Definition GCS the most widely recognised level of consciousness assessment tool is this This scored scale is based on evaluation of three categories: @ Eye opening. © Verbal resporse. @ Motor response. The best possible score onthe GCS is 15, and the lowest score is 3 . Generally a score of 7 or less on the GCS indicates coma © Pupillary Function Eyes open response 1 spontaneous eyes openwithout verbal or noxious stimuli~~score(4) 2. Tospeech__ eyes openwithverbal stimuli score (3) 3 To pain__eyes opento noxious stimuli score (2) 4- None__no eye opening with any form of stimuli score (1) @ Verbal response 1 oriented__aware of person, place, time and personal data score (5) 2- Confused__answers inappropriate but language use correct score (4) 3 Inappropriate words__disorganized, random speech score (3) 4- Incompressible sounds__moans groans and mumbles score (2) 5_ None__no verbal response even to noxious stimuli score (1)@ Best motor response 1+ Obeys commands _ performs simpletasks and repeat on command score(6) 2 Localizes pain_organized attempt to remove noxious stimuli score (5) 3 Withdrawal from pain__withdraws from source of noxious stimuli score (4) 4- Abnormal flexion _occurs spontaneously or to noxious stimuli score (3) 5 Abnormal extension__occurs spontaneously or to noxious stimuli score (2) 6__ None__no resporseto noxious stimuli‘flaccid score (1) Nursing care for parents coma 1. Maintaining patent airway @ Elevating the head end of the bed to 30 degree prevents aspiration. @ Positioning the patient in lateral or semi prone position. @ Suctioning. @ Chest physiotherapy. @ Auscultate in every 8 hours. @ Endo tracheal tube or tracheostomy. 2. Protecting the client @ Padded side railsRestrains. @ Take care to avoid any injury. @ Talk with the client in-between the procedures. @ Speak positively to enhance the self esteem and confidence of the patient.3.Maintaining fluid balance and managing nutritional needs Assess the hydration status. @ More amount of liquid. @ Start IV line. @ Liquid diet. @ NG tube. 4,Maintaining skin integrity @ Regular changing in position. @ Passive exercises. @ Back massage. @ Use splints or foam boots to prevent foot drop. @ Special beds to prevent pressure on bony prominences. 5.Preventing urinary retention @ Palpate for a full bladder. @ Insert an indwelling catheter. @ Condom catheter for male and absorbent pads for females in case of incontinence. @ Inducing stimulation to urinate.6. Providing sensory stimulation Provided at proper time to avoid sensory deprivation. @ Effort are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep. @ Maintain the same schedule each day. @ Orient the client to the day, date, and time accordingly. @ Touch and talk. @ Proper communication. @ Always address the client by name, and explain the procedure each time. 7. Family needs @ Family support. @ Educate the needs of client. @ Care to be provided.i en Agger! agzelad Coeutly Shad aula! b5159 prea! aglaltg citar AWS elaine Anal Presentation about Glasgow coma scaleand nursing care for parents coma Aa) pf Coed axe> slis/s Olvee/> cotta AdiiLe/s eet pall bee / Ue afte!