NEUROLOGICAL ASSESSMENT • Score 3: flexion to pain.
The patient flexes or bends the
(GLASGOW COMA SCALE)
Author: Phil Jevon, PGCE, BSc, RGN
The Glasgow Coma Scale (GCS) is used to assess level of
consciousness in a wide variety of clinical settings,
particularly for patients with head injuries (NICE, 2007). In
this practical procedure, assessment of the patient's best
eye-opening response will be outlined and discussed, and, in
next week's article, assessment of the patient's best verbal
and motor responses will be described.
What the GCS assesses?
The GCS assesses the two aspects of consciousness:
• Arousal or wakefulness: being aware of the
environment;
• Awareness: demonstrating an understanding of what
has been said.
The 15-point scale assesses the patient's level of
consciousness by evaluating three behavioural responses:
• Eye opening;
• Verbal response;
• Motor response.
Eye opening
Assessment of eye opening involves the evaluation of
arousal (being aware of the environment):
• Score 4: eyes open spontaneously;
• Score 3: eyes open to speech;
• Score 2: eyes open in response to pain only, for
example trapezium squeeze (caution if applying a
painful stimulus);
• Score 1: eyes do not open to verbal or painful stimuli.
• Record 'C' if the patient is unable to open her or his
eyes because of swelling, ptosis (drooping of the upper
eye lid) or a dressing.
Verbal response
Assessment involves evaluating awareness:
• Score 5: orientated;
• Score 4: confused;
• Score 3: inappropriate words;
• Score 2: incomprehensible sounds;
• Score 1: no response. This is despite both verbal and
physical stimuli.
• Record 'D' if the patient is dysphasic and 'T' if the
patient has a tracheal or tracheostomy tube in situ.
Motor response
Assessment of motor response is designed to determine the
patient's ability to obey a command and to localize, and to
withdraw or assume abnormal body positions, in response to
a painful stimulus (Adam and Osborne, 2005):
• Score 6: obeys commands. The patient can perform
two different movements;
• Score 5: localizes to central pain. The patient does not
respond to a verbal stimulus but purposely moves an
arm to remove the cause of a central painful stimulus;
• Score 4: withdraws from pain. 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);
arm; characterized by internal rotation and adduction of
the shoulder and flexion of the elbow, much slower than
normal flexion;
• Score 2: extension to pain. The patient extends the arm
by straightening the elbow and may be associated with
internal shoulder and wrist rotation;
• Score 1: no response to painful stimuli.
Painful stimulus
A true localizing response to pain involves the patient
bringing an arm up to chin level. Painful stimuli that can elicit
this response include trapezium squeeze (Fig 4), suborbital
ridge pressure (Fig 5) (not recommended if there is a
suspected/confirmed facial fracture) and sternal rub (caution,
not recommended in some organizations) (Fig 6) (Jevon,
2007).
PROCEDURE:
• Explain the procedure to the patient.
• Ascertain the patient's acuity of hearing.
• Ideally, use an interpreter if the patient does not speak
English.
• Check the patient's notes for any medical condition that
may affect the accuracy of the GCS, for example
previous stroke, affecting the movement of the patient's
arms (Fig 1).
• Check the neurological observation chart for the GCS
scale (Fig 2).
• Check if the patient opens their eyes without the need
to speak or to touch them; if the patient does, then the
score is 4E.
• If the patient does not open their eyes, talk to them (Fig
3). Start off with a normal volume and speak louder if
necessary. If they now open their eyes, the score is 3E.
• If the patient does not open their eyes to speech,
administer a painful stimuli, for example trapezium
squeeze (using the thumb and two fingers grasp the
trapezius muscle where the neck meets the shoulder
and twist ) (Fig 4). Or apply suborbital pressure (locate
the notch on the suborbital margin and apply pressure
to it) (Fig 5). An alternative is the sternal rub (using the
knuckles of a clenched fist to apply grinding pressure to
the sternum; not recommended for repeated
assessment) (Fig 6).
• If the patient opens their eyes to a painful stimulus
record the score as 2E (Dougherty and Lister, 2005). If
the patient does not respond, then the score is 1E.
Allocating scores
Within each category (eye-opening, verbal and motor
responses), each level of response is allocated a numerical
value, on a scale of decreasing neurological deterioration.
