Feature
Assessing the neurological status
of patients with head injuries
A guide on using the Glasgow Coma Scale in
emergency departments to assess patients who have
sustained head injuries, by Michelle Caton-Richards
Summary
The aim of this article is to inform staff who are new to emergency care settings
how to use the Glasgow Coma Scale (GCS) when managing patients with head
injuries. It may also be useful as a refresher for experienced staff and a helpful
teaching tool. It emphasises the need for continual, standardised assessment
of neurological status and emphasises how the GCS is seen as best practice
nationally and internationally.
Keywords
Head injuries, neurological assessments, Glasgow Coma Scale scores
Patients with head injuries are common
presentations to emergency departments (EDs),
with about one million such patients attending UK
EDs each year (Sanders 2008).
According to the National Institute for Clinical
Excellence (2001), 80 per cent of head injuries are
non-life threatening and do not require patients to
be admitted. Some of the remaining 20 per cent of
head injuries require neurosurgical intervention,
however, so rapid response to patients with
deteriorating head injuries is paramount.
Wellington (2005) discusses the importance
of timely, effective assessment, observation
and intervention of patients with head injuries,
and awareness of the complications that can
arise from such injuries, to achieve the best
possible outcome.
It is vital that all emergency care professionals
understand the neurological observations that
should be documented, especially in patients with
impaired consciousness, to prevent secondary brain
injury due to hypoxia or hypotension (Watson 2006).
Wyatt et al (2008) agree that emergency nurses
are ‘fundamental to keeping morbidity to a
minimum by being vigilant and preventing secondary
28 March 2010 | Volume 17 | Number 10
brain injury’ while Fairley and Pearce (2006) state
that ‘accurate, consistent assessment of a patient
with impaired consciousness is crucial to determine
deterioration or improvement’.
Watson (2006) found, however, that nurses
frequently have concerns about undertaking
neurological assessments.
In the UK, the most widely used assessment
tool for measuring consciousness is Teasdale and
Jennett’s (1974) Glasgow Coma Scale (GCS) (Fairley
and Pearce 2006, Iankova 2006, Dawes et al 2007).
The GCS enables nurses to score wakefulness,
awareness and activity by observing eye opening,
verbal response and limb movements. Pupil response
and extent of limb movement are also recorded.
Scores on the GCS are between 3 and 15,
and patients with scores of 8 or less are considered
to have severe brain injury (Aucken and Crawford
1998) and may require anaesthetic reviews
or intubation.
Most ED and ambulance service staff use the GCS
to keep continuous records of patient consciousness
following head injury according to recommendations
of the National Institute for Health and Clinical
Excellence (NICE 2007).
Patients whose GCS scores are recorded are
usually those with head injuries or altered levels
of consciousness but the GCS scores of all patients
except those in the minor injuries area should
be recorded to ensure that nurses can recognise
changes in their conditions (Lower 1992).
Neurological observations should include not
only GCS scores, but also vital signs such as pulse
rate, blood pressure, oxygen saturation, respiratory
rate and temperature (NICE 2007). All of these
observations can be recorded on the GCS observation
chart (Figure 1).
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 Feature

Figure 1 Example of an observation chart

Time observations are made Notes
Spontaneously
Eyes
To speech Eyes closed by
open
To pain swelling = C
None
Orientated
Glasgow Coma Scale

Endotracheal
Best Confused
tube or
verbal Inappropriate words
tracheotomy
response Incomprehensible sounds
=T
None
Obey commands
Localise pain
Best Usually record
Withdraws from pain
motor the best arrival
Flexion to pain
response response
Extension to pain
None
Total score
40
39
Temperature 38
(°C) 37
36
35
200 Pupil scale
190 (mm)
180
170 1
160 2
150 3
140
Blood 130 4
pressure and 120
pulse rate 110 5
100
90 6
80
70
60 7
50
40 8
30
Respiration
Size
Right Reaction = +
Reaction
Pupils

No reaction = –
Size Eye closed = c
Left
Reaction
Normal power
Mild weakness If there is a
Severe weakness difference
Arms
Spastic flexion between limb
Limb movement

Extension movements
No response on the right
Normal power and left
Mild weakness sides, record
Severe weakness separately
Legs Spastic flexion and indicate
Extension as L and R
No response

