Liverpool Health Service CORPORATE MANUAL Intensive Care
Policy Issued: PATIENT CARE Pxx.xx
Reviewed: May 2002 Intensive Care Glasgow Coma Score
Review Date: May 2004 Page 1 of 1
NEUROLOGICAL ASSESSMENT USING THE
GLASGOW COMA SCALE (GCS)
Expected Outcome
• The Glasgow Coma Score forms part of the patient’s physical assessment and will be
assessed and documented during physical assessment.
• Ongoing GCS assessment will occur in patients with neurological compromise or those
patients with recognised potential for neurological compromise.
• Medical and nursing staff will perform neurological assessment utilising the GCS
accurately and reliably.
Policy Statement
• Neurological assessment using the Glasgow Coma Scale will be performed by registered
nurses accurately and as required by the patient’s condition.
• The Glasgow Coma Scale will incorporate assessment of limb strength and pupillary
response to light stimulation.
• Assessment of a patient’s neurological status, using the GCS, will be accompanied by
assessment of the patient’s vital signs.
• Changes to the patient’s neurological status will be reported immediately to the
appropriate medical staff.
• Where required, changes in neurological status will be acted upon immediately.
• If the patient’s GCS is less than 15, and then falls by one point, the appropriate medical
staff will be informed immediately.
• A MET call is to be initiated when the GCS falls by ≥ 2 points.
• Documentation is to occur at all times – even where documentation by exception exists.
• Only appropriate painful/noxious stimulus will be used:
⇒ Peripheral stimuli that may be used include (a) pressure to the side of the finger, next to the nail or (b)
pinching of the fine skin over the triceps muscle.
⇒ When using peripheral stimulus, care must be taken to ensure that motor response arises from the brain,
not mediated by the spine as a reflex arc. For this reason, central stimulus is advocated as first choice for
stimulus.
⇒ Currently, (following literature review) there are NO references to the validity of using nipple twists or
genital pain as an appropriate painful stimulus in either the nursing or medical sources. It may be used
when other forms of recognised painful stimulus have failed to elicit a response from the patient. It is not to
be used as a first line assessment of patient response to stimulus by staff.
Background
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.
Purpose
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.
