A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE OF

STAFF NURSES REGARDING GLASSGOW COMA SCALE AS A

PART OF NEUROLOGICAL ASSESSMENT AMONG THE
PATIENTS WITH NEUROLOGICAL DISORDERS IN SELECTED
HOSPITALS AT HARYANA.

Dissertation submitted to the faculty of Pt. B.D. Sharma University of

Health Sciences Rohtak, in partial fulfilment of the
requirements for the degree of

MASTER OF SCIENCE IN NURSING

(Medical Surgical Nursing)

March -2014

PRIYANKA GUPTA
VED NURSING COLLEGE
PREM INSTITUTE OF MEDICAL SCIENCES
BAROLI, PANIPAT

A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE OF

STAFF NURSES REGARDING GLASSGOW COMA SCALE AS A
PART OF NEUROLOGICAL ASSESSMENT AMONG THE
PATIENTS WITH NEUROLOGICAL DISORDERS IN SELECTED
HOSPITALS AT HARYANA.

1
Dissertation submitted to the faculty of Pt. B.D. Sharma University of
Health Sciences Rohtak, in partial fulfilment of the
requirements for the degree of

MASTER OF SCIENCE IN NURSING

(Medical Surgical Nursing)

March -2014

PRIYANKA GUPTA
VED NURSING COLLEGE
PREM INSTITUTE OF MEDICAL SCIENCE
BAROLI, PANIPAT

2
 CERTIFICATE
This is to certify that this thesis titled “A descriptive study to assess the knowledge of
staff nurses regarding glassgow coma scale as a part of neurological assessment among
the patients with neurological disorders in Selected Schools at Haryana” is the bonafide
work of Priyanka Gupta and was conducted at Ved nursing college, Baroli, Panipat in
the partial fulfilment of the requirement for the degree of Master of Science in Nursing.

-----------------------------
Prof. Mrs. Rita Sarkar
Principal
Ved Nursing College
Baroli, Panipat

GUIDE CO –GUIDE
-------------------------- ---------------------------
Mrs. Meenal Sharma Dr. Subhash Soni
H.O.D , Medical Surgical Nursing Physician, Heart Specialist
Ved Nursing College Prem Hospital
Baroli, Panipat Panipat.

3
 ACKNOWLEDGEMENT
“I lift up my eyes to the hills- where does my help come from?
My help comes from the Lord, the maker of heaven and earth.”
- Psalms 121:1

First of all, I will bow down before God almighty with deeper sense of
everlasting gratitude to God, that almighty without whose grace and blessing my
research would not have come out fruitfully.
I would like to thank Prof. Rita Sarkar (Obstetric & Gynaecology), Principal
of Ved Nursing College, Panipat, for her magnanimous as well as generous support and
guidance, immensely inspired me to materialize the dissertation work.
I would like to express my heartfelt gratitude and thanks to Mrs.Minal Sharma,
H.O.D (Medical Surgical Nursing) Ved Nursing College, Baroli, Panipat, My guide who
gave me timely guidance and meticulous supervision that helped in completing this
project and groomed me as a beginner researcher.
I express my sincere thanks to all my teachers for their kindness and cordial
relationship to conduct the study.
I am thankful to all the experts for their constructive criticism and valuable
suggestion towards validating the tool.
I am thankful to Mr. Aneja B.K, Bio-statistician (Ludhiana), for his expert
guidance.
I am ever indebted to all my respondents (teachers) and Principals who
consented and cooperated to become the part of this study.
I owe my success to my father Mr.Ravinder Kumar, my mother Mrs. Amita
Gupta for encouraging and supporting me throughout. Thank you for balancing me with
peace and joy and giving me strength.
Priy

anka Gupta

4
 LIST OF ABBREVATIONS

1. GCS Glasgow coma scale

2. CCU Critical care units

3. WHO World Health Organisation

4. TBI Traumatic Brain Injuries

5. RN Registered Nurse

6. JCS Jouvet Coma Scale

7. DNE Diabetic Neuropathy Examination

8. ED Emergency Department

9. INGCS Glasgow coma scale at the scene of injury

10. MCQs Multiple Choice Questions

11. df Degree of freedom

12. P value Probability of making type 1 error

(level of significance)
13. S.D. Standard deviation

5
 ABSTRACT

“A descriptive study to assess the knowledge regarding Glassgow Coma Scale as a part

of neurological assessment of patients with neurological disorders among staff nurses in

a selected hospital in Haryana”.

