Glasgow Coma Scale - AACN

1 Glasgow Coma Scale Saving a Life: Copyright 2016 Caring for the Potential Organ Donor American Association of Critical-Care Nurses The Glasgow Coma Scale (GCS) provides a way to assess and communicate about the level of consciousness of patients with acute brain injury. The GCS was designed to assess the depth and duration of coma and impaired consciousness based on eye opening, verbal response, and motor response. Instructions: Check for factors that could interfere with the ability to respond; observe eye opening, content of speech, and movements of right/left sides; stimulate sound and touch; assign the highest response observed.

2 Visit for more information on the GCS, including the latest structured approach to assessment of the GCS. Eye Opening Criteria Observed Rating Score Open before stimulus q Spontaneous 4 After spoken or shouted request q To sound 3 After finger tip stimulus q To pressure 2 No opening at any time, no interfering factor q None 1 Closed by local factor q Non testable NT Verbal Response Criteria Observed Rating Score Correctly gives name, place and date q Oriented 5 Not oriented but communicating coherently q Confused 4 Intelligible single words q Words 3 Only moans/groans q Sounds 2 No audible response.

3 No interfering factor q None 1 Factor interfering with communication q Non testable NT Best Motor Response Criteria Observed Rating Score Obey 2-part request q Obeys commands 6 Brings hand above clavicle to stimulus on head/neck q Localizing 5 Bends arm at elbow rapidly but features not predominantly abnormal q Normal flexion 4 Bends arm at elbow, features clearly predominantly abnormal q Abnormal flexion 3 Extends arm at elbow q Extension 2 No movement in arms/legs, no interfering factor q None 1 Paralyzed or other limiting factor q Non testable NT References Teasdale G, Jennett B.

4 Assessment of coma and impaired consciousness. A practical Scale . Lancet 1974; 2:81-4. Teasdale G, Allen D, Brennan P, McElhinney E, Mackinnon L. The Glasgow Coma Scale : an update after 40 years. Nursing Times. 2014;110:12-16. Glasgow Coma Scale website. Accessed June 28, 2016. CDC website. Accessed June 28, 2016.