EMERGENCY NURSE March 2010 | Volume 17 | Number 10 29

 Feature
The GCS comprises three scales, concerning
eye opening, verbal response and motor response,
for which scores are given. When completing GCS
observation charts, healthcare professionals should
also note each patient’s respiration and temperature,
and pupil response and limb movement.
Eye opening
■■ Patients whose eyes are open score 4.
■■ Patients whose eyes are closed are asked to open
them. If they are in a deep sleep, or are hard of
hearing in one or both ears, requests should be
shouted in each ear. If they open their eyes, they
score 3.
■■ If patients do not open their eyes to shouted
requests, painful stimuli such as squeezing of the
trapezium or application of supraorbital pressure
should be applied (Mooney and Comerford 2003,
Waterhouse 2005, Dawes et al 2007). While the
painful stimulus is applied, patients are asked one
or more times to open their eyes. If they do so,
they score 2.
■■ Patients who do not open their eyes score 1.
Verbal response
Before asking patients questions, their languages,
cultures, and sight and hearing difficulties, must
be considered. If patients become uncomfortable
when asked questions by healthcare professionals,
relatives can ask them instead. Patients who are too
frightened to answer questions should be reassured.
In patients with dementia, confusion may be normal,
so their medical histories and previous attendance
notes should be checked, or relatives or carers
should be contacted.
■■ Patients who can answer questions clearly score 5.
These questions should not be difficult to answer.
■■ Patients who can hold conversations but appear
confused score 4. Such confusion is evident when,
for example, patients cannot answer questions,
or fail to recognise close relatives or identify
where they are. It may also present as repetitive
questioning, forgetfulness or the mistaken use
of commonly used words (Haas and Ross 1986).
These details are important because confusion
may not manifest straightaway, so patients must
be listened to carefully.
■■ Patients who use words inappropriately or can
construct only partial sentences score 3. In some
patients, these responses are normal, so medical
histories should be checked and language barriers
taken into account. What healthcare professionals
may think is a random collections of words may
be all that patients can say in English, however,
and relatives or translators may be needed.
30 March 2010 | Volume 17 | Number 10
■■ Patients who make only incomprehensible
sounds such as grunts and groans score 2.
However, the presence of facial or mouth injuries
that prevent these patients from talking, and
cerebrovascular accidents or brain injuries, must
be taken into account before scoring.
■■ Patients who make no verbal response score 1.
Motor response
When motor responses are being checked, patients
should not be asked to wiggle their toes or squeeze
other people’s hands because these may be natural
reflexes rather than responses to instructions.
Patients with spinal injuries such as central cord
syndrome can squeeze other people’s hands,
sometimes with normal strength, but cannot lift
their arms due to bicep muscle weakness (Sheerin
2005). Patients on spinal boards should be asked to
make thumbs-up signs.
■■ Patients who can follow instructions, such as ‘Lift
your arms’ or ‘Bend your legs’, score 6.
■■ In patients who cannot follow motor instructions,
painful stimuli such as squeezing of the
trapezium should be applied. Patients who raise
their hands to prevent this score 5.
■■ Patients who cannot raise their hands but only
withdraw from such stimuli score 4.
■■ Patients who cannot withdraw from, but can
bend their limbs in response to, painful stimuli
score 3. This movement is known as abnormal
flexion, and as decorticate posturing or rigidity
(Wyatt et al 2008).
■■ Patients who cannot withdraw from, but can
extend their limbs in response to, painful stimuli
score 2. This movement is known as abnormal
extension, and as decerebrate posturing or rigidity
(Wyatt et al 2008).
■■ Patients who make no response to painful stimuli
score 1.
Pupil response
The sizes and shapes of patients’ pupils are
measured against those in, and recorded on, GCS
charts. Pupils are normally round and their normal
range of size is between 2mm and 6mm in diameter
(Dawes et al 2007).
In each patient, a bright light is shone from
the outside to the middle of each eye, one after
the other, to measure pupil response. It may be
necessary to dim or turn off lights in the area to
obtain an accurate response. The light should induce
pupil constriction in both eyes, even when the light
is shone into only one eye, and pupil dilation in
both eyes when the light is moved away. If there is
a positive reaction, a ‘+’ is recorded; if there is only
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 Feature

