The Glasgow Coma Scale, or GCS, is a tool nurses use to assess a patient's level of consciousness. The scale rates three areas, eye opening, verbal response and motor response. It is taught in nursing school as a basic physical assessment tool. The possible range of scores is 3-15. The higher the number, the more alert the patient. Lower numbers indicate coma.
- Skill level:
- Moderately Easy
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Things you need
- Pen light (optional)
- Blunt-end scissors or similar metal object
Assess the patient's eye opening. A total of 4 points may be given for eye opening. A patient who opens their eyes spontaneously, such as an alert patient sitting in a chair, would be scored a 4. If the patient is asleep or lying with eyes closed, but opens them upon command, a 3 is awarded. If the patient only opens their eyes to painful stimulus, such as running the tip of blunt scissors along the bottom of the foot, or a pinch, the patient is scored a 2. A patient who does not open their eyes no matter what is given a 1. Some patients may rouse if a very bright penlight is held a few inches from their eyes in order to induce a response.
Ask the patient questions, or engage in routine conversation to assess verbal response. A patient who engages in normal, appropriate conversation would be given a 5 on the GCS. A patient who makes appropriate conversation but is confused, such as an Alzheimer's patient, would be scored as a 4. The patient who makes inappropriate conversation, such as answering a question on an entirely different subject, would be given a 3. If the patient cannot make conversation, but instead has very garbled speech or makes incomprehensible sounds,they would be given a 2. The patient who is unable to speak or make any sounds for any reason, such as being on a ventilator with a breathing tube in their mouth, would be given a 1.
If the patient is lying still, ask him to wiggle his feet or raise his left arm and assess the response. A patient who moves arms and legs either spontaneously or on command is given a 6. If the patient displays purposeful movement with a painful or unpleasant stimulus, such as trying to push it away, the patient is given a 5. The patient who only withdraws away from pain with no other response is given a 4. A score of 3 is given to the patient demonstrating decorticate posturing, in which the patient's extremities are drawn inward toward the centre of the body. If the patient is in the decerebrate posture, the extremities are turned away from the body, and the score is 2. The lack of any movement or posturing is given a 1.
Record the GCS findings in the patient's chart. Assess with routine physical assessment, or whenever a change in GCS is noted. Report findings to physician as indicated.
Tips and warnings
- Any changes on the GCS should be evaluated and reported to the patient's physician. A patient who is a 15, and becomes confused or displays a change in motor response must be evaluated immediately, and the physician notified. This may indicate a more serious problem, such as a stroke, and requires follow-up tests.
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