- The Glasgow Coma Scale (GCS) aims to determine the state of a person's consciousness for initial and subsequent assessment using a numerical total (a score out of 15, the lowest available score (3) indicating a person is completely unresponsive).
- The Glasgow Coma Scale allows you to apply numerical scores to patient responses in three separate areas. These are:
- Eye opening (a score out of 4)
- Verbal response (a score out of 5)
- Motor response (a score out of 6)
- Note: It is important to use the best motor response in calculating the score.
- When assessing the motor response to pain we are looking to see whether the patient has a coordinated motor response to commands i.e. squeeze my hands, performs a basic localised movement or simply flexes or extends limbs and/ or spine in response to painful stimuli.
| 1. Eye Opening: | |||
|---|---|---|---|
| Score | Adult Response | Child <2 years Response | |
| 4 | Spontaneous | Spontaneous | |
| 3 | To Voice | To Voice | |
| 2 | To Pain | To Pain | |
| 1 | None | None | |
| 2. Best Verbal Response: | |||
| Score | Adult Response | Child <2 years Response | |
| 5 | Oriented | Smiles, listens, follows | |
| 4 | Confused | Cries, consolable | |
| 3 | Inappropriate words | Inappropriate persistent cry | |
| 2 | Incomprehensible words | Agitated, restless | |
| 1 | None | No response | |
| 3. Best Motor Response: | |||
| Score | Adult Response | Child <2 years Response | |
| 6 | Obeys commands | Obeys commands | |
| 5 | Purposeful movement | Purposeful movement | |
| 4 | Withdraws from pain | Withdraws from pain | |
| 3 | Flexion to pain | Flexion to pain | |
| 2 | Extension to pain | Extension to pain | |
| 1 | None | None | |
Calculate the sum of the score from 1 (Eye Opening), 2 (Best Verbal Response) and 3 (Best Motor Response). This number will give you a Glasgow Coma Score out of 15.
For example (adult patient):
- Eye Opening: To Voice (3)
- Best Verbal Response: Confused (4)
- Best Motor Response: Obeys commands (6)
- GCS = 3 + 4 + 6 = 13 out of 15.
- Record this on your ePCR as GCS 13/15 (E3, V4, M6)
Note: Painful stimuli refers to firm squeeze of trapezius muscle, must be adequate for task, but not excessive.
| Settings | |
|---|---|
| Extended Care: | |
| Colour assist: | |
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