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Nursing Knowledge
The Glasgow Coma Scale (GCS) is a reliable approach to assess an individual's neurological state. It measures the level of consciousness based on eye-opening, verbal response, and motor response. Each of these aspects is given a score, and these scores are then added together to give a total score.
The GCS scoring scale can be used for clients aged 3+.
The GCS score can range from 3 to 15, with 3 being the least neurologically responsive and 15 being the most neurologically responsive.
Breakdown:
To use the GCS, observe the client for eye-opening, language, and body movements. If a client is unable to be tested due to medications, paralysis, intubation, or similar factors, score that section as NT (Not Testable). Calculate the final GCS score by adding corresponding values for eye-opening, verbal responses, and motor responses.
To calculate the final GCS score, add corresponding values for eye-opening, verbal responses, and motor responses.
The three categories of neurological concerns based on GCS scores are mild (13–14), moderate (9–12), and severe (3–8).
A normal GCS score, indicating full neurological health, is 15. However, a GCS score of 13 or above is generally considered to be within the normal range. Scores below this may suggest a varying degree of neurological impairment or injury.
Decorticate and decerebrate posturing are signs of severe brain damage, often related to conditions like traumatic brain injury, brain tumor, or brain hemorrhage.
In terms of the GCS, decerebrate and decorticate postures are part of the motor response component. A client displaying decorticate posturing would score 3 in the motor response section, while a client displaying decerebrate posturing would score 2, indicating more severe damage.
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