It differs from the “abnormal flexion response to pain” shown below due to the absence of the other features mentioned (e.g. This response is also referred to as a “ normal flexion response” as the patient typically flexes their arm rapidly at their elbow to move away from the painful stimulus. the patient tries to pull their arm away from you when applying a painful stimulus to their fingertip). This is another possible response to a painful stimulus, which involves the patient trying to withdraw from the pain (e.g. head, neck) and brings their hand above their clavicle, this would be classed as localising to pain, with the patient scoring 5 points. If the patient makes attempts to reach towards the site at which you are applying a painful stimulus (e.g. This assessment involves applying a painful stimulus and observing the patient for a response. If they are able to follow this command correctly, they would score 6 points and the assessment would be over. “Lift your right arm off the bed and make a fist.”). Obeys commands (6 points)Īsk the patient to perform a two-part request (e.g. if they were unable to move their right arm, but able to obey commands with their left arm, they’d receive a score of 6 points). You should score the patient based on the highest scoring response you were able to elicit in any single limb (e.g. The final part of the GCS assessment involves assessing a patient’s motor response. Motor response (M) A maximum possible score of 6 points If the patient is intubated or has other factors interfering with their ability to communicate verbally, their response cannot be tested, and for this, you would write NT (not testable). If the patient has no response to your questions, they would score 1 point. groans) then this would be classed as incomprehensible sounds, with the patient scoring 2 points. If the patient is making sounds, rather than speaking words (e.g.

If the patient responds with seemingly random words that are completely unrelated to the question you asked, this would be classed as inappropriate words and they would score 3 points. Sometimes confusion can be quite subtle, so pay close attention to their responses. they don’t know where they are, or what the date is), this would be classed as confused conversation and they would score 4 points. If the patient is able to reply, but their responses don’t seem quite right (e.g.

If the patient is able to answer your questions appropriately, the assessment of verbal response is complete, with the patient scoring 5 points. “Do you know where you are at the moment?”.Some common questions you can ask to help assess this might include: You should score the patient based on the highest scoring response they demonstrate during the assessment. Verbal response (V) A maximum possible score of 5 pointsĪssessing a patient’s verbal response initially involves trying to engage the patient in conversation and assess if they are orientated. oedema, trauma, dressings), you should document that eye response could not be assessed ( NT). If the patient cannot open their eyes for some reason (e.g. If the patient does not open their eyes to a painful stimulus, they score 1 point. If the patient’s eyes open in response to a painful stimulus, they score 2 points. Applying pressure to the patient’s supraorbital notch.Squeezing one of the patient’s trapezius muscles (known as a trapezius squeeze).Applying pressure to one of the patient’s fingertips.There are different ways of assessing response to pain, but the most common are: If the patient doesn’t open their eyes in response to sound, you need to move on to assessing eye-opening to pain. If the patient’s eyes open in response to the sound of your voice, they score 3 points. If the patient doesn’t open their eyes spontaneously, you need to speak to the patient “Hey Mrs Smith, are you ok?” If however, the patient is not opening their eyes spontaneously, you need to work through the following steps until a response is obtained. You would then move on to assessing verbal response, as shown in the next section. If the patient is opening their eyes spontaneously, your assessment of this behaviour is complete, with the patient scoring 4 points.

To assess eye response, initially observe if the patient is opening their eyes spontaneously. You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.Įye-opening (E) A maximum possible score of 4 points Eyes opening spontaneously (4 points)

Glasgow coma scale score sheet