Inappropriate scoring of GCS in acute stroke patients

[dudette10, MSN, RN]

I have recently had a conversation with colleagues about the use of the GCS in acute stroke patients. Based on what I've seen in a medical record during clinical (I'm an instructor), the scoring might be a 7 for a patient who has passed a swallow eval but due to reduced motor response (they have a CVA!!!) and morning assessment of eye opening (you mean they NEVER spontaneously open their eyes?! when you also state they passed a swallow eval and can take PO meds crushed) and confused verbal response when the patient has a history of dementia.

For this particular patient, that scoring was completely inappropriate. I've tried searching for information regarding using GCS in acute stroke patients, but I'm not coming up with specific answers as it relates to nurse scoring outside of the ICU and ER.

Have you seen this issue?

[chare]

The Glasgow Coma Score (GCS) was designed to provide a detailed evaluation of an individual with an alteration to level of consciousness (LOC). As many patient's post stroke are afflicted with an altered LOC, why exactly do you feel that the GCS is inappropriate for use? And what in particular did you feel was inappropriate in the patient you mentioned>

Having said that, I do agree that the GCS can be problematic with some patients. Your scenario of the patient with pre-existing dementia with confused speech is one such problem. Intubated patients are another issue. Glasgow Coma Scale recognizes these confounders and suggest that it is appropriate to note that a particular area is non-testable. When this occurs a total score should not be calculated, however it is appropriate to use the remaining components to trend the patient's recovery.

Another score, the Full Outline of Un-Responsiveness (FOUR) score has been proposed. The FOUR Score evaluates the following components: eye response, motor response, brainstem reflexes, and respiration pattern, with a score of 0 – 4 assigned, based upon response. While it might overcome some of the shortcomings of the GCS, it seems to be infrequently used in practice.

Validity of the FOUR Score Coma Scale in the Medical Intensive Care Unit

[KelRN215, BSN, RN]

Some people don't understand how they're supposed to score the GCS. When I worked peds neuro, we were supposed to do GCS q 4 hr for all of our patients on neuro checks. Some overnight nurses always marked eye opening "to voice" or "to pain" when it really was spontaneous, just the patient was asleep and they opened their eyes when woken up either by voice or touch. Being asleep doesn't mean one doesn't open one's eyes spontaneously.

And then there were the developmentally delayed kids who just didn't have the cognition to obey commands or were non-verbal at baseline but their level of consciousness wasn't altered. If a developmentally delayed non-verbal kid with CP is smiling and laughing and clapping their hands and that's their baseline, they're fine but I know nurses who would have scored them as a verbal response of 1 or 2 and a motor response of 4 or 5. Our EMR had an infant version of the GCS too and I always used that one for children who were developmentally delayed to the infant level because it was a more accurate assessment of their neuro status. They'd be a 15 on the infant scale but maybe an 11 or 12 on the standard scale.

[dudette10, MSN, RN]

chare: I'm sorry for my ambiguous wording. I said "use," but what I really meant was inappropriate scoring. I remember that when I was working the floor, there seemed to be quite a bit of inappropriate scoring using the GCS or even using calculating the score in the absence of brain injury.

Kel: YES! That is what I mean...inappropriate scoring without taking into account context or baseline. GCS is a score of altered level of consciousness (arousal and responsiveness) NOT altered mental status (which can be present even with intact arousal and responsiveness).

For this particular patient that I'm referring to--who asked questions about where they were which may be due to dementia--the patient was given a GCS of 7, which is categorized as comatose. The scoring was completely inappropriate.

[MunoRN, RN]

GCS in general isn't a particularly useful tool for any purpose, I've worked places where it simply isn't used and for good reason, but you aren't actually supposed to adjust the score based on how you think the person would have scored given different circumstances. If it's 2 in the morning and it takes voice stimulation or noxious stimuli to get their eyes to open, then that's the score. One of the reasons GCS isn't all that useful clinically is because those performing the assessment too often substitute what they think their score should be for what it actually is.

[dudette10, MSN, RN]

One of the reasons GCS isn't all that useful clinically is because those performing the assessment too often substitute what they think their score should be for what it actually is.

No, I'm not saying substitute what one thinks it should be for what it is. Interfering factors should be recognized and dealt with appropriately. That's not "making up" a score. I've read so much about this yesterday, I can't remember where I saw this, but it was from a credible source: if someone is sedated, GCS scoring should be deemed more accurate during sedation vacations to eliminate the interfering factor. That's difference than hypothesizing what the number might be.

[MunoRN, RN]

No, I'm not saying substitute what one thinks it should be for what it is. Interfering factors should be recognized and dealt with appropriately. That's not "making up" a score. I've read so much about this yesterday, I can't remember where I saw this, but it was from a credible source: if someone is sedated, GCS scoring should be deemed more accurate during sedation vacations to eliminate the interfering factor. That's difference than hypothesizing what the number might be.

A GCS done during a sedation vacation is potentially more useful than one done during sedation, but that doesn't mean you should substitute what you know a patient can do when un-sedated for what they are actually doing at the time of the assessment.

For instance, an example that was brought up was a sleeping patient, the correct scoring for eye opening in a sleeping patient is whether they open their eyes to voice or noxious stimuli, it was suggested that if you feel the patient would have opened their eyes spontaneously if they were awake then that's the score they should be given, which is incorrect.

[Guest374845]

The gold standard remains the NIHSS score. That could be the reason you might not be coming up with much information outside of an initial ED GCS or so!e scored in the ICU for neuro checks and post-tpa monitoring.

[MunoRN, RN]

The gold standard remains the NIHSS score. That could be the reason you might not be coming up with much information outside of an initial ED GCS or so!e scored in the ICU for neuro checks and post-tpa monitoring.

Actually the NIHSS is of little use in directing decision making, outside of a pre-TPA risk assessment, it has no established role in ongoing assessments and is correctly identified as an overvalued assessment parameter.

[applewhitern, BSN, RN]

We are required to be certified in NIHSS and use it.

[Guest374845]

Actually the NIHSS is of little use in directing decision making, outside of a pre-TPA risk assessment, it has no established role in ongoing assessments and is correctly identified as an overvalued assessment parameter.

This is completely correct but the culture at some hospitals (mine...) is that it is superior to GCS at all times (or mayb it's something to do with the CMS stroke metrics and all the charting demanded of us at all levels of care). Thus, if that culture is pervasive in the literature, she may have trouble finding evidence to the contrary, ala an alternative exam such as GCS in her searches.