A nurse is conducting an hourly neurological assessment on a post-stroke male patient. Upon assessment, the patient only moans and withdraws to pain without opening his eyes. What is his total score in the Glasgow coma scale?

Explanation

• Glasgow Coma Scale scores range from 3-15. Categories are: eye opening response, verbal response, and motor response.

• This patient only moans (2 pts) and withdraws to pain (4 pts) without opening his eyes (1 pt). What is his total score in the Glasgow coma scale? 7 pts - severe cognitive deficits

Scoring is calculated as follows (correct scoring for this patient are bolded):

• Eye opening response: spontaneous -4 pts, opens to verbal command-3 pts, opens to pain-2 pts, no response-1 pt 

• Verbal response: oriented-5 pts, confused conversation but able to answer questions-4 pts, inappropriate responses-3 pts, incomprehensible speech-2 pts, no response-1 pt 

• Motor response: obeys commands for movement-6 pts, purposeful movement to painful stimulus-5 pts, withdraws from pain-4 pts, abnormal (spastic) flexion or decorticate posture- 3 pts, extensor (rigid) response or decerebrate posture-2 pts, no response-1 pt 

Overall Score:
• 8 or less, severe cognitive deficits
• 9-12, moderate cognitive deficits
• 13-15, mild cognitive deficits

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