#WeNurses - Thursday 6th October 2016 8pm (GMT Standard Time) The Glasgow Coma Scale for adults: are we doing it right?

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Hosted by WeNurses using #WeNurses

This chat is guest hosted by @Ismalia_S @SueWoodward_KCL @NeuroNurseForum

The Glasgow ComaScale (GCS) is the gold standard for assessment and decision making in patients with acute neurological conditions at risk of deterioration (Teasdale and Jennett 1974; Middleton 2012; Teasdale et al 2014). Developed in 1970, it continues to be used to assess the level of consciousness in these patients.

It is fundamental that nurses have the knowledge that underpins this assessment and are able to identify deterioration when it occurs but:

  • When was the last time you were taught about how toperform a GCS assessment correctly?
  • How confident do we feel?
  • When you report and document your findings, do you use the score and/or do you use the scale?

Throughout the years, peripherally and centrally applied painful stimuli have been the subject of discussion (3) what are the differences between these two stimuli? And, when it comes to assessment of neurological deterioration, (5) is it only the GCS that matters?

We’ve come across clinical situations or factors that impact the way we perform the GCS and we had to overcome these but (6) which situations do you encounter in your nursing practice and how to you over come those? (7) do you always carry out a GCS assessment during nursing handover? How important is it to do it?

In 2014, Teasdale et al (2014) made new recommendations for the assessment of the GCS. However, not all hospitals across the UK have adopted them.

 This chat aims to promote best evidence based practice when using the GCS, help nurses develop their skills and provide answers to the most common questions related with this assessment.


Suggested reading:

Braine M,Cook N (2016) The Glasgow Coma Scale and Evidence-Informed Practice: a critical review of where we are and where we need to be. Journal of Clinical Nursing. Accepted Author Manuscript. doi:10.1111/jocn.13390.

Middleton P( 2012) Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australasian Emergency Nursing Journal, 15, 170—183.

Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G (2014) The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurology, 13, 844–54.

Waterhouse C(2009) The use of painful stimulus in relation to Glasgow Coma Scale observations. British Journal of Neuroscience Nursing, 5, 5, 209-215.

Woodward S, Mestecky A editors (2011) Neuroscience Nursing: evidence-based practice. First edition. Willey-Blackwell. Oxford


About our Guest Hosts:

This chat is hosted by Ismalia de Sousa (@Ismalia_S), Dr Sue Woodward (SueWoodward_KCL) and the RCN Neuroscience Forum Steering Committee (@NeuroNurseForum)    

I’m Ismalia de Sousa, a clinical nurse specialist in stroke at Imperial college Healthcare NHS Trust and a member of the RCN Neuroscience forum Steering Committee. I’ve been a registered nurse for the past 7 years,working in stroke care. The Glasgow coma scale is a fundamental and day-to-day nursing assessment of patients with stroke or other neurological conditions at risk of deterioration and throughout the years I’ve always noticed how there was never a consensus when carrying out the assessment. How many times my GCS assessment was different from other nurses or doctors? I’ve lost count! Despite discussions around the use of peripherally and centrally applied stimulus, the GCS continues to be a gold standard assessment. This year, at the RCN Congress,the RCN Neuroscience Forum Steering Committee held a fringe event about the GCS and how to best assess patients using the GCS (https://www2.rcn.org.uk/newsevents/congress/2016/events/sunday/the-glasgow-coma-scale-doing-it-right).

Dr Sue Woodward is head of clinical education at Florence Nightingale School of Nursing and Midwifery. She has been a lecturer in nursing and worked in neuroscience nursing for more than 30 years and for a lot of times Sue has thought student nurses how to best assess patients using the GCS. Sue is also the Chair of the RCN Neuroscience Forum Steering Committee,founding Editor-in-chief of the British Journal of Neuroscience Nursing and actively involved in research focusing on bowel management in neurological conditions.






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 Chat Summary

 

A broad range of nurses and student nurses, who have been in practice for varying years participated in a Twitter chat. We learned the majority were only taught about the Glasgow Coma Scale (GCS) at university and while for student nurses this might have been in the last 3 years, for those with more years of experience, training took place 20 or 30 years ago. In addition, very few have had an update since.

Confidence is felt more in those who use it in their clinical practice every day in comparison with those that don’t, but this poses the question whether update training around the GCS should be mandatory, even in the areas that don’t regularly use it. If patients in these areas are at risk of clinical deterioration and a GCS assessment is needed, it is crucial that we can do this well!

