when/how to/whom to use Glasgow coma scale

[iannivlem, RN]

i am starting my career in a foreign country ( JUBAIL, Kingdom of SA) in a tertiary hospital accredited by JCI.... however, some things in their system i am in doubt. one is the GCS. we are using GCS to patient under sedation, relaxant and on mechanical ventilator. patient who has cervical spine fracture; quadraplegic. and the result will always be GCS 3 (E1V1M1) to the first and GCS 10 (E4V5M1) for the later patient who is conscious and very coherent. i did my search over the net, consulted my funda of nursing and it does not make sense. i opened this to our head nurse and unit supervisor, i also use this "GCS 3; E1V1M1" during endorsement, but what i had is mockery from them.

[Ivanna_Nurse, BSN, RN]

I use the GCS on all of my patients, really. My GCS will be 3 for someone snowed on propofol and fentanyl, however, if I give them a sedation vacation my GCS will change on most pts. A GCS change on a pt can dictate a different plan of care. Look in your policy manual about the documentation, here GCS is part of our flowsheet. Good luck :) Ivanna

[meandragonbrett]

GCS can still be used on patients who are sedated. Some patients will continue to open their eyes spontaneously while sedated. They generally should be able to follow commands when sedated but easily lapse back to sleep when not verbally stimulated. Their verbal score would be a "1T" t standing for tube or trach.

A GCS is part of a comprehensive neurological exam on an ICU patient whether they are mechanically ventilated or not.

If they have received paralyzing drugs and have a GCS of 3, I would make a notation in my narrative that explains the change in their score.

[uniquenurse, BSN, RN]

I am a Philippine trained nurse worked in KSA for >2 years and currently working in Emergency Department here in the UK for 9 years. GCS is basically used for patients with head injury who require neurological observations such as head injury. It is also being used for patients who suffered from CVA, TIA, and other neurological conditions which affect patient's level of consciousness. In trauma patients, a quicker way to assess patient's level of consciousness is by using AVPU score (A=Alert, V= response to VERBAL stimuli, P= response to PAINFUL stimuli, U= Unresponsive).GOODLUCK on your new job. CONGRATULATIONS!!!

[uniquenurse, BSN, RN]

for the patient that you scored 10(the one who was conscious and coherent), you are right when you scored him 5 for the best verbal response as the patient was orientated and 4 for the best eye response as the patient eyes were spontaneously open then you scored him 1 for the best motor response.

remember, with the best motor response, you are not scoring your patient by only considering limb power alone, instead you are scoring them for the following aspects:

1. no response to pain.

2.extensor posturing to pain: the stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm) - decerebrate posture.

3.abnormal flexor response to pain: pressure on the nail bed causes abnormal flexion of limbs - decorticate posture.

4.withdraws to pain: pulls limb away from painful stimulus.

5.localizing response to pain: put pressure on the patient's finger nail bed with a pencil then try supraorbital and sternal pressure: purposeful movements towards changing painful stimuli is a 'localizing' response.

6.obeying command: the patient does simple things you ask (beware of accepting a grasp reflex in this category).

if i will assess your patient who was conscious and coherent, i will probably ask him to do simple things such as: "give me a smile", "open your mouth", or "stick your tongue out". if he obey these commands then he will have a score of 6 for the best motor response therefore his gcs will be 15/15.

i hope these pointers will give you a bit of guidance about gcs and neurological assessment. best of luck!!!

[NotReady4PrimeTime, RN]

I agree with the OP that the GCS is frequently both used inappropriately and easily misinterpreted. After all, the keys I'm typing this on could be said to have a GCS of 3... so how valuable is that information? As an initial assessment of neurologic function, it can be very helpful as long as the patient has not been administered any drugs that would alter the findings. It's all about context. The greatest value will be found in those patients whose GCS is either very low or very high at initial assessment. The low scores should improve over time as the patient's brain recovers and the very high ones should remain high. Unanticipated findings can be very important and lead to changes in care plan. There's a time and a place for GCS monitoring but I don't think it's a routine assessment of any great utility in otherwise normal people.

[FlyingScot, RN]

My understanding is that the Glasgow Coma Score should not be used to monitor neurological function of a sedated patent. There are various sedation scales available that give you much more information than the GCS and certainly better information to guide your nursing care. The Ramsey Sedation Scale seems to be the one most utilized.