Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool that evaluates a patient's level of consciousness by scoring three responses: eye opening (1-4), verbal response (1-5), and motor response (1-6), for a total score of 3-15.
Exam Tip
GCS has 3 components: Eye (1-4), Verbal (1-5), Motor (1-6). Total range: 3-15. GCS 8 or below = severe/coma, consider intubation. Report any decrease of 2+ points immediately. Document each component separately (E3V4M5) plus total.
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 voice/command (eyes open when spoken to) |
| 2 | To pain (eyes open only with painful 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 | Inappropriate words (random/exclamatory words) |
| 2 | Incomprehensible sounds (moaning, groaning) |
| 1 | None (no verbal response) |
Motor Response (M): 1-6
| Score | Response |
|---|---|
| 6 | Obeys commands (follows instructions) |
| 5 | Localizes pain (reaches toward painful stimulus) |
| 4 | Withdrawal (pulls away from pain) |
| 3 | Abnormal flexion (decorticate posturing) |
| 2 | Extension (decerebrate posturing) |
| 1 | None (no motor response) |
Interpreting GCS Scores
| Total Score | Severity | Clinical Significance |
|---|---|---|
| 15 | Normal | Fully alert and oriented |
| 13-15 | Mild brain injury | Usually good prognosis |
| 9-12 | Moderate brain injury | Requires close monitoring |
| 3-8 | Severe brain injury | Coma; may need intubation (GCS <=8) |
| 3 | Minimum score | Deep coma or brain death |
Key Nursing Considerations
- Document each component separately (e.g., E3V4M5 = 12) in addition to total score
- Assess and document at regular intervals as ordered
- Report any decrease of 2 or more points immediately
- GCS of 8 or below typically requires intubation for airway protection
- 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. A GCS of 8 or below = severe injury requiring airway protection. Always report a declining GCS to the RN immediately.
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Nursing Process
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