NEUROLOGICAL ASSESSMENT USING THE GLASGOW COMA SCALE (GCS) - Patient Care Policy

Sep 20, 2026

Policy for neurological assessment in intensive care using the Glasgow Coma Scale (GCS). Defines expected outcomes for accurate, reliable scoring and documentation during routine physical assessment, including ongoing reassessment when neurological compromise is suspected. Specifies that registered nurses perform GCS with consideration of limb strength, pupillary light response, and concurrent vital signs, and that changes are reported and acted on immediately. Includes background, purpose, assessment components, scoring sequence, allowable painful stimuli, and required documentation on ICU flowcharts or GCS charts.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

AccessFree to download

Policy Statement

Expected Outcome

Documentation Requirements

Background and Purpose

Assessment Method

Components and Scoring

Sequence of Stimulation

Eye-Opening Criteria

Additional Assessments and Recording

Painful/Noxious Stimulation Guidance

Peripheral vs Central Stimulus

Guidance on Stimulus Types

Liverpool Health Service Policy Issued: CORPORATE MANUAL PATIENT CARE Intensive Care Pxx.xx NEUROLOGICAL ASSESSMENT USING THE GLASGOW COMA SCALE (GCS) Expected Outcome • The Glasgow Coma Score forms part of the patient’s physical assessment and will be assessed and documented during physical assessment. • Ongoing GCS assessment will occur in patients with neurological compromise or those patients with recognised potential for neurological compromise. • Medical and nursing staff will perform neurological assessment utilising the GCS accurately and reliably. Policy Statement • Neurological assessment using the Glasgow Coma Scale will be performed by registered nurses accurately and as required by the patient’s condition. • The Glasgow Coma Scale will incorporate assessment of limb strength and pupillary response to light stimulation. • Assessment of a patient’s neurological status, using the GCS, will be accompanied by assessment of the patient’s vital signs. • Changes to the patient’s neurological status will be reported immediately to the appropriate medical staff. • Where required, changes in neurological status will be acted upon immediately. • If the patient’s GCS is less than 15, and then falls by one point, the appropriate medical staff will be informed immediately. • A MET call is to be initiated when the GCS falls by ≥ 2 points. • Documentation is to occur at all times – even where documentation by exception exists. • Only appropriate painful/noxious stimulus will be used: ⇒ Peripheral stimuli that may be used include (a) pressure to the side of the finger, next to the nail or (b) pinching of the fine skin over the triceps muscle. ⇒ When using peripheral stimulus, care must be taken to ensure that motor response arises from the brain, not mediated by the spine as a reflex arc. For this reason, central stimulus is advocated as first choice for stimulus. ⇒ Currently, (following literature review) there are NO references to the validity of using nipple twists or genital pain as an appropriate painful stimulus in either the nursing or medical sources. It may be used when other forms of recognised painful stimulus have failed to elicit a response from the patient. It is not tobe used as a first line assessment of patient response to stimulus by staff. Background The GCS was developed at Glasgow University and Drs Teasdale and Jennett published its development in 1974. It is a scaled assessment that reviews three areas of neurological functioning and attributes a score to each. Purpose The GCS is a 15-point scoring system designed to objectively assess cortical cerebral function in conjunction with pupillary function and limb strength assessment. It aims to remove both personal interpretations of a patient's condition and confusing descriptors. After education and assessment, staff will be able to assess a patient's condition in a reproducible manner. Results of the score will be used to establish a baseline then used to assess whether the patient's condition is improving, stable or deteriorating. The GCS is always used in conjunction with a patient history as many conditions and events may result inan abnormal score. Reviewed: May 2002 Intensive Care Glasgow Coma Score Review Date: May 2004 Page 1 of 1 Liverpool Health Service Policy Issued: CORPORATE MANUAL PATIENT CARE Intensive Care Pxx.xx Assessment • To assess degrees of coma, three aspects of functioning are considered: ⇒ Eye-opening. ⇒ Verbal response. ⇒ Motor movement. • These are collectively attributed a score out of 15. • These areas of assessment correspond to the complex organisation of the sensory/motor cortex, functions of the lobes of the brain and the brainstem The assessment is carried out in 3 stages: EYE OPENING VERBAL RESPONSE BEST MOTOR RESPONSE | spontaneous to speech
to pain nil | 4 3
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FAQs

Who is responsible for performing and documenting neurological assessment using the GCS?

Registered nurses perform neurological assessment using the Glasgow Coma Scale accurately and as required by the patient’s condition. Documentation must occur at all times, including when documentation by exception exists.

What does the GCS incorporate during assessment?

The GCS reviews eye-opening, verbal response, and best motor response (a score out of 15). The policy also requires assessment of limb strength and pupillary response to light stimulation, alongside the patient’s vital signs.

When should staff inform medical staff or initiate a MET call based on GCS changes?

If the patient’s GCS is less than 15 and falls by one point, appropriate medical staff must be informed immediately. A MET call is to be initiated when the GCS falls by two or more points.

Sep 20, 2026

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