{"id":2273,"date":"2024-03-12T15:07:39","date_gmt":"2024-03-12T19:07:39","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/glasgow-coma-scale-2\/"},"modified":"2024-05-31T10:49:06","modified_gmt":"2024-05-31T14:49:06","slug":"glasgow-coma-scale-2","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/glasgow-coma-scale-2\/","title":{"raw":"Glasgow Coma Scale","rendered":"Glasgow Coma Scale"},"content":{"raw":"The Glasgow Coma Scale (GCS) is a common neurological tool to assess level of consciousness<\/strong> and detect and track clinical changes in consciousness when clients have had a traumatic brain injury or any condition that causes an impairment in consciousness (Teasdale et al., 2014).\u00a0<\/span>\r\n\r\nGCS is used in the context of head injuries, cerebral hemorrhage or lesions, stroke, and general trauma. It is commonly used in acute and emergency care, critical care, post-operative care, and in neurological settings. It is important to elicit a baseline and then monitor trends, particularly with an altered GCS or during the acute phase of a neurological condition.<\/span>\r\n\r\nSteps in the GCS assessment<\/strong> include:<\/span>\r\n
    \r\n \t
  1. Assess for any factors that could influence your assessment (see Contextualizing Inclusivity textbox below).<\/span><\/li>\r\n \t
  2. Observe behaviours as per Table 3<\/strong> and apply verbal and physical stimuli as needed (e.g., if spontaneous behaviours are absent).<\/span><\/li>\r\n \t
  3. Judge criteria with rating and score.<\/span><\/li>\r\n \t
  4. Evaluate the score for each component (eye opening, verbal response, best motor response).<\/span><\/li>\r\n \t
  5. Evaluate the total GCS score by adding up scores for the three components of the GCS<\/span>\r\n
      \r\n \t
    1. If any components are \u201cnon-testable,\u201d note this and do not provide a total score. For example, verbal responses may not be testable if a client has a breathing tube, and eye opening may not be testable if a client has periorbital edema that prevents eye opening.<\/span><\/li>\r\n<\/ol>\r\n<\/li>\r\n<\/ol>\r\nSee Video 2<\/strong> on how to use the Glasgow Coma Scale with a demonstration.<\/span>\r\n\r\n[embed]https:\/\/youtu.be\/v6qpEQxJQO4[\/embed]\r\n\r\n \r\n\r\nTable 3<\/strong>: Components of the Glasgow Coma Scale<\/a>. (copyright Teasdale, 2015<\/span>, permission to use in this resource).<\/span>\r\n\r\n\r\n\r\n
       \r\n\r\nEye opening<\/strong><\/span>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
       \r\n\r\nCriterion<\/strong><\/span><\/td>\r\n \r\n\r\nRating<\/strong><\/span><\/td>\r\n \r\n\r\nScore<\/strong><\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nOpen before stimulus<\/span><\/td>\r\n \r\n\r\nSpontaneous<\/span><\/td>\r\n \r\n\r\n4<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nAfter spoken or shouted request<\/span><\/td>\r\n \r\n\r\nTo sound<\/span><\/td>\r\n \r\n\r\n3<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nAfter fingertip stimulus<\/span><\/td>\r\n \r\n\r\nTo pressure<\/span><\/td>\r\n \r\n\r\n2<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nNo opening at any time, no interfering factor<\/span><\/td>\r\n \r\n\r\nNone<\/span><\/td>\r\n \r\n\r\n1<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nClosed by local factor<\/span><\/td>\r\n \r\n\r\nNon-testable<\/span><\/td>\r\n \r\n\r\nNT\u00a0<\/span><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n \r\n\r\nVerbal response<\/strong><\/span>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
       \r\n\r\nCriterion<\/strong><\/span><\/td>\r\n \r\n\r\nRating<\/strong><\/span><\/td>\r\n \r\n\r\nScore<\/strong><\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nCorrectly gives name, place, and date<\/span><\/td>\r\n \r\n\r\nOriented<\/span><\/td>\r\n \r\n\r\n5<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nNot oriented but communicates coherently<\/span><\/td>\r\n \r\n\r\nConfused<\/span><\/td>\r\n \r\n\r\n4<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nIntelligible single words<\/span><\/td>\r\n \r\n\r\nWords<\/span><\/td>\r\n \r\n\r\n3<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nOnly moans\/groans<\/span><\/td>\r\n \r\n\r\nSounds<\/span><\/td>\r\n \r\n\r\n2<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nNo audible response, no interfering factor<\/span><\/td>\r\n \r\n\r\nNone<\/span><\/td>\r\n \r\n\r\n1<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nFactor interfering with communication<\/span><\/td>\r\n \r\n\r\nNon-testable<\/span><\/td>\r\n \r\n\r\n\u00a0NT<\/span><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n \r\n\r\nBest motor response<\/strong><\/span>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
       \r\n\r\nCriterion<\/strong><\/span><\/td>\r\n \r\n\r\nRating<\/strong><\/span><\/td>\r\n \r\n\r\nScore<\/strong><\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nObeys 2-part request<\/span><\/td>\r\n \r\n\r\nObeys commands<\/span><\/td>\r\n \r\n\r\n6<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nBrings hand above clavicle to stimulus on head neck<\/span><\/td>\r\n \r\n\r\nLocalising<\/span><\/td>\r\n \r\n\r\n5<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nBends arm at elbow rapidly but features not predominantly abnormal<\/span><\/td>\r\n \r\n\r\nNormal flexion<\/span><\/td>\r\n \r\n\r\n4<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nBends arm at elbow, features clearly predominantly abnormal<\/span><\/td>\r\n \r\n\r\nAbnormal flexion<\/span><\/td>\r\n \r\n\r\n3<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nExtends arm at elbow<\/span><\/td>\r\n \r\n\r\nExtension<\/span><\/td>\r\n \r\n\r\n2<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nNo movement in arms\/legs, no interfering factor<\/span><\/td>\r\n \r\n\r\nNone<\/span><\/td>\r\n \r\n\r\n1<\/span><\/td>\r\n<\/tr>\r\n
       \r\n\r\nParalysed or other limiting factor<\/span><\/td>\r\n \r\n\r\nNon-testable<\/span><\/td>\r\n \r\n\r\nNT\u00a0<\/span><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
      \r\n