The application of painful stimuli has been a source of debate over the years and has had multiple variations. However, if variations occur, it means that there is a need for training and standardisation of approaches. Nevertheless, the rule is the same: a centrally applied painful stimuli should be used when assessing the motor response component of the GCS and directed to the core of the central nervous system – a cranial nerve (CN) - such as the CN XI (spinal accessory nerve) using the trapezius muscle or the CN V ( Trigeminal nerve) using the ophthalmic branch of the nerve that lies in the supraorbital notch. @Ismalia_S highlighted in theTweet chat that exceptions may occur when assessing motor response (for example in patients with spinal cord injury). During discussion around painful stimuli, @SueWoodward_KCL raised the important fact that nurses should not be under-stimulating when applying painful stimuli, with some chat contributors sharing the fact they ask their students to practice applying the painful stimuli to each other.

Breaking down the GCS by using the components of the scale (E4, V4 and M6) and not only the score (e.g. GCS 14/15) is better to report clinical findings as the only scores that can be fully understood areGCS 3/15 and GCS 15/15.

We also discussed how other assessments and tools are important to assess neurological deterioration together with the GCS, such as the AVPU, limb assessment, pupil assessment, vital signs or even other specific tools that nurses use in their area of practice. The “Look, Listen and Feel” approach and our clinical judgement are also fundamental, and any variations from our baseline assessment should be reported.

Variations of age and disability, people with dementia, learning difficulties and language barriers may affect the way the GCS is carried out. Involvement of families in some of these cases may be appropriate.

Our last question focused on carrying out a GCS assessment during handover and it was great to see that student nurses are being taught to do it as this may reduce inter-rater reliability.





