Glasgow Coma Scale (Nursing)

00:00 Hi, welcome to our video series on nursing's neuro assessment.

00:05 Now, we're gonna learn so much about patients in just this simple type of assessment.

00:10 So I'm gonna walk you through each step of what every nurse needs to know about how to assess a patient's neurological system.

00:18 Now let's get into some terminology first.

00:21 You'll see the term, L-O-C.

00:23 We abbreviate a lot of things in nursing and in the medical field, but that just means, level of consciousness and we're gonna look at mentation.

00:32 So when we're talking about neuro assessment, that's what we're looking at.

00:35 Level of consciousness or LOC and mentation.

00:39 So we're gonna look at how the patient moves, what they can feel - that's sensation, and their reflexes.

00:46 Ready? alright. Let's get started.

00:48 Now there's some standardized tools that we use in nursing.

00:51 One is the National Institute of Health Stroke Scale that's it for trying to see what's going on with a possible stroke patient.

00:59 Also you'll see the Glasgow Coma Scale or GCS.

01:03 So you've got the NIHSS, a lot of times we will just abbreviate it to that but now you know that's what it means, or the Glasgow Coma Scale, GCS.

01:13 Ok, so the Glasgow Coma Scale is based on three patient responses.

01:18 Now, this is kind of fun because you can practice this on your roommate or with your friends and kinda see what their Glasgow coma scale would be.

01:26 So it's three patient responses - eye opening, verbal response and motor response.

01:33 Now, how you can remember this, is it's three words: Glasgow, Coma, Scale, and we're looking at the eyes, the mouth and the motor response.

01:43 Opening, verbal response and motor response.

01:47 Now, we've shown you the numbers there because patients get a score because you assess them and give it to them for their best response in each one of these areas, then you add the three scores together.

01:58 So we look at their eyes, we look at their verbal response and we look at their motor response and we give them a score.

02:04 Add them together and that is their total Glasgow coma scale score.

02:09 Now it has a range from 3 to 15.

02:12 Well, that should make sense, right? Because if you add up, if you gave them a 1, 1 and a 1, they would be dead.

02:18 But if gave them a 1, 1 and a 1, that would be a score of 3.

02:23 If we added 4, 5 and 6 together, that would be 15.

02:28 So when we say 3 to 15, that kinda gives you an idea and a reference of what we're talking about.

02:34 The higher the number, the better.

02:36 That's why I said, when you give it all 1s, that's really good in golf but not very good in the Glasgow coma scale.

02:43 So the higher the number, the better.

02:46 Now score less than 8 usually indicates a coma, so make sure you write a note to yourself that the higher the score, the better.

02:54 So say 15, put a thumbs up or a star by it and remember that a score less than 8 usually indicates coma.

03:02 Okay, we're gonna define coma for you a little bit later.

03:05 That's a really, really bad sign.

03:08 So a score of less that 8 indicates coma, that means the patient probably can't breathe on their own, so they're gonna have to be intubated.

03:15 Or we put a special tube in their mouth and down into their airway and we connect them to a mechanical ventilator.

03:21 So someone with a score less that 8 usually cannot breath on their own, we're gonna have to intubate them and put them on a ventilator.

03:29 Okay, so how many times did I repeat those things? I know, but remember, repetition is your friend when you're learning new concepts.

03:38 So we know we score on three things, it can go from 3 to 15, the higher the better, and a score of less than 8 means big trouble, likely to be intubated and put on a mechanical ventilator.