METHOD

A Descriptive research with purposive sampling technique was used to select 80

staff nurses working in CCUs of selected hospitals in Kaithal. Data was collected by

means of structured questionnaire, included 30 items and the scores was categorized in

Good(23-30), average(15-22) and poor(0-14)

FINDINGS

The findings of the study revealed that the total mean of knowledge score

regarding to the GCS among staff nurses was 17.94+ 4.524. There was significant level

of association of experience in CCU with knowledge sores of staff nurses and most staff

nurses (n=52,65%) had average level of knowledge. And they want to improve their

theoretical knowledge as well as their practical skills.

CONCLUSION

A short training course including teaching program needed to make sure that staff

nurses are able to use the GCS effectively .

6
 TABLE OF CONTENTS
Sr. No Chapter Page No.

1. INTRODUCTION
 Background of the study 1-
5
 Need for the study 5-
7
 Statement of the problem 7
 Objectives 7
 Assumption 7
 Operational definition 7-
8
 Delimitations 8
 Conceptual framework of the study 9-
12

2. REVIEW OF LITERATURE
13-22
3. METHODOLOGY
 Research approach 24
 Research design 24
 Variables 24
 Population 25
 Sample and sampling technique 25
 Setting 26
 Tools and techniques of data collection 26
 Reliability 27
 Ethical clearance 28
 Pilot study 28

7
  Procedure for data collection 28
 Plan for data analysis 29
4. ANALYSIS AND INTERPRETATION
31- 40
5. DISCUSSION
 Discussion
41-43
 Implications
44- 45
 Limitations 46
 Recommendations 46
 Conclusions 47
6. REFERENCES
48- 54

8
 LIST OF TABLES

Table No. Title Page No.

1. Scoring of Glasgow coma scale

2. Socio-demographic characteristics of nurses

33

3. Mean ,median, S.D. of test knowledge score of nurses

37

4. Frequency and percentage(%)distribution of knowledge scores

38

5. Association between the test level of knowledge with their selected

Socio-demographic variables.

39

9
 LIST OF FIGURES

Fig. No. Title Page No.

1. Conceptual framework 11

2. Schematic representation of research design 30

3. Graph showing the distribution of staff nurses according to age group 34

4. Graph showing the distribution of staff nurses according to their gender 35

5. Graph showing the distribution of staff nurses according to their

educational qualification. 35

6. Graph showing the distribution of staff nurses according to the

experience in Critical Care Units. 36

7. Graph showing the distribution of staff nurses according to their

total years of experience. 36

8. Graph showing mean and median of knowledge scores among

staff nurses. 37

9. Graph showing the frequency and percentage of knowledge

scores of staff nurses. 38

10
 ANNEXURES

Page no.

 Annexure I Requisition letter to experts for tool validation 56

 Annexure II: Certification of validation 57
 Annexure III: List of experts 58-59
 Annexure IV: Letter seeking permission to conduct pilot study 60
 Annexure V: Letter seeking permission to conduct main study 61-65
 Annexure VI: Screening sheet 66
 Annexure VII: Subject information sheet 67-69
 Annexure VIII: Consent form 70
 Annexure IX: Tools 71- 76
 Annexure X: Answer key 77
 Annexure XI: Blueprint of the tool 78
 Annexure XII: Coding sheet 79
 Annexure XIII: Master data sheet 80-82

