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Glasgow Coma Scale (GCS) for healthcare professionals: How to strengthen your neurological assessment. 09/21/23 at 8am PST @Lwnurses #LWN #LearnWithNurses Vanessa Teed MSN, RN, CEN, CGNC Certified Global Nurse Consultant Nurse Educator and Adjunct Faculty, El Camino College, California USA vteed@elcamino.edu Linkedin.com/in/vanessateedUsing Medall.org INTRODUCTION Nursessavelives.Y oucansavelives. Neurological disorders are the leading cause of disability and death worldwide , with a 39% increase in deaths over the past 30 years. The greatest burden is in low- and middle-income countries. Nurses in any practice setting may encounter patients with neurological disorders and injuries. (Feigin et al., 2020; Pan, 2020)Why Strengthen your Neurological Assessment Skills? Testing a nurses knowledge of the Glasgow Coma Scale. Three independent studies in 2016 1. Nigeria, Edo State – 226 nurses – Tertiary Hospital. • Ehwarieme & Anarado = Good knowledge 41.7%. 2. Malaysia, Kuala Lumpur - 135 nurses – Emergency (ER) • Basauhra Singh, et. al = Good Knowledge 41.48% 3. Brazil, Sao Paulo – 127 nurses – Intensive Care Unit (ICU) • Santos et. Al = Good knowledge of the GCS but poor knowledge of the scale Learning Objectives 1. Describe the Glasgow Coma Scale (GCS) and its purpose 2. Identify the components of Glasgow coma scale 3. Recognize how to appropriately calculate a Glasgow coma scale 4. Demonstrate an understanding of the implications of different GCS scores 5. Summarize the best practices for administering the Glasgow Coma ScaleReflection Think back to a scenario where you as the nurse used the Glasgow Coma Scale (GCS) to assess a patient. Did you feel confident? The Glasgow Coma Scale (GCS) Universally Most widely used Introduced in 1974 Was featured in the Now used for acute Accepted Tool neurological tool at the University of 1980 & 1988 and chronic for measuring Glasgow by journal of Advanced patients in a variety neurosurgery Trauma and Life of settings and comas and Professors Sir support the GCS countries. Known for its decreases in Graham Teasdale was recommended validity, consciousness and Bryan Jennett for all types of reliability, and while working in injuries. objectivity. the Institute for Neurological Sciences at the Southern General Hospital. (Teasdale et. Al., 2014; Jennett, 2002; Glasgow Coma Scale, www.glasgowcomascale.org/) The Purpose of the GCS v Widely used to assess level of consciousness in patients with severe brain injury or other types of brain injury. v Level of consciousness is either the state of awareness, wakefulness, or alertness. Coma is a state of unarousable unresponsiveness. (Tindall, 1990). v Used to establish baseline findings, detect deterioration, and monitor progress. v Standardized & objectiveness enhances communication and minimizes errors v Used in conjunction with a complete neurological assessment. v Interpretation of the GCS is correlated to other neurological findings (Brennen, 2020; Hammond & Zimmermann, 2019; www.glasgowcomascale.org/Image canva.com;) The Components of the Glasgow Coma Scale Opening of the Eyes (E), and Verbal (V), and motor responses (M). From The Glasgow Coma Scale, www.glasgowcomascale.org. Adapted with permission. How to appropriately calculate a Glasgow Coma Scale score First Check & Observe Physiologic conditions may alter the accuracy and scoring. Assess disease process, look for handicaps, language barriers, eye or facial Trauma, hearing or visual loss, sedation, intubated, spinal cord injuries, substance abuse. Numerical Value measured against the criteria of the 3-15 scale. 