Question

Glasgow Coma Scale

What does it test?

Can you think of any portion of the test that might be affected by a patient who is intubated?

What are the guidelines when administering it?

How is it scored? What is the highest score? What is the lowest score?

When should the nurse notify the health care provider after completing this assessment? Why? (Which scores or changes in scores would be most concerning prompting the nurse to notify the HCP because of them)

Answer 1

Glasgow cima scale is a tool which reliably and correctly measures the state of consciousness in initial or subsequent neurological assessment.

The Glasgow coma scale tests the level or state of consciousness in a patient.

This test can affect the intubated patient. In case of incubated patient they can not speak. So their verbal response can not be assessed. Their assessment score is measured by scoring the eye opening response and motor response. A suffix T is added to represent that the patient is incubated. The maximum GCS score in this case will be 10T and minimum GCS score will be 2T.

Guidelines =

The GCS scale measurements is based on assessing patient's 3 response stimuli. The highest score will be 15 and the lowest score is 3.

- the patient should be in a comfortable position when measuring the level of consciousness through GCS scale.

- if the score is in 3 - 8 then the patient is in coma.

- maintain patient's privacy during assessment .

- proper set up and clean techniques has to be used to prevent infection transmission.

The GCS scale is scored based on 3 responses they are - i) Eye opening response,

ii) Best verbal response,

iii) Best motor response. They each are scored like this way -

I. Eye Opening Response =  

a. Spontaneous - 4

b. To voice - 3

c. To pain - 2

d. None - 1

2. Best Verbal Response =

a. Oriented - 5

b. Confused speach - 4

c. Inappropriate words - 3

d. Incomprehensible sounds - 2

e. None - 1

3. Best Motor Response =

a. Patient Obeys Command - 6

b. Localizes Pain - 5

c. Withdraws the site of pain - 4

d. Flexion - 3

e. Extension - 2

d. None - 1.

The highest score will be 15 and the lowest is 3.

After completing the assessment the nurse should notify the health care providers when the score will be in between 3 - 8 . As this range of score represent coma or sever head injury and requires prompt treatment. Also the score range 9 - 12 need emergency care as this represents moderate head injury.