While critics might argue that supraorbital ridge pressure could cause the patient to grimace and keep the eyes closed, finger tip pressure could lead to misinterpretation of the eye opening response due to other complicating factors such as hemiparesis and high spinal cord injury. These guidelines recommend that eye opening to pain is assessed by applying supraorbital ridge pressure to stimulate the supraorbital nerve, increasing the pressure until a response is obtained. Eye opening to pain is recorded when a patient opens his eyes to a painful stimulus: finger tip pressure and supraorbital ridge pressure are the two most commonly used methods of applying a painful stimulus. There is no eye opening to loud, clear commands. Eye opening to speech is allocated a score of 3. If there is no spontaneous eye opening, this is recorded when a patient opens his eyes to loud, clear commands. Spontaneous eye opening is allocated a score of 4. This observation is made without any speech or touch. This is recorded when a patient is observed to be awake with eyes open. It is important to exclude the fact that a patient is asleep before proceeding to assess eye opening. Eye opening is then meaningless under these circumstances. If a patient's eyes are closed as a result of swelling or facial fractures this is recorded as ‘C' on the chart. As well as calculating a total GCS - a score for each of the three components must be calculated and recorded as a separate score. A score is applied to each category and totalled to give an overall value ranging from 3 to 15. The Glasgow coma scale is based on three aspects of a patient's behaviour - eye opening, verbal response and motor response ( see Table 1). A deterioration of one point in the ‘Motor Response' or one point in the ‘Verbal Response' or an overall deterioration of two points in the GCS is of clinical significance and must be reported to medical staff. recovery, ICU), a GCS must be assessed by both the nurse escorting the patient and the nurse receiving the patient (at the same time) in order to avoid misinterpretation and facilitate continuity of assessment.Ģ.9 Although the Glasgow coma scale should be communicated using its individual components, a score from 3 to 15 may be used to summarise the scale. Changes in a patient's neurologic function, pupil responses, or the GCS must be recorded in relevant nursing documentation including the date, time, and signature.Ģ.4 As the GCS is an assessment of conscious level, it cannot be determined with accuracy in the patient who is receiving anaesthetic agents neurological assessment then focuses on pupillary responses.Ģ.5 Some drugs may affect pupillary reaction and the effects of any prescribed medication must be considered when assessing the pupils.Ģ.6 A GCS can still be determined in a patient who is sedated although it must be noted that the score obtained might not be an accurate reflection of what the patient is capable of.Ģ.7 Within the neurosurgical intensive care and high dependency units, a GCS must be assessed at verbal handover/beginning of the shift by both nurses (at the same time) in order to avoid misinterpretation and facilitate continuity.Ģ.8 When a patient with an impaired level of consciousness is transferred to another ward/department (e.g. If the motor response is different on each side, the better response is incorporate within the Glasgow coma scale.Ģ.3 Responses must be recorded on the relevant observation chart in black ink. Spinal reflexes may cause the arms/legs to flex briskly in response to pain and must not be interpreted as a response.Ģ.2 Always record the best arm response. The following are important points to note when assessing a patient's level of consciousness using the Glasgow coma scale and calculating a Glasgow coma score (GCS).Ģ.1 The arms give a wider range of responses and for this reason are always observed using the Glasgow coma scale. Recommendations for assessing eye opening, verbal response and motor response are specified. The guidelines focus on the practical aspects of carrying out and interpreting the Glasgow coma scale and pupil responses. It is the method favoured by The Leeds Teaching Hospitals NHS Trust and these guidelines have been developed to standardise practice so that the Glasgow coma scale and pupil responses can be assessed in a consistent manner to minimise misinterpretation. The Glasgow coma scale developed by Teasdale and Jennett (1974) is the most widely used assessment tool to measure a patient's level of consciousness. Introduction and BackgroundĪssessment of conscious level is an essential component of neurological examination and is usually performed together with assessment of pupillary size and reaction, vital signs, and focal neurological signs in the limbs. Guidelines for Assessing the Glasgow Coma Scale and Pupil Responses in Adultsĥ.
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