sluggish reaction, an ‘s’ is recorded; if there is no
reaction, a ‘-’ is recorded; and, if the eye is closed
due to swelling or bruising, a ‘c’ is recorded.
Past medical histories regarding the eyes,
such as cataract surgery, glaucoma or blindness,
all of which can affect pupil reaction, should
be noted. Abnormally large, abnormally constricted
or sluggish pupils can be due to drug use, as well as
brain injury or abnormalities, so patients should be
asked whether they have taken recreational drugs
(Fairley et al 2005, Jevon 2008). Extra information
should be documented.
Limb assessment
Separate limb assessments are undertaken to
determine inequality or weakness between the left
and right arms and legs.
Patients are asked to lift their limbs and use
them to exert force. This can determine whether
limb movement is normal, or slightly or severely
weak. In patients who cannot move their limbs at
all, painful stimuli are applied to elicit response, and
verify extension and flexion.
Regular assessment
The National Institute for Health and Clinical
Excellence (2007) recommends regular neurological
observations, especially in the first four hours
after injury, when critical changes such as rising
intracranial pressure can occur (Woodrow 2000).
Observations and their frequency are as follows:
■■ Initial assessment within 15 minutes of a patient
arriving at the ED.
■■ Half-hourly assessments until the patient has
a GCS score of 15.
■■ Further assessments every two hours, with the
regimen being restarted if the GCS score drops
below 15.
Changes in vital signs or GCS score must be reported
to the senior healthcare professional in the ED because
low blood pressure and poor oxygen saturation can
lead to secondary brain injury (Watson 2006).
According to NICE (2007) guidelines, the following
should also be reported to the senior healthcare
professional in the ED:
■■ A drop in GCS score of 1 point lasting more than
30 minutes.
■■ A drop of 3 or more in eye opening or verbal
response score lasting more than 30 minutes.
■■ A drop of 2 or more in motor response score.
■■ Agitated or abnormal behaviour.
■■ Severe, persistent headache despite pain relief.
■■ New or evolving neurological symptoms such as
pupil or limb asymmetry, or facial movement.
Implications for practice
The Glasgow Coma Scale (GCS) is an internationally
recognised tool for the management of patients
with head injuries and those who are unconscious,
so registered nurses must understand how it
should be used.
In using the GCS, healthcare professionals must:
■■ Calculate patients’ GCS scores on their arrival to the
ED to ensure that there are baseline scores against
which subsequent scores can be measured.
■■ Ensure that the GCS scores of patients who
have been undergoing neurological observations
are consistent by discussing them with the
appropriate nurses during handovers.
■■ Do not assume low GCS scores are caused by This article has been subject
to double-blind review
alcohol use, even in patients who have been
drinking alcohol. Michelle Caton-Richards
■■ Do not assume that patients’ GCS scores will was at time of writing a
sister in the emergency
remain unchanged while they sleep but wake department at the Royal Surrey
them every 15, 30 or 60 minutes depending on County Hospital, Guildford,
how often the GCS is being assessed. and is now an associate
advanced nurse practitioner
■■ If GCS scores drop, repeat assessments once at Heatherwood and
and then consult a senior colleague. Wexham Park Hospitals
NHS Foundation Trust, Berkshire

References
Aucken S, Crawford B (1998) Neurological
assessment. In Guerrero D (Ed) Neuro-Oncology
for Nurses. Whurr, London.
Dawes E, Lloyd H, Durham L (2007)
Monitoring and recording patients’ neurological
observations. Nursing Standard. 22, 10, 40-45.
Fairley D, Pearce A (2006) Assessment of
consciousness: part one. Nursing Times.
102, 4, 26-27.
Fairley D, Timothy J, Donaldson-Hugh M et al
(2005) Using a coma scale to assess patient
consciousness levels. Nursing Times.
101, 25, 38-41.
Haas DC, Ross GS (1986) Transient global
amnesia triggered by mild head trauma. Brain.
109, 2, 251-257.
Iankova A (2006) The Glasgow Coma Scale:
clinical application in emergency departments.
Emergency Nurse. 14, 8, 30-35.
Jevon P (2008) Neurological assessment:
part 2. Pupillary assessment. Nursing Times.
104, 28, 26-27.
Lower J (1992) Rapid neuro assessment.
American Journal of Nursing. 92, 6, 38-45.
Mooney GP, Comerford DM (2003) Neurological
observations. Nursing Times. 99, 17, 24-25.
National Institute for Clinical Excellence
(2001) Scope for the Development of a Clinical
Guideline on Head Injury in Children and
Adults: Assessment, Investigation And Early
Management. NICE, London.
National Institute for Health and Clinical Waterhouse C (2005) The Glasgow Coma
Excellence (2007) Head Injury: Triage, Scale and other neurological observations.
Assessment, Investigation and Early Nursing Standard. 19, 33, 56-64.
Management of Head Injury in Infants,
Watson D (2006) The impact of accurate patient
Children and Adults. www.nice.org.uk/CG056
assessment on quality of care. Nursing Times.
(Last accessed: February 18 2010.)
102, 34, 34-37.
Sanders KL (2008) Head injuries. In Dolan B,
Wellington B (2005) Development of a guide
Holt L (Eds) Accident and Emergency: Theory
for neurological observations. Nursing Times.
into Practice. Second Edition. Elsevier Health
101, 32, 34-36.
Sciences, Atlanta GA.
Woodrow P (2000) Head injuries: acute care.
Sheerin F (2005 Spinal cord injury: causation
Nursing Standard. 14, 35, 37-44.
and pathophysiology. Emergency Nurse.
12, 9, 29-38. Wyatt JP, Illingworth RN, Graham CA et al
(2008) Oxford Handbook of Emergency
Teasdale G, Jennett B (1974) Assessment of
Medicine. Third Edition. Oxford University
coma and impaired consciousness: a practical
Press, Oxford.
scale. The Lancet. 2, 7282, 81-84.

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