# Help me with a GCS



## Sassafras (Aug 1, 2010)

Trying to determine verbal for a patient I recently had (doing trip sheet LOL).  Eyes open spontaneously, looks smiles yay 4, motor good as well, other than hemiparalysis from stroke 10 years ago.  Verbal is the clinker, he's oriented, but b/c of the past CVA history he is very difficult to understand.  His speech is garbled but with patience I can understand most of what he says and it's lucid conversation.  Would you put him as a 5 or lower due to the difficulty with the speech?


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## 46Young (Aug 1, 2010)

Sassafras said:


> Trying to determine verbal for a patient I recently had (doing trip sheet LOL).  Eyes open spontaneously, looks smiles yay 4, motor good as well, other than hemiparalysis from stroke 10 years ago.  Verbal is the clinker, he's oriented, but b/c of the past CVA history he is very difficult to understand.  His speech is garbled but with patience I can understand most of what he says and it's lucid conversation.  Would you put him as a 5 or lower due to the difficulty with the speech?



If the pt has caregivers, they're your best resource as to their baseline. Ask if their mental status is normal for them. If it is, then you can document "alert to normal mentation". It isn't A&O4, but it's still normal for them. This covers the verbal response as well as alertness. The GCS is really just one of many assessment tools for mainly traumas, anyway. It isn't the end all-be all for the pt's mental/neuro status. For this pt in particular, you just said that 
you were able to understand him. Assuming he's oriented, then it's a 4/5/6. The assessment in verbal response is intended for mental status changes, to show a trend. If he's able to hold a conversation but has no clue what time of day it is or where he is, for example, then it's a 4/4/6, since his slurred speech is secondary to his PMHx, not an acute event for which you were called.


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## LucidResq (Aug 1, 2010)

I agree... I believe in this situation he would be a 5 especially if you have confirmation from caregivers that this is normal for him. 

As long as he was oriented, comprehensible (even if comprehending him took some patience) and was using appropriate words...

Of course I think it would be important to document the speech problems and that you had some difficulty understanding him.


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## Sassafras (Aug 1, 2010)

LucidResq said:


> I agree... I believe in this situation he would be a 5 especially if you have confirmation from caregivers that this is normal for him.
> 
> As long as he was oriented, comprehensible (even if comprehending him took some patience) and was using appropriate words...
> 
> Of course I think it would be important to document the speech problems and that you had some difficulty understanding him.



This is what I did. Trip sheet took a while but ithink I got it ironed out.


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## the_negro_puppy (Aug 2, 2010)

GCS is generally used to assess the neurological status of acute patients...the thing to remember is always going for what is normal for the patient.


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## JPINFV (Aug 2, 2010)

Another documentation trick is to document why a lower score was given if it was low due to an acute process. What would you give a patient who is a mute? How about a patient with a trach who is unable to speak because of it? There's a big difference between a 4/5/1 without clarification and "4/5/1, verbal 1 due to trach."


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## Sassafras (Aug 2, 2010)

Annnnd, probie is still learning.


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## 8jimi8 (Aug 2, 2010)

Just to reiterate,

a GCS score, doesn't do much for the patient, it is just a way to help you prioritize your care.  Obviously you could strip away his old deficits and he'd be closer to a normal number, so as others have said, the GCS _is_ low, but it is low with a context.


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## ajax (Aug 2, 2010)

*A related question:*

What if your patient speaks only icelandic? The visiting nurse who called you knows that he speaks only icelandic, but she does not speak any icelandic herself. She also does not know his PMH, as she is just filling in for the day. The patient is cool, light pink (maybe pale, maybe just icelandic?) and dry on 4 LPM O2 via NC at all times. The nurse called because he has a stage 4 ulcer on his foot. 

He opens his eyes spontaneously, and when you gesture that he should do something he copies you, but it usually takes him a while (30 seconds?) to get the point. When you ask him questions, and you do because you keep hoping some word will spark recognition for him, he responds about half of the time with some noise coming out of his mouth. He may be speaking, or may be incomprehensible - Icelandic sounds an awful lot like gibberish. Our electronic paperwork requires a GCS. What would you call his verbal score, and what would you write in your narrative about it?


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## JPINFV (Aug 2, 2010)

If it requires a number, then 4/5/2. Narritive: "GCS language score of 2 due to language barrier." Ideally, I'd score it something along the lines of 4/5/UTO (unable to obtain). Composit GCS of "UTO." Narritive, "Patient alert with language barrier" at the start and later, "GCS UTO due to language barrier."


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## Sassafras (Aug 2, 2010)

Our software actually has a place to denote language barrier as things that get in the way of care, but um....hmmm good point about the verbal score.


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