NCM 118 SL
College of Nursing
GLASGOW COMA SCALE
(GCS)
GLASGOW COMA SCALE (GCS)
• An international method of grading neurological responses of the injured
or severely ill patient.
• Assess 3 parameters of consciousness:
E-eye opening response
V-verbal response
M-motor response
EXAMPLE (E4,V5,M6) 15
GCS= 15 highest score for responsiveness.
GCS=3 is the lowest score
Test Score Patient’s
response
Eye opening
4 Open eyes
Spontaneous spontaneously
To speech 3 Open eyes
when told to
To pain 2 Open eyes only
in painful
stimulus
None 1 Doesn’t open
eyes in
response to
Two types of painful/pressure
stimuli
1) Central stimuli:
Pressure or pain is applied to the center of the body
(hence its core) to create pain. This tests the brain’s
response to it.
a. trapezius squeeze
b. supraorbital pressure
a. Trapezius squeeze
•Used first.
•use the index finger and
thumb and squeeze 1 ½ to 2
inches of this trapezius muscle.
•Start with slight pressure and
then increase the pressure for
up to 10 seconds… note the
patient’s motor movement
b. Supraorbital pressure
•Find the notch under the
inner part of the eyebrow.
•Apply pressure to this notch
with the thumb and gradually
increase pressure for up to 10
seconds…. note patient’s
motor movement
2) Peripheral stimuli:
•Pressure or pain is applied to a
peripheral extremity like the
fingernail bed to create pain.
This tests the spinal cords
response to pain.
•Use an object like a pen light or
pen to gradually increase
pressure on the nail bed for up
to 10 seconds. Note the eye-
opening response.
Test Score Patient’s
response
Verbal response
Oriented 5 Tell current
date
Confused 4 Tell incorrect
year
Inappropriate 3 Replies
words randomly with
incorrect word
Incomprehens 2 Moan or
ive screams
None 1 No response
• Patients who are intubated are
unable to speak, and their verbal
score cannot be assessed.
• They are evaluated only based
on eye opening and motor
scores, and the suffix “T” (ex:
E1,VT,M2)is added to their score
to indicate intubation.
• In intubated patients, the
maximum GCS score is 10T and
the minimum score is 2T.
Test Score Patient’s response
Motor response
Obeys 6 Shows two fingers when asked
Localize 5 Reaches toward painful
stimulus and tries to remove it
Withdraws 4 Moves away from painful
stimulus
Abnormal 3 Assumes a decorticate posture
flexion
Abnormal 2 Assumes a decebrate posture
extension
None 1 No response, just lies flaccid –
an ominous sign
Motor response: Localize (5
Points)
•When stimuli is applied (example:
trapezius squeeze) the patient
bends the elbow (elbow flexion)
and moves the arm and hand up
above the collar bone trying to
remove the pain/pressure.
•With this movement the patient is
trying to LOCATE (hence localizes)
the pressure/pain.
Motor response: Withdraws (4 Points)
•When stimuli is applied (example: trapezius squeeze) the patient flexes hence bends
the elbow (elbow flexion) but quickly withdraws it.
•The hand and arm never make it up to the stimuli or up to the collar bone (so the
patient doesn’t locate the pain but withdraws from it).
ABNORMAL FINDINGS
• Client with lesions of the corticospinal
tract draws hands up to chest
(decorticate or abnormal flexor
posture) when stimulated.
• Client with lesions of the diencephalon,
midbrain, or pons extends arms and
legs, arches neck, and rotates hands
and arms internally (decerebrate or
abnormal extensor posture) when
stimulated.
Abnormalities:
GCS 14- spontaneous but may be inapropriate
-reflexes are intact & pupil response is normal
GCS 13-14= requires stimulus to respond
-reflexes intact; pupil response normal to unequal.
GCS 12-13= requires vigorous, continous stimuli to respond; reflexes intact; pupil
response normal, unequal or sluggish
GCS 8-10= responds to pain; no cognitive response; reflexes abnormal; normal pupil
response
GCS 6= awake & aware; responds w/eyes only; normal pupil response
GCS 3-6= abnormal response to pain or varied response to pain; reflexes abnormal or
absent; dilated or pinpoint
GCS 3=
no response; reflexes abnormal & absent; dilated pinpoint
1
You’re assessing a patient's Glasgow Coma Scale
at the bedside. What is the patient’s score based
on these findings: when you arrive to the
patient’s bedside the patient is looking around,
the patient tells you they are at a concert hall and
the year is 1960 (it is 2023) but they state their
correct name, and they are open to successfully
open their mouth and stick out their tongue.
ANSWER:
GCS 14 (E4 V4 M6)
2
When you arrive to the patient’s bedside the
patient’s eyes are closed, but they open when
you speak to the patient, the patient doesn’t
respond appropriately to questions asked and
says words that don’t make sense. In addition,
the patient can’t obey a motor command.
Therefore, when you apply a central stimulus the
patient moves to locate and remove the stimulus.
ANSWER:
GCS 11 (E3 V3 M5)
3
When you arrive to the patient’s bedside the
patient’s eyes are closed but they open when
you speak to the patient. The nurse cannot
assess best verbal response because the patient
is intubated. In addition, the patient can’t obey
a motor command. Therefore, when you apply a
central stimulus the patient flexes to withdraw
from the stimulus.
ANSWER:
GCS 7T (E3 Vt M4)
4
When you arrive to the patient’s bedside the
patient’s eyes are closed and don’t open when
spoken to. The nurse applies a peripheral painful
stimulus, and the patient’s eyes open. When asked
questions the patient groans and moans noises. In
addition, the patient can’t obey a motor command.
Therefore, when you apply a central stimulus the
patient flexes to withdraw from the stimulus.
ANSWER:
GCS 8 (E2 V2 M4)
THANK YOU
FOR
LISTENING!
