Glasgow Coma Scale Assessment Nursing NCLEX Mnemonic

hey everyone it's sarah register nurse rn.com in this video i'm going to be talking about the glasgow coma scale and as always whenever you get done watching this youtube video you can access the free quiz that will test you on this content so let's get started the glasgow coma scale is used to assess a patient's level of consciousness and level of consciousness is how alert and responsive a patient is to their environment and the stimuli around them so in order to be alert and responsive to your environment with all of its stimuli you have to have really good brain functioning therefore this tool is really helpful in evaluating patients who've experienced traumatic brain injuries or other conditions where brain functioning and consciousness is altered so we can use this tool to calculate a specific score so in practice you may hear someone say their patient has a gcs of 7 or a gcs of 10 whenever they say this they are referring to the glasgow coma scale that is where those letters gcs come from now when assessing the gcs you want to make sure that you get a baseline score on your patient you want to know where they started at and then throughout your shift make sure you are often reassessing the gcs per your facilities protocol because we want to be able to look at their score and say okay they're improving they're not really changing or they're deteriorating because level of consciousness tells us so much about our patient any changes in level of consciousness could be a warning sign that something is going on with our patient and we need to investigate it so this tool assesses three responses by the patient to a type of stimuli and those three responses include eye opening response verbal response and motor response so to help test the patient for their best response in these areas you may have to use some type of stimuli and this stimuli can be as simple as a verbal stimulus to the patient to a little bit more of an involved one where you have to touch the patient and deliver a painful or pressure stimulus now let me talk a little bit about the pressure painful stimuli there are two types that you can do to a patient to get a response one type is called a central stimuli and the other one is a peripheral stimuli a central stimuli is when pressure is applied to the center of the body or its core to create pain and this tests the brain's response to that pressure slash pain so there's a few ways you can do this one way that's typically used first is through the trapezius squeeze and you use your index finger and your thumb and squeeze about one and a half to two inches of the trapezius muscle and as you do this you will start out and increase the intensity or pressure on that muscle for up to 10 seconds and then know how the patient responds if no response is noted then you could move to supraorbital pressure and this is found around the eyes if you go to the eyebrow and go to the inner part and you just feel with your thumb you can feel a notch and here you will gradually apply pressure for up to 10 seconds to that notch and note the patient's response now it's important to know before you use these pressure techniques to achieve a response in your patient that your patient doesn't have some type of injury so for instance if your patient has some facial fractures especially around the eyes you would want to avoid using the supraorbital pressure technique because this could cause further damage now another type of central stimuli that can be used is called the sternal rub however it's really not recommended to use this anymore because it can cause bruising in patients the next type is called peripheral stimuli and this is where pressure is applied to a peripheral extremity for instance like the fingernail bed and this creates pain and this will actually help test the spinal cord's response to pain now let's look at the scoring for this scale so a patient can score anywhere between a 3 to a 15. the higher the score the better so they can't score any less than a 3 and no higher than a 15. so if a patient gets a 15 that means that they are alert and awake and we are really happy about that if they score an 8 or less that means that they are in a coma and usually require intubation because those airway reflexes that help protect us aren't working too well and then if they score a three this is the lowest score possible there's a high rate of death whenever a patient scores this and they are in a very deep coma usually with a severe head injury now as i pointed out earlier this tool is really good at helping us evaluate patients with a traumatic brain injury so we can look at those scores and we can sort of group them with either mild moderate or severe brain injury so a score of 3 to 8 would mean severe brain injury 9 to 12 would mean moderate brain injury and 13 to 15 would mean mild brain injury so with this scale each of these three response categories has their own points and we will take those points add them up and we get a total gcs so for eye opening response the max amount the patient can get is four points with a minimum of one it's never zero you can't test it it would be nt for not testable verbal response the max is five again the minimum is one there's no zero can't test it put nt and then for motor the max is six minimum is one so remember in this order evm for i verbal motor and then remember four five six four is the max for i five is the max for verbal and six is the max for motor so we add all that up and we get a total gcs now the total gcs is important but also these sub scores that we get from each of the response categories is just as important so remember that whenever it's being reported that you also usually see those sub scores with it so you may see it like gcs of seven so they have an e of two a v of two and an m of three now an important thing to know before you perform this scale assessment is to make sure that your patient doesn't have anything that could affect their ability to respond in any of these three categories for instance let's say your patient is paralyzed well that is going to affect their motor response or if they're intubated it's going to limit their verbal response or if they have any injuries to their face or any other bones or if they have facial swelling it's going to affect their ability to open their eyes along with any type of sedation or if they're hard of hearing or have mental deficits now the reason we want to know this is because one we want to make sure we're getting the best response out of our patient for these categories but we also want to make sure that we're interpreting their gcs score right that we have a good idea about what's going on with our patient because for instance let's say our patient is intubated well they have a tube in their throat we're going to have a lot of difficulty getting a verbal response out of them so with this we wouldn't give them a 1 because we can't test it we don't know if they wouldn't have a response so instead they would have nt not testable but for eye opening for e they got a 2 and for motor m they got a 4. so they have a gcs of 6 but that doesn't give us the whole idea of what's going on with them so it would look like a 6 with a t beside of it telling the person we're reporting this to or who's looking at this that they're intubated so you'd want to take it a step further and look at those sub scores and you would look at the e which was a 2 you would look at the v which doesn't tell you much but it would have a t with it telling you if they're intubated and then an m which would have a four so that would help give you a little bit of a better idea what's going on with the patient and lets us know hey yeah it says six but we weren't really able to