Glasgow Coma Scale (GCS) Assessment Nursing 1.

To do this: use the index finger and thumb

and squeeze 1 ½ to 2 inches of this trapezius muscle.
The Glasgow Coma Scale (GCS) is used to
assess a patient’s level of consciousness. 2. Start with slight pressure and then increase
Level of consciousness is how alert and the pressure for up to 10 seconds… note patient’s
responsive a patient is to their environment motor movement
and stimuli around them.
3. No response…move to the supraorbital
The Glasgow Coma Scale is a very helpful tool
pressure:
for evaluating a patient who has experienced a
traumatic brain injury or other conditions
where brain function or consciousness is
altered.
To assess the GCS a baseline score should be
obtained, and then it should be reassessed
often through the nursing shift per the facility’s
protocol to assess if the patient is improving,
staying the same, or deteriorating.
It’s important to note that assessing a
patient’s level of consciousness is very
important because any changes in it could 1. Find the notch under the inner part of the
indicate something serious is happening to eyebrow
the patient and it needs to be investigated. 2. Apply pressure to this notch with the thumb
and gradually increase pressure for up to 10
What the Glasgow Coma Scale Assesses? seconds…. note patient’s motor movement
The GCS scale assesses THREE responses by 3. Sternal rub is no longer recommended
the patient to a type of stimuli. because it can cause bruising (BMJ case reports,
These three responses are: Eye-opening 2014).
response, Verbal response, Motor response
Stimuli used during the assessment can range Peripheral stimuli:
from verbal or audible stimuli to pressure or pain is applied to a
painful/pressure stimuli. peripheral extremity like the
Two types of painful/pressure stimuli can be fingernail bed to create pain.
used to achieve a response in a patient. These This tests the spinal cords
types include: central and peripheral stimuli response to pain.

Central stimuli: pressure or pain is applied to the GCS Scoring

center of the body (hence its core) to create pain. This Glasgow Coma Scale scores can range from 3
tests the brain’s response to it. to 15. As pointed out above this scale is useful
Used first is the trapezius squeeze with patient’s who’ve sustained a head/brain
injury. The score can be used to describe the
injury.
o 3-8: severe brain injury
o 9-12: moderate brain injury
o 13-15: mild brain injury
A GCS is never higher than 15 or lower than
3….the higher the score the better for the
patient.
o GCS 15: fully alert and awake
o GCS 8 or less: the patient is in a coma
and requires intubation due to the
 inability of airway reflexes that protect
us from aspiration to work
o GCS 3: lowest score possible and very
high death rate…deep coma, severe
brain injury
Each response category of the GCS has its
own points, which are added up to give the
total GCS. A total GCS score is obtained from
adding up all the responses. Now the overall
score is important but so are the subscores.
The subscores are the scores from each of the
three responses.
o For example, you may see a Glasgow
Coma Scale score reported like GCS 7
(E2 V2 M3). GCS 7 is the total score,
while E2 V2 M3 are the subscores that
describe each patient response
category of the scale.
Before Assessing the GCS….
Before conducting the assessment, see what
the patient’s baseline scores were, and if they have
anything that would affect their response to stimuli or
make testing a specific response category (eye-
opening, verbal, motor) more difficult.
o Examples of this would include that
the patient is: sedated, hard of
hearing, mental deficits, paralyzed,
intubated, injury to bones, swelling
etc.
Glasgow Coma Scale in Detail
To help you remember what to assess and
how to score it while you’re at the bedside
remember EVM = 4,5,6
E: Eye-opening response: patient can receive a max
of 4 points and a minimum of 1 in this part of the scale
rating. Therefore, the patient can be assigned either
1,2,3, 4 or NT (non-testable)
4 Points: eyes spontaneously open (walk to
the bed side and just look at the patient… are
the eyes open?)
3 Points: eyes open to sound, speak in a tone
that is loud and clear to be heard (note if the
patient has hearing difficulties before
attempting or injuries that can prevent hearing
clearly)
2 Points: eyes open to pressure applied to nail
bed (use an object like a pen light or pen to
gradually increase pressure on the nail bed for
up to 10 seconds….note eye-opening
response)
1 Point: no response to any of the above
stimuli
o *NT: example…eye swelling or an
injury that prevents the eyes from
opening
V: Verbal response: patient can receive a max of 5
points and minimum of 1 points or NT (non-testable).
Therefore, the patient can be assigned either 1, 2, 3, 4,
5 or NT (non-testable)
5 Points: oriented (ask a series of questions:
can you state your name, month and year,
where you are at?)
4 Points: confused (answers the questions
but with incorrect answers…example they are
in the hospital but they say at home or they
give an incorrect year or name)
3 Points: inappropriate words (says random
words that don’t make sense to the questions)
2 Points: makes only sounds but no words to
the questions
1 Point: no response
o *NT: example…patient is intubated
M: Motor response: patient can receive a max of 6
points or a minimum of 1 point or NT (non-testable).
Therefore, the patient can be assigned either 1, 2, 3, 4,
5, 6 or NT (non-testable)
6 Points: obeys a motor command (tell
patient to do something that requires two
steps….open your mouth and stick out your
tongue or lift your hands and squeeze my
fingers and let go)
o If the patient doesn’t obey verbal
stimulus to perform a motor
command, use a central pressure
stimuli by using the trapezius muscle
squeeze. If no response, use
supraorbital pressure.
5 Points: Localizes the
pressure/pain (the
brain will try to locate
and remove the
painful stimulus)
4 Points: Withdrawal (also called normal
flexion)…the brain will try to withdraw from the
painful stimulus motor response, glasgow
coma scale, withdrawal, normal flexion, 4
points
o When stimuli is applied (example:
trapezius squeeze) the patient flexes
hence bends the elbow (elbow flexion)
but quickly withdraws it. The hand and
arm never make it up to the stimuli or
up to the collar bone (so the patient
doesn’t locate the pain but withdraws
from it).
3 Points: Abnormal flexion (decorticate
posturing) remember “COR” from the word
decorticate motor response, glasgow coma
scale, abnormal flexion, decorticate
posturing, 3 points
o When stimuli is applied (example:
trapezius squeeze) the patient flexes
hence bends the elbow gradually and
moves the arm to the center (hence
CORE) of the body with pronation of
the forearm and flexion of the wrist
and the hands will turn into fists. There
won’t be the withdrawal from the
stimuli like in the previous response.
This is NOT a good finding and means
the cortex is affected.
2 Points: Extension (decerebrate posturing):
Remember all the “e” in decerebrate for
Extension.
o When stimuli is applied (example:
trapezius squeeze) the patient will
extend the arm at the elbow with
internal rotation of the arm. This is the
worst type of posturing and is not a
good sign. It indicates the brainstem is
affected.
1 Point: no response
o *NT: example…patient on sedation
and paralyzed
Different Component in Phhysical Assessment Percussion