11
INTRODUCTION

12
 CHAPTER- 1

INTRODUCTION

The brain is the central unit that controls all the functions of our body. The brain

cannot function all by itself without the neurons. Neurons are the primary functional unit

of the nervous system. The nervous system is a network of these neurons that relays

message back and forth from the brain to different parts of the body.2 it is a highly

specialized system responsible for the control and integration of the body’s many

activities.1

The level of consciousness is the sensitive and reliable indicators of the patient’s

neurological status. Consciousness is dynamic and subject to change, it can occur rapidly

within seconds, minutes and hours or very slowly, over a periods of days, weeks, months

and years.4 The state of consciousness is characterized by the ability to get in contact with

reality, to recognize the objects that are a part of it and to interact with it. 5 The causes of

alterations in the consciousness is Traumatic Brain injury. 6 Traumatic Brain injury occurs

when a sudden trauma causes damage to the brain. The intra cranial causes are tumor,

haematoma, abscess, head injury, cerebral hemorrhage, epilepsy, inflammation of brain

tissues, Alzheimer’s, cerebral edema. The extra cranial causes are hypertension or

hypotension; hypoglycemia; fluid and electrolyte imbalance; sepsis; shock; hypoxia;

liver, renal dysfunction.3

Neurological assessment is a key component in the care of an unconscious

patient.7 The Neurological Examination is a systemic process that includes a variety of

clinical tests, observations, and assessments designed to evaluate a complex system. It is

13
divided into five components: Cerebral function, Cranial nerves, Motor system, Sensory

system, and Reflexes. These components determine whether the Nervous System is

Impaired. It is the foundational database for the nursing students to use in making nursing

diagnosis, planning care implementing interventions and evaluating care for the patient.4

There are numerous tools used to determine the level of consciousness. The most

common tool used to determine the conscious level is Glasgow Coma Scale. The

Glassgow coma scale is an internationally recognized tool which assesses the level of

consciousness of a patient.4 It is used with ease and help to standardize clinical

observations of the patients with impaired consciousness.3

Also referred to as the “Glasgow coma score,” it operates on a scale of “3” to

“15,” in which progressively higher scores indicate higher levels of consciousness 1. The

Glasgow Coma Scale was introduced in 1974 by Graham Teasdale and Bryan J. Jennett

as a method for determining objectively the severity of brain dysfunction and coma 6

hours after the occurrence of head trauma.8 The Glasgow coma scale is often incorporated

to give continuous monitoring under standard conditions.3

Administering the scale takes 3–5 minutes and requires no special equipment. It

monitors the progress of head injured patients, patients who undergoing intracranial

surgery or any other neurological disorders like cerebrovascular accident, encephalitis,

meningitis.3 it helps in comparing the different groups of the patients. It is used as a triage

tool in patients with Traumatic Brain Injury.9

The Glasgow Coma Scale is a scale assessment that measure the degree of consciousness under 3 distinct categories of neurological

functioning and each category is further subdivided and given a score.10 The essence of the GCS is the independent assessment of graded responses in

three behavioral domains – eye opening (E), motor response (M) and verbal activity (V) (Table 1)

14
 Glassgow Coma Scale

Eye opening Verbal response Motor response Score

Obeys 6

Oriented Localizes 5

Spontaneously Confused Withdraws 4

To voice Inappropriate Abnormal flexion 3

To pain Incomprehensible Abnormal extension 2

No eye opening No vocalization No movements 1

_______/4 _______/5 ________/6 ______/15

Today, physicians use the Glasgow Coma Score to assess patient survivability.

Patients with scores between 13 and 15 are considered mildly impaired and will often

fully recover. Patients with scores between 9 and 12 are categorized as moderately

disabled. A majority of patients will have experienced a loss of consciousness more than

30 minutes with scores between 9 and 12, and will often have physical and cognitive

impairments that may resolve with rehabilitative therapy. Patients with GCS scores of 3

to 8 are often comatose, unconscious with no purposeful movements, have no interaction

with their environment, or have no localized response to pain.4 Approximately 50% of

patients with a score of 8 will be unconscious or in a coma, and almost all patients with a

score of 7 or less will be unconscious or in a coma. 1 A patient with a GCS of 3 is either

dead or in a vegetative state with possible sleep-wake cycles.4

15
 The advantage of Glasgow coma scale is that it is specific and structured,

allowing different health care professionals to arrive at the same conclusion regarding

patient’s status. Therefore it is very important that every nurse working in the field like

High Dependency Units has enough knowledge to assess and intervene appropriately and

she/he should also be able to communicate any change in patient's condition for

multidisciplinary intervention12.

