What is the nurses responsibility when assessing a patient and using the GCS? -
CORRECT ANSWER-To elicit the best response on each of the scales: the higher the
scores, the higher the level of brain functioning. The sub-scale scores are particularly
important if a patient is untestable in one area. For example, severe peri-orbital edema
may make eye opening impossible.
What are the highest and lowest scores of the GCS? - CORRECT ANSWER-Highest
GCS score is 15 for a fully alert person, and the lowest possible score is 3.
A GCS score of 8 or less generally indicates what? - CORRECT ANSWER-Coma.
How can plotting the results of the GCS scores on a graph help in your assessment? -
CORRECT ANSWER-This can be used to determine whether the patient is stable,
improving, or deteriorating.
What is the Glasgow Coma Scale? - CORRECT ANSWER-Quick, practical, and
standardized system for assessing the LOC. Specific assessments evaluate the
patient's response to varying degrees of stimulus.
What are the three areas assessed in the GCS? - CORRECT ANSWER-Patient's ability
to (1) speak, (2) obey commands, and (3) open the eyes when a verbal or painful
stimulus is applied.
What are the three indicators of response evaluated in the Glasgow Coma Scale? -
CORRECT ANSWER-(1) opening of the eyes, (2) the best verbal response, and (3) the
best motor response (Table 57-5).
The GCS offers several advantages in the assessment of the unconscious patient. -
CORRECT ANSWER-It allows different health care professionals to arrive at the same
conclusion regarding the patient's status and can be used to discriminate between
different or changing states.
What is the gold standard for assessing a patients LOC? - CORRECT ANSWER-GCS;
other scales are also used in the clinical setting. In cases of stroke or hemorrhage
associated with increased ICP, use the NIH Stroke Scale (Table 58-9). Other
components of the neurologic assessment include cranial nerve assessment and motor
and sensory testing.