Emergency Nurse

CPD | assessment
neurological assessment

The Glasgow Coma Scale in adults: doing

it right
de Sousa I, Woodward S (2016) The Glasgow Coma Scale in adults: doing it right. Emergency Nurse.
Date of submission: 20 August 2016; date of acceptance: 7 October 2016. doi: 10.7748/en.2016.e1638

Ismalia de Sousa
Clinical nurse specialist in stroke, Stroke and Neurosciences, Charing Cross Hospital, Imperial College Healthcare NHS Trust,
London

Sue Woodward
Head of clinical education, Florence Nightingale School of Nursing and Midwifery, King's College London

Correspondence
[email protected] [Q1. is this the correct email address?]

Peer review
This article has been subject to external double-blind review and has been checked for plagiarism using automated
software

Conflict of interest
None declared

Abstract
After 40 years, the Glasgow Coma Scale (GCS) is the resource of choice for assessing the level of consciousness in patients
with neurological conditions. Clinicians’ ability to monitor patients’ conditions, identify deterioration and make clinical
decisions depend on their ability to carry out GCS assessments, so it is vital that they understand it. This article explores how
best to use the GCS in clinical practice and examines some of the factors that can affect the accuracy of assessments. The
article also explains the difference between peripheral and central stimuli.

emergency nursing, Glasgow Coma Scale, GCS, neurological assessment

Aims and intended learning outcomes

The aim of this article is to describe how to use the Glasgow Coma Scale (GCS) to perform neurological
assessments in adults. After reading this article and completing the time out activities you should be able to:
• Explain how to use the GCS in adult patients.
• Summarise the three components of the GCS and their criteria.
• Describe the signs and symptoms of raised intracranial pressure.
• Outline clinical situations or factors that can affect GCS assessments.
• Discuss the difference between peripheral and central stimuli, and identify their locations in the body.

Background
The Glasgow Coma Scale (GCS) is the gold standard for the assessment, trend monitoring, classification and
prognosis of, and clinical decision making about, consciousness in patients with acute neurological conditions or
brain injuries (Teasdale and Jennett 1974, Middleton 2012, Teasdale et al 2014).
Developed by Jennett and Teasdale in 1970, the GCS was originally called the Coma Index (Fischer and Mathieson
2001) and, before its introduction, the evaluation of consciousness was based on assessing the concepts of comatose,
sub-comatose, stupor, obtundation, semi-purposeful and posturing (Teasdale et al 2014).
Today, the GCS is used in at least 80 countries (Teasdale et al 2014) and has become an important tool for
healthcare professionals to communicate patients’ neurological conditions. Other resources, such as early warning
scoring tools, the trauma score, the revised Acute Physiology and Chronic Health Evaluation II score and the World
Federation of Neurosurgeons subarachnoid haemorrhage grading system, have incorporated elements of the GCS
(Braine and Cook 2016). Recently, Teasdale et al (2014) updated the GCS and made recommendations for practice,
although these have not been incorporated fully into UK practice.
Inter-rater reliability, or the degree of agreement between assessors of the GCS, can be problematic and has
prompted much discussion in recent years. Motor response has a higher inter-rater reliability compared with eye
opening and verbal response (Teasdale et al 2014), although outcomes can be affected by assessors’ experience and
technique (Holdgate et al 2006, Teasdale et al 2014), which suggests that education is vital to developing GCS
assessors’ competence. Although patients’ level of consciousness can be measured with other tools, such as the Alert,
Voice, Pain, Unresponsive scale adopted by the National Early Warning Scoring system (Royal College of Physicians
2012), this article focuses on the GCS.