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 #WeNurses transcript

 
@nadasj89
06 October 2016 20:00
RT @WeNurses: The Glasgow Coma Scale #WeNurses with @NeuroNurseForum > http://buff.ly/2cUV9iY Tonight at 8pm https://t.co/TMqTpGU3Vi
@WeNurses
06 October 2016 20:00
IN 1 HOUR #WeNurses on the Glasgow Coma Scale > http://buff.ly/2dxQGRG #BringYourOwnPenTorch https://t.co/gSg4ocacyv
@Bartontd
06 October 2016 20:03
RT @WeNurses: IN 1 HOUR #WeNurses on the Glasgow Coma Scale > https://t.co/tFlJhjhdkm #BringYourOwnPenTorch https://t.co/gSg4ocacyv
@USWCareSciences
06 October 2016 20:08
RT @JusticeforLB: Hope any student #WeNurses trust their instincts when it comes to good care; please disagree if you think someone's at ri…
@WeNurses
06 October 2016 20:18
RT @keeling_michael: Tonight's #wenurses chat on the GCS might be of interest to followers of #whywedoresearch https://twitter.com/wenurses/status/784060005981024256
@AgencyNurse
06 October 2016 20:19
At 8pm via #WeNurses https://twitter.com/wenurses/status/784091016815083520
@SueWoodward_KCL
06 October 2016 20:20
RT @Ismalia_S: Thanks @Marie_Batey ! It will be great to have all of you on board! :) #GCSchat #wenurses @WeNurses https://t.co/hmtjPjbQrb
@HealthUKTD
06 October 2016 20:22
RT @keeling_michael: Tonight's #wenurses chat on the GCS might be of interest to followers of #whywedoresearch https://twitter.com/wenurses/status/784060005981024256
@nadasj89
06 October 2016 20:24
@creator9988 @WeNurses ???? ???????? #WeNurses
@DaveAshton_
06 October 2016 20:26
RT @keeling_michael: Tonight's #wenurses chat on the GCS might be of interest to followers of #whywedoresearch https://twitter.com/wenurses/status/784060005981024256
@DaveAshton_
06 October 2016 20:26
RT @AgencyNurse: At 8pm via #WeNurses https://twitter.com/wenurses/status/784091016815083520
@SueWoodward_KCL
06 October 2016 20:27
All set and following live feed #GCSchat #WeNurses just over 30 minutes to go ??
@jululupostbox
06 October 2016 20:29
RT @SueWoodward_KCL: All set and following live feed #GCSchat #WeNurses just over 30 minutes to go ??
@WeNurses
06 October 2016 20:30
The Glasgow Coma Scale - how confident do you feel about GCS? #WeNurses in 1/2 an hour See you at 8pm >… https://twitter.com/i/web/status/784098446391316480
@Ismalia_S
06 October 2016 20:32
Let's do it! :) #GCSchat #wenurses https://twitter.com/SueWoodward_KCL/status/784097713247879168
@Ismalia_S
06 October 2016 20:33
RT @WeNurses: The Glasgow Coma Scale - how confident do you feel about GCS? #WeNurses in 1/2 an hour See you at 8pm > https://t.co/ePT…
@koredemma
06 October 2016 20:35
RT @WeNurses: The Glasgow Coma Scale #WeNurses with @NeuroNurseForum > http://buff.ly/2cUV9iY Tonight at 8pm https://t.co/TMqTpGU3Vi
@NeuroNurseForum
06 October 2016 20:35
@keeling_michael @WeNurses you must be awake nurse michael! You have a 15min neuro obs (incl GCS) to perform ;) #GCSchat #wenurses
@HealthUKTD
06 October 2016 20:36
RT @WeNurses: IN 1 HOUR #WeNurses on the Glasgow Coma Scale > http://buff.ly/2dxQGRG #BringYourOwnPenTorch https://t.co/gSg4ocacyv
@falls_blackpool
06 October 2016 20:38
RT @WeNurses: The Glasgow Coma Scale - how confident do you feel about GCS? #WeNurses in 1/2 an hour See you at 8pm > https://t.co/ePT…
@falls_blackpool
06 October 2016 20:39
@WeNurses @Ismalia_S fab can't wait!! #GCS @SignUpToSafety @TracyBurrell1 @cherith63 #wenurses #chat #SU2S ?????? https://t.co/UW0nPJhXkR
@falls_blackpool
06 October 2016 20:40
RT @SueWoodward_KCL: All set and following live feed #GCSchat #WeNurses just over 30 minutes to go ??
@Ismalia_S
06 October 2016 20:41
Glad you are going to join us! @SueWoodward_KCL @NeuroNurseForum #GCSchat #WeNurses https://twitter.com/falls_blackpool/status/784100903297118208
@falls_blackpool
06 October 2016 20:41
RT @Ismalia_S: Glad you are going to join us! @SueWoodward_KCL @NeuroNurseForum #GCSchat #WeNurses https://twitter.com/falls_blackpool/status/784100903297118208
@SueWoodward_KCL
06 October 2016 20:42
RT @Ismalia_S: Glad you are going to join us! @SueWoodward_KCL @NeuroNurseForum #GCSchat #WeNurses https://t.co/AG90gGwaI3
@Bartontd
06 October 2016 20:43
RT @falls_blackpool: @WeNurses @Ismalia_S fab can't wait!! #GCS @SignUpToSafety @TracyBurrell1 @cherith63 #wenurses #chat #SU2S ?????? https:/…
@WeNurses
06 October 2016 20:45
In 15 mins Getting to grips with The Glasgow Coma Scale #WeNurses with @NeuroNurseForum http://buff.ly/2cV19bD… https://twitter.com/i/web/status/784102180668203008
@NeuroNurseForum
06 October 2016 20:45
RT @WeNurses: In 15 mins Getting to grips with The Glasgow Coma Scale #WeNurses with @NeuroNurseForum https://t.co/WGrlDHSX8F #PenTorc…
@Ismalia_S
06 October 2016 20:46
RT @WeNurses: In 15 mins Getting to grips with The Glasgow Coma Scale #WeNurses with @NeuroNurseForum https://t.co/WGrlDHSX8F #PenTorc…
@simplyme_hope
06 October 2016 20:49
RT @WeNurses: The Glasgow Coma Scale - how confident do you feel about GCS? #WeNurses in 1/2 an hour See you at 8pm > https://t.co/ePT…
@Ismalia_S
06 October 2016 20:50
We will need many more! @SueWoodward_KCL @NeuroNurseForum #GCSchat #wenurses https://twitter.com/WeNurses/status/784102180668203008
@AgencyNurse
06 October 2016 20:50
RT @WeNurses: In 15 mins Getting to grips with The Glasgow Coma Scale #WeNurses with @NeuroNurseForum https://t.co/WGrlDHSX8F #PenTorc…
@falls_blackpool
06 October 2016 20:51
RT @WeNurses: IN 1 HOUR #WeNurses on the Glasgow Coma Scale > https://t.co/tFlJhjhdkm #BringYourOwnPenTorch https://t.co/gSg4ocacyv
@SueWoodward_KCL
06 October 2016 20:51
RT @Ismalia_S: We will need many more! @SueWoodward_KCL @NeuroNurseForum #GCSchat #wenurses https://t.co/GnadobUBs2
@Bartontd
06 October 2016 20:52
RT @WeNurses: In 15 mins Getting to grips with The Glasgow Coma Scale #WeNurses with @NeuroNurseForum https://t.co/WGrlDHSX8F #PenTorc…
@Ismalia_S
06 October 2016 20:55
Almost 5 minutes to kick off the #GCSchat #wenurses @SueWoodward_KCL @NeuroNurseForum
@AWatSmartwork
06 October 2016 20:59
RT @WeNurses: IN 1 HOUR #WeNurses on the Glasgow Coma Scale > http://buff.ly/2dxQGRG #BringYourOwnPenTorch https://t.co/gSg4ocacyv




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