Glasgow Coma Scale

[small_potato]

I am confused about the Glasgow Coma scale. I have encountered 2 patients after acute stroke. They were both conscious.

Patient A

His eyes were open and looking at me. When I asked him where & who he was, he tried to speak and show some mouth movement but was unable to produce any sounds. What should his scores be for verbal response?

Patient B

His eyes were also open and looking at me. When I asked him to protrude his tongue, he was unable to do so. Then, I applied some painful stimulus to his finger. His arms seem paralytic and was unable to show any movement (and not in flexion & extension), but his legs moved upward. What should his scores be for motor response?

Thanks a lot:yeah:

[XB9S, BSN, MSN, EdD, RN, APN]

With the GCS you take the best possible reponse. So if your patient is asleep when you first assess but wakes on you calling them and is then able to stay awake that would be alert, if however they dose back off and is sleepy but still opens eyes when called this would be responds to voice and so on.

Now it gets a little more complicated when other factors are put in there. So your patient's verbal response. Your choices are

1. No verbal response
   
2. Incomprehensible sounds. (Moaning but no words.)
   
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
   
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
   
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient's name and age, where they are and why, the year, month, etc.)

Patient A

His eyes were open and looking at me. When I asked him where & who he was, he tried to speak and show some mouth movement but was unable to produce any sounds. What should his scores be for verbal response?

Your patient may be able to answer coherently even though there is no speach, does you patient know where he is, what date it is, is he able to communicate any other way, can he use finger boards that kind of stuff. Or do you get the feeling that your patient is confused and disorientated? Think of trache patients, they have no power of speech but can still be orientated so you need to use alternatives to assess speach / cognition. Did he mouth to you his name and the date or did you get the impression that he was not orientated.

Your second question

Patient B

His eyes were also open and looking at me. When I asked him to protrude his tongue, he was unable to do so. Then, I applied some painful stimulus to his finger. His arms seem paralytic and was unable to show any movement (and not in flexion & extension), but his legs moved upward. What should his scores be for motor response?

you say that he was able to poke his tongue out, well that sounds like he was obeying commands, a paraplegic may not respond to a finger pinch because of loss of function or sensation but will be able to obey commands within the limitations of motor problems. I would usually ask poke tongue out and blink, put your finger to your nose, that way you know that he understands what you are asking and is able to comply.

Hope this helps

[small_potato]

Your second question

you say that he was able to poke his tongue out, well that sounds like he was obeying commands, a paraplegic may not respond to a finger pinch because of loss of function or sensation but will be able to obey commands within the limitations of motor problems. I would usually ask poke tongue out and blink, put your finger to your nose, that way you know that he understands what you are asking and is able to comply.

Hope this helps

He cannot poke his tongue out, but move his leg upwards when I applied painful stimulus on his finger (his arms cannot move too). A nurse said it was "localized to pain", but I was confused.

[XB9S, BSN, MSN, EdD, RN, APN]

Sorry, I must of misread that part, so he doens't obey commands but does move is legs upwards to painful stimulai.

wikipedia

1. No motor response
   
2. Extension to pain adduction of arm, internal rotation of shoulder, pronation of forearm, extention of wrist, decerebrate response)
   
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
   
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
   
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
   
6. Obeys commands. (The patient does simple things as asked.)

I wouldnt say he is localising to pain but may be say that he is

withdrawing from pain providing the movements you describe are normal movements and not decorticate or decerebrate.