Trigger 2 258 week 1 PDF

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Trigger 2: What is the Glasgow Coma Scale (GCS) and what does this Scale assess? Aim of GCS  Assess the depth and duration of impaired consciousness and coma, awareness and arousability  Early detection of a deteriorating patient by clearly defining function  What is GCS?  Is part of the neurological assessment, which was used to measure the conscious state of a person following a traumatic brain injury.  It is now recognised as an assessment tool for reporting patient’s conscious state  It uses three categories that pertain to different areas of a patient’s conscious state: including eye opening, verbal response and motor response.  These three components of the GCS can be scored separately or combined in a sum score ranging from 3 -15  Eye opening – maximum score is 4  This component of the GCS is used to assesses for arousability and weakness  Spontaneous (4)  When patients open their eyes widely without a stimulus  To speech (3)  When patients open their eyes by calling their name  To pain (2)  When patients open their eyes to pain stimuli  Types of painful stimuli  Acceptable methods of painful stimuli  Trapezius pinch/ squeeze  Supra- orbital pressure  Sternal rub (used as a last measure)  None (1)  If the patient does not open their eyes to pain, to speech or spontaneously  Verbal response – maximum score is 5  This component of the GCS is used to measure appropriateness of speech and awareness  When assessing verbal response the patient is asked questions that reflect they are orientated to person, place and time. o Orientated (5)  Orientated to person, place and time o Confused (4)  Confused to either person, place or time o Inappropriate words (3)  Uses words or phrases that make little to no sense o Incomprehensible sounds (2)  Unintelligible sounds, moaning or groaning o None (1)  Make no sound or speech  The challenges of assessing a patient’s verbal response may include o CALD (Culturally and Linguistically Diverse) o Aphasia/ Dysphasia

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o Dementia o Tracheostomy/ Endotracheal (ET) tube Motor response – maximum score is 6 This component of the GCS is used to assess the patient’s overall ability to respond to an external stimuli and awareness o Obeys commands (6)  When patients understands and responds to instructions If patients does not responds to any instruction, then acceptable pain stimuli methods is applied o Localise to pain (5)  When patient responds to pain stimuli and moves to the source of pain o Withdraws to pain (4)  When patient responds to pain stimuli they will move away from the source of pain and does not localise o Flexion to pain (3)  When patient bends their arm at the elbow o Extension to pain (2)  If pain stimuli is applied, the patient will extend their elbows and their wrist internally rotate o None (1)  If the patient does not respond to pain stimuli

Advantages of GCS  Standardised approach to assessment of level of consciousness  Acts as a rule of thumb in management decisions  Means of defining the severity of brain injury Limitations  Poor predictor of outcome  Inconsistent use by health care professional  Clinical limitations: patients with spinal cord injury, sedated patients Reliability of GCS  The overall total GCS score has been seen as “less reliable” compared to the GCS component scores  The level of consistency when using this assessment tool is reliant upon experience and well-educated users References ADULT NEUROLOGICAL OBSERVATION CHART Education Package. (2018). Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0018/201753/AdultCha rtEdPackage.pdf Braine, M., & Cook, N. (2016). The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be. Journal Of Clinical Nursing, 26(1-2), 280-293. doi: 10.1111/jocn.13390

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13 – 14 – mild 9 – 12: moderate injury 3 – 2: severe When it is scored 8 check for level of consciousness Awaking up the patient to check if they are awake...