Glasgow Coma Scale Test PDF

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My lectures notes/additional notes from the Acute Medical Conditions Module as part of my BSC Adult Nursing Degree in 2014 -2017....

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GCS – self assessment quiz 1. What are the three components of the GCS? Eyes, Verbal and Motor 2. Each of the three components of the GCS have a numbers of steps – what are they? Eye component have 4, verbal 5, motor 6 3. What possible sequence of responses is assessed in the eye component? Spontaneous, to sound, to pressure, none 4. In each component of the GGCS the ‘best response’ is? Spontaneous for eyes Orientated for verbal Obey commands for motor 5. When assessing a patient, you should Check, observe, stimulate, rate 6. When assessing a patient, what is the reason for the check step in the assessment? Check to identify factors that may interfere with the assessment 7. If when you approach the patient they are awake and looking at you, how would you record this? Spontaneous eye opening 8. You are called to see a patient who has fallen through a plate glass door. As you approach the patient you observe that their eyes are extremely swollen and they are unable to open them. How would you record the eye component of the scale? Would document ‘NT’ 9. A 45 year old man is admitted to the ED after being assaulted. When you ask the patient to tell you his name, where he is and what the date is, he answers, Hamish, Hospital, and December. How would you record this finding? Would document as confused 10. You are accessing the motor component of a patient’s GCS. They are unable to obey commands but bend their elbow when their finger nail bed is stimulated. What do you do next? If a patients elbow bends when the finger is stimulated  a trapezius pinch should be done to see if they can localise 11. A patient reacts to supraorbital pressure by moving their hand up to their face. How would you record this response? Localising - as they have recognised the pain stimuli 12. Normal flexion, where a patients elbow bends and their arm moves rapidly away from their body and from a stimulus, is given what number is the GCS? M4 – Normal flexion 13. If you were told by a colleague that their assessment of a patients GCS was E2, V3 and M5, how would you interpret this? Eyes open to pressure, word but can localise to trapezius pinch...