Understanding the scale

The GCS is divided into three components of behaviour (Table 1): eye opening (E), verbal response (V) and motor
response (M). Each component is assessed independently and given a score, and the sum of the score for the three
components is the GCS score. The maximum score is 15 and the minimum is 3, but clinical findings should include
more than the GCS score because it can represent the sum of different components. A score of 13, for example, can
represent a patient who spontaneously opens his eyes (E4), is confused (V4) and responds to localised pain [Q2. is
this put correctly as an alternative to ‘localised to pain’?] (M5); or it can represent a patient who opens her eyes
to speech (E3), is orientated (V5) and localises to pain (M5).

Table 1. Glasgow Coma Scale

Eye opening (E) Score Verbal response (V) Score Motor response (M) Score

- - Obeys commands 6

- Orientated 5 Localises to pain 5

Spontaneously 4 Confused 4 Flexion/withdrawal to pain 4

To speech 3 Inappropriate words 3 Abnormal flexion 3

To pain 2 Incomprehensible sounds 2 Extends 2

None 1 None 1 None 1

 To improve reporting of clinical findings, the GCS should be broken down into each of its component scores.
However, a paradigm shift in nursing is needed to avoid giving the score more importance than the scale itself.
In some areas, nursing documentation is electronic, but the principles of the GCS, and the importance of its correct
documentation on a paper chart, (Figure 1) remain the same.

Figure 1. Paper version of completed Glasgow Coma Scale chart

TIME OUT 1
Policies and documentation
Review local guidelines, protocols and documentation related to the Glasgow Coma Scale (GCS). Discuss with colleagues
what determines the frequency of observations required for patients with different types of head injury or neurological
condition. How often do nurses carry out a GCS assessment during nursing handover?

Assessments
Before using the GCS nurses should be aware of a number of points. They should know about local policies,
guidelines and documentation that concern the tool, for example, because there may be differences in the frequency
of neurological assessment. The National Institute for Health and Care Excellence (2014) recommends that, for
patients with head injuries, GCS assessments should be undertaken every 30 minutes until a score of 15 is achieved.
When this score is achieved, the minimum frequency for observations is 30 minutes for two hours, hourly for four
hours and every two hours thereafter.
Nurses should also understand the rationale for assessing patients using the GCS and the frequency of
assessments. The GCS assesses the level of consciousness in patients with head injuries or neurological conditions
and should be carried out frequently in the early stages of injury when clinical deterioration is more likely. In patients
who have had a stroke, GCS scores should be recorded more than once an hour to assess whether there has been a
decrease in consciousness caused by secondary complications, such as sepsis. It is also important to establish a
baseline so that changes are recognised immediately.
In addition, nurses should know each patient’s history, including histories of post ictal, sedation, cranial nerve
injury, intoxication by drugs or alcohol, dementia, intubation, tracheostomy, spinal cord injuries, stroke, dysphasia,
orbital swelling or language barrier, to support the interpretation of results or to predict what could happen if the
patient deteriorates.
The GCS should be used as an adjunct to other assessments, such as the National Early Warning Score (Royal
College of Physicians 2012), pupil assessment, limb assessment and brain imaging, and nurses should know the signs
and symptoms of raised intracranial pressure, which can occur before GCS scores are reduced (Box 1).
When assessing GCS scores, clinicians should start from the top category of each component, which represents the
maximum score, and work down, applying increasing levels of stimulus if there is no response. Under-stimulation
through the inappropriate or inadequate application of painful stimuli compromises assessments.
Nurses should determine whether the patient is asleep before undertaking the assessment. When assessing eye
opening in patients who are awake with eyes open, a score of ‘spontaneously’ should be given (Fairley and Timothy
2005). Nurses should also remember that:
• Documentation should reflect the clinical findings at the time of each assessment.
• Assessments following baseline should be consistent, for example by using the same questions.
• Inter-rater reliability can be improved by assessing the GCS during nursing handover.
• If they are in doubt, they can ask for a second opinion.
Box 1. Early signs and symptoms of raised intracranial pressure

• Seizure
• Increase focal neurology
• Increased effort in assessing the Glasgow Coma Scale
• Headache
• Photophobia
• Nausea and/or vomiting
• Changes in pupil size, and pupils’ reaction to light
• Restlessness
• Sudden calmness

TIME OUT 2
Intracranial pressure
Look at Box 1 and imagine you are explaining the signs and symptoms of raised intracranial pressure to a colleague.
What counts as ‘restlessness’ or ‘sudden calmness’? What points would you emphasise about pupil size and reactivity?

