(1) Ask the patient to run his left heel along his right shin (while standing)
and vice versa.
(2) Ask the patient to close his eyes, extend his arms, and touch his index
finger to his nose.
(3) Ask the patient to walk in a straight line, forward and backward.
Observe posture and balance.
2-16. LEVEL OF CONSCIOUSNESS
a. The Glasgow Coma Scale (GCS) is a standardized, objective, reliable
instrument for the assessment of level of consciousness.
b. The scale measures three areas of observable behavioral responses (verbal,
motor, and eye). Patient responses are graded by the degree of dysfunction. The
patient's best response in each of the three areas is recorded. The combined score of
the three areas is the "consciousness level" score.
c. Recording and/or graphing the scores on a flow sheet permits easy tracking
of the patient's status.
d. Response scale. (Explanation)
(a) 4 points--eyes open spontaneously.
(b) 3 points--eyes open in response to sound.
2 points--eyes open in response to painful stimuli.
(d) 1 point--eyes do not open in response to any stimuli.
(a) 5 points--the patient is oriented to person, place, and time.
4 points--the patient is confused but is able to communicate.
(c) 3 points--the patient speaks in a disorganized manner.
(d) 2 points--the patient's response is moaning or groaning sounds.
(e) 1 point--the patient does not respond.