GCS

 

Neurologic Vital Signs Nicole

ligno

Katherine Rebolos

 

History •

•

•

Published in 1974

Graham Teasdale and Bryan J. Jennett, professors of neurosurgery University of Glasgow's Institute of University Neurological Sciences at the city's Southern General Hospital

 

Guidelines Ensure that the

best response is recor recorded ded for

each category If

possible, have the same person assess the patient’ss GCS each time patient’

 

Contraindication Not

used in newborns. n ewborns. APGAR score will be

used for this age group.

 

Equipments Pen

light

Glasgow Coma

SPERM

Scale Assessment As sessment tool

Assessment Tool

 

SPERM Sensorium Awake: Perceives the environment clearly and responds quickly and appropriately to visual, auditory, and other sensory stimuli. Drowsy:

Dooends s nsottopst ceuivlieatpp heroepnrviiartoenlymbeuntt sfluolw lylyanodr w reistp nd setirm ppr h delay. He or she may be roused by verbal stimuli but may ignore some of them.

 

SPERM

Sensorium Stuporous:

Aroused by intense stimuli only. Loud noise may elic el icit it a no nons nspe peci cifi ficc react eactio ion. n. Comatose:

Does not perceive the environment and intense stimuli produce a rudimentary response if any

 

SPERM

Pupils  2-4mm (Normal) 

Pinpoint -Seen with opiate overdose and pontine hemorrhage

 Small-

Normal in w well ell lighted lighted environmen environment. t. May May also mean pontine pontine hemoorrhage, hemoorrhage, and metabolic metabolic coma coma

 Midposition-Norm -Normal al

but brain if in in midpositi midpo sition on and non non reactive the cause is mid damage  Large-Normal in dark room, seen with drug intake  Dilated-T -Terminal erminal stage stage of severe ano anoxia-ishemia xia-ishemia or at death

 

SPERM

Eye Movement  Spontaneous Full  Spontaneous Limited  (+) Doll’s Eye Sign  (-) Doll’ Dol l’ss Eye Sign

AKA: oculocephalic refle reflex, x, It is where rotation/flexion rotation/flexion of the of the head cause transient ey eye e movement in the opposite direction. Assesses brain stem functioning. Only present in unconscious patients.

 

SPERM Respiration  Regular Normal 

(12-20/min)

Regular Fast (>20/min) (