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Nur 411 Glascow Coma Scale Assessment Sheet
- Course
- Nur 411
- Institution
- Borough Of Manhattan Community College
Glascow Coma Scale - Explanation and tool for GCS
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BMCC / CUNYNeurological Assessment Sheet
GLASCOW COMA Initials Initials Comments
SCALE
Determine what type of nursing care for the patient / medical treatment
Best GCS = 15
Lowest GCS = 3
It is never 0
Anything < 8 is an issue
EYE MOVEMENT
Open Spontaneously 4
To Verbal Command 3
To Pain 2
No response 1
Untested
BEST VERBAL Response (use painful stimuli if necessary) T= Intubated, E= Endotracheal tube
Orientated x3 & 5
converses
Disorientated & 4
Converses
What is your name? Miss just
one they are disorientated –
forget where they are but can
talk perfectly fine
Inappropriate words – 3
Good morning? The cat is
purple? Not even making the
connection.
Incomprehensible 2
sounds – making a noise but
not making sense?
No Verbalization 1
Untested
BEST MOTOR Response
Obeys verbal 6
commands
Localizes Pain 5
Flexion withdrawal to 4
pain
Abnormal Flexion (w/ 3
pain) (decorticate)-
damage at the cortical
spinal pathway
Abnormal extension 2
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