This tool was created in 1974 as a way to communicate a patient’s LOC (level of consciousness) after an acute brain injury. In 1980 it was promoted to help assess all patient’s after an injury. It is now used in 80 countries worldwide and has become a gold standard.
As you study the chart above you will notice the chart is easily divided into 3 steps/assessments.
- 1st step: Patient’s visual or eye response
- Score your patient a 4 if he/she can open their eyes spontaneously
- Score your patient a 3 if they open their eyes to verbal speech “Mr. X”or light touch
- Score your patient a 2 if your patient requires painful stimuli to open their eyes
- Score your patient a 1 if their eyes do not open. Patient is unresponsive.
- 2nd step:Patient’s verbal response (if intubated or tracheotomy score NT=not testable)
- Score your patient a 5 if patient is oriented x 3 (He or she knows who they are, where they are, and what the date is)
- Score your patient a 4 if you not they are having some confusion or forgetfulness (unable to answer all orientation questions)
- Score your patient a 3 if they are not understood and using inappropriate words (i.e. swearing, unrelated words, aggressive)
- Score your patient a 2 if they are not able to form words and just can make sounds
- Score your patient a 1 if they are unresponsive and make no noises
- 3rd step: Patient’s motor response
- Score your patient a 6 if able to follow all commands in moving extremities
- Score your patient a 5 if moves extremities to localized pain
- Score your patient a 4 if extremely flexs to pain
- Score your patient a 3 if patient is in decorticate position
- Score your patient a 2 if patient is in decerebrate position
- Score your patient a 1 if patient has no movements
To score your patient the range will be from 3 to 15. The higher the score the better. Anyone with a score under 8 is said to be comatose. I have also come across the saying “Under 8 intubate”
How often should you observe a patient’s GCS: the glaucoma coma scale states on a half hour basis until score is 15. If 15 then every 30 mins for 2 hours, then 1 hour for next 4 hours, then every 2 hours. Should the score deteriorate observations should go back to every 30 mins. BUT ALWAYS FOLLOW YOUR HOSPITAL/FACILITY POLICY!
ALSO PLEASE REMEMBER:
GCSis different for children!
|Eye Opening||Verbal Response||Best Motor Response|
|Spontaneous||Talks normally||Obeys commands|
|To sound||Words||Localises pain|
|To pain||Vocal sounds||Flexion to pain|
|None||Cries||Extension to pain|
|6 months||Vocal sounds||10|