NVS: Glasgow Coma

Scale

NCM 118 SKILLS LABORATORY

Introduction:
 The state of consciousness of a patient is evaluated
using the Glasgow Coma Scale (GCS). How aware
and receptive a patient is to their surroundings and
external stimuli is referred to as their level of
consciousness.
 A patient with a traumatic brain injury or other
conditions that affect brain function or
consciousness can be assessed using the Glasgow
Coma Scale.
 A baseline score should be calculated to assess the
GCS, and it should then be recalculated frequently
throughout the nursing shift in accordance with the
facility's procedure to determine if the patient is
improving, remaining the same, or deteriorating.

 It is crucial to keep in mind that gauging a patient's

degree of consciousness is crucial because any
fluctuations could mean that something significant is
going on with the patient and needs to be looked into.
What the Glasgow Coma Scale Assesses?
 The GCS scale assesses THREE responses by the patient to
a type of stimuli.
 These three responses are: Eye-opening response,
Verbal response, Motor response

 Stimuli used during the assessment can range from

verbal or audible stimuli to painful/pressure stimuli.

 There are two types of painful/pressure stimuli that can

be used to achieve a response in a patient. These types
include: central and peripheral stimuli
Centralstimuli: pressure or pain is applied to the center of the body
(hence its core) to create pain. This tests the brain’s response to it.

 Used first is the trapezius squeeze

To do this: use the index finger and thumb
and squeeze 1 ½ to 2 inches of this trapezius
muscle.

Start with slight pressure and then increase

the pressure for up to 10 seconds… note
patient’s motor movement

No response…move to the supraorbital

pressure:
No response…move to the supraorbital pressure:
Find the notch under the inner part of the
eyebrow

Apply pressure to this notch with the thumb

and gradually increase pressure for up to 10
seconds…. note patient’s motor movement

Sternal rub is no longer recommended

because it can cause bruising (BMJ case
reports, 2014).
Peripheral stimuli: pressure or pain is applied to a
peripheral extremity like the fingernail bed to create pain.
This tests the spinal cords response to pain.
 GCS Scoring
 Glasgow Coma Scale scores can range from 3 to 15.

 As pointed out above this scale is useful with patient’s who’ve

sustained a head/brain injury. The score can be used to describe the
injury.

 3-8: severe brain injury

 9-12: moderate brain injury

 13-15: mild brain injury

 A GCS is never higher than 15 or lower than 3….the higher the score
the better for the patient.

 GCS 15: fully alert and awake

 GCS 8 or less: the patient is in a coma and requires intubation due to

the inability of airway reflexes that protect us from aspiration to work

 GCS 3: lowest score possible and very high death rate…deep coma,
severe brain injury
 The GCS assigns points to each response category that are
then combined together to determine the overall GCS. The
sum of all the answers yields a final GCS score. Currently,
both the total score and the subscores are significant. The
three responses' individual scores make up the subscores.

 For instance, a Glasgow Coma Scale score of 7 may be

given (E2 V2 M3). The total score on the GCS is 7, and the
subscores on the scale for each patient response category
are E2, V2, and M3.
 Before Assessing the GCS…

 Check the patient's baseline scores before beginning

the exam to see if there are any factors affecting their
ability to respond to stimuli or that would make
assessing a particular response category (eye-
opening, verbal, or motor) more challenging.

 Examples of this include the patient being drugged,

deaf, mentally impaired, paralyzed, intubated, suffering
from bone injuries, edema, etc.
Eye Swelling affects Eye-opening response
Intubation affects verbal response
 Let's imagine the patient is intubated as an
illustration. Since the patient has a tube in their
throat, it will be difficult to elicit a verbal answer from
them, thus you cannot test this response category.
As a result, this section would be marked as NT, or
not testable. Because you can't test it and are unsure
of their linguistic ability to react if they could, you
wouldn't assign them 1 point (no response).

 Therefore, the GCS may resemble this GCS 7T. (E3

Vt M4). This informs us that although the patient is
intubated, the overall score is 7. (capital T tells us
this).
 Glasgow Coma Scale in Detail
 To help you remember what to assess and how
to score it while you’re at the bedside
remember EVM = 4,5,6

 E: Eye-opening response: patient can receive a

max of 4 points and a minimum of 1 in this part
of the scale rating. Therefore, the patient can
be assigned either 1,2,3, 4 or NT (non-testable)
 4 Points: eyes spontaneously open (walk to the bed side and just look
at the patient… are the eyes open?)

