Hi, welcome to our video series
on nursing's neuro assessment.
Now, we're gonna learn so much about patients
in just this simple type of assessment.
So I'm gonna walk you through each
step of what every nurse needs to know
about how to assess a patient's
Now let's get into some
You'll see the term, L-O-C.
We abbreviate a lot of things in
nursing and in the medical field,
but that just means, level of consciousness
and we're gonna look at mentation.
So when we're talking about neuro
assessment, that's what we're looking at.
Level of consciousness
or LOC and mentation.
So we're gonna look at how the patient moves, what
they can feel - that's sensation, and their reflexes.
Let's get started.
Now there's some standardized
tools that we use in nursing.
One is the National Institute
of Health Stroke Scale
that's it for trying to see what's going
on with a possible stroke patient.
Also you'll see the Glasgow
Coma Scale or GCS.
So you've got the NIHSS, a lot of times
we will just abbreviate it to that
but now you know
that's what it means,
or the Glasgow Coma Scale, GCS.
Ok, so the Glasgow Coma Scale is
based on three patient responses.
Now, this is kind of fun because you can practice
this on your roommate or with your friends
and kinda see what their
Glasgow coma scale would be.
So it's three patient responses - eye
opening, verbal response and motor response.
Now, how you can remember
this, is it's three words:
Glasgow, Coma, Scale, and we're looking at
the eyes, the mouth and the motor response.
Opening, verbal response
and motor response.
Now, we've shown you the numbers
there because patients get a score
because you assess them and give it to them for
their best response in each one of these areas,
then you add the three
So we look at their eyes, we
look at their verbal response
and we look at their motor
response and we give them a score.
Add them together and that is their
total Glasgow coma scale score.
Now it has a range from 3 to 15.
Well, that should
make sense, right?
Because if you add up, if you gave them
a 1, 1 and a 1, they would be dead.
But if gave them a 1, 1 and a
1, that would be a score of 3.
If we added 4, 5 and 6
together, that would be 15.
So when we say 3 to 15, that kinda gives you an
idea and a reference of what we're talking about.
The higher the
number, the better.
That's why I said, when you give it
all 1s, that's really good in golf
but not very good in the
Glasgow coma scale.
So the higher the
number, the better.
Now score less thaN 8 usually indicates a coma,
so make sure you write a note to yourself
that the higher the
score, the better.
So say 15, put a thumbs up or a star by it and remember
that a score less than 8 usually indicates coma.
Okay, we're gonna define coma
for you a little bit later.
That's a really,
really bad sign.
So a score of less that 8 indicates coma, that means
the patient probably can't breathe on their own,
so they're gonna have
to be intubated.
Or we put a special tube in their
mouth and down into their airway
and we connect them to a
So someone with a score less that 8
usually cannot breath on their own,
we're gonna have to intubate them
and put them on a ventilator.
Okay, so how many times did
I repeat those things?
I know, but remember, repetition is your
friend when you're learning new concepts.
So we know we score on three
things, it can go from 3 to 15,
the higher the better, and a score
of less than 8 means big trouble,
likely to be intubated and put
on a mechanical ventilator.