Glasgow Coma Scale

gwenith, BSN, RN · Mar 19, 2004

The Glasgow Coma Scale has been used successfully for a number of years now BUT it has it's limitations. I find it especially limited with the non-verbal or ventilated patient. It is frustrating because you are getting appropriate responses that indicate the patient is fully orientated but cannot indicate that within the chart as it currently stands.

Is anyone using a modified scale for non-verbal patients?

Is anyone using the Adelaide children's Scale?

Does anyone have any other "gripes" or problems with the GCS??

Sarah, RNBScN · Jul 7, 2004

The Glasgow Coma Scale has been used successfully for a number of years now BUT it has it's limitations. I find it especially limited with the non-verbal or ventilated patient. It is frustrating because you are getting appropriate responses that indicate the patient is fully orientated but cannot indicate that within the chart as it currently stands.
Is anyone using a modified scale for non-verbal patients?
Is anyone using the Adelaide children's Scale?
Does anyone have any other "gripes" or problems with the GCS??

-------------------------------------

Hi

Can you explain the modified scale and Adelaide Children's Scale? Please advise.

Thanks,

Marcie

suzanne4, RN · Jul 7, 2004

I used to modify the GCS if my patient was oriented but non-verbal due to being vented, etc. Especially if a patient is mouthing the words, and you know that they know what is going on. I actually would put oriented but put (V) in brackets for vented. And all of the of the docs accepted this, and it was a very busy facility that specialized in neurosurgery.

gwenith, BSN, RN · Jul 8, 2004

Adelaide childrens scale

Table 3.3: Children's Modified Glasgow Coma Scale
Eyes openAny ageScoreSpontaneously
To speech
To pain
No response4
3
2
1 Best verbal response> 5 years2-5 years0-23 monthsScoreOrientated and converses

Confused

Inappropriate words

Incomprehensible sounds

No responseAppropriate words and phrases

Inappropriate words

Cries and/or screams

Grunts

No responseSmiles, coos, cries appropriately

Cries but consolable

Persistent cries and/or screams

Grunts

No response5

4

3

2

1 Best motor response> 1 year

Localises pain

Flexion-withdrawal

Flexion-abnormal (decorticate rigidity)

Extension (decerebrate)

No response[/size]Spontaneously moves

Localises pain

Flexion-withdrawal

Flexion-abnormal (decorticate rigidity)

Extension (decerebrate)

No response6

5

4

3

2

1

I was hoping someone somewhere was using one of the modified charts I have seen for non-verbal patients. Like Susanne I often score orientated if the patient is making appropriate responses but I often think there is room for a modification for vented patients.

gwenith, BSN, RN · Jul 8, 2004

Ah RATS!!! Ot didn't work out

well here is the link

http://www.chw.edu.au/prof/handbook/sect03.htm

NeuroICURN · Jul 8, 2004

The Glasgow Coma Scale has been used successfully for a number of years now BUT it has it's limitations. I find it especially limited with the non-verbal or ventilated patient. It is frustrating because you are getting appropriate responses that indicate the patient is fully orientated but cannot indicate that within the chart as it currently stands.
Is anyone using a modified scale for non-verbal patients?
Is anyone using the Adelaide children's Scale?
Does anyone have any other "gripes" or problems with the GCS??

Yeah, I understand those concerns, but that's what makes someone who is oriented x3, on a ventilator and following commands an "11T". The "T" being specifically for patient's who are on a ventilator and therefore cannot have their speech assessed. I thought this was a standard?? I didn't think the one we used was a "modified" one.

Just in case, our scale runs like this:

Eye Opening: 4 = spontaneous, 3 = to voice, 2 = to pain, 1 = no response 1UTA = Unable to assess (for times when someone is sedated, like with propofol).

Speech: 5 = oriented, 4 = confused, 3 = incomprehensible sounds, 2 = moaning (forgive me if I put 3 & 2 in wrong order, I just woke up), 1 = no response, 1T = Patient is intubated or trached, 1UTA = Unable to assess (again for sedation reasons).

Motor: 6 = follows commands, 5 = localizes, 4 = withdraws, 3 = decorticates, 2 = decerebrates, 1 = no response, 1UTA = Unable to assess.

We don't use the Adelaide scale because we don't take children in our ICU. Our patient's are at least 13...which even that young is rare for us because a lot of them will go to our Pediatric ICU which has open visitation and is more suited for children.

As for them being oriented, but on a ventilator, I handle it this way. (First let me say that we use a computer system called "Emtek" to chart and each assessment, there is 5 screens. Three of them are 1. VS screen, 2. Neuro screen, 3. Assessment screen.) On the VS screen, I chart the accurate GCS score from above. In the neuro screen, under LOC, I'll chart: "Patient is awake, alert and oriented to self, place and time. Patient follows commands with all extremities." Then there is a space below that to actually chart about speech, which I'll chart: "UTA patient's speech. Patient is orally intubated. Patient nods head for yes/no questions and is mouthing words to communicate." (or whatever the case may be). Then, I also note this is in the assessment screen (which is where the BIG note, for all body systems, goes).

Glascow is only a small tool in the big picture. We've never really had a problem where it doesn't fit our needs...only because we usually explain ours more than "Mr X is an 11T". Our docs want to know specifically what the pt. is doing.

Hope this helps Gwenith!!!! Goodness knows you've helped many of us soooo much!! :)

NeuroICURN

Elenaster · Jul 8, 2004

Good answers Neuro! We don't have any modified scales, but I generally do a narrative neuro note with my initial assessments to cover areas that are not addressed by the GCS.

