![]() ![]() The average size is 2-5mm (Bersten et al, 2003). Pupil size should be measured, ideally with reference to a neurological observation chart or similar. Although not part of the Glasgow Coma Scale (covered in part three of this series next week), examination of the pupils is an essential adjunct to it, especially when the patient’s level of consciousness is impaired (Bersten et al, 2003). ![]() 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 (Smith, 2003).īoth pupils should be the same shape, size and react equally to light. Regardless of what pain is applied no response or reaction is made by the patient.Įffective Glasgow Coma Scale DemonstrationĪ practical video demonstrating each stage within the Glasgow Coma Scale on a Patient.Īfter the initial 3 stage assessment, it is important to assess pupil reaction and limb movement. Stimulus causes th e patient to extend their arm by straightening the elbow and may be associated with internal shoulder and wrist rotation. This movement is much slower than normal flexion.Įxtension to pain- during a painful stimulus an extension movement is made. Stimulus causes abnormal flexion of limbs, such as the patient bending their arm characterized by internal rotation and adduction of the shoulder and flexion of the elbow. When a painful stimuli is applied, the patient flexes or bends the arm towards the source of the pain but fails to locate the source of that pain.įlexion Abnormal- during a painful stimulus an abnormal response is made. The patient does not respond to a verbal stimulus but purposely moves an arm to remove the cause of the central painful stimulus.įlexion Withdrawal- withdraws to painful stimuli. When a painful stimuli is applied to the patient, they localize to the site of that pain. Localizes- localizes to painful stimulus. The patient can perform two different movements such as stand up or stick tongue out. Obey Commands- fully obeys simple commands given. No sounds at all are being made by the patient. Regardless of the questions being asked, the patient does not understand, and only makes comprehensible sounds. Inappropriate Sounds- only incomprehensible sounds are being made by the patient. Clear words are heard but are inappropriate answers to the question asked. Inappropriate Words- sentences contain inappropriate words and jumbled phrases consisting of words.Īfter a question is asked the patient struggles to articulate their words. Struggles to understand and answer questions logically. Knows own name, DOB, where they are, what day it is, what time it is, who is prime minister for example.Ĭonfused- responses remain confused, but speech is coherent. Orientated- fully alert and orientated to time and place. To pain- eyes will only open to a painful stimuli on their skin.Ī pply pressure to a nail bed, or trapezius squeeze. To speech- eyes will only open to the sound of your voice. Spontaneous- eyes open spontaneously/ normally. So what exactly does that mean? Eye Opening The Glasgow Coma Scale provides a practical 3 stage method for assessment of impairment of conscious level in response to defined stimuli. stroke, as this would affect the movement of the patients arms. Check patient notes for any medical condition that may affect the accuracy of the GCS, e.g.Ascertain the patient’s acuity of hearing.It is important to understand that when carrying out any neurological assessment the following points need to be made due to affecting the accuracy of the results: ![]()
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