Glasgow Coma Scale Assessment Nursing NCLEX Mnemonic

Summary

In this video, Sarah, a registered nurse, explains the Glasgow Coma Scale (GCS), a critical tool used to assess a patient's level of consciousness, particularly after traumatic brain injuries. The scale evaluates three key responses: eye opening, verbal response, and motor response, each with specific scoring. Scores range from 3 (deep coma) to 15 (fully alert). Sarah covers how to test these responses, the significance of each score, and factors like sedation or paralysis that can influence results. The video emphasizes the importance of accurate assessment and documentation for effective patient care.

Takeaways

• 😀 The Glasgow Coma Scale (GCS) is used to assess a patient's level of consciousness and brain function, especially in cases of traumatic brain injury.
• 😀 GCS is scored from 3 to 15, with 15 indicating full alertness and 3 indicating a deep coma or severe brain injury.
• 😀 The GCS is based on three categories: Eye opening response (E), Verbal response (V), and Motor response (M).
• 😀 A baseline GCS score should be established for each patient, and frequent reassessments are necessary to track changes in consciousness.
• 😀 A GCS score of 8 or less generally indicates a coma and may require intubation to secure the airway.
• 😀 GCS scores can be grouped into mild (13-15), moderate (9-12), and severe (3-8) brain injuries.
• 😀 The scoring for each category is: Eye response (1-4), Verbal response (1-5), and Motor response (1-6).
• 😀 A GCS score may be reported alongside 'NT' (Not Testable) if certain responses cannot be assessed, such as in intubated patients.
• 😀 Painful stimuli can be used to assess motor responses, with central stimuli (e.g., trapezius squeeze) and peripheral stimuli (e.g., nail bed pressure) being common methods.
• 😀 It is important to account for factors that could affect the GCS, such as paralysis, sedation, or facial injuries, which may alter the patient's ability to respond.

Q & A

What is the Glasgow Coma Scale (GCS) used for?

The GCS is used to assess a patient's level of consciousness and brain function, particularly in patients who have experienced traumatic brain injuries or other conditions affecting brain activity.

What does a GCS score of 15 indicate?

A GCS score of 15 indicates that the patient is fully alert, responsive, and conscious, showing no significant neurological impairment.

What is the significance of the GCS score when it is 8 or less?

A GCS score of 8 or less suggests that the patient is in a coma and may require intubation due to impaired airway reflexes.

What are the three categories assessed by the Glasgow Coma Scale?

The three categories assessed by the GCS are eye opening response, verbal response, and motor response.

What is the highest score a patient can achieve for eye opening response?

The highest score for eye opening response is 4 points, which is given if the patient opens their eyes spontaneously.

How is a verbal response scored in the GCS?

The verbal response is scored from 1 to 5, where 5 indicates the patient is oriented and correctly answers questions, and 1 means there is no verbal response.

How is motor response evaluated in the GCS?

Motor response is scored from 1 to 6. The highest score (6) is given if the patient can obey commands, while the lowest score (1) is given if there is no motor response.

What does a GCS score of 3 represent?

A GCS score of 3 represents the lowest level of consciousness, indicating deep coma, often associated with a severe head injury, and a high risk of death.

Why might a patient's verbal response be scored as 'not testable' (NT)?

A patient's verbal response might be scored as 'NT' if they are intubated or have other conditions (e.g., paralysis or sedation) that prevent verbal communication.

What does a score of 2 in the motor response category signify?

A score of 2 in the motor response category signifies that the patient exhibits extension (decerebrate posturing), which indicates severe brainstem injury.