The childs glasgow coma scale has evolved from adaptations to jennett and teasdales glasgow coma scale 1, by james and trauner 2, eyre and sharples and by tatman, warren and whitehouse 3, and paediatric nurse colleagues, kirkham and the british paediatric neurology association gcs audit group. Glasgow coma scale gcs the fundamentals for nurses dr ravi dadlani consultant neurosurgeon 05th october 2015 2. Background the gcs was developed at the university of glasgows institute of neurological sciences. Oct 15, 2015 gcs the fundamentals for nurses and nursing students 1.
It is most often used when a person has a traumatic brain injury tbi. Pdf glasgow coma scale gcs was introduced in 1974 as a tool to standardize the assessment of the level of consciousness of patients. The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of a human being and transmit signals between different parts of its body. The glasgow coma scales rainbow rehabilitation centers. Do it this way rate for factors interfering with communication, ability to respond and other injuries eye opening, content of speech and movements of right and left sides sound. The glasgow coma scale describes the best responses of the patient in terms of eye opening, motor response, and verbal response. The aim of this study was to assess the knowledge of ghanaian nurses about the glasgow coma scale and identify factors. During this time, the tool has been scrutinised, evaluated, challenged and re. The glasgow coma scale gcs is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury.
Nger tip, trapezius or supraorbital notch assign according to highest response observed. The final gcs score or grade is the sum of these numbers. Nursing students understanding of the glasgow coma scale. Jan 12, 2016 glasgow coma scale gcs, developed by taesdale and jennet in 1974 at the university of glasgow, scotland, uk, is employed worldwide to identify neurologic dysfunction and followup progress of level of consciousness, predict prognosis, and standardize communication among health professionals. It is numerical rating system, originally used for measuring conscious state following traumatic brain injury, which has become a widely used and recognised. The glasgow coma scale, which can identify changes to consciousness in traumatic brain injury patients, is a tool that requires nurses to fully understand its purpose and how to use it. Background in 1974 sir graham teasdale 1940 bryan jennett 19262008 neurosurgeons in glasgow 3.
Comparison of field and admission assessment marek majdan, ewout w. First described in 1974, this renowned scale provides an assessment of coma and impaired consciousness. It is used because it is simple, has a relatively high degree of reliability and correlates well with outcomes following severe brain injury. Gcs the fundamentals for nurses and nursing students. One level i and 3 level ii trauma centers in our health care system perceived a deficiency in the documentation of the gcs. The lowest score is 3, and the highest score is 15. Glasgow coma scale gcs how to assess gcs geeky medics. Glasgow coma scale gcs, developed by taesdale and jennet in 1974 at the university of glasgow, scotland, uk, is employed worldwide to identify neurologic dysfunction and followup progress of level of consciousness, predict prognosis, and. Apr 08, 20 a students guide to understanding how to utilize the glasgow coma scale as a useful assessment tool. Gcs of less than 8 indicated severe brain injury and generally these patients are comatose.
Glasgow coma scale over time 0 download 11 pages 2,550 words add in library click this icon and make it bookmark in your library to refer it later. The glasgow coma scale is an objective way to assesses a patients level of consciousness. Zuercher m et al 2009 the use of glasgow coma scale in injury assessment. The glasgow coma scale gcs is used to assess level of consciousness in a wide variety of clinical settings, particularly for patients with head injuries nice, 2007. The glasgow coma scale gcs for first aiders glasgow coma scale full template. A patients glasgow coma score gcs should be documented on a coma scale chart. It is the dedication of healthcare workers that will lead us through this crisis. Neurological assessment using the glasgow coma scale will be performed by registered nurses accurately and as required by the patients condition. The adult neurological observation chart has been designed as a standardised assessment tool. Teasdale was professor and head of the department of neurosurgery, university of glasgow 1981 to 2003.
