No Coma,No Glasgow

[ohbet]

The Glasgow Coma Scale was designed to measure the depth of Coma. This means that a person must already be in a Coma prior to the test administration.

When we have a new admit, The Glasgow is on our admission assessment and 99% nurses administer the test to people not in a coma.

I have become unpopular by pointing this out but the practice continues.

Any thoughts or similar experiences with the misuse of this test?

[cathy949]

P_RN. Thanks for the site, medal.org.

[hapeewendy]

JMP while I agree with many of your post

I disagree wholeheartedly 100% about your comment about not using the GCS scale on "regular floors"

the floor I work on is far from regular, and far from routine and emergency situations happen daily

(where do you think many of your ICU patients come from? - from a med/surg floor d/t complications)

I wasnt suggesting for a moment that we as nurses devote a crazy amount of time GCS'ing the heck out of every patient, that is absurd and of course our priorities are ABC's but when you are assessing your patient , it really is not simple enough to chart or only assess alert and oriented...

total neurlogical fucntion assessment as you mentioned is not the GCS , we use a comprehensive neurovital form for that (much like the one you use on your unit I'm sure), I think what people were trying to say in response to the original post is that , ohbet suggested that the GCS is to monitor the status and progression of a person in a coma , when in fact it is as bestblond I believe it was a tool used to gauge peoples responses to various neuro stimuli etc...

I dont think that the nurses ohbet works with are "running around doing GCS on everyone " , if they are they probably are only doing so because it is ,as ohbet mentioned part of the admission package and they feel obligated to complete all that is expected of them on an admission note.

the med/surg floor I work on has a huge percent of neuro patients , many of whom have needed ICU beds that were not available, so in many cases we have had to institute the neurovitals you mentioned in your post - if the nurses on my med/surg floor had not picked up signs and symptoms and charted accordigly and used the GCS as they felt appropriate then all that would be found in the patients chart would be , pt confused or pt disoriented, which is of course not acceptable.

the thing you mentioned that hit the nail on the head JMP was that it is a universal system, which means that information is instantly available to all of us to interpret on the patient, this better enables everyone to monitor changes and intervene appropriately.

in the ICU how frequently do you normally find yourself doing neurovitals? and do you complete it on a separate graphic record? just trying to get some info on this from the ICU standpoint if you dont mind

thanks JMP

cheers

[Dplear]

Ohbet

Let me pose a question for you about that person that comes in for a brokern lag rehab. say that he is a "walkie talkie" and doing fine. An agency nurse or a float nurse comes in or even a doc covering for the primary doc comes in and see's the pt now possibly gorked out ( ar eal possibility esp if he throws a clot with a broken leg...) How are they to know if this is his base line or not if it is not docunebted on ADNISSION what his base line was at that time. You run a very real possibility that he may be mistreated or diagnosed. chew on that for a bit and hopefully we can change your mind about the glasgow coma scale.

Dave

[ohbet]

OK fine, I'll just give the test.Every one is getting this test,it doesnt matter who they are,how they present, what the history or how intact they are are cognitively,everone is getting it,no matter what.If I do a history and there is no alcohol,no epilepsy,no insulin use,no druge use ,no metabolic causes, no trauma,no infection, no psychiatric causes and no stroke or other cardiovascular causes,it doesnt matter ,they get it the GCS,as if I dont have enough to do.

As a matter of fact ,the first thing I do when I get to work this morning is Im going to sit my Head Nurse down and administer the test to her,then I think Ill give it to the DON,then the eve shift nurses,then the CNAs then the..........

[JMP]

Ohbet

GCS has the word "coma" in it....... Ok .....lets talk turkey here.

The GCS was originally developed to assist general communication concerning the severity of neurologic injury.

Some points to keep in mind, it provides data about LOC ONLY AND MUST NEVER BE considered a complete nerologic assessment. IT IS NOT sensitive to lateralization, in other words, decreasing motor response ONLY ON ONE SIDE or unilateral changes in pupils.

Whatever tool you use, it should be one that can pick up decreasing sublte changes in LOC, such as pervious ORIENTATION TO TIME PLACE AND PERSON. PLEASE NOTE: assessment of pt's ability to follow commands is one of the highest levels of functioning evaluated. "show me your thumb" is a good one. Common mistakes people make is to say " Oh BOb, your Mom is here, show her how well you are doing.... come on BOB show her your thumb....... like you did before". It is called sensory overload.

