Glasgow Coma Scale Flashcards
PPE
Hand sanitiser, disposable gloves, clinical waste bag
Indications
Any patient requiring a physiological
assessment
Patients with illnesses that may
rapidly affect the patient’s level of
consciousness (LOC)
Contraindications
Patient who need immediate
correction of an airway, breathing or
circulation problem, use AVPU scale
instead.
Prepare patient
Patient positioned for airway
patency, comfort, and safety.
Check for factors that will interfere
with communication or ability
to respond.
Speech, hearing, language
difficulty, pain, injuries,
distractions, can lead to an
inaccurate result.
Assess both sides for best results of each.
Assess eye response
Observe for spontaneous purposeful eye opening.
Eyes open
Scores 4
If eyes are not open, ask the patient
loudly and clearly to open
them. Eyes open.
Score 3
If no response to verbal request,
elicit pain response by applying
central pressure. Eyes open
Score 2.
If the eyes do not open
Score 1
Assess verbal response
Assess orientation to person, time
and place by asking, ‘What
is your name?’, ‘What time/day is it
today’? and ‘Do you know
where you are now?’.
Oriented verbal response
Scores 5
If the patient answers these
questions but provides incorrect
answer(s), they are confused
Scores 4
Random or muddled speech
unrelated to questioning is
inappropriate
Scores 3
Intentional orally formed sounds
that are not clear as words or
are incomprehensible
Scores 2
No verbal reaction
Scores 1