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learning zone
CONTINUING PROFESSIONAL DEVELOPMENT
Page 56 Page 66 Page 67 Page 68
The Glasgow Coma Neurological assessment Guidelines on how Read Marilyn Bailey’s
Scale and other multiple choice to write a practice practice profile on
neurological observations questionnaire profile palliative care

The Glasgow Coma Scale and other

neurological observations
NS289 Waterhouse C (2005) The Glasgow Coma Scale and other neurological observations. Nursing
Standard. 19, 33, 56-64. Date of acceptance: October 14 2004.

Summary Introduction
The primary tool used by nurses to assess a patient’s neurological Many patients are admitted to neurosurgical units
status is the neurological observation chart incorporating the from general clinical areas such as medical units or
Glasgow Coma Scale. This article explains the correct use of the accident and emergency departments. Nurses
chart and how to interpret the findings. working in these areas need to be able to perform a
Author basic neurological assessment accurately and
understand the significance of the findings.
Cath Waterhouse is lecturer practitioner, Royal Hallamshire Accurate assessment and prompt action when
Hospital, Sheffield. Email: [email protected] needed can improve the eventual outcome, not
Keywords just in terms of survival but also by minimising the
degree of residual neurological deficit.
Glasgow Coma Scale; Neurological assessment; Observations; The neurological observation chart
Vital signs incorporating the GCS is well established both
These keywords are based on the subject headings from the British nationally and internationally (Teasdale and
Nursing Index. This article has been subject to double-blind review. Jennett 1974) as the primary tool used by nurses
For related articles and author guidelines visit the online archive at to make quick, repeated evaluations of several
www.nursing-standard.co.uk and search using the keywords. key indicators of neurological status (Auken and
Crawford 1998):

Level of consciousness (GCS).
Aims and intended learning outcomes
Pupil size and response to light.
This article aims to raise awareness of basic
Limb movements (motor and sensory function).
neurological observations, namely the Glasgow

Vital signs.
Coma Scale (GCS), pupil reaction, limb responses
and vital signs. It should be of value to all nurses Recently published guidelines for the
who care for patients at risk of neurological management of patients with head injuries
deterioration. It explains how to complete the (National Institute for Clinical Excellence (NICE)
neurological observation chart, which includes 2003) stipulate the use of the GCS for assessment
the GCS, accurately, safely and consistently. After and classification of all head-injured patients.
reading this article you should be able to: Although there have been some useful articles

Outline the rationale for using the GCS. on the GCS tool (Ellis and Cavanagh 1992, Shah
1999, Woodward 1997a, b, c, d), benchmarking

Assess a patient’s level of consciousness by
standards have relied on consensus and the
evaluating three behavioural responses: eye
expertise of skilled nurses from neuroscience
opening, verbal response and motor response.
units throughout the UK.

Perform a neurological assessment, using the The layout and appearance of the neurological
GCS, pupil reaction, limb responses and vital observation chart incorporating the GCS will vary,
signs, and interpret the findings. depending on the trust in which you work.

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Time out 1 FIGURE 1

Cross-section of the brain
Obtain your local neurological
observation chart:
■ Identify which section makes up the GCS.
Note what other observations are contained
within the form.
■ Consider the relevance of the observations
to determining the level of consciousness.

The GCS was originally developed to monitor the

progress of patients with an acute head injury;
however, it is now generally considered to be a
useful tool for assessing all patients who are
potentially at risk of neurological deterioration,
regardless of their primary pathology. The GCS is
designed to assess the integrity of normal brain
function and is the best tool for consistently
assessing a patient’s level of consciousness (Auken FIGURE 2
and Crawford 1998). Lateral view of the brain
However, the apparent ‘simplicity’ of the tool
leaves it open to misunderstanding and misuse
(Addison and Crawford 1999). ‘Quick and easy
to use’ does not denote insignificant (Shah 1999).
In practice, although practitioners may be able to
tick the right ‘boxes’ on the chart, few nurses
appreciate the mechanism underpinning the
assessment, which enables them to act
appropriately when the patient’s condition
changes. Not infrequently, a patient’s changing
neurological state is not identified early enough to
be either life-saving or prevent further brain
insults (Ellis and Cavanagh 1992).