By assigning a numerical value to the level of response to
the individual criteria in each section, three figures are
obtained which add up to a maximum score of 15 and a
minimum of three.
Communication of information about a patient should be
based on the three separate responses on the GCS, for
example if the patient's GCS is 12, based on scores of four
for eye opening, four for verbal response and four for motor
response, this should be communicated as E4, V4, M4. If the
total score is being communicated, to avoid confusion the
denominator should be specified, for example 12/15 (NICE,
2007).
Abnormal GCS
If a patient presents in A&E with a GCS <15, she or he must
be assessed immediately. A patient with a GCS less than or
equal to eight requires the early involvement of an
anaesthetist or critical care physician to provide appropriate
airway management and to assist with resuscitation.
A reduction in motor score by one or an overall deterioration
of two is significant and should be reported. Although
aggregate scores are often documented, the weighting of
scores between eye, verbal and motor responses remains
untested. Therefore documenting responses provides a
clearer indication of remaining functions and deficits in the
patient.
The following are indications for urgent medical review
(NICE, 2007):
• Development of agitation or abnormal behaviour;
• A sustained (that is for at least 30 minutes) drop of one
point in GCS;
• A drop of three or more points in the eye-opening or
verbal response scores or two or more in the motor
response score;
• Development of severe or increasing headache or
persisting vomiting;
• New or evolving neurological symptoms or signs, for
example pupil inequality or asymmetry of limb or facial
movement.
Limitations
There are limitations with using the GCS on patients with
head injuries who are sedated or ventilated. It is not
designed to assess sedation scores but cerebral function.
In addition, differences in GCS scores of two or more have
been reported on the same patients by different
practitioners. This reinforces that clinical decisions should
not solely be based upon GCS (Holdgate, 2006) but be used
as a component of monitoring neurological function. GCS
should only be used as an aid to patient assessment (Adam
and Osborne, 2005).
Motor response
• Ask the patient to perform two different movements, for
example stick the tongue out (Fig 2) or squeeze your
hand and let it go (Fig 3); if the patient responds
accurately, record 6M (obeys commands).
• If the patient does not obey commands, apply a painful
stimulus and observe reaction. If the patient purposely
moves an arm to the point of pain, record 5M (localises
to central pain). If the patient bends the arm at the
elbows but fails to locate the pain, record 4M
(withdrawal from pain). If she or he flexes the arms
towards the trunk (Fig 4), record 3M (flexion to pain or
decorticate posture). If the patient extends the arms
(Fig 5), record 2M (extension to pain or decerebrate
posture). If there is no response, record 1M.
Post procedure
• Record the findings on the patient's chart and in the
patient's notes (Fig 6). Report any
abnormalities/changes as required.
Professional responsibilities
This procedure should be undertaken only after
approved training, supervised practice and competency
assessment, and carried out in accordance with local
policies and protocols.
References:
Adam, S., Osborne, S. (2005) Critical Care Nursing
Science and Practice (2nd ed). Oxford: Oxford University
Press.
Dougherty, L., Lister, S. (2005) The Royal Marsden
Hospital Manual of Clinical Nursing Procedures (6th ed).
Oxford: Blackwell Publishing.
Jevon, P. (2007) Treating the Critical Care Patient. Oxford:
Blackwell Publishing.
NICE (2007) Head Injury: Triage, Assessment, Investigation
and Early Management of Head Injury in Infants, Children
and Adults. www.nice.org.uk56
http://www.nursingtimes.net/neurological-assessment-
glasgow-coma-scale/1735582.article

PROCEDURE

Verbal response
• Ask the patient's name, where she or he is and the
current day, month and year. If the questions are
answered correctly, record the score as 5V (orientated).
• If the patient can hold a conversation
but is unable to answer the questions correctly, record
the score as 4V (confused).
• If the patient is unable to hold a conversation and is just
saying single words rather than sentences, record the
score as 3V (inappropriate words).
• If the patient is groaning and not saying any
recognisable words, record the score as 2V
(incomprehensible sounds). A painful stimulus, for
example a trapezium squeeze (Fig 1), may be required
to elicit this response. See last week's procedure for
more details.
• If the patient does not respond verbally, record the
score as 1V (no verbal response).
• If the patient has a tracheal tube in situ, record T, or is
dysphagic, record D.