Using the GSC on the floor, I feel is still dumb.

Wendy: I find myself doing neuro vitals in the ICU on head injuries, like traumas....... bleeds. It can be done on a flow sheet, if neuro vitals are ordered q4, for example. However, we do a head to toe assessment....so, LOC would be done as part of the CNS evaulation. Many of our pts are heavily sedated, propofol, midaz, fentanyl, etc. So the sedation drugs must be mentioned in your assessment as well. ALL OF OUR pts are intubated, so the GCS is no good....... and does not really mean much in this setting. It is meant to be used in a ER or EMS setting to evaulate pts LOC.

THe best measure of LOC in most locations, including ICU is the pts ability to move all 4 limbs, grip hands and wiggle toes......in other words.......following simple commands.

[ohbet]

Pay attention to what JMP is saying,the scale purpose,what it was designed originally for is to use when someone has a neuro injury, and not for the entire worlds population.

[hapeewendy]

I'm done commenting on this one....

we all have differing views on the subject

and I for one would like to agree to disagree

its not that I for one am not "paying attention" to what anyone else is posting.

I read what you all type and then I give my input

it seems like this is a major major sore spot with you just from your responses so I would suggest bringing it up to your Nurse manager or director of nursing practice , maybe they can help change the policy or explain to you why it is part of each admission .

Many times an incident happens that spins the wheels of change into motion, maybe there was a method to their madness in including this ...

maybe there wasnt, either way we can sit here and debate the GCS and its purpose and its name til we all turn blue and need intubation

but the point remains we all have different ideas on what constitutes good nursing practice and what doesnt.......

you have your seemingly strong beliefs on this one so I thin its a perfect opportunity to try to get to the bottom of the rationale for why the GCS is part of an admission at your facility.....

many season and experienced nurses have brought opinions to the table on this one, I dont think any of them were wrong in supporting the use of the GCS....

[CEN35]

ok why do it on a perfectly normal patient?

saunders,encyclopedia and dictionary of medicine , nursing and allied health has to say about the purpose of the test ,glasgow coma scale: "a standardized system for assessing response to stimuli in a neurologically impaired patient."

doing it shows, there was no neuro impairment. sometimes you don't do things to prove there is a problem, but rather there was not.

besides working in the er the last six years, i can't tell you how many times some patients have come in fine, and then had some neuro s/sx. using the gcs showed approximately when the problem occured. at that point, i went into a complete neuro exam to check out all the cranial nerves. in the er, you never know for sure why they are there for while. better safe than sorry!

me :)

[JMP]

CEN

ER is one of the places GCS makes sense, In my view. Where I am in ICU, makes no sense. Out with the EMS, makes sense, of course. Up on the floors????????? That was my point. Makes no sense.

As stated in my earlier post, GCS is does not account for unilateral pupil changes, for example. Does not account for lateral changes, one side weaker than other. Most floor nurses, not all, but I would bet most have no idea what a GCS of 7 vs. 9 mean...........or am I wrong?

I just think a CNS evaulation outside of ER or EMS would be better served by stating, alert, orientated, able to follow commands. VS> CGS of 11. Just my thoughts.

[CEN35]

right on jmp!

me :)

[ohbet]

Dplear,they will know his baseline because on the admission assessment,Before the part on the admission assessment that has the blasted GCS,there is a question whether the patient is alert? and then a question weather he is oriented and to what is the patient orie;nted to?,person? place? time? All?. If he is alert and Ox3,forget the GCS,and youve got your baseline

[pebbles, BSN, RN]

Our Neuro assessment flowsheets show assesments in several categories.

Top of sheet is the GCS rating.

Below that is pupil size and response to light, left and right.

Then the vitals, including MAP.

Then limb response and strength, left and right, upper and lower extrmities - check off whether limb movement spontaneous, in response to pain, ect, flaccid or spastic.

This flowsheet is a vital assessment tool that is used in all areas of the hospital when we are concerned about the neurological status of a patient. GCS is very important, for many reasons that have been previously stated in this thread. But it won't tell the whole story. Equally important are the nurse's narrative notes about the patients behaviour and responses to stimuli, etc.