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FIGURE 1
How to use the Glasgow Coma Scale
Eye opening:
If the patient is unable to open his or her eye(s) as a result of trauma or surgery, the letter 'C - indicating closed - should be recorded in
the first box. Otherwise this section should be completed as follows:
Tlie score indicates the 4 = Spontaneously The patient's eyes should open spontaneously as you approach. If the patient
patient's state of arousal is asieep, wake the patient, ensuring he or she is fully roused and then
complete the assessment
3 = To speech Tlie patient will respond to your voice. T)ie best way to do this is to say his
or her name. If there is no initial response, a raised voice should be used.
2 = To pain The patient opens his or her eyes to painful stimuli. Ttie best way to do this is
to apply peripheral painful stimuli. Avoid central painful stimuli as it may
cause the patient to grimace.
This indicates the patient's 5 = Orientated The patient must be able to state his or her name, who he or she is, where
orientation to time, place he or she is and the month of the year.
and person
4 = Confused If the patient is able to hold a conversation but unable to answer the
questions above correctly he or she should be considered to be confused.
Correct wrongly answered questions, but change the order each time to avoid
the patient just repeating them.
3 = Inappropriate words The patient will use random vi/ords that make little sense or are out of
context, typically swearing and shouting. Painful stimuli may be required to
gain a response.
2 = Incomprehensible Tlie patient will only respond with moaning and groaning. Painful stimuli may
soLinds be required to gain a response.
Thisindicates brain 6 = Obeys commands Ask the patient to perform a couple of different movements such as sticking
function out his or her tongue or lifting his or her arm.
5 = Localises to pain Apply a central painful stimulus using one of the recommended methods
(Table 2), The patient should purposefully move the arm towards the site of
pain to remove the cause of pain.
4 = Withdraws from pain The patient will flex his or her arms in response to pain but will not move
towards the source of pain.
3 = Flexion to pain Tiie patient will flex his or her arms in response to pain but the wrist will also
rotate and the thumb may also flex and move across the fingers.
2 = Extension to pain Arms will straighten and the shoulder will rotate inwards when a painful stimulus
is applied. Tlie legs may also straighten with toes pointing downwards.
Both eyes should constrict when a light is shone into one Accountability
eye. This is called consensual reaction.
Nurses are accountable and responsible for
These reactions are recorded as {+) for reaction, (si) for
a sluggish reaction and (-) for no reaction.
providing optimum care for patients.
Tbe Nursing and Midwifery Council's (NMC)
(Adapted from Woodward i997b) Code of Conduct provides the main source of
Normal power Ttie patient will be able to push against To determine whether the patient has normal power, mild
resistance with no difficulty. or severe weakness. Each limb is assessed and recorded
separately.
Miid weakness The patient will be able to push against Arms - while holding the wrist ask tbe patient to pull you
resistance but will be easily overcome. towards him or her and then push you away.
Severe weakness The patient will be able to move his or her limbs Legs - holding the top of the ankle ask the patient to lift his
independently but wil) be unable to move against or her leg off the bed then holding the back of the ankle ask
resistance. the patient to pull the ieg towards him or her.
Spastic flexion The patient's limbs will flex in response to painful To determine a response of spastic flexion or extension apply
stimuli. Arms, vt^rists and possibly the thumb central painful stimuli. If no response is elicited use peripheral
will bend inwards. Legs will pull upwards. painful stimulus.
is important in situations where patients may not Record only what you see.
be able to communicate their medical history. Listen to family members and friends.
Report any changes in ttie patient's condition.
Accountability also involves being up to date Do not be influenced by previous observations.
with new developments, best practice and Do not use nail-bed pressure or sternal rubs.
ensuring consistency. Nurses should be fully
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