Neurological Assessment (Glasgow Coma Scale)
Category: Neurological
Overview
Systematic evaluation of neurological function using the Glasgow Coma Scale to assess level of consciousness and detect changes in neurological status.
Indications
Head injury, altered mental status, stroke, seizure disorders, post-anesthesia recovery, neurological monitoring, baseline assessment.
Contraindications
Severe facial trauma preventing eye opening assessment, language barriers without interpreter, sedation affecting accurate assessment.
Equipment Needed
Penlight, Glasgow Coma Scale reference card, documentation materials, stethoscope for vital signs.
Procedure Steps
1. Explain procedure to patient if conscious
2. Ensure adequate lighting for assessment
3. Assess eye opening response (4 points): spontaneous, to speech, to pain, none
4. Assess verbal response (5 points): oriented, confused, inappropriate words, incomprehensible sounds, none
5. Assess motor response (6 points): obeys commands, localizes pain, withdraws from pain, abnormal flexion, abnormal extension, none
6. Calculate total GCS score (3-15 points)
7. Assess pupil size, shape, and reaction to light
8. Check for focal neurological deficits
9. Monitor vital signs and trends
10. Document findings and report significant changes
11. Reassess per protocol or as condition changes
Safety Considerations
Use appropriate stimuli for pain response - avoid tissue damage. Compare to baseline assessments. Report GCS changes of 2 points or more immediately. Ensure patient safety if confused or agitated.
Potential Complications
Inaccurate assessment due to sedation, language barriers, or hearing impairment. Delayed recognition of neurological deterioration. Injury from inappropriate pain stimuli.
Documentation
Record individual GCS component scores, total score, pupil assessment, vital signs, time of assessment, and any changes from baseline.
References
American Association of Neuroscience Nurses. (2020). Core Curriculum for Neuroscience Nursing, 6th Edition. Brain Trauma Foundation Guidelines.