SKILL 1: Assessing Glasgow Coma Scale

NAME: SIGNAR, NIKITA F. DATE: March21, 2022

DEFINITION
The Glasgow Coma Scale (GCS) is used  to objectively describe the extent of impaired consciousness in all
types of acute medical and trauma patients. The scale assesses patients according to three aspects of
responsiveness: eye-opening, motor, and verbal responses.

PURPOSE
Glasgow Coma Scale was designed and should be used to assess the depth and duration coma and
impaired consciousness. This scale helps to gauge the impact of a wide variety of conditions such as acute
brain damage due to traumatic and/or vascular injuries or infections, metabolic disorders (e.g., hepatic, or
renal failure, hypoglycemia, diabetic ketosis), etc.

EQUIPMENT
- Recording sheet and pen
THINGS TO CONSIDER
 Introduce yourself to the patient.
 Let patient know what you are going to do and what you expect for them.
 Know the proper way to use the Glasgow coma scale chart.

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify patient correctly and explain the To have patient’s trust and cooperation
procedure to the patient. throughout the assessment

2. Perform hand hygiene. To prevent contamination

A. Assess best eye-opening response

3. Observe eye opening before stimulus. To assess for eye-opening response

4. Call patient’s name if eyes are not opening To know if the patient is attentive and
spontaneously. how he response about his environment
5. If no response, apply pressure on the A fully conscious patient will locate the
nailbed by using a pen/pencil, squeeze pain as it pinches by the examiner and
the trapezius muscle or apply pressure on pushes it away as he felt pain. It will
the supraorbital notch. indicate the patient had brain injury if he
did not respond to pain.
6. Record patient score for best eye
For baseline data; Common causes of
response:
unresponsiveness patient include: low
Spontaneous - 4
blood sugar, low blood pressure,
To sound - 3 To
syncope, or the loss of consciousness
pressure -2
due to lack of blood flow to the brain
No Response - 1

7. If eyes are closed due to swelling, write NT means not tested due to closed
“C” or NT if non testable due to other local factors (e.g., edema, trauma,
factors. dressings). The examiner should
document that eye response could not
be assessed (NT).
B. BEST VERBAL RESPONSE
To determine if the patient attentive
8. Ask patient’s name, place, and date. and how he response about his
environment
9. Record patient score:
Alert and oriented -5
Confused -4

Inappropriate words -3

Incomprehensible -2 For baseline data. Common

causes of unresponsiveness
No Response -1 patient include low blood sugar,
low blood pressure, syncope, or
10. If verbal response non testable due to NTthemeans
loss ofnotconsciousness
tested due non-testable
due to
factors interfering with communications, factor
lack ofinterfering
blood flowwith
to thetheir
brainability to
write NT. communicate verbally.
C. BEST MOTOR RESPONSE
11. Ask patient to wiggle toes or move/raise To test for motor function
arms.
12. If no response, apply firm and gentle A fully conscious patient will locate the
pressure on nailbed by using pen/pencil, pain as it pinches by the examiner and
or trapezius muscle squeeze, or on the pushes it away as he felt pain. It will
supraorbital notch. indicate the patient had brain injury if
he did not respond to pain.
13. Record patient score:
Follows Direction/Command -6 For baseline data. Common
Localizes Pain -5 causes of unresponsiveness
patient include low blood sugar,
Withdraws from Pain -4
low blood pressure, syncope, or
Decorticate Posturing - 3 Decerebrate the loss of consciousness due to
Posturing - 2 lack of blood flow to the brain
No Response -1
14. If best motor response is non testable NT means not tested due to non-
due to paralysis or other limiting factor, testable, paralyzed, and other limiting
write NT. factor
15. Add up the score for each category. Refer To determine patient’s condition and to
the score to the doctor. provide medical interventions
 16. Place the patient in a comfortable To promote patient’s comfortably and
position. rest
17. Document time GCS was done and GCS For legal purposes and for baseline
score. data

Ability to answer questions

TOTAL SCORE

SKILL 2: Neurologic Assessment (Motor Function)

NAME: SIGNAR, NIKITA F. DATE: March 21, 2022

DEFINITION

A neurological assessment checks for disorders of the central nervous system. The assessment
examines your balance, muscle strength, and other functions of the central nervous system.
PURPOSE

A neurological assessment used to help find out if you have disorder of the nervous system. Early
diagnosis can help you get the right treatment and may decrease long-term complications.

EQUIPMENT

 Gloves
 Pen and paper for writing down the data

THINGS TO CONSIDER

 Introduce yourself to the patient.

