Answer:
Based on the client's responses, the nurse should document the following scores for each section of the Glasgow Coma Scale (GCS):
1. Eye Opening Response: The client opens their eyes when spoken to.
- Score: 3
2. Verbal Response: The client speaks incoherently.
- Score: 4
3. Motor Response: The client moves their extremities when pain is applied.
- Score: 5
To calculate the total GCS score, you simply add up the scores from each section:
Eye Opening Response (3) + Verbal Response (4) + Motor Response (5) = Total GCS Score
3 + 4 + 5 = 12
Therefore, the nurse should document a GCS score of 12 for this client. It is important to note that the GCS score ranges from 3 to 15, with 3 being the worst and 15 being the best possible score. A lower score indicates a more severe impairment in consciousness.
Step-by-step explanation:
The Glasgow Coma Scale (GCS) is a tool used to assess a person's level of consciousness and neurological functioning. It consists of three components: eye opening response, verbal response, and motor response. Each component is assigned a score, and the scores are then added together to obtain the total GCS score.
1. Eye Opening Response: This component evaluates the person's ability to open their eyes in response to stimuli. The scores range from 1 to 4:
- Score of 4: Spontaneous eye opening
- Score of 3: Eye opening in response to verbal stimuli (such as being spoken to)
- Score of 2: Eye opening in response to pain stimuli (such as applying pressure)
- Score of 1: No eye opening
In this case, the client opens their eyes when spoken to, which corresponds to a score of 3.
2. Verbal Response: This component assesses the person's ability to speak and communicate. The scores range from 1 to 5:
- Score of 5: Oriented and coherent speech
- Score of 4: Confused and incoherent speech
- Score of 3: Inappropriate words
- Score of 2: Incomprehensible sounds
- Score of 1: No verbal response
In this case, the client speaks incoherently, indicating a score of 4.
3. Motor Response: This component evaluates the person's motor movements in response to stimuli. The scores range from 1 to 6:
- Score of 6: Obeys commands
- Score of 5: Localizes pain (purposeful movement towards the source of pain)
- Score of 4: Withdraws from pain (pulling away from the source of pain)
- Score of 3: Abnormal flexion (decerebrate posturing)
- Score of 2: Extension response (decorticate posturing)
- Score of 1: No motor response
In this case, the client moves their extremities when pain is applied, indicating a score of 5.
To calculate the total GCS score, you simply add up the scores from each section. In this case, the scores are:
Eye Opening Response (3) + Verbal Response (4) + Motor Response (5) = Total GCS Score
3 + 4 + 5 = 12
Therefore, the nurse should document a GCS score of 12 for this client. The GCS score helps healthcare professionals assess the severity of neurological impairment and monitor changes in a person's level of consciousness over time.