GCS verbal response

Published

Hello, im a still a fairly new RN in the ED

I had a pt come in to the ER with a mass in the third ventricle that was increasing ICP (confirmed by CT), my initial gcs was 11 (E2,V4,M5)and I was during neuro check every 30 min. Beside being Bradycardic in the 40's he was not showing any other signs of hernitaion, pupils still reactive to light, SBP was in the 110's-120's with no signs of widening pulse pressure, respirations were even and unlaboured.

My question/concern was that during my neuro checks.

Verbal: for the verbal part though i has to stimulate him for about 10 seconds before i can get words coming out of him, all he would say was that his head hurt, not really answering any questions, would you give him a 4 or a 3? some nurses in my unit stated that i had to stimulate him too much before i got a response and that it was a 1? can someone please help me out with it, i feel horrible that i gave him too high of of a GCS score, and that if i would have seen a GCS of a 8, i would have pushed for an intubation on him.

The pt was transferred out quickly since i work at a smaller hospital and they were not able to perform any type of intervention besides administration of mannitol.

Thanks for the help.

Up Vote Up Vote ×

You go by the best response when scoring gcs. If you are getting a verbal response, that shows that portion of the brain is still functioning

Up Vote Up Vote ×
Specializes in Pedi.

1 is no verbal response. Saying "my head hurts" is a verbal response.

The Glasgow Coma Scale:

Eye Opening

1. None

2. To pain

3. To speech

4. Spontaneous

Verbal Response

1. None

2. Incomprehensible sounds (moaning/no words)

3. Inappropriate words

4. Confused

5. Oriented

Motor response

1. None

2. Decerebrate

3. Decorticate

4. Withdraws to pain

5. Localizes pain

6. Obeys commands

Someone with an intracranial mass blocking the flow of CSF probably has a huge headache so I wouldn't necessarily say that "my head hurts" indicates confusion or inappropriate words. But you couldn't really assess if he was otherwise confused. Was that because he was somnolent and kept going in and out of consciousness? Sounds like the patient needed an emergent EVD.

Up Vote Up Vote ×

Yes, without any stimulus the pt would either lay in bed without any response or move around in bed every few minutes. Yeah I pray that he was able to get it drained in time. This has me double thinking my GCS scores. Would you give him a 3 then? really hard to say if he was confused or not.

Up Vote Up Vote ×
Specializes in Pedi.
Yes, without any stimulus the pt would either lay in bed without any response or move around in bed every few minutes. Yeah I pray that he was able to get it drained in time. This has me double thinking my GCS scores. Would you give him a 3 then? really hard to say if he was confused or not.

I wouldn't give him a 3 because I don't think saying "my head hurts" would be considered "inappropriate words" in someone with untreated hydrocephalus and possibly impending herniation whose head probably did hurt.

Up Vote Up Vote ×
Specializes in OR, Nursing Professional Development.

Did you take this question to your preceptor or another trusted coworker? We were not there and cannot assess- those that are there and can would be able to provide you with accurate feedback.

Up Vote Up Vote ×
Specializes in ICU, LTACH, Internal Medicine.

Verbal: (you ask patient how he is doing and if he needs something; your name is not Minnie):

5: hi, how'ya doin'? I'm fine, just my head hurts like h*** and I want turkey sandvich and some coffee and lots of sugar in it... LOTS. Where's my phone? What pill it is? Thank you, you're sweetheart!

4: (after being nudged a bit, speaks slowly): hi... my head hurts... my head... dun'know, my head hurts, give me some water, I want to drink... thanks...

3: head... water... Minnie, help me!... head...(cannot say who Minnie is)

2: moans and groans, tries to speak but can't

1: nothing

In any case, it is not that important if patient knows the year, month and who's the President. What is important is symptom (i.e. speech) remaining the same or worsening during the time as you care for the patient. And you need to differentiate between changes caused by disease and effects of drugs you administer.

Up Vote Up Vote ×

Remember, consciousness is a different measure. We measure consciousness using the RASS scale. So given the you need to stimulate the patient, he would probably be scored a -1/-2. Your first indicator that the patient is worsening will be that his level ofconsciousness is decreasing

Up Vote Up Vote ×
Specializes in Education, FP, LNC, Forensics, ED, OB.

Duplicate threads merged.

Up Vote Up Vote ×

THank you for the help

Up Vote Up Vote ×
+ Join the Discussion