gcs(Glasgow Coma Scale) ppt to understand.pptx

Glasgow Coma Scale ppt

1. Glasgow Coma Scale (GCS)

2. Introduction GCS is a quick, practical, & standardized system for assessing the degree of impaired consciousness. Three indicators of response are evaluated: Opening of eyes The best verbal response & the best motor response Specific behaviours observed as responses to the testing stimulus in each of these areas are given a numeric value & can be plotted on a graph. The subscale scores are particularly important if a patient is untestable in one area. for example severe periorbital edema may makes eye opening impossible. the total GCS score is the sum of the numeric values assigned to each of the three areas are evaluated. the highest GCS score is 15 for a fully alert person, & the lowest possible score is 3. a GCS score of 8 or less is generally indicative of coma.

3. INDICATIONS FOR USE: Conscious/semi-conscious patient due to any reason Obvious or suspected HI To assess the arousal aspect of consciousness. Post neurosurgery or vascular surgery to carotid vertebral artery Severe unexplained headache Neuro impairment Prolonged epileptic seizure Drug overdose The nurses responsibility is to elicit the best response on each of the scales: the higher the scores, the higher the level of brain functioning. a graph can be used to determine whether the patient is stable, improving, or deteriorating. Articles GCS proforma (in some situations a neurological assessment chart).  A pen torch (PENLIGHT) A tray for the assessment of vital signs

4. Eye opening: Score 4 if patient’s eyes are open upon approaching the bed, or remain open when not spoken to. Score 3 if patient’s eyes open when spoken to or shouted at. Score 2 if patient’s eyes open after applying a central pain stimulus. Score 1 if patient’s eyes don’t open at all. Put “C” if eye closed due to swelling. (1 point) Verbal response: Score 5 if patient knows who they are, the day, and where they are. Score 4 if patient’s responses to questions are incorrect, but appropriate. Score 3 if patient’s response to questions are inappropriate or irrelevant to question. Score 2 if patient’s response incomprehensible ( eg moans). Score 1 if no response. Put “T” if patient scores 1 because they’re intubated . Motor response: Use the best response at time of assessment, normally arms, but may be legs. Score 6 if patient obeys simple commends. Ensure pateint’s hand squeeze is not grasp reflex by asking them to release their grip also. Score 5 if patient localizes with hands/arms to sternal rub. Score 4 if patient withdraws hand, briskly, to nail bed pressure. Score 3 if patient has abnormal flexion to central pain stimulus ( ie Decorticate posturing). Score 2 if patient extends to central pain stimulus ( ie Decerebratye posturing or abnormal extension). Score 1 for no movement.

5. Procedure s.n . Nursing action Rationale 1 Explain procedure to patient Unconscious patient may retain ability to hear. 2 Keep patient in comfortable position To promote comfort to patient. 3 Score responses in GCS sheets. To assess GCS score. 4 Add total score at bottom of sheet during each assessment. 5 Assess vital signs for completion of procedure Vital Signs  It is important that the patient's temperature, blood pressure, pulse and respiration are also included because changes in vital signs may indicate a compression or damage in the brain stem . 6 Document accurately & report changes if any. To maintain accuracy in records.

6. CATEGORY OF RESPONSE APPROPRIATE STIMULUS RESPONSE SCORE EYE OPENING Approach to bed side Verbal command Pain Spontaneous response Opening of eyes to name or command Lack of opening of eyes to previous stimuli but opening to pain Lack of opening of eyes to any stimulus Untestable 4 3 2 1 U BEST VERBAL RESPONSE Verbal questioning with maximum arousal Appropriate orientation, conversant; correct identification of self, place. year.,& month Confusion; conversant, but disorientation in one or more spheres Inappropriate or disorganized use of words (e.g. cursing) lack of sustained conversation Incomprehensible words, sounds (e.g. moaning) Lack of sound, even with painful stimuli Untestable 5 4 3 2 1 U BEST MOTOR RESPONSE Verbal commands (e.g. raise your arm, hold up two fingers ) Pain (pressure on proximal nail bed) Obedience of command Localization of pain, lack of obedience but presence of attempts to remove offending stimulus Flexion withdrawal, flexion of arm in response to pain without abnormal flexion posture Abnormal flexion, flexing of arm at elbow & pronation , making a fist Abnormal extension, extension of arm at elbow usually with adduction & internal rotation of arm at shoulder Lack of response Untestable 6 5 4 3 2 1 U

7. Note: Document if patient has GCS of 3 due to paralysis or sedation. If eye closed due to swelling document “C” under eye opening. Docuement “T” for verbal response if patient intubated or has a tracheostomy . If motor response differs from R to L document “R” or “L” in appropriate boxes. Make note if patient is a quadriplegic/paraplegic. Responses to peripheral pain stimuli (nail bed pressure) may be possible even with a complete cord transection . Therefore peripheral stimulus is an inappropriate stimulus for assessing the GCS.