Bachelor of paramedic science clinical skill information sheet objective rationale action manage safety safety is the first priority in managing any patient. Medical and nursing staff will perform neurological assessment utilising the gcs accurately and reliably. These dictionaries are the result of the work of many authors who worked very hard and finally skals their product free of charge on the internet thus making it easier to all of us to communicate with each other. Introduction the glasgow coma scale gcs was introduced in 1974, and revised in 1977, by graham teasdale and bryan jennett, from the university of glasgow, scot land. The glasgow coma scale is based on a 15point scale for estimating and categorizing the outcomes of brain injury on the basis of overall. The glasgow coma scale gcs is a required data element in the illinois trauma registry. An audit was performed and insufficient documentation was confirmed. The glasgow coma scale provides a practical method for assessment of impairment of conscious level in response to defined stimuli. The glasgow coma scale gcs is a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment. Assessment of nurses knowledge about glasgow coma scale. Glasgow coma scale eye opening response spontaneousopen with blinking at baseline 4 points to verbal stimuli, command, speech 3 points.
The glasgow coma scales the glasgow coma scale gcs is the most widely used scoring system used in quantifying the level of consciousness following traumatic brain injury. Knowledge of the glasgow coma scale among nurses in a. Knowledge of the glasgow coma scale gcs is recognized as an asset to all clinical nurses. The glasgow coma scale gcs is a tool that healthcare providers use to measure a persons level of consciousness. Glasgow coma scale centers for disease control and. It is commonly used in the context of head trauma, but it is also useful in a wide variety of other nontrauma related settings. Feb 15, 2015 stroke nursing cva cerebrovascular accident ischemic hemorrhagic symptoms treatment tpa duration. However, many studies in different countries have reported low levels of knowledge of the gcs among nurses. Gcs poster 11x17 nursing school notes nursing notes glasgow. This article addresses the variations in technique that have developed since the scale was published. While the 15point scale is the predominant one in use, this is in fact a modification and is more correctly referred to as the modified glasgow coma scale. The scale assesses a patients best eye, verbal, and motor responsiveness. The glasgow coma scalescore gcs estimates coma severity based on eye 4, verbal 5, and motor 6 criteria. Glasgow coma scale fundamentals of nursing paramedic school.
Critical thinking used with the skill and knowledge in assessing the gcs is the foundation of all nursing practice. May 24, 2016 the glasgow coma scale has permeated and influenced practice for over 40 years, being well. An explorative survey using a semistructured questionnaire was used. Adult and pediatric adult glasgow pediatric glasgow eye opening 4 eye opening 4 spontaneous 4 spontaneous 4 to speech 3 to speech 3 to pain 2 to pain 2 none 1 none 1 best motor response 6 best motor response 6 obeys commands 6 spontaneous movement 6 localizes pain 5 withdraws to touch 5. Assessing nurses knowledge of glasgow coma scale in. Assessment of nurses knowledge about glasgow coma scale at a. However mistakes are made consistently by inexperienced users of up to. Pdf simplifying glasgow coma scale use for nurses full template. Glasgow coma scale explained rhea mehta, gp trainee1, krishna chinthapalli, consultant neurologist2 1east surrey hospital, redhill, uk. A new word each day native speaker examples quick vocabulary challenges.
Results of the assessment are used to guide initial decision making about treatment and monitor trends in patient responsiveness. The glasgow coma scale is a standardized system used to assess the degree of brain impairment and to identify the seriousness of injury in relation to outcome. Waterhouse c 2009 the use of painful stimulus in relation to glasgow coma scale observations. Neurological assessment part 3 glasgow coma scale nursing. The glasgow coma scale is a tool to help the physician quickly neurologically assess a patient whether it is for serial neurological exams or in classifying.
