GLASGOW COMA SCALE :

MONITORING AND RECORDING

Submitted To - Presented By -
Ms. Pahari Shrama Tripti Pun
Tutor, AIN (AIN/2018/499)
Guwahati 2nd year,Bsc. Nursing
 • Definition
CONTENTS • Purpose
• Principles
• Indications
• Contraindications
• Preparation of unit
• Preparation of articles
• Preliminary assessment
• Assess general condition of
the patient
• Steps of procedure
• After care of the patient
• Recording
• Complications
• Conclusion
 DEFINITION
The Glasgow Coma Scale (GCS) and pupillary reactivity are well-
known prognostic factors in traumatic brain injury (TBI).The
Glasgow coma scale (GCS) is used to objectively describe the
extent of impaired consciousness in all types of acute medical and
trauma patients.

OR

The Glasgow Coma Scale(GCS) is a neurological scale which aims

to give a reliable way of recording the conscious state of a person.
 PURPOSE
GCS was introduced as a measure of consciousness level
in the setting of traumatic brain injury it's ease of
application has seen its use progress to the assessment
of consciousness level in many other patients types.
PRINCIPLES
CHECK
For factors Interfering with communication
ability to respond and other injuries.

OBSERVE
Eye opening , content of speech and
movements of right and left sides
STIMULATE
Sound: spoken or shouted request
Physical: Pressure on finger tip,
trapezius or supraorbital notch
RATE
Assign according to highest
response observed
POINTS TO BE KEPT IN MIND

The scale assesses patients according to three aspects of

responsiveness and
in order to obtain a total score , the best response to each
of three(3) categories are assessed :
1) Eye Opening (1-4)
2) Verbal Response and(1-5)
3) Motor Response(1-6)
The highest possible score is 15 (fully conscious) and the
lowest possible score is 3( coma or dead ) .
 INDICATIONS

coma for at least six

TBI ( Traumatic hours in the
Brain Injury patients) neurosurgical ICU
For the assessment setting, though it is
of a patient's commonly used
conciousness level throughout hospital
departments.
 CONTRAINDICATIONS

Generally not containdicated in anyone.

But in(Children =< 5 years)
 PREPARATION OF UNIT

• Provide privacy to the patient before starting the assessment if

necessary using a screen.
• As the procedure requires quick assessment of the verbal and
motor responses ,the medical professional should choose , a
quiet and well illuminated room free of noise in order to avoid
any type of disturbance that may lead to the False information
generation.
 PREPARATION OF ARTICLES

ARTICLES PURPOSE
TORCH LIGHT In order to check the pupillary
reactivity.
PEN / PENCIL In order to check the motor response
to painful stimuli,by compressing the
nail bed

HAND GLOVES In order to avoid spread of infection.

( IF REQUIRED )
PRELIMINARY ASSESSMENT

Proper preliminary check is required to correctly identify

any factors that might interfere with the assessment, it's
important to identify local factors like hearing impairment
or inability to speak , that could cause a lack of capacity to
respond.
ASSESS THE GENERAL
CONDITION OF THE PATIENT
1) Check for the vitals (T,P,R) in order to gather baseline
data.
2) Check for any sign of infection or skin rashes or swelling
at the site of cannulation or sutures or insertions if any.
3) check the positioning of the patient and if required
change the position according to the patient comfort.
 STEPS OF PROCEDURE
PROCEDURE RATIONALE
1) Check the physicians order,progress To obtain the history of the patient's
notes and nursing care plan. condition.

2) Identify the patient and introduce
the purpose of the examination and
yourself if ,the patient is conscious or
able to understand you.
In order to examine the correct patient
and avoid any error.
Explanation should be provided in
order to avoid any anxiety or lack of
cooperation from the patient side.
7)Now the procedure is started and we To show the degree of impairment.
have to make a series of standard
observations of three aspects of the
patient's responsiveness ,eye opening ,
Verbal and motor response to
stimulation and the step in each
component can be rated according to
defined criteria .

8)When assessing a patient there are For accuracy of the procedure and the
four steps check, observe , stimulate correct outcome.
and rate.
3) Proper positioning It's easier to do the GCS scoring in supine
Patient should be in supine position position.

4)Ensure privacy. To maintain dignity and modesty.

To avoid any mistake in absence of proper

5)Now, place the prepared article tray on
articles.
the patient's bed side ( whichever is
Also saves both time and energy of the
closer at reach for you) table.
patient and the caregiver.

