the glasgow coma scale

8/12/2019 The Glasgow Coma Scale

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The Glasgow Coma Scale (GCS)

Evidence based practice

Sophie Porter

3rdyear Kingston University Student

Studying a Bachelors with honours in nursing


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Introduction to the GCS

Neurological assessment tool

Published in 1974 by Jennett and Teasdale

Aim of the tool: determining the severity of apatients brain dysfunction

Originally intended for post head injury patients, now a

tool for all acute medical and trauma patients.

It is widely used to assess level of consciousness in avariety of clinical settings and is a recommendedobservation tool in all patients with head injuries

(NICE, 2007)


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Scoring system

A patients assessment will result in a score

between three; no response and fifteen; fully

alert and responsive (Jevon, 2008)

The score out of 15 is derived from the three

tests on eye opening, verbal response and motor

response. Alongside this, pupil response,neurological limb response and basic vital signs

are also recorded (Fairley et al, 2005).


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How is the score composed?


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E=4, V=5, M=6


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How are the components assessed?

(Jevon, 2008)

Eyes Opening:

Score 4: eyes open spontaneously;

Score 3: eyes open to speech;

Score 2: eyes open in response to pain only, forexample trapezium squeeze (caution if applying apainful stimulus);

Score 1: eyes do not open to verbal or painful

stimuli.

C is recorded for patients unable to open eyesdue to for example swelling


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(Jevon, 2008)

Verbal Response: Score 5: orientated; must be able to tell you their full

name, the place in which they are and the date. If thepatient doesnt know any of these it is assumed they

are confused. Score 4: confused; not able to answer orientation

questions

Score 3: inappropriate words; swearing, aggression,unrelated words to the questions being asked

Score 2: incomprehensible sounds;

Score 1: no verbal response.

D is marked for patients who are dysphasic (unableto speak coherently. T is marked for those with a

tracheostomy


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(Jevon, 2008)

Best Motor Response: Score 6: obeys commands. The patient can perform two

different movements; primative reflexes should not be tested

Score 5: localises to central pain. The patient does not

respond to a verbal stimulus but purposely moves an arm toremove the cause of a central painful stimulus

Score 4: normal flexion. The patient flexes or bends the arm

towards the source of the pain but fails to locate the source of

the pain (no wrist rotation)

Score 3: abnormal flexion to pain (see picture)

Score 2: extension to pain (see picture)

Score 1: no response to painful stimuli.


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Abnormal flexion and extension to

pain


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Verbal Response Validity

Determines the level of awareness patients have of their environment(Richards and Edwards, 2003, p.32)

Temporal lobe of the cerebral cortex: controls a persons ability to percepttheir environment and access their long and short term memory(Waterhouse, 2009, p.210)

Confusion, memory loss and inability to compose sentences could be anindication of damage or abnormalities in the temporal lobe. (Yonelinas etal 2002, p.1236)

This damage, causing increased pressure on the cranium, could include;haemorrhaging, tumours, fluid around the brain (hydrocephalus), infectioni.e. meningitis, or swelling of the brain matter itself (Bradley et al, 2008).

Of course there are other reasons which may cause confusion...


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Best Motor Response Validity

How well a patient can respond to simplecommands, recording the best limb.

Good indication of how well the brain isfunctioning as a whole (Edwards, 2001, p.95)

In particular the primary motor and sensorycortex (Waterhouse, 2009, p.210) these areasallow us to generate voluntary movement(Marieb, 2001, p. 436-437)

Difficult to understand what deterioration in thiscomponent would indicate without moreextensive investigations

Lack of clarity questions the components validity


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Reliability of components: factors

Differences between application of stimulus

Sedation- causes decreased arousal

No considerations for neurological diseasesi.e. dementia

Medication side effectsdelirium

Untrained healthcare practioner: inter-userreliability

Broken limbs etc


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Thank you for

listening


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References

NICE (2007) Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury inInfants, Children and Adults. [Online]. Available at: http://www.nice.org.uk(Accessed: 12 February2012).

Jevon, P. (2008) Neurological assessment part 2- pupillary assessment, Nursing Times, 104, July[Online]. Available at: http://www.nursingtimes.net/Binaries/0-4-1/4-1710333.pdf (Accessed: 15February 2012).

Fairley, D., Timothy, J. and Cosgrove, J. (2005) Using a coma scale to assess patient consciousnesslevels, Nursing Times, 101, June [Online]. Available at: http://www.nursingtimes.net/nursing-

practice-clinical-research/using-a-coma-scale-to-assess-patient-consciousness-levels/203819.article(Accessed: 15 February 2012).

Yonelinas, P., Kroll, N.E.A., Quamme, J.R., Lazzara, M.M., Suave, M.J., Widaman, K.F. and Knight,R.T.(2002) Effects of extensive temporal lobe damage or mild hypoxia on recollection andfamiliarity, Nature Neuroscience, 5, November [Online]. Available at:http://psychology.ucdavis.edu/labs/Widaman/mypdfs/wid111.pdf (Accessed: 22 February 2012).

Waterhouse, C. (2009) The use of painful stimulus in relation to Glasgow Coma Scale observations,British Journal of Neuroscience Nursing, 5(5), pp. 209-215

Tortora, G.J. and Grabowski, S.R. (2003) Principles of anatomy and physiology. 10thedn. USA: JohnWiley and Sons, Inc

Hickey, J.V. (1997) The clinical practice of Neurological and Neurosurgical Nursing. 4th edn. NewYork: JB Lippincott.
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the glasgow coma scale

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