Calculating and comparing the scores
At 08:00 he opens his eyes to voice (E3), has confused speech (V4), and obeys commands (M6), for a Glasgow Coma Scale (GCS) of 13. At 12:00 he opens his eyes spontaneously (E4), still has confused speech (V4), and localizes to pressure but does not obey commands (M5), again a total of 13. The total is unchanged only because a better eye score hides a worse motor score. The motor score fell, and the nurse notifies the physician now.
Why the motor score matters most
The motor component of the GCS is the most reliable predictor of neurologic outcome and the most sensitive indicator of deterioration in a client with brain injury. Eye opening can fluctuate with stimulation and alertness, while a decline from obeying commands to merely localizing suggests worsening brain function, possibly from increasing cerebral edema, a developing hematoma, or rising intracranial pressure. Any fall in the motor score, even 1 point, is a significant sign of decline and is reported promptly, which is why each component is recorded, not just the total.
| Component | 08:00 | 12:00 | Change |
|---|
| Eye (E) | Opens to voice: 3 | Spontaneous: 4 | Better |
| Verbal (V) | Confused: 4 | Confused: 4 | Same |
| Motor (M) | Obeys: 6 | Localizes: 5 | Worse |
| Total | 13 | 13 | Unchanged |
Why the other conclusions are wrong
Continuing hourly checks because the total is unchanged ignores the hidden motor decline. Concluding that eye opening improved, so he is recovering gives weight to the less reliable component and misses the important change. Saying the score fell 1 point and is below the level to report is factually wrong: the total did not fall at all, and any motor decline is reportable regardless of the total.
Nursing actions
The nurse notifies the physician immediately, performs a full neurologic assessment including pupils and limb strength, checks vital signs for signs of rising intracranial pressure, and anticipates urgent repeat CT. Neurologic observations are increased in frequency.
Exam takeaway
Watch out Always break the GCS into components. An unchanged total can hide a motor decline, and a fall in the motor score is reported even when the total stays the same.