15 indicates the person is awake 3 is the minimum score, indicates deep unconsciousness or a severe head injury. NT Not Testable Adapted from Glasgow Coma Scale: Do it this way (2015). www.glasgowcomascale.org Copyright 2015 Teasdale. Adapted with permission. The GCS Eye (E) Possible score (E) 4 Adapted from Glasgow Coma Scale: Do it this way (2015). www.glasgowcomascale.org Copyright 2015 Teasdale. Adapted with permission. The GCS Verbal (V) Possible score (V) 5 Adapted from Glasgow Coma Scale: Do it this way (2015). www.glasgowcomascale.org Copyright 2015 Teasdale. Adapted with permission. The GCS Motor (M) Possible score (M) 6 The GCS Motor (M) Adapted from Glasgow Coma Scale: Do it this way (2015). www.glasgowcomascale.org Copyright 2015 Teasdale. Adapted with permission. v A study by Kumar et al. (2019) found the total GCS score predicted outcomes with 88% accuracy in acute stroke patients, particularly early mortality after the event. v GCS total score is out of 15 v Written as E (_) V(_) M(_ ) v Great resources & video at • https://www.glasgowcomascale.org/#video Adapted from Glasgow Coma Scale: Do it this way (2015). www.glasgowcomascale.org Copyright 2015 Teasdale. Adapted with permission. The GCS and Children Application of the Glasgow Coma Scale in Pediatrics The Glasgow Coma Scale can be used in children older than 5 years with no modification. The GCS is not applicable for children younger than 5 years of age. Research done by Simpson, D. & Reilly, P. v University of Adelaide v 1982 & 1988 v Created a “paediatric coma scale” (Hammon & Zimmermann, 2019; Jain & Iverson, 2023; Kirschen et. al., 2019; glasgowcomascale.org, Image canva.com) Challenges & Barriers affecting accuracy of scoring v Experience level & knowledge deficit v Neurological assessment is one of the most complex portions of a physical exam. v Nurses who care for neurological patients need to have excellent assessment and reasoning skills. v Understanding what is normal and what is not. v What to look for, how to do it, and how to record the information, and what actions to take. v Symptoms vary based on disease or disorder v Changes can be subtle or intense, stable or progressive. (Albin 2020; Hammon & Zimmermann, 2019; Image canva.com) Implications of different GCS scores v Murray et. al (1993) routine prediction service was shown to change patient management in a study of 1025 patients admitted to four British neurosurgical units between 1986 and 1989 following severe head injuries. v A widely used classification system for early severity of head injury into v mild score 13–15 v moderate score 9–12 v severe score < 8 v The lower the score the poorer the prognosis. v Warning sign that something is happening and needs further assessment v Most frequent causes of altered mental status - hypoglycemia & hypoxia v Critically ill & Emergent patients are at a high risk, early recognition and treatment of such injuries may prevent or mitigate long term and irrepressible injury. v Important to know the brain disorders and diseases, adverse processes affecting the brain. Haemorrhage, seizure, stroke, hypoxia, ischemic, trauma, encephalopathy, metabolic disturbances. (Albin, 2020; Ehwarieme & Anarado, 2016; National Institute for Health and Care Excellence (NICE) 2019; Murray et. al., 1993) Image canva.com)Best practices for administering the Glasgow Coma Scale Discover country specific tools and the GCS used at your place of work. Find a credible resource or tool that you understand and that works for you. Learn it, practice it. A good nursing neurological assessment has several benefits, including v early detection and intervention v accurate diagnosis and treatment planning v prevention of complications v ensuring patient safety v delivery of high-quality care To improve your neurological assessment & GCS skills: Practice! And Embrace a growth mindset and understand that learning is ongoing. Continue to study and learn on the necessary nursing interventions, diagnostic tools, treatments, and their implications. It’s ok to ask for help! References Albin, A. (2020). A Study to Assess the Effectiveness of Planned Teaching Programme on selected Neurological Assessment in terms of Knowledge and Practice among staff nurses working in selected units of selected hospitals of Ahmedabad city, Gujarat state. International Journal of Advances in Nursing Management. 