Glasgow Coma Scale Flashcards
What does GCS stand for?
Glasgow Coma Scale
What does AEIOU TIPSS stand for? and what is its purpose?
A: Alcohol E: Epilepsy I: Insulin O: Opium U: Uraemia
T: Tumour I: Injury P: Psychiatric S: Sepsis S: Stroke
These are some common causes of altered consciousness
What are 7 common causes of falls?
Delirium, cardiac/neurological/muscular-skeletal condition, side-effects from medications, balance/strength/mobility, poor eyesight, poor memory, and incontinence/urinary urgency.
What are the two components that we can divide consciousness into?
Alertness/wakefulness: the appearance of wakefulness
Alertness/cognition: content of cognitive mental functions.
What is the first stimuli assessment we do in the GCS?
Eye opening
Does eye opening mean the patient is aware of their surroundings?
NO
How do we do the first 3 steps of an ‘eye opening’ assessment in the GCS?
Observe the patient before speaking to them. (If their eyes are open, or they open as you approach score a 4 - spontaneous)
Next, talk to the patient with a normal voice, say their name or ask them to open their eyes. (If they open their eyes - score a 3 for speech)
If this fails speak louder or shout. Not touching the pt. (If the patient opens their eyes score a 3 - to speech)
What are the steps after (to speech) that we preform for an “eye opening” assessment?
Next, touch or shake the patient (if the patient opens their eyes score 2 - to pain)
If this fails, use noxious stimuli.
Explain to the patient and family what you are going to do and why, apply a peripheral painful stimulus (applying pressure with barrel of pen to the lateral outer aspect of the second or third interpharangeal joint, gradual pressure 10-15 secs) If the patient opens their eyes score 2 - pain.
If this fails and the patient has still not opened their eyes score 1 - none.
Note: if the patients eyes are closed due to facial injurys or swelling document “C” and a score cannot be assigned for this category.
Verbal responses depend on what in the brain?
Wernickes speech centre which in in the temporal lobe and on broca’s speech centre in the frontal lobe.
What are the steps involved for a “Best verbal response” assessment?
First ask the patient the following questions: ‘Who are you’, ‘Where are you’, and ‘Why are you here’ + ‘What is the current month’ and ‘What is the current season’. - don’t use closed questions. If the patient answers all of these correctly, score 5 - orientated.
If the patient answers one or more of the above questions wrongly but is able to talk in sentences, score 4 - confused. (Orientation to time is often lost first)
If the patient tries to respond to the questions but is unable to talk in full sentences and uses random words or repeats the same phrase or work, score 3
If you hear no intelligible words - score 2. If the patient doesn’t produce any sounds - score 1.
Note: if the patient is unable to respond verbally due to an endotracheal tube, document ‘T’
What are the steps involved for a “Best motor response” assessment? (1-6)
1st. Ask the patient to obey at least two simple commands
Examples: Lift your arms up, hold up your thumb, stick out your tongue. If the patient follows the command, score 6 - obeys commands
If this fails move on. Observe the patient, are they trying to pull their O2 supply ect moving their hand above chin level. This would be ‘localising to pain’ - score a 5.
If both of these are not present we move to applying a painful stimulus. Firstly explain to the patient what you are going to do and why. Apply supra-orbital pressure gradually for 30 seconds, then try the trapezius squeeze for up to 30 seconds.
If the patient try’s to locate the stimulus in an attempt to remove the source of pain, score 5 - localises to pain (note: the patient must bring arm above chin level and across bodys midline). If the patient flexes their arm towards the source of pain but fails to localise or remove it, score 4 - withdrawal from pain/normal flexion. If the patient flexes the arm at the elbow and rotates wrist in response to pain, score 3 - abnormal flexion. If the patient straightens the arm at elbow and rotates it inwards with legs extending and the feet plantar-flexed, score 2 - extension.
If no movement is observed, score 1 - none.
What are some recommendations for clinical practice?
- Listen to the patients family’s concerns
- When communicating a GCS score, state each component of score not just total
- Ensure the same staff member carries out all observations during shift
- at shift handover, observations should be done together with nurse leaving and nurse arriving
- Ask for second opinion when in doubt
- Mark dots not lines on chart
- A drop of one point in motor response is of clinical significance and must be reported to the medical team immediately
- During the night shift, do not assume the patient is asleep and omit assessment
- Clarify with the team the freq of the GCS obs and how long these should be continued for.
How do you do supra-orbital pressure? Are what are the considerations with this type of painful stimulus?
Apply pressure above the eye gradually for a maximum of 30 seconds.
This targets the trigeminal nerve (cranial nerve V), and is contraindicated by orbital damage, skull fracture and glaucoma. This method is also risky for patients with reduced awareness due to potential sudden movement that may cause injury to their eyes.
How do you do the trapezius squeese? Are what are the considerations with this type of painful stimulus?
Apply pressure by grasping approximately 3cm of the muscle between the thumb and forefingers and twisting for up to 30seconds.
This targets the spinal accessory nerve and is documented as the most suitable method. Especially in the presence of orbital damage, skull fracture or glaucoma. Although this method could be difficult on a large or obese patient.
Why are sternal rubs and nail-bed pressures no longer used?
These methods cause prolonged discomfort and damage