Time out 2
Anatomy and physiology
Recall a patient that you have
nursed recently who was having The skull is a hard, unyielding structure
neurological observations carried out. containing brain parenchyma and cerebrospinal
■ Identify the potential causes of a reduced fluid (CSF), interstitial fluid and arterial and
level of consciousness in the patient. It is venous blood. There is little ‘free space’ to
quite possible that a patient’s low level of accommodate expanding lesions such as a blood
consciousness is not an intracranial pressure clot, tumour or oedema. Therefore, any increase
problem but is post-ictal or drugs-related, in the volume of one of the primary components
for example. will, unless compensated for by a corresponding
■ Discuss these with a colleague and add four reduction in the volume of another component,
other possible causes of a reduced level of lead to an increase in pressure inside the skull.
consciousness. This will compress the blood vessels and severely
compromise blood flow and perfusion to the
cerebral tissues (Hickey 2002 , Lindsay and Bone
Time out 3 2004). Total intracranial volume = brain + CSF +
blood. Possible causes of raised intracranial
Label as many of the marked pressure (ICP) are listed in Box 1.
structures on Figures 1 and 2 as you Consciousness Consciousness has been defined
can without using a textbook. Check and as ‘a general awareness of oneself and the
complete the exercise using a general anatomy surrounding environment, it is a dynamic state
and physiology textbook, such as Martini that is subject to change’ (Hickey 2002).
(2001) or Tortora and Anagnostakos (2003). Consciousness consists of two components:

Arousal or wakefulness, which is largely a

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neurological condition. In practice, this means

learning zone neurological assessment that you should imagine that you are ‘taking the
patient’s photograph’ and then record what you
see in it, thereby avoiding the temptation to adjust
function of a specialised group of neurones the information to take into account either the
within the brainstem known as the reticular patient’s medical history or any pre-existing
activating system (RAS). barriers to communication or language. Another
potential error is failure to stimulate patients

Awareness and cognition, which is a function
sufficiently to get a true reflection of their
of the higher cortical areas of the cerebral
neurological responses (Addison and Crawford
cortex activated via the thalamic portion of the
1999, Lower 1992).
RAS.
Unless you have a firm baseline for
The Glasgow Coma Scale comparison, you are not going to recognise when
the patient’s neurological condition deteriorates
The score derived from the GCS provides an and will not be able to react appropriately to the
essential baseline for comparison with future rising ICP (Lower 1992).
scores to determine whether a patient’s How to assess best eye response This directly
neurological condition is improving, static or assesses the functioning of the brainstem and
deteriorating. Its graphic, visual format ensures demonstrates to the assessor that the RAS has
uniformity and gives a quick, concise, visual been stimulated and the patient is aware of his or
interpretation of the patient’s level of her environment. Note that eye opening is not
consciousness, and hence neurological status over always an indication of intact neurological
a period of time (Shah 1999). functioning. Patients who have been assessed as
The GSC evaluates three key categories of being in a persistent vegetative state will open
behaviour that most closely reflect activity in the their eyes (they also track movement) as a direct
higher centres of the brain: eye opening, verbal reflex action generated by the RAS.
response and motor response. These enable us to Eye opening spontaneously – scores 4 This is
determine whether the patient has cerebral recorded when the patient is seen to be awake,
dysfunction. Within each category, each level of with eyes open. Approach the patient. If aware of
response is allocated a numerical value, on a scale your presence, the patient should open his or her
of increasing neurological deterioration and eyes without the need for speech or touch.
brain insult. The lowest score that a patient can Eye opening to verbal command – scores 3
achieve is 3, indicating total unresponsiveness. Again, this observation is made without
The maximum score is 15, indicating an awake, touching the patient. Speak to the patient in a
alert and fully responsive patient (Table 1) normal voice first. Then, if necessary, gradually
(NICE 2003). raise your voice. In some cases the patient will
The GCS was designed specifically as a tool for respond better to a familiar family voice.
detecting and monitoring changes in a patient’s Eye opening to pain – scores 2 Initially, to avoid
unnecessary distress, simply touch or shake the
BOX 1 patient’s shoulder. If there is no response to this
Causes of raised intracranial pressure manoeuvre, a deeper stimulus is required, and a
peripheral stimulus must be applied. Before any