6)Perform handwashing and wear gloves In order to avoid any case of cross
if necessary infection or transfer of micro-organisms.
9)There are three aspects of behaviour The highest response from each category
that are independently measured as elicited by the healthcare professional is
part of an assessment of a patient’s scored on the chart
GCS -
motor responsiveness, verbal
performance and eye-opening.
10)EYE OPENING (E)
( MAXIMUM SCORE - 4) In order to score the eye response

EYE OPENING SPONTANEOUSLY

(4 POINTS)
To asess eye response, initially
observe the patient for spontaneous
eye -opening.
If the patient is opening their eyes
spontaneously, your assessment of
the behaviour is complete, with the
patient scoring 4 points.
If however, the patient is not opening
their eyes spontaneously, you need to
work through the following steps until
a response is obtained.
EYE OPENING TO SOUND
(3 POINTS)

If the patient doesn’t open their

eyes spontaneously, you need
to speak to the patient “Hey
Miss Smith, are you ok?”
If the patient’s eyes open in
response to the sound of your
voice, they would score 3
points.
EYES OPENING TO PAIN
(2 POINTS)
If the patient doesn’t open their eyes in
response to sound, you need to move
on to assessing eye-opening to pain.
There are different ways of assessing
response to pain, but the most
common are:
• Applying pressure to one of the
patient’s fingertips using a pen/pencil
• Squeezing one of the patient’s
trapezius muscles (referred to as
“trapezius squeeze”).
• Applying pressure to the patient’
supraorbital notch.
• If the patient’s eyes open in response
to a painful stimulus, they would score
2 points.
NO RESPONSE
(1 POINT )

If the patient does not open their eyes

to a painful stimulus, they score 1
point.

NOT TESTABLE
( NT)

If the patient cannot open their eyes

due to oedema, trauma, dressing etc,
you should document that eye response
could not be assessed (NT).

20
SUMMARY

Eye opening spontaneously 4 points

Eye opening to sound 3 points

Eye opening to pain 2 points

No response 1 points

Not testable NT
10) VERBAL RESPONSE (V) In order to score the verbal
(MAXIMUM SCORE- 5 ) response level of
the patient.
Assessing a patient’s verbal response
initially involves trying to engage the
patient in conversation and assess if
they are orientated.
You should score the patient based
on the highest scoring response they
demonstrate during the assessment.
Some common questions you can
ask to help assess this might include:
“Can you tell me your name?”
“Do you know where you are at the
moment?”
“Do you know what the date is
today?”
ORIENTED RESPONSE
(5 POINTS )
If the patient is able to answer your
questions appropriately, the
assessment of verbal response is
complete, with the patient scoring 5
Points.

CONFUSED CONVERSATION
( 4 POINTS )
If the patient is able to reply, but their
responses don’t seem quite right (e.g.
they don’t know where they are, or
what the date is), this would be
classed as confused conversation and
they would score 4 points.
Sometimes confusion can be quite
subtle, so pay close attention to their
responses.

INAPPROPRIATE WORDS
( 3 POINTS )
If the patient responds with seemingly
random words that are completely
unrelated to the question you asked,
this would be classed as inappropriate
words and they would score 3 points.

INCOMPREHENSIBLE SOUNDS
( 2 POINTS )
If the patient is making sounds, rather
than speaking words (e.g. groans)
then this would be classed as
incomprehensible sounds, with the
patient scoring 2 points.
NO RESPONSE
( 1 POINT )

If the patient has no response to your

questions, they would score 1 point.

NOT TESTABLE ( NT )

If the patient is intubated or has other

factors interfering with their ability to
communicate verbally, their response
cannot be tested, and for this, you
would write NT (not testable).
SUMMARY

Orientated 5 points

Confused conversation 4 points

Inappropriate words 3 points

Incomprehensible Sounds 2 points

No response 1 point

Not testable NT
11) MOTOR RESPONSE ( M ) In order to check the level of
( MAXIMUM SCORE- 6 ) consciousness according to the
motor response.
The final part of the GCS assessment
involves assessing a patient’s motor
response.
You should score the patient based on
the highest scoring response you were
able to elicit in any single limb (e.g. if
they were unable to move their right
arm, but able to obey commands with
their left arm, they’d receive a score of
6 points).
OBEY COMMANDS
( 6 POINTS )
Ask the patient to perform a two-part
request (e.g. “Lift your right arm off
the bed and make a fist.”).
If they are able to follow this command
correctly, they would score 6 points
and the assessment would be over.

LOCALISES TO PAIN
( 5 POINTS )
This assessment involves you applying
a painful stimulus and observing the
patient for a response.
There are different ways of assessing
response to pain, but the most
common are :
• Squeezing one of the patient’s
trapezius muscles (referred to as a
“trapezius squeeze”)
• Applying pressure to the patient’s
supraorbital notch
If the patient makes attempts to reach
towards the site at which you are
applying a painful stimulus
(head/neck) and brings their hand
above their clavicle, this would be
classed as localising to pain, with the
patient scoring 5 points.
WITHDRAWS TO PAIN
( 4 POINTS )
This is another possible response to a
painful stimulus, which involves the
patient trying to withdraw from the
pain (e.g. the patient tries to pull their
arm away from you when applying a
painful stimulus to their fingertip).
This response is also referred to as a
“normal flexion response” as the
patient typically flexes their arm
rapidly at their elbow to move away
from the painful stimulus.
It differs from the “abnormal flexion
response to pain” shown below due to
the absence of the other features
mentioned (e.g. internal rotation of the
shoulder, pronation of forearm, wrist
flexion).
Withdrawal to pain scores 4 points on
the Glasgow Coma Scale.