Eye opening
In the GCS, eye opening is a measure of arousal and wakefulness, not awareness (Woodward and Mestecky 2011)
(Table 2). It is therefore a measure of the activity of the reticular activating system (Figure 2) that derives from the
reticular formation located in the brainstem (Teasdale and Jennett 1974). The reticular formation is not a discrete
anatomical structure, but a physiological entity comprised of a network of neurones in the spinal cord, thalamus and
cerebral cortex. An input received from sensory, auditory and visual stimulus through the spinal cord to the thalamus
should activate the cerebral cortex (Woodward and Mestecky 2011) and cause a response in the patient.
In patients with orbital swelling, eye opening cannot be assessed and a score should not be allocated to this
component of the scale. Teasdale and Jennett (1974) recommend that, in this situation, nurses document ‘C’,
signifying ‘eyes closed’, on the GCS chart.

TIME OUT 3
Assessing eye opening
Think about how you might assess eye opening in sleeping patients. What would be your approach and what would you
score?

Table 2. Eye-opening response

Response Score (E) Meaning
Spontaneous 4 Spontaneous opening when awake
To sound 3 Response to verbal stimulus
To pain 2 Painful peripheral stimuli required
None 1 Not opening at any time
Figure 2. The reticular activating system

Full arousal and wakefulness in a patient is characterised by spontaneous eye opening when he or she is
approached or has woken up. If a patient fails to respond in this way, nurses should use verbal stimulus, for example
by saying ‘Hello [patient’s name], can you hear me?’ If the first attempt does not elicit a response, nurses should try
again in a louder voice.
Patients assessed as E3 (eyes opening to speech) usually require constant verbal stimulus to keep their eyes open,
which can be an early sign of neurological deterioration. Nurses in these situations must measure and record the
effort they put into verbal stimulus, and compare it with the effort they required in previous assessments. [Q3. is this
put correctly?]
If nurses obtain no answer from verbal stimulus, they should try painful peripheral stimulus, such as the
application of pressure with a pen to the side of one of the patient’s fingers. Peripherally-applied stimuli are
necessary to assess the function of the primary motor and primary sensory cortex areas (Braine and Cooke 2016) .
[Q4. is this correct? It said Braine & Neal originally. If not, please provide reference details for Braine & Neal].
The stimulus travels through the nerve tracts to the spinal cord, ascends to the thalamus and continues through the
internal capsule until it reaches the sensory cortex area, triggering a reaction to open the eyes (Waterhouse 2009). If
the patient’s eyes do not open after a painful stimulus has been applied, the eye opening scored is 1.
Various locations have been recommended for peripheral stimulus, but Waterhouse (2009) suggests applying
pressure ‘with a pen to the lateral outer aspect of the second or third interphalangeal joint with graduating intensity
for 10 to 15 seconds’. In patients with spinal cord injuries above T4, peripheral painful stimulus is ineffective and
direct central painful stimuli, such as supraorbital pressure, is needed instead. The trapezius pinch (Figure 2) can also
be used, except in patients with spinal cord injuries above C5.

TIME OUT 4
Painful peripheral stimuli
If painful peripheral stimuli are needed to assess eye opening, which of the following techniques would you use:
Mandibular pressure, lateral outer aspect of the second or third interphalangeal joint, nail bed pressure or trapezius pinch?