NEED OF THE STUDY

The accuracy of the assessment data and the nurses critical thinking skill to

identify the change, interpret its significance and take appropriate action from the

foundation of neuroscience nursing practice. The neurological assessment is a key

component in the care of the neurological patient. It can help the Nursing students to

detect the presence of neurological disease or injury and monitor its progression,

determine the type of care and gauge the patients’ response to intervention. This will

also help the nurses to reach out high quality care of the patients. 11,12

The Glasgow Coma Scale is the corner stone of the neurological assessment of

patients used by both nursing and medical staff. The Glasgow coma scale is neurological

scale that gives a reliable, objective way of recording the conscious state of the person for

initial as well as subsequent assessment.

The Glasgow Coma Scale is the best measure of overall brain dysfunction caused

by the Traumatic Brain injuries.13 Traumatic Brain injuries caused by motor vehicle

accident, falls is leading cause of death and lifelong disability for young adults. This is

16
done using a GCS that determines what interventions are needed and provides a baseline

to judge progress towards recovery. 14

Every year, millions of people succumb from Traumatic Brain injuries.

Traumatic Brain injuries are the cause of mortality, morbidity, disability and socio-

economic losses around the world. As per WHO estimates, nearly 12 lakh people died in

road crashes in 2002 around the world. It is estimated that 1.5 to 2 millions people are

injured and 1 million people succumb to death every year in India, Immediate Trauma

care is neglected area in India.15

The mortality rate due to brain injury at the global level is estimated to be

97/100,000 population per year. In India, it is the seventh leading cause of mortality

contributing to11% of deaths; 78% of cases are due to road traffic injuries alone.16

A review study was conducted in the United States of America. The purpose of

the review was to provide the summary of findings on the ability of the GCS scores to

predict outcome in TBI patients. A search was done to identify the study that investigated

the predictive ability of the GCS score. Studies that used GCS as a variable in predicting

outcome with adult patients who had sustained some type of head injury were included.

GCS scores are more accurate at predicting outcome in head injured patients when they

are combined with age of the patient and Pupillary response and when broad outcome

categories are used. The motor component of GCS yields similar prediction rates as the

summed GCS scores and better prediction occurs with very high or very low GCS scores.

Information about the cumulative research findings on the predictive ability of the

GCS scores aids nurses in providing support and education to the family members during

17
the acute stage of injury, and in coordinating the services of the members of healthcare

team which could result in improving outcomes for both patients and family.14

Therefore a proper neurological assessment using the Glasgow Coma Scale is the

essential part of the nursing care. Hence it is very essential for the nurse to have

knowledge and skills about neurological assessment and Glasgow Coma Scale. Therefore

the investigator has chosen this study to evaluate the nursing knowledge regarding

Glasgow Coma Scale who works in Critical areas or units of the selected hospitals.

STATEMENT OF THE PROBLEM

“A descriptive study to assess the knowledge regarding Glassgow Coma Scale as

a part of neurological assessment of patients with neurological disorders among staff

nurses in a selected hospital in Haryana”

AIM OF THE STUDY

Assess the knowledge regarding Glasgow Coma Scale as a part of the

neurological assessment of patients with neurological disorders among staff nurses.

OBJECTIVES

 To assess the knowledge regarding the Glassgow coma scale among staff

nurses in a selected hospital.

 To identify the association between knowledge score of Glassgow Coma

Scale with their selected socio demographic variables

OPERATIONAL DEFINITIONS

Assess: In this study it refers to the organized systematic continuous process of

collecting data regarding neurological assessment among staff nurses.

