VOL: 102, ISSUE: 05, PAGE NO: 26
Debra Fairley, MSc, PGDip, BSc, RGN, is critical care nurse consultant
Amanda Pearce, BSc, RGN, DipN, is staff nurse; both at the Leeds Teaching Hospitals NHS Trust
The second part of this two-part series examines the Glasgow coma scale (GCS) (Teasdale and Jennett, 1976; 1974) (Fig 1).
- If a patient’s eyes are closed as a result of swelling or facial fracture this is recorded as a ‘C’ on their chart.
- Spontaneous eye-opening. Establish that the patient is not asleep. Assess without speech or touch. A score of 4 is allocated when a patient is observed to be awake with their eyes open.
- Eye-opening to speech. If there is no spontaneous eye-opening, response to speech is assessed and allocated a score of 3 if eyes are opened to loud, clear commands.
- Eye-opening to pain. If there is no eye opening to speech, response to pain is assessed. A score of 2 is allocated if the patient opens their eyes to a painful stimulus. Fingertip pressure and supraorbital ridge pressure are the most commonly used methods of applying a painful stimulus. Because of the risk of misinterpreting the response to fingertip pressure (due to factors such as hemiparesis and high spinal cord injury) supraorbital ridge pressure is considered the most reliable method of assessment (Fairley et al, 2005).
- None. No eye-opening to pain is allocated a score of 1. In addition, a patient with flaccid ocular muscles may lie with their eyes open all the time. This is not a true arousal response and should be recorded as ‘no eye opening’ and allocated a score of 1.
Best verbal response
- If the patient has an endotracheal tube or tracheostomy tube in situ, this is recorded as ‘T’ on their chart under ‘no response’ and allocated a score of 1. If the patient is dysphasic, best verbal response cannot be determined accurately. This is recorded as a ‘D’ on their chart under ‘no response’ and allocated a score of 1.
- To be classified ‘orientated’, and allocated a score of 5, patients must be able to correctly identify: who they are (name); where they are; the current month/year.
- A patient is classified ‘confused’ when one or more questions are answered incorrectly, in which case a score of 4 is allocated.
- A patient is classified as using ‘inappropriate words’ when conversational exchange is absent or there is a tendency to use single words more than sentences. Swearing is common. This is allocated a score of 3.
- When words and speech cannot be identified, the term ‘incomprehensible sounds’ is recorded. A patient may be mumbling, groaning or screaming. A score of 2 is allocated.
- If the patient does not respond verbally to verbal or physical stimuli, ‘none’ is recorded and a score of 1 is allocated.
Best motor response
- ‘Obeys commands’. The patient is asked to grip and release the assessor’s fingers to discount a reflex action. If in doubt, try another movement such as raising eyebrows. A patient score of 6 is given.
- ‘Localises to pain’. If the patient is unresponsive to verbal commands, response to a painful stimulus is assessed. Supraorbital ridge pressure is the most reliable and effective technique for distinguishing localising from flexion/abnormal flexion and to minimise misinterpretation (Fig 2). In patients with facial fractures or gross eye swelling, pinching the earlobe may be preferable.
To be classified as localising to pain, a patient must move their hand up beyond the chin and across the midline of the body (Fig 3). A score of 5 is allocated.
- ‘Normal flexion’. No localising to pain is seen. This is recorded when a patient bends their arms at the elbow in response to painful stimulus (Fig 4). It is a rapid response (likened to withdrawing from touching something hot) characterised by shoulder abduction. A patient who has a flexion response to pain is allocated a score of 4.
- ‘Abnormal flexion’. Characterised by internal rotation, adduction of the shoulder and flexion of the elbow. A much slower response than normal flexion, it may be accompanied by spastic wrist flexion (Fig 5) and is allocated a score of 3.
- ‘Extension to pain’ is recorded when there is no abnormal flexion to painful stimulus. The patient has straightening of the elbow joint, adduction, internal rotation of the shoulder, inward rotation and spastic flexion of the wrist (Fig 6). A score of 2 is allocated.
- ‘No motor response’ is recorded when there is no response to a painful stimulus and is allocated a score of 1.
A deterioration of one point in the motor or verbal response or an overall deterioration of two points is significant. Professional responsibilities
All nurses who carry out clinical procedures must have undertaken a programme of education and demonstrated competence under supervision.
The practitioner is responsible for ensuring that her or his practice is compliant with NMC guidelines. The practitioner should also ensure that she or he is familiar with local trust policies.