8. Pupillary assessment Pupillary assessment is an important part of neurological assessment because changes in the size, equality and reactivity of the pupils can provide vital diagnostic information in the critically ill patient . Both pupils should be the same shape, size and react equally to light. Although not part of the Glasgow Coma Scale ,examination of the pupils is an essential adjunct to it, especially when the patient’s level of consciousness is impaired Anatomy and physiology The pupil is the ‘black hole’ in the centre of the iris, a flattened muscular diaphragm which is attached to the ciliary body.Relaxation and contraction of the muscles of the iris causes it to dilate (in darkness) or constrict (in bright light). Evaluation of pupillary reaction is effectively an assessment of the third cranial nerve ( oculomotor nerve), which controls constriction of the pupil. Compression of this nerve will result in fixed dilated pupils.

9. Pupil size and shape Pupil size should be measured, ideally with reference to a neurological observation chart or similar. The average size is 2-5mm ( Bersten et al, 2003). The pupils should be equal in size. Pupil shape should be ascertained. It should be round; abnormal shapes may indicate cerebral damage; oval shape could indicate intracranial hypertension.The pupils should be identical in shape . If the 3 rd cranial nerve ( occulomotor ) is compressed, the pupil on the affected side becomes larger until it fully dilates. If ICP continues to increase, both pupil dilates . Reaction to a bright light Pupil reaction to light should be brisk and after removal of the light source, the pupil should return to its original size. There should also be a consensual reaction to the light source, that is the opposite pupil also constricts when the light source is applied to one eye . Pupil reaction should be documented as per local policy, for example B (brisk), S (sluggish) or N (no reaction). Both pupils should react equally to light . Sluggish reaction can indicate early pressure on 3 rd CN. A fixed pupil unresponsive to light stimulus usually indicates increased ICP. Unreactive pupils can be caused by an expanding mass, for example a blood clot exerting pressure on the third cranial nerve; a fixed and dilated pupil may be due to herniation of the medial temporal lobe .

10. Pre Procedure assessment Prior to undertaking pupillary assessment: Note if the patient has any pre-existing irregularity with the pupils, for example cataracts, false eye or previous eye injury; Check if there are any pre-existing factors that can cause pupillary dilation, for example medications including tricyclics , atropine and sympathomimetics and traumatic mydriasis . Check if there are any pre-existing factors that can cause pupillary constriction, for example medications including narcotics and topical beta-blockers. Assemble equipment: a pen torch and the patient’s observation chart (in some situations a neurological assessment chart). If possible, dim the overhead light source (a darkened room is ideal but practically this will rarely be possible); dim light will facilitate a better view of the pupils and their reaction to light.

11. Procedure s.n . Nursing action/ step of procedure Rationale 1 Wash and dry hands. To prevent cross –infection. 2 Explain procedure to patient , even if she or he is unconscious. To gain patient’s cooperation. Unconscious patient may retain ability to hear. 3 Adopt a position in front of the patient. To perform pupillary assessment. 4 Look into each of the patient’s eyes, examining the size of the pupils. Note the size (mm) of each pupil; if available, use the scale printed on the neurological assessment chart as a comparison. Compare the sizes of the pupils. To assess pupils size. 5 Note the shape of each pupil. Compare the shapes of the pupils. to assess pupils shape

12. s.n . Nursing action/ step of procedure Rationale 6 6.1. After providing prior warning to the patient, move the torchlight from the side of the head towards the pupil and note any change in pupil size and the speed of the reaction (brisk or sluggish). Taking care to avoid shining the light in the other eye, observe whether the opposite pupil also reacts (consensual reflex). 6.2. Repeat the above procedure in the opposite eye. To assess pupillary reaction to bright light. 7 Document the findings of the pupillary assessment as per local policy and guidelines. If necessary, inform the nurse in-charge of any changes or abnormalities. To maintain accuracy in records.