Glasgow Coma Scale (GCS) is used to measure?

KPSC Staff Nurse - 2016

Medical & Surgical Nursing

Easy

Appeared in: KPSC Staff Nurse - 2016

Explanation

The Glasgow Coma Scale (GCS) is the international standard for objectively assessing a patient's level of consciousness.
It evaluates neurological function across three domains: eye opening (E), verbal response (V), and motor response (M).
The sum of the scores (E+V+M) provides a total score from 3 to 15, which quantifies the patient's level of consciousness and can be trended to monitor for improvement or deterioration.

Option A: Intracranial Pressure (ICP) is the pressure exerted by fluids inside the skull on the brain tissue. It is measured directly using invasive monitoring devices like an intraventricular catheter, not a clinical assessment scale.
Option B: Memory is a higher cognitive function. While a patient with a good GCS score is likely to have intact memory, the GCS itself does not test for recall of past or present events.
Option D: Fluid volume status is a measure of a patient's hydration. It is assessed through physical signs (e.g., skin turgor, mucous membranes), vital signs (blood pressure, heart rate), and monitoring fluid intake and output.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Purpose and components of the Glasgow Coma Scale (GCS) as background academic context rather than a clinical decision trigger.
The GCS is a critical tool in emergency, ICU, and neurological settings for the initial assessment and continuous monitoring of patients with traumatic brain injury, stroke, or any condition causing altered mental status.
A drop of 2 or more points in a patient's GCS score is a clinically significant finding that indicates neurological deterioration and requires immediate notification of the healthcare provider.
What if the patient is intubated and cannot speak? The verbal component is documented as 'T' (for tube), and the score is reported out of 10 (e.g., GCS 7T). The assessment then relies heavily on the eye and motor responses to gauge neurological status.

How to Approach the Question

Identify the core subject of the question, which is the 'Glasgow Coma Scale (GCS)'.
Recognize this as a factual recall question asking for the primary function of a specific, named clinical tool.
Recall the three components of the GCS: Eye, Verbal, and Motor responses. Understand that these are all measures of a patient's responsiveness.
Evaluate the given options: 'Intra Cranial Pressure' is a physical pressure, 'Memory' is a cognitive function, 'Level of Consciousness' is a state of arousal and awareness, and 'Fluid volume' relates to hydration.
Connect the function of assessing responsiveness (Eye, Verbal, Motor) to the most fitting option, which is 'Level of Consciousness'.

Concept Tested & Keywords

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 86-88

E6 Nursing Fundamentals Taylor p. 412-414