Glasgow Coma Scale: How to Score and Document It

The Glasgow Coma Scale is often remembered as “out of fifteen”, but the total is only the headline. The useful clinical information sits in the three components: eye opening, verbal response and motor response. A patient recorded simply as “GCS 12” could have several very different patterns of impairment.

The scale supports a structured description of consciousness. It does not diagnose the cause and it should not replace an ABCDE assessment, pupil examination, blood-glucose check or wider neurological assessment.

The three components

Eye response: E4 to E1

• E4: eyes open spontaneously.
• E3: eyes open to sound.
• E2: eyes open to pressure.
• E1: no eye opening.

Observe before prompting. If the patient’s eyes are already open, that is spontaneous eye opening. If not, use a clear verbal prompt before considering pressure. Swelling, injury or another physical barrier may make the response untestable.

Verbal response: V5 to V1

• V5: orientated.
• V4: confused conversation.
• V3: words, but not a coherent conversation.
• V2: sounds without recognisable words.
• V1: no verbal response.

Orientation is usually explored through appropriate questions about the person, place and time. Consider language, hearing, learning disability, aphasia, developmental stage, intoxication, sedation and an artificial airway. An intubated patient has not demonstrated “no verbal response” in the same way as a patient who is able to speak but makes no sound. Record the reason the component cannot be tested according to the chart and local policy.

Motor response: M6 to M1

• M6: obeys commands.
• M5: localises pressure.
• M4: normal flexion or withdrawal.
• M3: abnormal flexion.
• M2: extension.
• M1: no motor response.

Begin with a simple command that the patient can reasonably perform. If a response to pressure must be assessed, use the technique taught by your university and placement organisation under appropriate supervision. Avoid outdated or unnecessarily harmful practices such as forceful sternal rubbing. Interpret asymmetry carefully and record the best response in line with the chart being used.

Document the components, not just the total

The total ranges from 3 to 15, but document it in a form such as E3 V4 M6 = GCS 13. Include limitations, interventions and the time of assessment. This makes change visible and prevents different patterns from being hidden behind the same total.

Trend matters. A fall in one component may be clinically significant even when the total changes only slightly. NICE recommends using the Glasgow Coma Scale as part of assessment and observation after head injury, alongside pupils, limb movements, respiratory rate, heart rate, blood pressure, temperature and oxygen saturation (NICE, 2023).

Why might the score be reduced?

Possible causes include head injury, stroke, seizure, hypoglycaemia, hypoxia, infection, shock, poisoning, alcohol, prescribed medicines and metabolic disturbance. The score tells you how the patient is responding, not which diagnosis explains it.

Start or return to an ABCDE assessment, check blood glucose where appropriate, examine the pupils, review medicines and seek urgent help for acute change.

Common mistakes

• Recording only a total score.
• Scoring what you think the patient could do rather than what was observed.
• Using painful pressure before sound or a simple command.
• Ignoring barriers such as aphasia, intubation, hearing loss or swelling.
• Comparing scores without checking how each assessment was performed.
• Waiting for the score to fall further before escalating an obvious acute change.

Your role as a student nurse

Use the version of the scale and chart approved locally. Ask a supervisor to observe your technique until you are competent and compare findings when you are unsure. Escalate new reduction, asymmetry or other neurological change immediately through the local pathway.

The Glasgow Coma Scale is not difficult because it contains many numbers. It is difficult because real patients may have injuries, communication differences and treatments that complicate the response. Clear component documentation is what makes the assessment useful.

References

National Institute for Health and Care Excellence (NICE) (2023) Head injury: assessment and early management. NICE guideline NG232. Available at: https://www.nice.org.uk/guidance/ng232 

Resuscitation Council UK (2024) The ABCDE approach. Available at: https://www.resus.org.uk/library/abcde-approach

Teasdale, G. and Jennett, B. (1974) ‘Assessment of coma and impaired consciousness: a practical scale’, The Lancet, 304(7872), pp. 81–84. Available at: https://doi.org/10.1016/S0140-6736(74)91639-0