V: Verbal response: patient can receive a max of 5 points and minimum of 1 points or NT (non-testable).

*NT: example…eye swelling or an injury that prevents the eyes from opening Therefore, the patient can be assigned either 1,2,3, 4 or NT (non-testable)Ĥ Points: eyes spontaneously open (walk to the bed side and just look at the patient… are the eyes open?)ģ Points: eyes open to sound, speak in a tone that is loud and clear to be heard (note if the patient has hearing difficulties before attempting or injuries that can prevent hearing clearly)Ģ Points: eyes open to pressure applied to nail bed (use an object like a pen light or pen to gradually increase pressure on the nail bed for up to 10 seconds….note eye-opening response)ġ Point: no response to any of the above stimuli To help you remember what to assess and how to score it while you’re at the bedside remember EVM = 4,5,6Į: Eye-opening response: patient can receive a max of 4 points and a minimum of 1 in this part of the scale rating. This tell us the overall score is 7 but the patient is intubated (capital T tells us this). So, the GCS may look like this GCS 7T (E3 Vt M4). Note: you would not give them 1 point (no response) because you can’t test it and don’t know if they could respond verbally if they could. Therefore, this part would be labeled NT for not testable. Well, it will be hard to get a verbal response out of the patient because they have a tube in their throat, so you can’t test this response category. Before Assessing the GCS….įor example, let’s say the patient is intubated. GCS 7 is the total score, while E2 V2 M3 are the subscores that describe each patient response category of the scale. The subscores are the scores from each of the three responses.įor example, you may see a Glasgow Coma Scale score reported like GCS 7 (E2 V2 M3). Now the overall score is important but so are the subscores. A total GCS score is obtained from adding up all the responses.

GCS 3: lowest score possible and very high death rate…deep coma, severe brain injuryĮach response category of the GCS has its own points, which are added up to give the total GCS. GCS 8 or less: the patient is in a coma and requires intubation due to the inability of airway reflexes that protect us from aspiration to work *A GCS is never higher than 15 or lower than 3….the higher the score the better for the patient. The score can be used to describe the injury. Glasgow Coma Scale scores can range from 3 to 15.Īs pointed out above this scale is useful with patient’s who’ve sustained a head/brain injury.

Glasgow coma scale score sheet