ABNORMAL FLEXION RESPONSE

TO PAIN
( 3 POINTS )
Abnormal flexion to a painful stimulus
typically involves adduction of arm,
internal rotation of the shoulder,
pronation of forearm and wrist flexion
(known as decorticate posturing).
Decorticate posturing indicates that
there may be significant damage to
areas including the cerebral
hemispheres, the internal capsule, and
the thalamus.

DECORTICATE POSITIONING

ABNORMAL EXTENSION
RESPONSE TO PAIN
( 2 POINTS )
Abnormal extension to a painful
stimulus is also known as decerebrate
posturing
In decerebrate posturing, the head is
extended, with the arms and legs also
extended and internally rotated.
The patient appears rigid with their
teeth clenched.
The signs can be on just one side of
the body or on both sides, and it may
be just in the upper limbs.
Decerebrate posturing indicates brain
stem damage. It is exhibited by
people with lesions or compression in
the midbrain and lesions in the
cerebellum
Progression from decorticate
posturing to decerebrate posturing is
often indicative of uncal
(transtentorial) or tonsilar brain
herniation (often referred to as
“coning”).

DECEREBRATE POSITION
NO RESPONSE
( 1 POINT )
The complete absence of a motor
response to a painful stimulus scores
1 point.

NOT TESTABLE ( NT )
If the patient is unable to provide a
motor response (e.g. paralysis), this
should be documented as not testable
( NT )
 SUMMARY
Obeys command 6 points

Localises to pain 5 points

Withdraws to pain 4 points

Flexion decorticate posture 3 points

Abnormal extension 2 points

decerebrate posture
No response 1 point

Not testable NT
12) Once you have assessed eye-opening, Add the eye , verbal and motor
verbal response and motor response response together and score the
you add the scores together to patient's GCS ,
calculate the patient’s GCS. accordingly

The GCS should be documented

showing the score for each individual Documentation is very important
behaviour tested: in order to maintain a proper and
symstematic data record , for any
GCS 15 [E4, V5, M6] reference in the future .
13) For more accuracy towards the
measurement of the level of
consciousness , pupillary reactivity
can also be checked along with the GCS
scoring .

GLASGOW COMA SCALE

PUPILS SCORE ( GCS - P )

The Glasgow Coma Scale Pupils

Score (GCS-P) was described in 2018
as a strategy to combine the two key
indicators of the severity of traumatic
brain injury into a single simple index.
Calculation of the GCS-P is by
subtracting the Pupil Reactivity Score
(PRS) from the Glasgow Coma Scale
(GCS) total score:
● GCS-P = GCS – PRS

The Pupil Reactivity Score is

calculated as follows.

Pupils unreactive to light - Pupil

Reactivity Score

● Both pupils - 2
● One pupil - 1
● Neither pupil - 0
The GCS-P score can range from 1
and 15 and extends the range over
which early severity can be shown to
relate to outcomes of either mortality
or independent recovery.
14) CLASSIFICATION OF SEVERITY
OF TBI
The relationship between the GCS GCS score at the end helps to
Score and outcome is the basis for a study / examine the condition of
common classification of acute the patient more accurately and
traumatic brain injury: provides a new way to reform the
● Severe, GCS 3 to 8 intervention as required according
● Moderate, GCS 9 to 12 to the patient's condition
● Mild, GCS 13 to 15
● With the GCS-P score values
between one and 8 denote a severe
injury.
 GCS SCORING
Sometimes conditions like tracheal intubation and severe facial/eye
swelling or damage make it impossible to test the verbal and eye
responses.
In these circumstances, the score is given as 1 with a modifier attached
(e.g. "E1c", where "c" = closed, or "V1t" where t = tube).
Often the 1 is left out, so the scale reads Ec or Vt. A composite might be "
GCS 5tc". This would mean, for example, eyes closed because of
swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal
flexion".
VIDEO LINK IN YOUTUBE

https://youtu.be/v6qpEQxJQO4
 AFTER CARE OF THE PATIENT
1. Tell the patient that the assessment is over.
2. Change the position of the patient , if the patient wasn't lying in
supine position.
3. Ensure that the patient is comfortable .
4. Replace the articles properly before leaving.
5. Record and report your findings in the nurses records and inform the
physician if required.
 RECORDING
Record your calculated score of the GCS in the patient chart and
nurses record with the proper time and date .For any further
reference in the future .
● COMPLICATIONS
1) As GCS was developed for the assessment of traumatic brain injury, its
adaptation to other patient groups can sometimes present limitations.Paramedics
must use their clinical judgement to provide an accurate assessment of conscious
state.
2) A modified GCS is required for paediatric patient.
3) The application of a painful stimulus by a paramedic during the assessment of
an intoxicated patient has the propensity to elicit a violent response and should be
minimised.
4) Repeat application of painful stimuli is rarely required , so it may cause irritation
from the patient's side .
THANK YOU FOR LISTENING