Glasgow coma scale eye opening response spontaneousopen with blinking at baseline 4 points to verbal stimuli, command, speech 3 points to pain only not applied to face 2 points no response 1 point verbal response oriented 5 points confused conversation, but able to answer questions 4 points inappropriate words 3. Glasgow coma scale motor score and pupillary reaction to predict sixmonth mortality in patients with traumatic brain injury. The glasgow coma scale is an objective method of evaluating a trauma patients neurologic status. Glasgow coma scale eye opening response spontaneousopen with blinking at baseline 4 points to verbal stimuli, command, speech 3 points to pain only not applied to face 2 points no response 1 point verbal response.
Always wear gloves and goggles when attending to a patient. An educational plan was developed and implemented to improve. The glasgow coma scale will incorporate assessment of limb strength and pupillary response to light stimulation. The glasgow coma scale gcs is a tool used to assess and calculate a patients level of consciousness. Table 1 glasgow coma scale components of the gcs and how each section is scored individually adapted from. Gcs the fundamentals for nurses and nursing students 1. A students guide to understanding how to utilize the glasgow coma scale as a useful assessment tool. Steyerberg, daan nieboer, walter mauritz, martin rusnak, hester f. The summation of the individual scores for each of these parameters results in the glasgow coma score gcs.
Z, 3 the tool was designed as a clinical scale for assessing the depth and duration of impaired con sciousness and coma. A glasgow coma scale gcs assessment should be conducted on every patient. A car accident, fall, or being hit on the head with a hard object can cause a tbi. Oct 19, 2017 the glasgow coma scale, which can identify changes to consciousness in traumatic brain injury patients, is a tool that requires nurses to fully understand its purpose and how to use it. Clinicians use this scale to rate the best eye opening response, the best verbal response, and the best motor response an individual makes. The glasgow coma scale gcs is an international tool used to measure the level of consciousness for traumatically injured patients. Assessing nurses knowledge of glasgow coma scale in emergency. Since the glasgow coma scale was developed 40 years ago it has been accepted throughout the world as a method for assessing impaired consciousness. Assessment of level of consciousness using the glasgow coma scale gcs is a tool requiring knowledge that is important in detecting early deterioration in a patients level of consciousness. This article addresses the variations in technique that have. Basically, it is used to help gauge the severity of an acute brain injury. Sep 03, 2014 glasgow coma scale the glasgow coma scale gcs was developed to assess the level of neurologic injury, and includes assessments of movement, speech, and eye opening this avoids the need to make arbitrary distinctions between consciousness and different levels of coma brain injury is often classified as severe gcs. The original scale was a 14point scale, omitting the category of abnormal flexion. Glasgow coma and glasgow outcome scales for brain injury.
The glasgow coma scale is an integral part of clinical practice and research across the world. The chart has been developed to reduce the amount of variation in chart design and to improve consistency in assessment skills and interpretation of assessment. Identifying the patients that require scoring is the first step in properly using the scale. Glasgow coma scale an overview sciencedirect topics. Trauma nurse coordinators from 1 level i and 3 level ii trauma centers noted that the gcs was unable to be reported in the registry because of the lack of documentation of the numeric values. Simple bedside assessment of level of consciousness. It was developed more than 40 years ago by two neurosurgeons in glasgow and is widely applied today. This article addresses the gap between the literature and practice in relation to the use of the glasgow coma scale gcs. To explore third year nursing students understanding of the glasgow coma scale gcs. Stroke nursing cva cerebrovascular accident ischemic hemorrhagic symptoms treatment tpa duration. Coma levels are commonly assessed by two different scales. It will explore level of consciousness and the gcs.
Goldhill2 1 research registrar, 2 senior lecturer and honorary consultant in anaesthesia and critical care medicine, department. The instigation of both central and peripheral painful stimuli is analyzed in an effort to prevent ritualistic practice. The glasgow coma scale has permeated and influenced practice for over 40 years, being well. Waterhouse c 2005 the glasgow coma scale and other neurological observations. This study aims to explore the knowledge and competence in assessing the gcs among. Policy statement neurological assessment using the glasgow coma scale will be performed by registered nurses accurately and as required by the patients condition.