Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Neurological assessment Part 3 - Glasgow Coma Scale

  • Comment

This practical procedure discusses the assessment of the patient’s best eye-opening response

Click here to download the PDF of this article, with graphics included.

Click here for more articles in our Practical Procedures series.

Author

Phil Jevon, PGCE, BSc, RGN, is resuscitation officer/clinical skills lead, honorary clinical lecturer, Manor Hospital, Walsall.

Nursing Times; 104: 29, 28-29.

The Glasgow Coma Scale (GCS) is used to assess level of consciousness in a wide variety of clinical settings, particularly for patients with head injuries (NICE, 2007). In this practical procedure, assessment of the patient’s best eye-opening response will be outlined and discussed, and, in next week’s article, assessment of the patient’s best verbal and motor responses will be described.

What the GCS assesses

The GCS assesses the two aspects of consciousness:

  • Arousal or wakefulness: being aware of the environment;
  • Awareness: demonstrating an understanding of what has been said.

The 15-point scale assesses the patient’s level of consciousness by evaluating three behavioural responses:

  • Eye opening;
  • Verbal response;
  • Motor response.

Eye opening

Assessment of eye opening involves the evaluation of arousal (being aware of the environment):

  • Score 4: eyes open spontaneously;
  • Score 3: eyes open to speech;
  • Score 2: eyes open in response to pain only, for example trapezium squeeze (caution if applying a painful stimulus);
  • Score 1: eyes do not open to verbal or painful stimuli.
  • Record ‘C’ if the patient is unable to open her or his eyes because of swelling, ptosis (drooping of the upper eye lid) or a dressing.

Verbal response

Assessment involves evaluating awareness:

  • Score 5: orientated;
  • Score 4: confused;
  • Score 3: inappropriate words;
  • Score 2: incomprehensible sounds;
  • Score 1: no response. This is despite both verbal and physical stimuli.
  • Record ‘D’ if the patient is dysphasic and ‘T’ if the patient has a tracheal or tracheostomy tube in situ.

Motor response

Assessment of motor response is designed to determine the patient’s ability to obey a command and to localise, and to withdraw or assume abnormal body positions, in response to a painful stimulus (Adam and Osborne, 2005):

  • Score 6: obeys commands. The patient can perform two different movements;
  • Score 5: localises to central pain. The patient does not respond to a verbal stimulus but purposely moves an arm to remove the cause of a central painful stimulus;
  • Score 4: withdraws from pain. The patient flexes or bends the arm towards the source of the pain but fails to locate the source of the pain (no wrist rotation);
  • Score 3: flexion to pain. The patient flexes or bends the arm; characterised by internal rotation and adduction of the shoulder and flexion of the elbow, much slower than normal flexion;
  • Score 2: extension to pain. The patient extends the arm by straightening the elbow and may be associated with internal shoulder and wrist rotation;
  • Score 1: no response to painful stimuli.

Painful stimulus

A true localising response to pain involves the patient bringing an arm up to chin level. Painful stimuli that can elicit this response include trapezium squeeze (Fig 4), suborbital ridge pressure (Fig 5) (not recommended if there is a suspected/confirmed facial fracture) and sternal rub (caution, not recommended in some organisations) (Fig 6) (Jevon, 2007).

The procedure

  • Explain the procedure to the patient.
  • Ascertain the patient’s acuity of hearing.
  • Ideally, use an interpreter if the patient does not speak English.
  • Check the patient’s notes for any medical condition that may affect the accuracy of the GCS, for example previous stroke, affecting the movement of the patient’s arms (Fig 1).
  • Check the neurological observation chart for the GCS scale (Fig 2).
  • Check if the patient opens their eyes without the need to speak or to touch them; if the patient does, then the score is 4E.
  • If the patient does not open their eyes, talk to them (Fig 3). Start off with a normal volume and speak louder if necessary. If they now open their eyes, the score is 3E.
  • If the patient does not open their eyes to speech, administer a painful stimuli, for example trapezium squeeze (using the thumb and two fingers grasp the trapezius muscle where the neck meets the shoulder and twist ) (Fig 4). Or apply suborbital pressure (locate the notch on the suborbital margin and apply pressure to it) (Fig 5). An alternative is the sternal rub (using the knuckles of a clenched fist to apply grinding pressure to the sternum; not recommended for repeated assessment) (Fig 6).
  • If the patient opens their eyes to a painful stimulus record the score as 2E (Dougherty and Lister, 2005). If the patient does not respond, then the score is 1E.

Professional responsibilities

This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

 

 

  • Comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.