Assess a patient's level of consciousness using the Glasgow Coma Scale. Select the best eye, verbal, and motor responses to calculate the GCS score and severity classification.
GCS Score
15 / 15
Severity
Mild brain injury
E4 + V5 + M6 = 15
Mild: 13–15 | Moderate: 9–12 | Severe: 3–8
GCS 8 or below: Consider endotracheal intubation for airway protection. Patient unable to maintain airway independently.
GCS below 15 after head trauma: CT head recommended per guidelines (Canadian CT Head Rule). Evaluate for intracranial pathology.
GCS 12 or below: Consider ICU-level monitoring. Frequent neuro checks (q1-2h) with escalation protocol for declining scores.
GCS 8 or below with traumatic brain injury: Urgent neurosurgical evaluation. Consider ICP monitoring if GCS 3-8.
Clinical decisions should be based on full clinical assessment, not GCS score alone.
The Glasgow Coma Scale was developed in 1974 by Graham Teasdale and Bryan Jennett at the University of Glasgow. It provides a reliable, objective way to record the conscious state of a patient. The scale is widely used in trauma care and critical care nursing to guide treatment decisions, predict outcomes, and communicate patient status across care teams.
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool that measures a patient's level of consciousness. It evaluates three responses: eye opening (1–4), verbal (1–5), and motor (1–6), producing a total score from 3 (deep coma) to 15 (fully alert).
GCS is used in emergency departments, ICUs, and neurological assessments to evaluate patients with head injuries, strokes, altered mental status, or any condition affecting consciousness. It is commonly assessed at regular intervals to track neurological changes.
A GCS score of 8 or below generally indicates a severe brain injury, and the patient may be unable to protect their airway. The common guideline is 'GCS of 8, intubate' — meaning endotracheal intubation should be strongly considered to protect the airway.
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