 3 Points: eyes open to sound, speak in a tone that is loud and clear to
be heard (note if the patient has hearing difficulties before attempting or
injuries that can prevent hearing clearly)

 2 Points: eyes open to pressure applied to nail bed (use an object like
a pen light or pen to gradually increase pressure on the nail bed for up
to 10 seconds….note eye-opening response)

 1 Point: no response to any of the above stimuli

 *NT: example…eye swelling or an injury that prevents the eyes from

opening
V: Verbal response: patient can receive a max of 5 points and
minimum of 1 points or NT (non-testable). Therefore, the
patient can be assigned either 1, 2, 3, 4, 5 or NT (non-testable)

 5 Points: oriented (ask a series of questions: can you state your name, month and
year, where you are at?)

 4 Points: confused (answers the questions but with incorrect answers…example

they are in the hospital but they say at home or they give an incorrect year or name)

 3 Points: inappropriate words (says random words that don’t make sense to the
questions)

 2 Points: makes only sounds but no words to the questions

 1 Point: no response

 *NT: example…patient is intubated

M: Motor response: patient can receive a max of 6
points or a minimum of 1 point or NT (non-testable).
Therefore, the patient can be assigned either 1, 2, 3, 4,
5, 6 or NT (non-testable)

6 Points: obeys a motor command (tell patient to do

something that requires two steps….open your mouth and
stick out your tongue or lift your hands and squeeze my fingers
and let go)

If the patient doesn’t obey verbal stimulus to perform a motor

command, use a central pressure stimuli by using the
trapezius muscle squeeze. If no response, use supraorbital
pressure.

5 Points: Localizes the pressure/pain (the brain will try to

locate and remove the painful stimulus)
The patient bends their elbows (elbow flexion) and raises their arm and hand
above the collar bone when stimulation is administered (for instance, a trapezius
squeeze), in an effort to relieve the discomfort or pressure. The patient is
attempting to LOCATE (and thereby localizes) the pressure or discomfort with
this movement.
4 Points: Withdrawal (also called normal flexion)…
the brain will try to withdraw from the painful stimulus

When stimuli is applied (example: trapezius squeeze) the patient flexes

hence bends the elbow (elbow flexion) but quickly withdraws it. The hand and
arm never make it up to the stimuli or up to the collar bone (so the patient
doesn’t locate the pain but withdraws from it
3 Points: Abnormal flexion (decorticate posturing) remember “COR” from the word decorticate
 When a stimulus is delivered (for instance, a
trapezius squeeze), the patient flexes, bending the
elbow progressively and moving the arm to the
core (thus, CORE) of the body. The hands will also
clench into fists. Instead of withdrawing from the
stimulus like in the prior response, there won't be
any. This indicates that the cortex is impacted,
which is NOT a favorable finding.
2 Points: Extension (decerebrate posturing): Remember all the “e” in
decerebrate for Extension.

When stimuli is applied (example: trapezius squeeze) the patient will extend the
arm at the elbow with internal rotation of the arm. This is the worst type of
posturing and is not a good sign. It indicates the brainstem is affected.
 1 Point: no response

 *NT: example…patient on sedation and

paralyzed
Let’s Practice:
You find the following in your patient:
The patient can't respond to queries verbally
and only opens his eyes when pressure is
placed to the nail bed. However, when you
perform a trapezius squeeze, the patient bends
his elbow and raises his arm and hand above
the collar bone in an effort to relieve the
discomfort or pressure.
You find the following in your patient:
The patient can't respond to queries verbally and
only opens his eyes when pressure is placed to
the nail bed. However, when you perform a
trapezius squeeze, the patient bends his elbow
and raises his arm and hand above the collar bone
in an effort to relieve the discomfort or pressure.
Answer: GCS 9 (E2 V2 M5)
 At the patient's bedside, you evaluate her
Glasgow Coma Scale. Based on these
observations, how well did the patient perform?
When you first get to the patient's bedside, she
is looking around, telling you she is in a concert
hall, and that the year is 1960 (it is actually
2022), but she give you her correct name, and
she was able to open her mouth and stick out
her tongue.
 At the patient's bedside, you evaluate her
Glasgow Coma Scale. Based on these
observations, how well did the patient perform?
When you first get to the patient's bedside, she is
looking around, telling you she is in a concert hall,
and that the year is 1960 (it is actually 2022), but
she give you her correct name, and she was able
to open her mouth and stick out her tongue.
 The answer is: GCS 14 (E4 V4 M6)
 You’re assessing a patient’s Glasgow Coma Scale at
the bedside. What is the patient’s score based on these
findings: when you arrive to the patient’s bedside the
patient’s eyes are closed and don’t open when spoken
to. The nurse applies a peripheral painful stimulus, and
the patient’s eyes open. When asked questions the
patient groans and moans noises. In addition, the
patient can’t obey a motor command. Therefore, when
you apply a central stimulus the patient flexes to
withdraw from the stimulus.
 You’re assessing a patient’s Glasgow Coma Scale at the
bedside. What is the patient’s score based on these
findings: when you arrive to the patient’s bedside the
patient’s eyes are closed and don’t open when spoken to.
The nurse applies a peripheral painful stimulus, and the
patient’s eyes open. When asked questions the patient
groans and moans noises. In addition, the patient can’t
obey a motor command. Therefore, when you apply a
central stimulus the patient flexes to withdraw from the
stimulus.

The answer is: GCS 8 (E2 V2 M4)