Extradural, subdural or intracerebral haematoma stimulus is applied, it is essential to explain to the
patient and relatives exactly what you are going

Cerebral oedema (primary and secondary) occurring as a response to do and why, apologising for the need to hurt
to injury the patient (even if he or she appears to be

Obstructed venous return due to a thrombus or embolism unconscious).
At this stage of the assessment it is important

Hypercapnia (excess carbon dioxide in the blood) causes to use a peripheral painful stimulus, as the
vasodilation of cerebral vessels, and hence a rise in intracranial application of a central painful stimulus tends to
pressure make patients close their eyes and induces a

Tumour and its associated oedema resulting from compression grimacing effect (Teasdale and Jennett 1974),
of surrounding tissue and increasing permeability of the which is not the response you are trying to
capillary walls achieve.
Peripheral stimulation involves applying

Hydrocephalus – increase in the volume of cerebospinal fluid pressure with a pen to the lateral outer aspect of

Metabolic factors - renal and hepatic disease, electrolyte imbalance the second or third finger, rotating the point of
resulting in diffuse cerebral oedema(Hickey 2002) stimulation around on each assessment. Pain
should be applied gradually, up to a maximum of
ten seconds, and then released. This can be

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repeated, but the patient should suffer only

TABLE 1
momentarily and not experience long-term pain
(Fairley and Cosgrove 1999). If the desired Glasgow Coma Scale and Score (NICE 2003)
response is still not observed it is important to
Feature Response Score
seek a second opinion.
Under no circumstances should sternal Best eye response Open spontaneously 4
rubbing or nail-bed pressure be used, as this Open to verbal command 3
can result in unnecessary bruising and
Open to pain 2
prolonged residual discomfort (Fairley and
Cosgrove 1999). No eye opening 1
No eye opening – scores 1 This score is recorded Best verbal response Orientated 5
when no response to a painful stimulus is
Confused 4
observed. This should only be recorded when the
nurse is satisfied that a sufficient stimulus was Inappropriate words 3
used. Remember that inadequate stimulation Incomprehensible sounds 2
will lead to an inaccurate assessment. No verbal response 1
Points to note

If the patient’s eyes are closed as a result of Best motor response Obeys commands 6
swelling or facial fractures, this is recorded Localising pain 5
as ‘C’ on the chart. In such cases it is Withdrawal from pain 4
impossible to perform an accurate
Flexion to pain 3
assessment of the patient’s level of arousal or
awareness. Extension to pain 2
No motor response 1

A good sensitive indicator of neurological
change is the patient’s level of consciousness –
is the patient becoming more difficult to
the patient’s ability to articulate and express a
rouse? Patients will often become increasingly
reply.
restless, or a previously restless patient may
Orientated – scores 5 This assesses orientation to
become atypically quiet.
time, place and person. Patients must be able to

Even if the patient is thought to be in a chronic tell you:
state of long-term coma, his or her eyes may be
Who they are (their name).
wide open but he or she will not be aware of

Where they are and why (in which town or city
him or herself or the environment. One of the
and the name of the hospital).
criteria for diagnosing persistent vegetative
syndrome is that the patient develops a
The current year and month (avoid using the
sleep-wakefulness cycle (Berrol 1986, Jennett day of the week or the date).
and Teasdale 1977). Remember only record
what you see. If all three questions are answered correctly, the
patient may be classed as orientated.
Time out 4 Confused – scores 4 If one or more of the above
questions are answered incorrectly, the patient
■ Reflect on and write down how must be recorded as being confused. If the patient
you would carry out the eye has recently been transferred from another
opening part of the Glasgow Coma hospital, some degree of disorientation is
Scale assessment. understandable, but remember that such subtle
■ Observe a colleague (or ask him or her to orientation loss can be a good early indicator of
describe his or her practice) and discuss, and neurological deterioration (Frawley 1990).
note, any variations in approach. At the same time, it is important to attempt to
■ Identify where eliciting an eye opening re-orientate patients by correcting all wrong
response is difficult or impossible, yet answers. Reassure them, and ask them to try to
unrelated to conscious level. How should remember for the next time you ask. Typically,
these situations be managed? patients who are deteriorating will lose
orientation to time, place and person – in that
order (Shah 1999).
How to assess best verbal response Best verbal Inappropriate words – scores 3 Completely
response provides the practitioner with understandable conversation is usually absent or
information about the patient’s speech, extremely limited. Patients offer words rather
comprehension and functioning areas of the than sentences, which make little sense in the
higher, cognitive centres of the brain, and reflects context of the questions. Sometimes these words

