Critical points of GCS

EYE OPENING:

Nurses used central pain stimulus (i.e., trapezius squeeze) when patient did not open his eyes spontaneously

Nurses used pen to apply pressure to the nail bed

VERBAL RESPONSE:

Nurses have interchanged “inappropriate words” and “confusion” in assessing verbal response

Nurses asked one or two questions out of 3 (time, place and person) to elicit orientation level for verbal response

MOTOR RESPONSE

Nurses used peripheral pain stimulus (i.e., nail bed pressure) to assess motor response when patient is not obeying commands

Nurses had confusion on the difference between localizing and withdrawal to pain

Nurses still use sub sternal rub in applying pain stimulus

CHECKING PUPIL SIZE

Nurses checked eye pupil reaction first and followed by assessing the pupil size