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Notes

NCLEX image.jpgGlasgow Coma Scale

Adult-ChildInfant
Eyes Open SpontaneousSpontaneous4
On commandTo voice 3
To painTo pain2
UnresponsiveUnresponsive1
Best Verbal OrientedCoos, babbles 5
ConfusedIrritable, fussy 4
InappropriateCries to pain 3
IncomprehensibleGrunts, moans 2
UnresponsiveUnresponsive1
Best Motor Obeys commandsPurposeful 6
Localizes painLocalizes pain5
Withdraws from painWithdraws from pain4
Abnormal flexionAbnormal flexion3
Abnormal extensionAbnormal extension2
UnresponsiveUnresponsive1

Reporting: The total GCS score should be broken down into its relative components (e.g., a GCS of 11 can be stated as E3V3M5).

Score: 13-14 indicates mild brain injury; 9-12 indicates moderate brain injury; and 3-8 indicates severe brain injury.

Teasdale, G., & Jeanett, B. (1974). Assessment of coma and impaired conciousness: a practical scale. The Lancet, 304(7872), 81-84. With permission.