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learning zone neurological assessment Time out 5

From your experience, what
barriers unrelated to altered
are communicated as obscenities. Patients with a consciousness may prevent you from
motor dysphasia are often difficult to assess as obtaining or
they are frequently unable to utter the words they interpreting a verbal response from a patient?
wish to say, or are unable to think of the right
words to express themselves. Patients may also How to assess best motor response Best motor
continue for an exceptionally long period, response tests the area of the brain that identifies
repeating a phrase or particular words – this is sensory input and translates this into a motor
known as perseveration (Patten 1998). response. The best possible motor response is
Incomprehensible sounds – scores 2 Although being able to obey simple commands
the patient’s response can follow verbal convincingly, and is the highest level of motor
questioning, more often it comes in direct response (Frawley 1990).
response to a painful stimulus. The patient Obeys commands – scores 6 The patient can
responds to speech or painful stimulation with no accurately respond to instructions. Ask the
understandable words, and may only be able to patient to perform a couple of different
produce moaning, groaning or crying sounds. If movements, for example, stick out his or her
the patient has sustained damage to the speech tongue, raise his or her eyebrows, show his or her
centres in the brain and is unable to talk, but teeth and hold up his or her thumb. If asking
remains aware and alert, the score must still be patients to ‘squeeze my fingers’, ensure that you
recorded as 2, unless alternative communication also ask them to ‘let go’, to discount a primitive
devices such as writing, computers or light writers grasp reflex. It is good practice to have patients
can be used. obey two different commands, and at the very
No verbal response – scores 1 The patient is least they should obey the same command twice
unable to produce any speech or sounds in (Lower 1992).
response to speech or painful stimuli. Localising pain - scores 5 This is the response to a
Points to note central painful stimulus. It involves the higher

If the patient is unable to respond because of centres of the brain recognising that something is
the presence of a tracheostomy or hurting the patient and trying to remove that pain
endotracheal tube, this should be recorded on source (Jennett and Teasdale 1977). A painful
the chart as a letter ‘T’. stimulus should be applied only when the patient
shows no response to verbal instruction, and need

If the patient is dysphasic, this should be not be applied if the patient is already localising,
recorded on the chart as a letter ‘D’. for example, by pulling at an oxygen mask or

The recording of accurate baseline nasogastric tube.
observations is the most important element of To be classified as localisation, patients must
the tool as it allows the practitioner to identify move their hand to the point of stimulation,
the earliest subtle signs. For this reason, every bringing the hand up towards the chin, across the
assessor must apply the same stimulus in the midline, in an obvious, co-ordinated attempt to
same manner and question each patient in the remove the cause of the pain. It is useful to start
same way (Frawley 1990). with the arm in a 30° flexed position to minimise
any anomalies when assessing abnormal flexion

One criticism of the GCS tool (Williams or extension.
1992) is that patients cannot be adequately Three methods of applying a central painful
assessed if they have any kind of stimulus have been recognised by the National
communication difficulties related to age Neuroscience Benchmarking Group:
(cannot be used for patients under five years 1. Supra-orbital pressure – This was identified
old), language (no comprehension of the as the ‘gold standard’ but must only be used
English language), or any pre-existing when the practitioner has been trained to apply it
pathology that might affect speech such as correctly. Just below the inner aspect of the
learning difficulties or stroke. It is important eyebrow is a small notch through which a branch
not to attempt to adapt, change or write on of the facial nerve runs. The nurse’s hand rests on
the chart to ‘fit in’ with the patient – you the head of the patient, and the flat of the thumb
must only record what you see. Information or the knuckle is placed on the supra-orbital
gathered from the family, such as the ridge under the eyebrow. Pressure is gradually
patient’s preferred name or details of any increased for a maximum of 30 seconds. This is
pre-existing deficits, may be invaluable in contraindicated if there is any orbital damage or
making an accurate assessment. skull fracture (in which case the ‘trapezius
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squeeze’ is a suitable alternative (Ellis and

