Honan One Minute Nurse: Glasgow Coma Scale

What is the highest score a patient can receive in the Glasgow Coma Scale (GCS)?

15 Rationale: Eyes can score up to 4 points, verbal up to 5 points, and motor up to 6 points for a total of a 15-point maximum on the GCS.

How many points will a patient receive for spontaneous eye opening on the Glasgow Coma Scale (GCS)?

4 Rationale: The patient who spontaneously opens their eyes receives 4 points for spontaneous eye opening, meaning they can open their eyes without direction. They will get 3 points for opening their eyes in response to speech, 2 points for opening their eyes in response to painful stimuli, and 1 point for no eye opening.

What is the Glasgow Coma Scale (GCS) used to assess?

Level of consciousness Rationale: The GCS is used to assess level of consciousness. It does not address pulses, arrythmias, or strength.

A patient scored 4 points for verbal response on the Glasgow Coma Scale (GCS). What does that indicate?

The patient is confused. Rationale: If the patient is fully oriented, they get 5 points. If they are confused but speaking coherently, they get 4 points. If the patient is saying inappropriate words and jumbled phrases, they'll get 3 points. Incomprehensible sounds scores 2 points, and 1 point is assigned for no verbal response.

What is the best term for decorticate posturing?

The patient withdraws into their core Rationale: Decorticate posturing is when the patient withdraws into their core. Decerebrate is when the arms extend away from the body.