      \r\nClinical Tips: Physical Stimuli and Flexion Responses<\/strong><\/h2>\r\n<\/header>\r\n
      \r\n\r\nIf no response is elicited when using the GCS, you may need to apply physical stimuli<\/strong> (see Figure 5<\/strong>), which are usually applied in the following order to:<\/span>\r\n
        \r\n \t
      1. Finger nail bed.<\/span><\/li>\r\n \t
      2. Trapezius muscle.<\/span><\/li>\r\n \t
      3. Supraorbital notch.<\/span><\/li>\r\n<\/ol>\r\n\"\"\r\n\r\nFigure 5<\/strong>: Physical stimulus.<\/span>\r\n\r\nCopyright Teasdale, 2015 (used with permission),<\/span> https:\/\/www.glasgowcomascale.org\/downloads\/GCS-Assessment-Aid-English.pdf?v=3<\/a>.\r\n\r\n<\/div>\r\n<\/div>\r\n
        \r\n

        Contextualizing Inclusivity<\/strong><\/span><\/h2>\r\nBefore using the GCS, assess for factors that could influence the validity of the tool.\u00a0<\/span>\r\n\r\nFor example, children<\/strong> under five may not be able to obey commands and answer questions. The GCS components provided in Table 3<\/strong> are considered reliable for those over the age of 5 (Royal College of Physicians and Surgeons of Glasgow, n.d.). When working with children, it is best to check with your institution about whether they use a specific scale, e.g., the<\/span> Paediatric Glasgow Coma Scale<\/a> or other tools to evaluate level of consciousness.\u00a0<\/span>\r\n\r\nAnother issue is that a hearing impairment<\/strong> can influence a client\u2019s ability to respond to verbal stimuli. You may need to employ alternative options such as gently touching the client\u2019s arm to observe if their eyes are open, using sign language, or writing on a piece of paper.\u00a0<\/span>\r\n\r\nOther factors could include [pb_glossary id=\"2401\"]language discordance[\/pb_glossary] or barriers that inhibit clients from speaking,\u00a0 such as a breathing tube. Many pathologies<\/strong> and conditions<\/strong> can affect the validity of the GCS such as the presence of hypoxemia, intellectual and neurological deficits, and movement disorders, pharmacological agents such as sedation, and use of alcohol, cannabis, or other substances that affect cognition.<\/span>\r\n\r\n<\/div>\r\n
        \r\n

        Prioritizing Care<\/strong><\/span><\/h2>\r\n<\/header>\r\n
        \r\n\r\nGCS scores<\/strong> can range from 3 (unresponsiveness in all three components of the GCS tool) to 15 (no deficits in responsiveness in all three components of the GCS tool) (National Institute for Health and Care Excellence [NICE], 2023). With acute traumatic brain injury, GCS scores are classified as:<\/span>\r\n