Cavanagh 1992)). Time out 6
2. Jaw margin pressure Pressure is applied at the
angle of the jaw. Rest the flat of the thumb against Discuss with a medical colleague
the corner of the maxillary and mandibular and a nursing colleague, the conditions,
junction and apply gradually increasing pressure other than serious reduction in level of
for a maximum of 30 seconds. consciousness, that may contribute to a
3. The trapezius squeeze – The trapezius muscle patient becoming unable to move their limbs.
extends across the back of the shoulders from the
middle of the neck. Hold the muscle between the General notes
thumb and forefingers and apply gradually
increasing pressure for a maximum of 30 The level of consciousness is the most sensitive
seconds. The trapezius muscle has both a sensory indicator of neurological deterioration. Unless
and a motor component and there is a risk of the patient is receiving anaesthetic agents or
eliciting a spinal reflex on stimulation. sedatives, it should be possible to identify
Other methods of applying a central painful deterioration using the GCS, before changes in
stimulus are not recommended because they can pupils or vital signs occur.
elicit a peripheral reflex response only. A deterioration of 1 point in the motor
Withdrawal from pain – scores 4 In response to response or an overall deterioration of 2 points in
a central painful stimulus, patients will bend the GCS score is clinically significant and must be
their arms at the elbow as a normal flexion reported immediately to a senior member of staff
reflex action, but fail to locate the source of the (Cree 2003, NICE 2003). To ensure consistency,
pain. the same member of staff should carry out the
Flexion to pain – scores 3 This is also known as assessment over a given shift. At handover, the
decorticate posturing. It occurs when there is a receiving nurse should observe how the GCS
block in the motor pathway between the cerebral score was obtained. Without such continuity,
cortex and the brain stem. It is a much slower subtle yet significant alterations can be missed
response to a painful stimulus, and can be (Grant et al 1990).
recognised by the patient flexing the upper arm Patients will often give out subtle clues that
and rotating the wrist. Often the thumb comes they are deteriorating such as becoming less
through the fingers. communicative with slower responses,
Extension to pain – scores 2 This is also known as particularly relating to changes in their
decerebrate posturing. It occurs when the motor behaviour. The practitioner must be attentive to
pathway is blocked or damaged within the these changes and document them in the patient’s
brainstem, and is characterised by straightening records. Lack of confidence in completing the
of the elbow and internal rotation of the shoulder chart can lead practitioners to be influenced by
and wrist. Often the legs are also in extension, the previous assessment (Watson et al 1992).
with the toes pointing downwards. Always ask a colleague to reassess if you are
No motor response – scores 1 The patient’s brain unsure of the procedure. The GCS was not
is incapable of processing any sensory input or intended to be used in isolation. It should be used
motor activity, and the patient is therefore unable in conjunction with other aspects of the
to move at all in response to a painful stimulus. neurological assessment, such as pupil reaction,
Before recording ‘none’, ensure that adequate limb responses, temperature and vital signs
stimulation has been applied. Note that a patient (Addison and Crawford 1999).
may be unresponsive because of local disease or
injury. Time out 7
Points to note

Always record the best arm response using a Consider the legal and ethical
central painful stimulus: when assessing motor aspects of causing direct pain to
response it is the brain that is being assessed, patients when assessing the motor response,
not the spinal response. Spinal reflexes may and the methods by which the pain stimulus is
cause limbs to flex briskly and can even occur applied. Discuss the key issues with your
in patients who have been certified brainstem colleagues and reflect on their perceptions of
dead (Stewart 1996). these.

Nurses should also be aware of their own non-

Pupil reaction
verbal behaviour, as patients may simply
mimic what they see, giving rise to Pupil reaction is a very important observation as
interpretation error. it gives the practitioner a ‘window to view the
brain’ and is the only way of monitoring the

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learning zone neurological assessment
Brisk pupils are recorded as ‘+’, unreactive
pupils as ‘–’ and sluggish pupils as ‘S’.