I feel the GCS has limitations, and the most frustrating to me has been the fact that it in no way addressed cognitive functioning. For instance, I once had an adult patient with Down's Syndrome in overnight for obs after a VP shunt revision. She came out of surgery fine and was only in the ICU because of an underlying cardiac issue. She was alert, followed commands and able to converse with me on the same level of about a 5-6 year-old child, however I had to assign her a "4" for verbal on the GCS because she didn't know what day of the week it was, the year etc. Now this was her baseline intellectual functioning and I did not consider her to be confused, per se, but she was still unable to meet the criteria to be assigned a "5" for verbal.

You also have to be careful assuming that a patient that is orally intubated or trached that is attempting to communicate is truly oriented. I've had more than one occasion where I felt as soon as the patient was extubated, he/she would be completely with it because he/she was following all commands, nodding head yes or no, and mouthing words, only to discover upon extubation, the patient was extremely disoriented and confused.

NeuroICURN · Jul 8, 2004

Good answers Neuro! We don't have any modified scales, but I generally do a narrative neuro note with my initial assessments to cover areas that are not addressed by the GCS.
I feel the GCS has limitations, and the most frustrating to me has been the fact that it in no way addressed cognitive functioning. For instance, I once had an adult patient with Down's Syndrome in overnight for obs after a VP shunt revision. She came out of surgery fine and was only in the ICU because of an underlying cardiac issue. She was alert, followed commands and able to converse with me on the same level of about a 5-6 year-old child, however I had to assign her a "4" for verbal on the GCS because she didn't know what day of the week it was, the year etc. Now this was her baseline intellectual functioning and I did not consider her to be confused, per se, but she was still unable to meet the criteria to be assigned a "5" for verbal.
You also have to be careful assuming that a patient that is orally intubated or trached that is attempting to communicate is truly oriented. I've had more than one occasion where I felt as soon as the patient was extubated, he/she would be completely with it because he/she was following all commands, nodding head yes or no, and mouthing words, only to discover upon extubation, the patient was extremely disoriented and confused.

Good point about the pt. that had Down's. I've thought about that too, about how they may have a "less-than-perfect" Glascow score, but still be at their baseline. I guess that's just where your assessment note has to fill in the gaps. Ah, the work of a neuro nurse is never done! :)

As for assessing orientation status when a pt. is intubated or trached, I handle it like this.....I give them choices and have them nod their head yes or no. For example, I'll ask: "Is your last name Jones? Is your last name Smith? Is it Holiday?" If they nod appropriately for each, I give credit for that part. Then I'll give choices for place: "Are you at home?" "Are you in a hospital?", etc. Finally, time. Depending on how long the person has been there, is how specific I am. Since people in ICUs "lose" time first, I'm usually happy with at least year, occasionally you can even get the month out of them! LOL I'm also always careful not to put the correct answer in the same number slot either. That way, they don't learn that the correct answer is always choice #3.

I look forward to anyone's feedback on this!

Take care,

NeuroICURN

Good_Queen_Bess · Oct 31, 2004

I think the GCS is a good basic tool, but I acknowledge that it does have limitations. How we document these "problems" is to put a "D" for dysphasic or "T" for trache in the verbal response box where no. 1 or nil is.

As a side note, do other people find it almost amusing when you receive a referral or call telling you that a patient has a GCS of 1 or 2. What? How? Or when you ask what the patients GCS is, the other person says, "er.. er.." and you have to go through with them step by step as to what the patient is doing. I know we all have different skills, but GCS is a basic necessary skill IMHO.

BTW NICU RN, LOVE the avatar!! Good luck on tuesday.

NeuroICURN · Nov 1, 2004

I think the GCS is a good basic tool, but I acknowledge that it does have limitations. How we document these "problems" is to put a "D" for dysphasic or "T" for trache in the verbal response box where no. 1 or nil is.
As a side note, do other people find it almost amusing when you receive a referral or call telling you that a patient has a GCS of 1 or 2. What? How? Or when you ask what the patients GCS is, the other person says, "er.. er.." and you have to go through with them step by step as to what the patient is doing. I know we all have different skills, but GCS is a basic necessary skill IMHO.
BTW NICU RN, LOVE the avatar!! Good luck on tuesday.

Thanks...I loved that avatar too! God I hope it works out that Kerry is elected on Tuesday....I honestly can't imagine another 4 years of Bush. It's really bad, and I can't understand how people can't see how he's REALLY messed things up for us. But I digress......

Now, I've never gotten that they're a GCS of 1 or 2....but I have gotten that people are obtunded AND combative, at the same time! :chuckle I just shook my head. I also love when you're trying to get report from an outlying facility and if you ask a simple question, like orientation status, you get "I don't know". Sometimes I just want to scream "Well, how the hell am I supposed to know if they start having a change, if you can't tell me their baseline assessment for you???" Sometimes I wonder if the nurse at the OLH even SAW the pt! LOL There again, I just shake my head and tell them "It's ok, I'll figure it out when they get here". LOL

gwenith, BSN, RN · Nov 1, 2004

My best head shaker was the pupils. There was an argument - do you take the size of the pupils from before or AFTER you check for reaction. The answer of course is before referenced this to several texts and made up a learning package for the wards -guess?

Some twerp of a ND nurse insisted on switching on the overhead lights in the patient bays in the middle of the night so that the pupil size would be accurate:rolleyes: