Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) describes level of consciousness through eye opening (1-4), verbal response (1-5) and motor response (1-6). When all three can be tested, their sum ranges from 3 to 15.
Exam Tip
Score eye (1-4), verbal (1-5) and motor (1-6) separately. Add them only when all are testable. In acute traumatic brain injury, 8 or below calls for urgent airway assessment. Escalate deterioration promptly.
What Is the Glasgow Coma Scale?
The Glasgow Coma Scale (GCS) is the most widely used neurological assessment tool for evaluating a patient's level of consciousness. Developed in 1974, it provides a standardized way for healthcare providers to communicate about a patient's neurological status and track changes over time.
GCS Components and Scoring
Eye Opening Response (E): 1-4
| Score | Response |
|---|---|
| 4 | Spontaneous (eyes open without stimulation) |
| 3 | To sound (eyes open in response to spoken request) |
| 2 | To pressure (eyes open in response to an appropriate pressure stimulus) |
| 1 | None (no eye opening) |
Verbal Response (V): 1-5
| Score | Response |
|---|---|
| 5 | Oriented (knows who, where, when) |
| 4 | Confused (speaks but disoriented) |
| 3 | Words (intelligible single words without conversation) |
| 2 | Sounds (moans or groans without intelligible words) |
| 1 | None (no verbal response) |
Motor Response (M): 1-6
| Score | Response |
|---|---|
| 6 | Obeys commands (follows instructions) |
| 5 | Localizes pressure (moves toward the stimulus) |
| 4 | Normal flexion (withdrawal from pressure) |
| 3 | Abnormal flexion (decorticate posturing) |
| 2 | Extension (decerebrate posturing) |
| 1 | None (no motor response) |
Interpreting a Total After Traumatic Brain Injury
| Total Score | Severity | Clinical Significance |
|---|---|---|
| 13-15 | Mild | Even a score of 15 can occur with a brain injury |
| 9-12 | Moderate | Requires close monitoring |
| 3-8 | Severe | Requires urgent evaluation and assessment of airway protection |
Key Nursing Considerations
- Document each component (for example, E3 V4 M5 = 12). If intubation, swelling or another barrier prevents testing a component, record NT and the reason. Record the remaining components without calculating a total.
- Assess and document at regular intervals as ordered
- Escalate new deterioration promptly according to the neurologic observation protocol
- In acute traumatic brain injury, a score of 8 or below is an indication for urgent airway management. The team also assesses breathing and airway protective reflexes.
- Pupil assessment should accompany GCS evaluation
- Note factors that may affect scoring (sedation, intubation, eye swelling)
Exam Alert
GCS questions appear in the Physiological Adaptation and Reduction of Risk Potential categories on the NCLEX-PN. Know the three components and their scoring ranges. In acute traumatic brain injury, a GCS of 8 or below signals severe injury and urgent airway assessment. Escalate a new decline promptly.
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