A bright pen torch must be used – not an
neurological status of a sedated patient. Table 2 ophthalmoscope.
sets out guidelines for the assessment of pupil
Minor inequalities in the size of the pupils are
reaction to light and the rationale for the normal.
procedure.
Any changes in pupil reaction, shape or size
It is not uncommon for healthy people to have
are a late sign of raised ICP. Sluggish or suddenly pupils of unequal size.
dilated unequal pupils are an indication that
Very small pupils (1-2mm) may suggest the use
oedema or haematoma is worsening and the of opiates, fentanyl or barbiturates.
oculomotor cranial nerve is being compressed
through the foramen magnum. Urgent
The use of eye drops, such as atropine, can
intervention at this stage can make a significant dilate the pupils.
difference to the patient’s outcome. Remember
that some patients may have a pre-existing Limb responses
ophthalmic condition that produces a
unilaterally dilated pupil, such as a cataract or Evaluation of limb responses provides the
localised injury. assessor with detail of the geographical
A more subtle sign is constriction and dilation distribution of dysfunction, and is an important
of the pupil without regard to light. The pupil is consideration when performing a full
unable to sustain its constriction in the presence neurological assessment of the patient (Lower
of a bright light and re-dilates (referred to as 1992). Each limb should be assessed separately.
unilateral hippus (Patten 1998)). Ask patients to hold their arms out in front of
All of these signs are obvious danger signals them and observe for signs of weakness or ‘drift’.
and must be reported to the medical team Assess the legs by asking patients if they can push
urgently, as this is a medical emergency and and pull their feet towards the assessor, or ask
potentially life-threatening. whether they are able to raise their legs off the
Points to note bed and hold them there briefly. A peripheral

If both eyes are closed because of gross orbital painful stimulus needs to be applied to limbs that
swelling, this is recorded with a letter ‘C’. have not been seen to move.

TABLE 2
Guidelines for assessment of pupil reaction to light

Procedure Rationale
Inform the patient, whether conscious or not, Helps to reduce anxiety. Ensures, as far as
that you are going to look into his or her eyes possible, that the patient consents to, and
with a torch, and explain the procedure understands, the procedure
Reduce the light from overhead lights to see Enables a better view of the eye and reaction
any pupil reaction to a light stimulus
Wash hands thoroughly Prevents contamination of the eye and reduces
the risk of infection
Hold the patient’s eyes open and note as a Normal pupils are round, usually central and
baseline the size, shape and equality of the range in diameter from 1.5mm to 6.0mm
pupils as an indication of brain damage
Hold one of the patient’s eyes open, and move a To assess pupil reaction to light.
light from the outer aspect of the eye towards A normal reaction indicates no lesion or
the pupil. This should cause the eye to constrict pressure on the third cranial nerve or brainstem
quickly (direct light response) regulating the pupil reaction
Record unusual eye movements such as To assess cranial nerve damage
nystagmus or deviation to the side
Repeat tests on the opposite eye To assess equality of reaction and ensure that
all areas are functioning correctly
(Mallett and Dougherty 2000)

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Temperature emergency departments. They recommend that

head-injured patients with a GCS score of less
A patient’s temperature may be elevated as a than 15 should have half-hourly observations
result of infection; however, a patient who has recorded until the maximum score is reached,
sustained a severe head injury may have localised while patients with a GCS score of 15 should be
damage to the temperature-regulating centre in recorded half-hourly for two hours, one-hourly
the hypothalamus. As the patient’s temperature for four hours then two-hourly thereafter.
rises, cerebral cell metabolism produces excess Although this a useful guide, within clinical
carbon dioxide, producing vasodilation of the areas the patient’s neurological condition
cerebral blood vessels which compounds the usually dictates the frequency of the
existing cerebral swelling. observations, and any adverse change in the
patient’s condition is an indication to increase
Vital signs the frequency of observations. Quality of
observations is at least as important as quantity.
The final warning is Cushing’s triad or reflex – a Discontinuation of neurological
classic set of clinical and physiological signs and observations relies on individual clinical
symptoms which indicate that the ICP is judgement, but it is reasonable to stop them if
dangerously high and the patient is in danger of the patient has been consistently stable for a
‘coning’ (cerebral herniation) which will rapidly couple of days provided that the initial
lead to the death of the patient. The reflex is a pathology has been rectified (NICE 2003).
very late sign and is characterised by
hypertension, bradycardia and respiratory Discussion
irregularity.
Hypertension Typically the patient will have an Addison and Crawford (1999) reported that
elevated systolic blood pressure combined with a the GCS assessment tool is often
widening pulse pressure. This causes systemic misunderstood and misused, and there is little
vasoconstriction and hypertension. evidence to suggest that this situation has