 Always provide privacy for the patient.
 Know the proper way to do all the part of neurological exam.
 Let patient know what you are going to do and what you expect for them.

PROCEDURE RATIONALE 5 4 3 2 1
1. Identify the patient and explain each Identifying the patient ensures the right
assessment technique before patient and helps prevent errors.
performing. Explaining each assessment technique
relieves anxiety and facilitates
cooperation.
2. Instruct the patient to void first before The assessment will take long as it
starting the neurologic exam. finishes the whole procedure.
3. Gather the necessary equipment. To start the procedure with.
4. Do handwashing and don on gloves if To minimize contamination.
necessary.
5. Obtain the patient’s height, weight, and For baseline data.
vital signs
6. Provide privacy. To ensure the patient’s privacy and
gain his/her trust.
7. Carefully observe the patient throughout Observation is the key to perform an
the procedure. efficient neurological examination.
8. Observe the patient’s posture and
stance. Look for any involuntary To provide baseline assessment.
movements or tremors.
9. Assess muscle bulk, by inspecting the Muscle bulk should be symmetric
major muscle groups, and the intrinsic throughout the limbs, when comparing
muscles of the hands. the right and left sides, and proximal
 and distal portion of the extremities.
Loss of muscle bulk is known as
atrophy.
10. Assess muscle tone and range of motion Tone may be increased or decreased in
by passively moving the limbs of a relax various pathologic states, and various
patient. forms of altered muscle tone.
11. Assess for pronator drift. Ask the patient Pronation of the arm is subtle sign that
to close his eyes and hold their arms out is strongly indicative of upper motor
straight in front with palms up. Keep the neuron dysfunction.
position for 30 seconds.

Gross Motor and Balance Tests

12. WALKING GAIT
■ Ask the patient to walk across the Be prepared to catch the patient if
room and back. necessary.
■ Assess the patient’s gait.
13. ROMBERG TEST
■ Ask the patient to stand with feet Positive Romberg: cannot maintain foot
together and arms at the sides. stance; moves the feet apart to
■ First with eyes open, then eyes maintain stance. If the patient cannot
closed. maintain balance with the eyes shut,
■ Let your patient do this for 30 client may have sensory ataxia (lack of
seconds. coordination of the voluntary muscles).
■ Stand close to the patient during
this test.
14. STANDING ON ONE FOOT WITH EYES
CLOSED To determine a lesion involving the
■ Ask the patient to close his eyes midline cerebellar vermis.
and to stand on one foot.
■ Repeat on the other foot.
■ Stand close to the patient during
this test.
15. HEEL-TOE WALKING
■ Ask the patient to walk a straight Make sure you are at the back of the
line, placing the heel of one foot patient. Loss of balance may occur as
directly in front of the toes of the he tries to do assessment.
other foot.
■ TOE or HEEL WALKING: ask the
client to walk several steps on the
toes and then on the heels.

Fine Motor Tests: Upper Extremities

16. FINGER TO NOSE TEST
■ Have the patient touch your index To note if there is a presence of ataxia
finger and dysmetria.
■ Then their nose with their index
finger back and forth.
■ The client repeats the test with
the eyes closed if the test is
performed easily.
17. ALTERNATING SUPINATION AND
PRONATION OF HANDS AND KNEES To note if there is a presence of ataxia
Ask the patient to pat both knees with the and dysmetria.
palms of both hands and then with the
back of both hands alternately at an ever-
increasing rate.
18. FINGERS TO THUMB (Same Hand) An inability to check movements can
Ask the patient to touch each finger of be seen with lesions of the ipsilateral
one hand to the thumb of the same hand cerebellar hemisphere, as well as with
as rapidly as possible. severe sensory disturbances causing
altered proprioception.

Fine Motor Tests: Lower Extremities

19. Ask the client to lie supine. For the proper assessment of lower
extremities.
20. HEEL DOWN TO OPPOSITE SHIN
■ Have the patient take the heel of To note for ataxia and dysmetria. Upper
one foot and slide it up and down motor neuron lesions or sensory lesions
the shin of the other leg. that result in altered proprioception can
■ Repeat with the other foot. also result in ataxia and dysmetria.
■ Patient may also use a sitting
position for this test.
21. After the neurological assessment, place
To provide patient’s rest.
patient comfortably on bed.
22. Do aftercare. To minimize the spread of
microorganism.
23. Document all pertinent information, and if
there were any abnormalities noted refer For legal purposes.
it to the physician.

Ability to answer questions

TOTAL SCORE