MED/SURG: TRAUMA: DISABILITY Flashcards
Assessment: Mental Status
AVPU
Abbreviation and mnemonic for** prehospital assessment of mental status**.
Refers to assessments:
**alert; **
responsive to** verbal **stimuli;
responsive to painful stimuli;
unresponsive.
Assess LOC
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the ___1___ in a person following a ___2___. Basically, it is used to help gauge the ___3___.
The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. Basically, it is used to **help gauge the severity of an acute brain injury. **
Best Eye Response. (4)
No eye opening.
Eye opening to pain.
Eye opening to verbal command.
Eyes open spontaneously.
Best Verbal Response. (5)
No verbal response
Incomprehensible sounds.
Inappropriate words.
Confused
Orientated
Best Motor Response. (6)
No motor response.
Extension to pain.
Flexion to pain.
Withdrawal from pain.
Localising pain.
Obeys Commands.
Note that the phrase ‘GCS of 11’ is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.
A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.
Glasgow Coma Scale
In each component of the GCS the ‘Best Response’ is,
In each component of the GCS the ‘Best Response’ is,
The best response is that which is normal for that component:
spontaneous for eyes,
orientated for verbal
obey commands for motor.
Glasgow Coma Scale
When assessing a patient, you should:
The sequence in assessment is: C, O, S
Check, Observe, Stimulate
Glasgow Coma Scale
When assessing a patient, what is the reason for the CHECK step in the assessment?
Before making observations you should check to identify factors that may interfere with the assessment.
GCS
Q: You are called to see a patient who has fallen through a plate glass door. As you approach the patient you observe that their eyes are extremely swollen and they are unable to open them. How would you record the eye component of the scale?
If some local physical factor precludes the patient being able to make a response, that component of the scale is not testable (NT).
GCS
Q: You are assessing the motor component of a patient’s GCS. They are unable to obey commands but bend their elbow when their finger nail bed is stimulated. What do you do next?
If a patient bends their elbow when the finger is stimulated, the next step in assessing the motor response is to test if they can localise to a trapezius pinch.
GCS
P = responds to painful stimulus.
Central stimuli (4)
Peripheral stimuli (3)
Central stimuli
Trapezius pinch: pinch between the neck and shoulder.
Supraorbital pressure: press up on the upper ridge of the eye socket.
Sternal rub: rub the center of the sternum with knuckles.
Armpit pinch: pinch the margin of the armpit.
Peripheral stimuli
Nail bed pressure.
Pinch the thumb-index finger web.
Pinch the finger, toe, hand, or foot.
Normal flexion, where a patients elbow bends and their arm moves rapidly away from their body and from a stimulus, is given what number in the Glasgow Coma Scale?
Normal flexion, where a patients elbow bends and their arm moves rapidly away from their body and from a stimulus, is given what number in the Glasgow Coma Scale?
MOTOR 4
GCS
Q: In which of these scenarios of assessment of the motor component of the Glasgow Coma Scale is the best response on the patient’s right-hand side?
http://www.glasgowcomascale.org/self-test/
A: R arm localises, L arm flexing
