GCS of a quadriplegic?

akulahawkRN, ADN, RN, EMT-P · Jan 9, 2013

It sounds like this patient is obviously awake, (eyes open spontaneously), able to follow commands (within physical limits of being a quad), and is non-verbal due to trach. I'd give that patient a GCS E4, V-N/A (trach), M6. If you're able to communicate with the patient through non-verbal means and can establish that he's able to answer questions, you should be able to determine orientation status (person, place, time, event) and be able to render a more formal score, however you might still have to note how you were able to ascertain the verbal component. When the patient's face is puffed up to where he can't see, establishing the "eyes" portion of the GCS becomes difficult, just as establishing the "verbal" component becomes difficult with non-verbal patients. When that happens, note it and move on and the final score is what you got with a note as to the limitations of the score.

With the SubQ emphysema, I'd say GCS = 6 - unable to obtain Eye score due to SubQ emphysema, non-verbal due to trach placement, follows commands.

His GCS score could even be as high as 11... if you can determine that he's oriented.

BelgianRN · Jan 9, 2013

The GCS was designed with the mindset of neurotrauma evaluation. It gained popularity for other usages and pathologies. But i think the point is moot as to what their GCS is if you have signs he is oriented. You can't properly use the GCS to determine consciousness in patients with disabilities influencing your GCS and the GCS as such has no value in the evaluation of these patients.

Also get in the habit of reporting GCSs by their individual components. In my documentation I'll report a GCS like: GCS(EMV): 11(3-5-3) or if tubed/trached GCS(EMV): 9 (3-5-T).

sapphire18 · Jan 9, 2013

Even though he can't move his limbs, motor response is that he follows commands. Tubed/trached patients' total GCS scores will always be off bc of the verbal response (unless they have a pmv so they can speak).

machaix · Jan 9, 2013

Thanks for the inputs guys!

My seniors always reason out that the upper extremities establish the best motor response and so motor score should be based from it.

But the doctors say a different thing. So we don't really know which one to follow. We end up having different GCS scores for the patient. When we endorse, we say.. "for the doctors it's gcs.. Because because.. But for me it's..."

Is that acceptable? Having different documented gcs? Should nurses and doctors agree on what gcs should be documented?

Esme12, ASN, BSN, RN · Jan 10, 2013

IN the US the doctors and nurses are pretty much on the same page about this. It is not that the patient cannot physically open their eyes.....but that if they weren't swollen could/would they......you need to follow what your facilities procedure for the standard of practice. In teh nUS I would asterisk (star) the entry with an explanation as to my findings

The Glasgow coma scale (GCS) is a reliable and universally comparable way of recording the conscious state of a person. Three types of response are measured, and added together to give an overall score. The lower the score the lower the patient's conscious state. The GCS is used to help predict the progression of a person's condition.

The three responses measured are:

Best motor response - maximum score of 6
Best verbal response - maximum score of 5
Eye opening - maximum score of 4

The lowest score for each category is 1, therefore the lowest score is 3 (no response to pain + no verbalization + no eye opening). A GCS of 8 or less indicates severe injury, one of 9-12 moderate injury, and a GCS score of 13-15 is obtained when the injury is minor.

Grades of Best Motor Response

6 Carrying out request ('obeying command') -patient does simple things you ask.

5 Localizing response to pain.

4 Withdrawal to pain - pulls limb away from painful stimulus.

3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs - decorticate posture.

2 Extensor posturing to pain - stimulus causes limb extension - decerebrate posture.

1 No response to pain.

Grades of Best Verbal Response

5 Oriented - patient knows who and where they are, and why, and the year, season and month.

4 Confused conversation - patient responds in conversational manner, with some disorientation and confusion.

3 Inappropriate speech - random or exclamatory speech, with no conversational exchange.

2 Incomprehensible speech - no words uttered, only moaning.

1 No verbal response.

Eye Opening

4 Spontaneous eye opening.

3 Eye opening in response to speech - that is, any speech or shout.

2 Eye opening in response to pain.

1 No eye opening.

detroitdano · Jan 11, 2013

Following any command is a motor response. Stick out tongue, blink, close one eye, wiggle your toes. I'd give him a 6.

The GCS is silly. Even dead people score a 3.

Esme12, ASN, BSN, RN · Jan 12, 2013

Following any command is a motor response. Stick out tongue, blink, close one eye, wiggle your toes. I'd give him a 6.
The GCS is silly. Even dead people score a 3. I love Laura Gasparis

hodgieRN · Jan 15, 2013

I think GCS is so outdated and I hear your frustration. An intubated pt gets a 1 on verbal even if they are wide awake and waving hello. It has nothing to do with consciousness. I wished it was more like NIH scale were it goes more into detail with communication, not just talking.

machaix · Jan 17, 2013

Following any command is a motor response. Stick out tongue, blink, close one eye, wiggle your toes. I'd give him a 6.
The GCS is silly. Even dead people score a 3.
I don't think you have to use gcs for a dead patient? Just like ramsay sedation scale should not be used for a patient who is not sedated...

sapphire18 · Jan 18, 2013

I don't think you have to use gcs for a dead patient? Just like ramsay sedation scale should not be used for a patient who is not sedated...

Well nurses, doctors and donor services use it in determining if a pt may soon be eligible for donation...