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The Glasgow Coma Scale (GCS), a 15-point scoring system used to assess cortical cerebral function in conjunction with pupillary function and limb strength assessment. the importance of accurate and reliable assessment, the three stages of assessment (eye opening, verbal response, best motor response), and additional assessments of limb strength, pupillary size, equality, and reaction, and haemodynamic status.
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Reviewed: May 2002 Intensive Care Glasgow Coma Score
The GCS was developed at Glasgow University and Drs Teasdale and Jennett published its development in 1974. It is a scaled assessment that reviews three areas of neurological functioning and attributes a score to each.
The GCS is a 15-point scoring system designed to objectively assess cortical cerebral function in conjunction with pupillary function and limb strength assessment. It aims to remove both personal interpretations of a patient's condition and confusing descriptors.
After education and assessment, staff will be able to assess a patient's condition in a reproducible manner. Results of the score will be used to establish a baseline then used to assess whether the patient's condition is improving, stable or deteriorating. The GCS is always used in conjunction with a patient history as many conditions and events may result in an abnormal score.
Reviewed: May 2002 Intensive Care Glasgow Coma Score
The assessment is carried out in 3 stages:
EYE OPENING VERBAL RESPONSE BEST MOTOR RESPONSE
spontaneous 4 orientated 5 obeys 6 to speech 3 confused (conversation) 4 localizes 5 to pain 2 inappropriate (words) 3 withdraws 4 nil 1 incomprehensible (sounds) 2 abnormal (spastic) flexion 3 nil 1 extends 2 nil 1
Additional assessment is made of:
Documentation
Sequence of Stimulation
4 - Open spontaneously The eyes are open without stimulation, indicating that the arousal mechanisms of the reticular activating system (in the brainstem and hypothalamus) are active.
3 - To speech The patient responds to voice by opening their eyes. A normal voice level is used but, if insufficient, greater verbal stimulus may be required. A louder voice must be used for those patients with impaired hearing.
Reviewed: May 2002 Intensive Care Glasgow Coma Score
Verbal response assesses two key elements:
5 - Orientated
Non-English Speaking Background (NESB) Patients
Reviewed: May 2002 Intensive Care Glasgow Coma Score
6 - Obeys Commands
5 - Localises
4 – Withdraws (Normal Flexion)
3 - Abnormal Flexion (Spastic Flexion)
2 - Extension
1 - No movement
Paralysis and/or Sedation:
Reviewed: May 2002 Intensive Care Glasgow Coma Score
A focal (neurologic) deficit is a loss of movement, sensation or function of a nerve in a specific location; the loss is related to dysfunction in the brain or peripheral nervous system. There may be no decrease in the level of consciousness.
Comments
The cardinal rule when assessing a patient for NEUROLOGICAL DETERIORATION is: Report any decrease in the level of consciousness. Assess for speech changes, restlessness or sudden quiet behaviour, a change in the motor response or evidence of pronator drift and pupillary response changes.
References
Reviewed: May 2002 Intensive Care Glasgow Coma Score
Policy Author: M. Edgtton, CNC – Intensive Care.
Policy Reviewer/s: ICU Director, CNC – Intensive Care, CNC – Neurosciences.