations:

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Equipment
● Glasgow Coma Scale Chart
● Penlight
● PPE
Procedure RATIONALE

1. Observe Interim Guidelines on Health Facilities in the

in using PPE protective suit, N95 respirator/FFR,
facemask, eye goggles, face shield, and gloves when
appropriate.

2. Gather and prepare required equipment and

materials for the procedure and bring necessary
articles to the bedside, department, or special
area/care unit.

3. Eye opening.

a. When you enter the client’s room, try to close the

door louder than usual. If the client spontaneously
opens his eyes, the score is 4.
b. If the patient has no response to step a, greet the
client and ask him a simple question. If there is eye
opening upon hearing your voice, the score is 3.
c. If there is no response to step b, elicit pain by
pressing the client’s fingernail bed. A score of 2 is
given if the client opens his eyes upon feeling the
nail bed pressure.
d. If there is no response to step c, the score is 1. e.
Record as “Non-Testable” when the eyes are closed
by local factor (swelling of the eyes, interference of
eye opening)

Perception and Coordination II

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Mindanao State University – Iligan Institute of Technology College of Nursing
4. Assess Verbal Response.

a. Ask the client about his/her name, current

year/month/day, and place.
b. Based on the patient’s answers in step a, grade
him/her with the appropriate corresponding score
for:

Oriented: 5
Confused: 4
Inappropriate words: 3
Incomprehensible sounds: 2
None: 1
Non-testable: Presence of endotracheal tube

5. Assess Motor Response.

a. Perform 2-part request: Ask the patient to

squeeze and release your hand with his/her hand.
Ask the patient to stick his/her tongue out or to
smile showing his/her teeth.
b. If the patient is unable to perform the
above commands due to limitation, apply a central
stimulus by performing trapezius pinch for 10
seconds or apply central stimulus on the
supraorbital notch. Apply pressure with an
increasing intensity up to 10 seconds until you
observe the patient’s best response (CAUTION:
Application of pressure on the supraorbital notch
should not be done on patients with facial injuries
adjacent to the supraorbital notch.
c. Appropriately score the patient’s responses as
follows:

Obeys commands: 6
Localizing: 5
Normal flexion: 4
Abnormal flexion: 3
Extension: 2
None: 1
Non-testable: Paralyzed or other limiting factors.

6. Calculate the patient’s overall GCS score.

7. Appropriately document assessment findings

gathered. Notify the physician and members of the
health care team involved in the patient’s care for
any deterioration and improvement of patient’s
condition.

Perception and Coordination II

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Mindanao State University – Iligan Institute of Technology College of Nursing
Learner’s Reflection: (What did you learn most of the Instructor’s Comments:
activity? What is its impact on you?)

Reference:

Teasdale, G. (2015). The Glasgow Structured Approach to Assessment of the Glasgow Coma
Scale. https://www.glasgowcomascale.org/

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