Page 2040 - Saunders Comprehensive Review For NCLEX-RN

Memory Changes

▪ Short attention span
▪ Personality and behavioral changes
▪ Bewilderment

Box 58-5

Glasgow Coma Scale

Score

▪ The lowest possible score is 3 points (deep coma or death).
▪ The highest possible score is 15 points (fully awake).

Motor Response Points

▪ Obeys a simple response = 6
▪ Localizes painful stimuli = 5
▪ Normal flexion (withdrawal) = 4
▪ Abnormal flexion (decorticate posturing) = 3
▪ Extensor response (decerebrate posturing) = 2
▪ No motor response to pain = 1

Verbal Response Points

▪ Oriented = 5
▪ Confused conversation = 4
▪ Inappropriate words = 3
▪ Responds with incomprehensible sounds = 2

▪ No verbal response = 1

Eye-Opening Points

▪ Spontaneous = 4
▪ In response to sound = 3
▪ In response to pain = 2
▪ No response, even to painful stimuli = 1

Data from Ignatavicius D, Workman M: Medical-surgical nursing: patient-centered
collaborative care, ed 7, St. Louis, 2013, Saunders.

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