Verbal response
The verbal response component of the GCS (Table 3) is a measure of awareness or cognition in terms of
integration of speech and high cerebral function (Woodward and Mestecky 2011). For a person to be regarded as
orientated (V5), they must be able to answer correctly and without prompting the following questions:
• Person: ‘What is your name?’ or ‘What is your date of birth?’
• Place: ‘Where are you now?’ or ‘What is the name of this place?’
• Time: ‘What month is it?’ and ‘What year is it?’
If patients fail to answer at least one of the above questions correctly, nurses should conclude that they are confused
(V4) and document the area of confusion, for example time, person, and/or place. By asking these questions in
subsequent assessments, nurses can identify early deterioration in patients who answer them incorrectly. [Q5. is this
put correctly?]
 Table 3. Verbal response
Response Score (V) Meaning
Oriented 5 Oriented in person, place and time without providing clues
Confused 4 Communicates, but one or more components of person, place or time is wrong
Uses inappropriate words 3 Responses lack structured sentences or phrases
Makes incomprehensible sounds 2 Patient groans or moans
None 1 No audible response

Language barrier
Patients who require frequent neurological assessment but for whom there is a language barrier may require a
translator or family member to be present during GCS assessments. It is important that translators understand the
aim of the assessment, repeat only what nurses ask, do not provide patients with clues and translate exactly what
patients say, even if the response appears incorrect.

Intubation or tracheostomy
In patients who cannot speak because they are intubated or have undergone tracheostomy, a score should not be
allocated to this component of the scale. Teasdale et al (2014) recommend that, in this situation, nurses should
document ‘T’, signifying ‘tracheostomy’, or ‘VTube’ on the GCS chart. [Q6. is this put correctly?] It should be noted,
however, that some patients who have undergone tracheostomy can speak if a valve is in place, in which case their
level of awareness can be assessed.

Dysphasia
Dysphasia is a language impairment caused by an inability to understand and/or produce speech due to brain
damage (Intercollegiate Stroke Working Party 2012). There are different degrees of dysphasia, from total loss of
speech (scored as V1) to an inability to speak structured sentences (V3), and verbal assessments should reflect
clinical findings. The golden rule is to ‘score what you see’. Language problems are unlikely to change significantly
over time, so trends and patterns of response are more important than individual component scores in the
interpretation of GCS findings.

Locked-in syndrome
Locked-in syndrome results from a brainstem stroke, in which the body and most of the muscles are paralysed but
the level of consciousness is unaffected (Laureys et al 2005). The syndrome does not represent an alteration in
arousal or awareness, and patients may be orientated and able to communicate with eye movements. Communication
methods such as alphabet boards can be used.

TIME OUT 5
Verbal response
Define orientation in the verbal response component of the GCS.

Motor response
The motor response component of the GCS (Table 4) is a measure of primary motor and sensory cortex function.
In assessing motor response, nurses should document the best response possible. For example, if a patient has left-
sided weakness but can move the right side, movement in the right, not the left, leg should be assessed. When asking
patients to obey commands, nurses should make two-part requests, such as ‘Can you open your eyes?’ followed by
‘Can you close your eyes?’ or ‘Stick out your tongue’ followed by ‘Put your tongue back’. Assessors should avoid
mimicking responses in case they make the response they expect. Automatic actions, such as a hand grasp, or asking
patients to perform an action that could be a reflex, such as blinking, should also be avoided.
If patients fail to obey commands, central painful stimuli must be applied to continue assessments. Central
nervous system function can be assessed using a cranial nerve as a route of transmission [Q7. is this put correctly?]
(Waterhouse 2009).
The first option is the trapezius pinch [Q8. is this put correctly?], which applies pressure to the cranial nerve XI,
the spinal accessory nerve, that controls movement and sensation of the trapezius and sternocleidomastoid muscles
in the neck and back. Cranial nerve XI has a cranial part made up of fibres that originate in the medulla and a spinal
part made up of fibres that originate in the motor neurones in the spinal cord (C1 to C5). Spinal injuries above spinal
cord C5 impair application of pressure to cranial nerve XI (Braine and Cook 2016).
The trapezius pinch is carried out by grasping the medial area of the muscle between the neck and the shoulder,
superior to the clavicle, then twisting and squeezing the muscle with the thumb and index finger simultaneously
(Figure 3).

