The Glasgow Coma Scale helps describe a person’s level of consciousness through three components: eye opening, verbal response, and motor response. In nursing, documenting each component makes communication clearer than reporting a total alone.
This guide covers adult assessment. Using the scale requires training and must follow your institution’s protocol. For young children, use the appropriate pediatric assessment.
Before scoring, check the assessment conditions
Check for factors that limit the response, such as intubation, sedation, local injuries, or difficulty communicating. Do not automatically interpret a limitation as an absent neurological response.
Observe the person before applying a stimulus. Then use the standardized approach taught in your training. The official Glasgow Coma Scale assessment aid in Portuguese organizes assessment into checking, observing, stimulating, and scoring. This summary does not replace a practical demonstration of the technique.
What are the three components?
Eye opening: 1 to 4
There are four levels: the eyes open spontaneously (4), in response to sound (3), after appropriate pressure (2), or remain closed when no factor prevents assessment (1).
Verbal response: 1 to 5
Assess an oriented response (5), confused communication (4), individual words (3), sounds without words (2), or no verbal response when the component can be tested (1).
Motor response: 1 to 6
The score considers obeying commands (6), localizing the stimulus (5), normal flexion (4), abnormal flexion (3), extension (2), or no movement when the component can be tested (1). Distinguishing localization from flexion requires the standardized technique, not simply observing that the person moved.
When should you use “not testable”?
If a limitation prevents assessment of a component, document NT, or the equivalent designation used in the record, and explain the reason. An endotracheal tube, for example, may prevent verbal assessment. This differs from observing no response in a person who could respond.
The official guidance on interfering factors recommends that you do not assign 1 to a component that cannot be tested and do not report a total when a component is not testable. Components that can be assessed remain useful for tracking changes.
Do not stop sedation or other treatments on your own to obtain a score. Discuss the assessment conditions with the responsible team and follow the treatment orders and protocol.
How to document and communicate changes
When all components can be tested, the total ranges from 3 to 15. An example entry is “E4 V4 M6, total 14/15,” accompanied by the time and relevant description. For an intubated person, a possible example is “E3 VNT M6, verbal response not testable because of intubation,” without inventing a total.
Compare assessments performed under known conditions. Report changes in sedation or other limitations alongside the score. During handoff, highlight what changed and whether the team has already been notified.
How should a low score be interpreted?
In the classification of traumatic brain injury, the usual ranges are 13 to 15 for mild, 9 to 12 for moderate, and 8 or less for severe. These labels belong to that context; they do not summarize the severity of every condition.
The NICE guideline on head injury recommends early involvement of a clinician trained in advanced airway management when the Glasgow Coma Scale score is 8 or less. Clinical decisions also consider breathing, protective reflexes, and other conditions. Communicate deterioration immediately, without waiting for the total to reach a particular threshold.
For further review, see our nursing care plans. The scale describes responses; assessment and management remain the clinical team’s responsibility.