test their verbal response because they're intubated and possibly it might be a little bit higher but we don't know at this time so now let's look at this scale in depth so the first thing what you want to assess is the eye opening response so the e again the max amount of points you can get is four with a minimum of one and if you can't test it let's say their eyes are swollen shut or they have some crazy injuries to their eye it'd be not testable to be nt so the patient can get four points if their eyes are open opening spontaneously so let's say you walk into the room and your patient's looking around and their eyes are open they would get four points they would get three points let's say if your patient's eyes are closed but when you walk into the room and they're keeping them closed but you talk to them you introduce yourself so you provide some verbal stimulus and their eyes open that would be three points but let's say walk into the room you do that nothing happens they don't respond to that sound you will want to take it a little further and you would want to apply a pressure stimulus and that's what we talked about the beginning of the lecture so with this we're going to do a peripheral stimulus and with this what you can do is you can take a pen a pen light whatever you have and you're going to take it and you're going to apply it to the nail bed of a finger and if you do this to yourself it's a little uncomfortable so apply that and gradually increase pressure over 10 seconds and see the response their eyes open up to this they get two points now let's say you do all of that nothing happens those eyes are still closed it would be no response and they would get a one next is verbal response so the v with this again you can get a max of five points with a minimum of one and if you can't test it let's say because they're intubated or something like that it would be not testable so the patient would get five points if they're oriented but how do we know they're oriented well you have to ask them a series of questions so you could ask them to state their full name their date of birth the month or the year or where they're located where are they at right now and if they answer all that successfully they're oriented so they get five points they would get four points if they were confused so if they answered any of those questions with something that tells you that oh they don't really know for instance like where they're at they're in the hospital but they say that they're at home or the year is 2022 but they say it's 1978 or if they're not able to say their name they say they're someone else they're confused so we give them four points three points would be whenever you ask them questions they just start saying words that make absolutely no sense to those questions so we would give them three so they're inappropriate word usage two points would be that they just make sounds to those questions so no words it's usually moaning and groaning and so we give them two and then one point whenever we ask them those questions you have no response so it would be one point and finally we have motor response so m with this the patient can get a max of six points with a minimum of one and if you can't test it because let's say they're sedated or paralyzed would be nt for not testable so patient can get six points if they can obey a verbal motor command that you tell them to do so with this it needs to be at least two steps because we really want to make sure that the patient's doing this and it's not really a reflex so what you want to do is you can have the patient like lift up their hands or open their hands tell them to grasp grasp your fingers as hard as they can and then let go or you can have the patient open their mouth and stick out the tongue if they can do this all successfully they're good to go so we give them six points but let's say the patient cannot do this well you got to take it a step further and you have to apply one of those pressure painful stimuli that we talked about earlier and you want to use a central stimuli so first start out with the trapezius squeeze if you get no response move to the supraorbital pressure and see what happens now the patient will get five points if they try to localize this pressure stimulus that you're applying this is because that brain is trying to locate that stimulus and it's trying to remove it so whenever this occurs what you're going to see is that let's say you do the trapezius squeeze the patient's arm is going to bend at the elbow and move the arm and hand up above the collarbone trying to remove that pain now the patient will get four points if they try to withdraw from this pressure stimulus hence we refer to this as normal flexion so the brain is trying to withdraw itself from the painful stimulus instead of trying to locate it and remove it like before so when this stimulus is applied through the trapezius squeeze the patient flexes hence bends the elbow but quickly withdraws it from that stimulus and note there's no rotating of the wrist the hand and arm never make it up to that pressure stimulus or up to that collarbone so it doesn't locate it but it withdraws from it now three points is awarded if you see abnormal flexion and we refer to this as decorticate posturing and i want you to remember the cor the core and decorticate because it's key in helping you remember how this presents so when the stimulus is applied through the trapezius squeeze the patient flexes the elbow gradually and moves the arm to the center hence the core of the body with pronation of the forearm and flexion of the wrist and the hands will turn into fists there won't be the withdrawal from the stimulus like in the previous response and whenever you see this it's not good it means that our cortex is affected and then two points is awarded if you see extension and this is known as the cerebrate posturing and look at the word to cerebrate look at all of those ease there's actually four of them and that can help you remember that this is extension so when the stimulus is applied with this trapezius squeeze the patient will extend the elbow with internal rotation of the arm and this is actually worse posturing of all the types and it's not a good sign it tells us that our brain stem is affected and then the patient will receive one point if you applied this stimulus and there is absolutely no response at all so now let me test your knowledge and see if you could calculate the gcs here our patient is able to open their eyes whenever pressure is applied to the nail bed and whenever i ask some questions they only make sounds to the questions no words and then whenever i test the motor response i see this here our patient has a gcs of nine so they have an e of two which means that they're able to open their eyes when i applied pressure to their nail bed they have a v of two they only make sounds whenever i ask them questions to see if they're oriented or not and then they have an m of five they were able to localize pain whenever i applied a trapezius squeeze okay so that wraps up this review over the glasgow coma scale and don't forget to access the free quiz in the youtube description below

Channel: RegisteredNurseRN

Views: 168,451

Keywords: glasgow coma scale, glasgow coma score, glascow coma scale, glascow coma score, glasgow coma scale nclex, glasgow coma scale mnemonics, glasgow coma scale nursing, trapezius squeeze, supraorbital pressure, nail bed test, glasgow coma scale range, glasgow coma score meaning, glasgow coma scale interpretation, glasgow coma score assessment, nursing skills, clinical nursing skills, glasgow coma scale osce, glasgow coma scale emt, nursing, nclex, rn, lpn, nclex review

Id: a33Hq89sELc

Length: 15min 37sec (937 seconds)

Published: Mon Jul 18 2022