4 main types of Physical Assessment We are tapping something. In some instances,

using the sense of touch by fingers, hands, or
Inspection
small instrument but we are tapping over the
As the name suggests is involved with your patient’s body parts. It is done to examine the
sight. You can use your sight to assess the size size, shape, consistency/solid, and borders of
,shape, color, and symmetry of things. So if I body organs. The presence or absence of fluid
walk in the room and I see that my patient has in body areas. You can tell it by the sound that
a good, tall posture, or they’re hunched over, it makes once you tap against your fingers if
or something is asymmetrical, something is it’s a solid or filled organ.
swollen, I'm inspecting. Using the sense of
Auscultation
sight to assess the patient.
o Color (Skin Assessment) Listening to the sound of the body during a
o Size physical examination. It is a method used to
o Shapes listen to the sound of the body during a
o Position physical examination by using a stethoscope.
o Gait (manner of walking) You can assess the pitch, loudness, quality,
and duration. For example, in lungs, heart, and
Palpation
the bowel sound.
Palpation is using your sense of touch, and
Specific order in assessing…
here we’re going to assess for different things.
We can assess temperature, moisture, Most common order
vibration, texture, and tenderness.
1. Inspection
Palpation is sensing deep or light pressure.
2. Palpation
Deep pressure/palpation is used to feel
3. Percussion
internal organs and masses. This help identify
4. Auscultation
the size, shape tenderness, symmetry and
mobility. 4-5cm GI (GastroIntestinal)
Light pressure/palpation is used to feel
abnormalities that are on the surface. Use the 1. Inspect
front of the fingers by gently pressing down 2. Auscultate
into the area of the body about 1-2cm. 3. Palpate
Tenderness is a very important thing that we 4. Percuss
assess with our patients. So when it comes to Musculoskeletal
assessing, we're going to use the dorsal or the
posterior surface of the hand when we are 1. Inspect
assessing things like temperature. So if you 2. Palpate
think about a mom checking their child's 3. Percuss
temperature, their child’s temperature, Cardiac
they’re usually using the back of their hand, so
we’re using the dorsal surface to assess 1. Inspect
temperature. Now. The palmar surface, right 2. Palpate
underneath your fingers, that’s what we’re 3. Auscultate
going to use to assess for vibration. This is not
something we do very routinely. However,
when we are assessing for things like how
much vibrations are being transmitted
through the lungs, it help us to see if