Questions about Braden and Glasgow Coma Scales

[MattiesMama]

OK-for the GCS I'm looking for a little clarification....

For best motor response and best verbal response...am I correct in assuming that you go by their highest functional ability, even if they acheive that very rarely? For example-I have a pt who is usually unable to obey verbal commands because she is has a lot of spacticity and isn't in control of most body movements, but occasionally she will blink her eyes or squeeze your hand in response to questions. would she be a 5 (obeys verbal commands) or a 6 (moves to localized pain)?

For the Braden scale, it says:

1. Constantly Moist:

Perspiration, urine, etc keep skin moist

almost constantly. Dampness is detected

every time patient is moved or turned.

This same pt. is incontinant and wears briefs, has no real voiding pattern and is constantly leaking loose unformed feces, but she is not damp every time she is moved or turned...the rest of her skin is usually dry. So would she fall under this category? I guess I'm a little confused by the way the Braden scale is worded...does the pt. need to fit ALL of the criteria for it to apply? Does it make a difference if something only applies for one specific area of their body??

[Daytonite, BSN, RN]

for best motor response and best verbal response...am i correct in assuming that you go by their highest functional ability, even if they acheive that very rarely?

the score you give is based by

their response at the time you do your assessment

.

occasionally she will blink her eyes in response to questions

if her eyes always remain closed and your questions are what cause her to open her eyes, this is a "3" for

best eye opening

.

squeeze your hand in response to questions

if this is her response to a command to squeeze your hand it is a "6" for

best motor response.

what is her

best verbal response score

to add to this 3 + 6?

oriented x 3-----------------5

conversation-confused------4

speech inappropriate---------3

sounds incomprehensible-----2

no response (speech)--------1

for the braden scale:

this same pt. is incontinant and wears briefs

that is "constantly moist" for

moisture

and gets a score of "1".