NURSING CARE RELATED TO THE SENSORY AND
NEUROLOGICAL SYSTEMS

2-16

[Previous] [Next]

2-16. LEVEL OF CONSCIOUSNESS

a. The Glasgow Coma Scale (GCS) is a standardized, objective, reliable instrument for the assessment of level of consciousness.

b. The scale measures three areas of observable behavioral responses (verbal, motor, and eye). Patient responses are graded by the degree of dysfunction. The patient's best response in each of the three areas is recorded. The combined score of the three areas is the "consciousness level" score.

c. Recording and/or graphing the scores on a flow sheet permits easy tracking of the patient's status.

d. Response scale. (Explanation)

(1) Eye response.

(a) 4 points--eyes open spontaneously.

 

(b) 3 points--eyes open in response to sound.

 

(c) 2 points--eyes open in response to painful stimuli.

 

(d) 1 point--eyes do not open in response to any stimuli.

(2) Verbal response.

(a) 5 points--the patient is oriented to person, place, and time.

 

(b) 4 points--the patient is confused but is able to communicate.

 

(c) 3 points--the patient speaks in a disorganized manner. (Inappropriate speech.)

 

(d) 2 points--the patient's response is moaning or groaning sounds. (Incomprehensible sounds.)

 

(e) 1 point--the patient does not respond.

(3) Motor response.

(a) 6 points--the patient obeys commands appropriately and moves all extremities equally and spontaneously.

 

(b) 5 points--the patient "localizes" to the stimulus (pain). Attempts to locate the source of the pain and move the limb away from the stimulus.

 

(c) 4 points--the patient attempts to withdraw from the source of the (painful) stimuli in a less than purposeful movement. (Flexor withdrawal.)

 

(d) 3 points--the patient flexes an extremity abnormally. (Decorticate response.)

 

(e) 2 points--the patient extends an extremity abnormally. (Decerebrate response.)

 

(f) 1 point--the patient has no motor response. (Flaccid.)

e. Abbreviated Response Scale.

Eye Opening

Spontaneous = 4

To sound = 3

To pain = 2

None = 1

Best Verbal Response

Oriented = 5

Confused = 4

Inappropriate words = 3

Incomprehensible sounds = 2

None = 1

Best Motor Response

Obeys commands = 6

Localizes stimulus = 5

Withdrawal from stimulus = 4

Abnormal flexion (decorticate) = 3

Abnormal extension (decerebrate) = 2

Flaccid = 1

_____________________________________________________

TOTAL SCORE POSSIBLE = 3 through 15

[Previous] [Next]