Figure 3. The trapezius pinch

The second option is application of supraorbital pressure [Q9. is this put correctly?] to the fifth cranial nerve, the
trigeminal nerve, which originates in the brainstem. The trigeminal nerve has three sensory branches: V1 ophthalmic,
V2 maxillary, and V3 mandibular (Woodward and Mestecky 2011). The ophthalmic branch includes the supraorbital
nerve that lies in a small notch in the bone of the orbit, which is palpable just underneath the eyebrow (Figure 4). To
apply painful stimulus, nurses should locate the notch and press into it to compress the nerve against the bone. This
stimulus is not recommended in patients with orbital or facial fractures (Waterhouse 2009).

Figure 4. The supraorbital notch

Patients who are aware of pain induced by a trapezius pinch or supraorbital pressure will bring their hands
towards the stimulus and attempt to remove it. A motor response travels from the cerebral cortex to the spinal cord,
innervating a muscle and causing people to remove the stimulus (Waterhouse 2009). Patients who make a movement
but do not attempt to localise the stimulus should be given a score of 4, meaning normal flexion. Abnormal flexion or
extension represents severe neurological impairment and intracranial pressure, with poor survival prognosis.

Table 4. Motor response

Response Score (M) Meaning

Obeys commands 6 Specific response to a two-part request and not an automatic or reflex reaction

Localises to pain 5 There is a connection between the location of a central stimulus applied and a specific
movement made in response (the hand is brought above the clavicle towards the
stimulus on the head or neck, and not to the opposite side of the body)

Flexion or withdrawal 4 Rapid and variable response. Elbow flexion causing the arm to move away from the
in response to pain body, but no attempt to localise the stimulus
Abnormal flexion 3 Slow response and the same over time. The arm moves across the chest, the leg
extends, the forearm rotates and the thumb clenches

Extension 2 Leg extension and Elbow extension

None 1 No movement of arms or legs

Locked-in syndrome
Some eye movements, such as vertical movement, remain intact in patients with locked-in syndrome, so only their
ability to obey commands can be assessed in the motor response component. Nurses should ensure patients’ eyes are
open and ask them to follow finger movements or move their eyes in a range of directions. If a patient obeys
commands by using eye movements, a score of M6 should be documented; if there is no motor response at all, a score
of M1 should be documented. [Q10. is this put correctly?]

Confirmed or suspected spinal cord injury

In such cases the GCS assessment should be adapted according to the level of spinal cord injury. It is more
appropriate to use eye or tongue movements to measure motor response.

TIME OUT 6
Central painful stimuli
With a colleague, identify the areas for trapezius pinch and supra-orbital pressure, and take turns to apply central
painful stimuli on each other. Then discuss the levels of stimuli that were applied to elicit a response and their significance
to patient assessments.

Conclusion
The GCS is often used in nursing practice, yet errors in technique can affecting inter-rater reliability. The three
components of the scale, eye opening, verbal response and motor response, should be reported separately rather
than added together to produce a sum of the scores, which would be meaningless in a patient with neurological
deficits affecting the level of consciousness (GCS 15), or are unresponsive (GCS 3).
The GCS is used to identify evidence of increasing intracranial pressure and clinical decisions are based on its
findings, so it is essential that nurses undertake and interpret GCS assessments accurately. Consistency is vital in GCS
assessments and nurses should repeat the same questions during reassessment.
Correct application of painful stimuli is often misunderstood, and this article explains when and how to apply
peripheral and central painful stimuli.

TIME OUT 7
Reflection
Now that you have completed the article, write a reflective account of your learning as part of your portfolio for
revalidation.

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4, 52-58.
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London.

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Woodward S, Mestecky A (2011) Neuroscience Nursing: Evidence-Based Practice. First edition. Willey-Blackwell, West Sussex.