Glasgow Coma Scale (GCS)

Question 1

Steps to using the Glasgow Coma Scale (GCS)

Answer 1

-CHECK for anything that may limit or otherwise impact the assessment (e.g. eye injury, sedation, etc.)
-OBSERVE pt eye, verbal and motor responses to determine if they’re spontaneous and normal
-STIMULATE the patient verbally. If pt does not respond, provide physical stimulation using approved technique to apply physical pressure
-RATE the patient using all three components of the GCS, awarding the BEST score achieved in each section

Question 2

Eye-Opening Response

Answer 2

4 - Patients eyes open SPONTANEOUSLY
3 - Patient’s eyes open to a VERBAL COMMAND
2 - Patients eyes only open to a PAINFUL STIMULUS
1 - NO RESPONSE to either verbal or painful stimuli
NT - NOT TESTABLE (injury in eye or pre-existing condition doesn’t allow patient to open eyes)

Question 3

Verbal Response

Answer 3

5 - pt is ALERT and ORIENTED to person place & time
4 - pt is able to answer in FULL SENTENCES with INCORRECT ANSWERS and is CONFUSED
3 - Intelligible but INAPPROPRIATE words out of context
2 - pt speech is UNINTELLIGIBLE or INCOMPREHENSIBLE
1 - pt is UNRESPONSIVE
NT - NOT TESTABLE if patient is unable to speak due to pre-existing conditions

Question 4

Motor Response

Answer 4

6 - pt is able to OBEY SIMPLE MOTOR COMMANDS
5 - pt LOCALIZES to painful stimuli
4 - pt WITHDRAWS from a painful stimuli
3 - DECORTICATE: pts body flexes to painful stimuli
2 - DECEREBRATE: pts body extends outwards to painful stimuli
1 - NO MOTOR RESPONSE
NT - NOT TESTABLE if or is unable to move due to factors such as previous paralysis or or sedation