Fundamentals of Nursing
55 years old male looks at you when you speak to him, when you ask him about the date he says blue, and…
55 years old male looks at you when you speak to him, when you ask him about the date he says blue, and withdraws his legs to pain. The GCS score is?
الشرح
Core Concept: The Glasgow Coma Scale (GCS) is a neurological scale used to reliably measure a person's level of consciousness after a traumatic brain injury, based on eye, verbal, and motor responses.
Clinical Presentation:
- Altered mental status, trauma.
Diagnosis:
- *First-line:* Clinical assessment using the GCS.
- *Gold Standard:* Non-contrast CT head for structural injury.
Management:
- *Acute:* Calculate GCS: Eye-opening to voice = 4. Verbal response (inappropriate words, e.g., "blue") = 3. Motor response (withdraws to pain) = 4. Total GCS = 4 + 3 + 4 = *11*.
- *Definitive:* A GCS of 9-12 indicates moderate brain injury. Monitor closely for deterioration, maintain airway if GCS drops ≤ 8, and obtain neuroimaging.