![]() If the motor response is different on each side, the better response is incorporate within the Glasgow coma scale.Ģ.3 Responses must be recorded on the relevant observation chart in black ink. Spinal reflexes may cause the arms/legs to flex briskly in response to pain and must not be interpreted as a response.Ģ.2 Always record the best arm response. The following are important points to note when assessing a patient's level of consciousness using the Glasgow coma scale and calculating a Glasgow coma score (GCS).Ģ.1 The arms give a wider range of responses and for this reason are always observed using the Glasgow coma scale. Recommendations for assessing eye opening, verbal response and motor response are specified. ![]() The guidelines focus on the practical aspects of carrying out and interpreting the Glasgow coma scale and pupil responses. It is the method favoured by The Leeds Teaching Hospitals NHS Trust and these guidelines have been developed to standardise practice so that the Glasgow coma scale and pupil responses can be assessed in a consistent manner to minimise misinterpretation. The Glasgow coma scale developed by Teasdale and Jennett (1974) is the most widely used assessment tool to measure a patient's level of consciousness. Introduction and BackgroundĪssessment of conscious level is an essential component of neurological examination and is usually performed together with assessment of pupillary size and reaction, vital signs, and focal neurological signs in the limbs. Any neurological deterioration must be reported promptly as support and intervention may be required.Guidelines for Assessing the Glasgow Coma Scale and Pupil Responses in Adultsĥ. Professional knowledge, judgement and policy, will influence the frequency of this assessment, which can be as regular as every 15 minutes ( Derbyshire and Hill, 2018). The frequency of neurological observations will be informed by the condition of the patient and reviewed regularly by a registered practitioner ( NICE, 2017). Neurological observations should only be performed by appropriately competent staff and must be recorded accurately ( National Institute for Health and Care Excellence (NICE), 2017). If concerns are raised, assessment will include observations that indicate the function and status of an individual's nervous system. ![]() Generally, this relates to consciousness, which is the earliest and most sensitive indicator of change in neurological status ( Hickey, 2013). That is, issues related to neurological function, which in turn disable the individual in some manner. This is the ‘D’ for ‘disability’ in the ABCDE algorithm taught in professional health settings. Nurses completing a structured assessment will consider the neurological status of their patient. ![]()
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