 Welcome to Nursing School Explained and this video on the Glasgow Coma Scale which is an evaluation tool to help us determine the patient's mental status after a traumatic brain injury. Now it can also be used in other settings such as after a stroke for example, but after traumatic head injury this is usually kind of like the golden standard that we like to use. And it's divided into three different categories which are the eye response, the patient's verbal response and their motor response and we give them a number. So eye for eye opening we have four different scales. So the first one is spontaneous meaning you go in to assess the patient and their eyes open spontaneously or they are open already which is the biggest score of a four. Now if the patient's eyes are closed when you approach them and you say hello, mister or missus so and so and they open their eyes then that would be a three meaning that they've opened their eyes to your voice, to the sound of your voice. Now number two then or a score of two is when the patient opens their eyes to pain and we want to be mindful when we elicit a painful response or a response to pain from the patient. So this could be anything from most people think about external rub which can be quite invasive or maybe pinching their nail bits which can be kind of painful as well if you want to just try it on your own nail bit. And you always want to make sure that you start with the least amount of pain you can possibly inflict on this patient and then maybe pinch that fingernail a little bit more if there is no pain. And so if they then respond to pain by withdrawing or moaning that would give them a score of two if there is no eye opening at all it would be a score of one. For the verbal response so there are five numbers now or a scale five to one or one to five. So if the patient is oriented they get a score of five meaning we ask them for orientation questions orientation to person place time and event. If they answer less than four of the orientation questions correctly that means they are this oriented and they get a score of four. If they respond to your questions with inappropriate words meaning you ask them what happened to you and they say my brother then that would be an inappropriate response to the question that you just asked and would assign them a score of three. If there are incomprehensible words meaning there's just gibberish or some kind of sounds that don't make sense at all there would be a score of two. And again if the verbal response is none so the patient doesn't say or make a sound it would be a one. Now for motor response we have six different numbers here we can assign the patient. So if they obey the commands squeeze my fingers for example open your eyes smile those kind of things of the neurologic exam. If they obey commands they get a score of six. If they have purposeful movement meaning that they localize to pain meaning that maybe you tap them on your arm and they kind of try to move your hand away that would mean that they are able to localize where that where that touch happened and that would be a score of five. If they withdraw from pain meaning they just kind of jerk away from you that would be a score of four and then we have posturing here which is usually a pretty significant sign already that means that there are some probably some pretty significant brain injury going on is the court kid meaning that the patient is posturing and that is an involuntary response where the patient's hands and arms come towards the core that's how I remember that the court kid to the core which gives them a score of three and then the cerebrate gives them a score of two and that means the posturing has moved from the core all the way down to the cerebrate and I have some separate videos where I discuss the post posturing here exactly and so the cerebrate posturing is worse than the court kid because they get a three or a two depending on what response we have and then if there's no more response at all so if the patient is not moving they get a score of one so if we look this over the best score the patient can achieve is a 15 and the minimum score is a three so if the patient is completely unresponsive in the i motor and verbal response they still get a score of three so it is not a score of zero you cannot get a score of zero on a glass called coma scale and then this in between here less than eight of a gcs means that the patient is comatose so there's some significant insult that has happened to their brain and if there is a score of three meaning that there is no response at all in either category they are considered unresponsive or yeah unresponsive and then over here this is a tidbit that i always like gcs less than eight intubate meaning that the patient if they are comatose they are more than likely not able to protect their airway and it is our job to do that for them so then they will be intubated and if this is due to a traumatic brain injury they will have to go to all the imaging studies if they're stable enough to see what exactly is going on what kind of injury they sustained so thanks so much for watching on this this video on the glass call coma scale gcs please also check out my other skills videos about assessments and different scales so you become more familiar with those thanks for watching see you soon