8(2):118-122. https://doi.org/10.5958/2454- 2652.2020.00028.1 American Psychological Association (2020). Publication Manual of the American Psychological Association (7 Ed.) https://doi.org/10.1037/0000165-000 Basauhra Singh, H. K., Chong, M. C., Thambinayagam, H. C., Zakaria, M. I., Cheng, S. T., Tang, L. Y., & Azahar, N. H. (2016). Assessing Nurses Knowledge of Glasgow Coma Scale in Emergency and Outpatient Department. Nursing research and practice, 2016, 8056350. https://doi.org/10.1155/2016/8056350 Brennan, P. M., Murray, G. D., & Teasdale, G. M. (2020). A practical method for dealing with missing Glasgow Coma Scale verbal component scores. Journal of Neurosurgery, 135(1), 214-219. https://doi.org/10.3171/2020.6.JNS20992 Ehwarieme, T.A., & Anarado, A.N. (2016). Nurses' knowledge of Glasgow coma scale in neurological assessment of patients in a selected tertiary hospital in Edo State Nigeria. Africa journal of nursing and midwifery, 18, 74-86. doi: 10.25159/2520-5293/1068. Feigin, V. L., Vos, T., Nichols, E., Owolabi, M. O., Carroll, W. M., Dichgans, M., Deuschl, G., Parmar, P., Brainin, M., & Murray, C. (2020). The global burden of neurological disorders: translating evidence into policy. The Lancet. Neurology, 19(3), 255–265. https://doi.org/10.1016/S1474-4422(19)30411-9 Hammon, B.B. & Zimmermann, P.G. (2019) Sheehy’s Emergency Nursing: Principles and Practice (7th Edition) By Emergency Nurses Association (ENA) Elsevier Mosby. Jain, S., & Iverson, L. M. (2023). Glasgow Coma Scale. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513298/ Jennett, B. (2002). The Glasgow Coma Scale: History and current practice. Trauma, 4(2):91-103. https://10.1191/1460408602ta233oa Kirschen, M. P., Lourie, K., Snyder, M., Agarwal, K., DiDonato, P., Kraus, B., Madu, C., Geddes, K., Nadkarni, V., Davis, D., Wolfe, H., & Topjian, A. (2019). Routine Neurological Assessments by Nurses in the Pediatric Intensive Care Unit. Critical care nurse, 39(3), 20–32. https://doi.org/10.4037/ccn2019198 Kumar, V.A, Bhandarkar, P., Roy, N., Kumar. V., Kamble, J., Agrawal, A. (2019). Predictive value of Glasgow coma score and its components in interpreting outcome in trauma patients. Journal Datta Meghe Institute of Medical Sciences Univerversity, 14(2), 94-98. https://doi.org/10.4103/jdmimsu.jdmimsu_16_18 References Murray, L.S., Teasdale, G. M., Jennett, B., Kelly, D., Murray, G. D., Miller, J. D., Jones, P., Pickard, J. D., Bailey, S., Shaw, M. D. M., Achilles, J., & Lacey, J. (1993). Does prediction of outcome alter patient management? The Lancet (British Edition), 341(8859), 1487–1491. https://doi.org/10.1016/0140-6736(93)90631-P National Institute for Health and Care Excellence. (2019). Suspected neurological conditions: recognition and referral. (NICE Guideline NG127). https://www.nice.org.uk/guidance/qs198 Pan, H., Ding, S., Liu, X., Zou, Z., Xu, Q., & Ye, Z. (2021). Analysis of nursing assessment terminology for neurological conditions and its cross-mapping with the International Classification of Functioning, Disability and Health (ICF): A multi-centre cross-sectional study. Nursing open, 8(5), 2686–2695. https://doi.org/10.1002/nop2.825 Santos, Vancini-Campanharo, C. R., Lopes, M. C. B. T., Okuno, M. F. P., & Batista, R. E. A. (2016). Assessment of nurse’s knowledge about Glasgow coma scale at a university hospital. Einstein (São Paulo, Brazil), 14(2), 213–218. https://doi.org/10.1590/S1679-45082016AO3618 Teasdale, G., Allan, D., Brennan, P., McElhinney, E., Mackinnon, L. (Oct 15-Oct 21, 2014) Forty Years on: Updating the Glasgow Coma Scale. Nursing Times: NT; London, 110(42), 12- 16. https://www.proquest.com/magazines/forty-years-on-updating-glasgow-coma-scale/docview/1620411352/se-2 Teasdale, G., Allan, D., Brennan, P., McElhinney, E., Mackinnon, L. (n.d). Website. The Glasgow Structured Approach to Assessment of the Glasgow Coma Scale https://www.glasgowcomascale.org/who-we-are/ Tindall, S. C. (1990). Level of Consciousness. In H. K. Walker (Eds.) et. al., Clinical Methods: The History, Physical, and Laboratory Examinations. (3rd ed.). Butterworths. The Royal College of Physicians and Surgeons of Glasgow.(n.d.) The Glasgow Structured Approach to Assessment of the Glasgow Coma Scale.(n.d). https://www.glasgowcomascale.org/ IMAGES & Figures • The Glasgow Coma Scale (GCS), GCS Aid, GCS-P score, GCS P-Age CT prognostic charts and GCS verbal score imputation tool may be used for clinical care and clinical research at no cost. No license is required. https://www.glasgowcomascale.org/ • Glasgow University (GCS), and Sir Graham Teasdale (GCS Aid) Glasgow Coma Scale: Do it this way(2015) Adapted with permission. https://www.glasgowcomascale.org/ • Slides provided by Learn With Nurses • Slides and select images from canva.com