As the ICP increases, arterial blood cannot get changed or improved recently. Research has
through to perfuse the brain. Mean arterial shown that when the GCS observation chart is
pressure (MAP) minus ICP equals cerebral used by general nurses, as opposed to specialist
perfusion pressure (CPP) (MAP - ICP = CPP). ‘neuroscience’ nurses, it can take up to two
hours longer to detect a deterioration in the
When CPP falls below a critical threshold, blood patient’s neurological status (Crewe and Lye
cannot enter the brain. 1990, Fielding and Rowley 1990). This is

As systolic blood pressure increases, diastolic probably because experienced neuroscience
blood pressure remains relatively unchanged, nurses are more practised at identifying the
resulting in a widening pulse pressure. almost imperceptible signs of altered levels of
consciousness and drowsiness, as well as the
Bradycardia The heart rate may drop as low as more subtle behaviour changes that such
35-50 beats per minute. This allows each systole patients may exhibit.
to pump more blood at a higher pressure, forcing Soon after the introduction of the GCS,
blood into the brain during the peak arterial Jennett and Teasdale (1977) acknowledged
systolic blood pressure. that ‘the validity of the assumption that each of
Respiratory irregularity Pressure on the the three parts of the scale should count
respiratory centres in the lower pons and upper equally, and that each step should differ equally
medulla causes impairment of respiratory from the next to it, has still to be tested’. This
patterns. The following patterns may be seen: statement still holds true, despite research that

Cheyne-Stokes breathing. examined the inter-rater reliability of the chart
and concluded that the tool may be used with

Hyperventilation blows off carbon dioxide
confidence to evaluate neurological patients
and constricts cerebral vessels in an attempt to
(Lyons and Juarez 1995, Teasdale et al 1979).
lower ICP.
However, to state that a patient has a GCS

Cluster breathing – periods of rapid irregular score of 5 or 8 or 11 tells us very little about the
and noisy breathing separated by apnoeic patient’s exact neurological status, and it is
spells. important not to take any aspect of
neurological assessment in isolation (Watson et
Frequency of observations al 1992). When communicating the GCS score
it is good practice to state it in terms of the
The NICE (2003) guidelines are specifically individual components, for example, E3, V2,
aimed at managing patients in accident and M4 – indicating that the patient opens his or

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to all healthcare practitioners involved in the

learning zone neurological assessment care and management of potentially vulnerable
and unconscious patients, and should apply to
all neurological observations. Although many
her eyes to speech, offers incomprehensible specialist benchmarking groups have written
verbal responses and flexes to a painful best practice guidelines, further audits and
stimulus. research are needed to establish why errors are
‘The GCS is a tool that, with education, is still being made when performing neurological
simple to use, highlights changes in the patient’s observations.
condition and allows nurses and doctors To maintain the ethos of benchmarking, it is
working in different hospitals to communicate essential that we share our knowledge and skills
the patient’s state of consciousness in a clear with colleagues in other areas to ensure that
and objective way’ (Addison and Crawford neurological observations are performed
1999). Lowry (1999) was critical of the accurately, safely and consistently
structure of the chart; however, it is not the
chart design or its underlying objectives that are
flawed, but the way it is implemented in the
clinical areas. Time out 8
Conclusion Now that you have completed the
article you might like to write a
Addison and Crawford (1999) recommend that practice profile. Guidelines to help you are
all new staff are taught how to apply the GCS on page 67.
tool in clinical practice. This should be extended

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