18
 Knowledge: - In this study it refers to the correct response of staff nurse to the

structured questionnaire on neurological assessment as measured by a structured

knowledge assessment questionnaire.

Staff Nurse: - In this study it refers to a person educated and trained to care for

the patients with neurological disorders in neuro ward, which includes GNM staff,

graduate and post graduate nursing staff.

Glassgow coma scale:- Refers to the internationally standardized measurement

tool used to check the level of consciousness.

Neurological assessment:- In this study it refers to the neurological status of a

patient namely motor and sensory response, Pupillary response, voluntary motor strength,

Glasgow coma scale, normal and abnormal reflexes.

Patients:- It refers to those who are admitted in critical care units with

neurological disorders like traumatic brain injuries, non traumatic injuries like poisoning

and stroke with altered level of consciousness.

ASSUMPTION

The study is based on the following assumptions:

1. The staff nurses may have some knowledge regarding glassgow coma scale to

assess the conscious level of patients.

2. Knowledge on glassgow coma scale of patient is measurable.

3. Accurate knowledge of nurses regarding glassgow coma scale will help them to

identify the patient’s condition and have proper diagnosis.

19
CONCEPTUAL FRAMEWORK

It is a complex whole of interrelated concept or abstraction that is assembled

together in some rational scheme by virtue of their relevance of a common theme. A

conceptual model provide for logical thinking for systematic observation and

interpretation of observed data. The model also gives direction for relevant questions on

phenomena and points out solution to practical problem as well as serves a springboard

for the generation of hypothesis is to be used.

According to Treece and Treece (1986), conceptualization is the forming of ideas,

design and plans. It is the process of moving from an abstract idea to a concrete proposal.

Conceptual framework of the present study is based on the nursing process and it

aims for assessing the knowledge of staff nurses on Glasgow coma scale(GCS).

Nursing process is a series of planned steps and action directed toward meeting

needs and solving the problem of patient and their families, systematic, scientific problem

– solving in action.

Nursing process is a two phases, five steps process.

The two phases are nursing assessment and nursing management. The five steps

are data gathering, stating the nursing diagnosis, planning client care, implementing the

care plan and evaluating and modifying the plan.

Nursing assessment

Assessment, a two step process that enable to nurse to identify the patient’s need

and problems, the first step is data gathering and the second step is making a nursing

diagnosis.

20
 In this study, data is gathered in terms of demographic variables like age, gender,

educational qualification, experience in CCU and knowledge scores of 80 staff nurses

using structured questionnaire on Glasgow coma scale.

Nursing diagnosis is stated as altered knowledge of staff nurses related to

Glasgow coma scale

Planning phase

In this study, planning is clarification of doubts and queries of staff nurses with

the help of an unstructured teaching learning activity during administration of knowledge

questionnaire.

Implementation phase

During administration of structured knowledge questionnaire the unstructured

teaching learning activity instituted.

The rationale of implementation is to assess the knowledge on GCS among the

staff nurses so that their knowledge gets increase and thus benefitting the patients with

neurological disorders.

Evaluation phase

Reassessment of knowledge of staff nurses on GCS by using structured

questionnaire. This phase is not included in this study.

21
 Assessment Diagnosis

Knowledge assessment of 80 Altered knowledge of staff

staff nurses using structured nurses related to Glasgow
questionnaire on Glassgow Coma Scale.
Coma Scale

Implementation Plannin
On the spot g

The unstructured teaching An unstructured teaching

learning activity instituted. learning activity on GCS
with clarification of doubts
and queries.

Rationale
Evaluation

Assessment of the levels of knowledge Reassessment using

on GCS among the staff nurses in structured questionnaire
selected hospitals helps to institute an on GCS.
unstructured teaching learning program
to increase the knowledge, thus
benefitting the patients with
neurological disorders.

Key:-

Studied Not studied

Fig. 1: Nursing Process Theory

22
Study Report
This chapter deals with the Introduction, background, need for the study,
statement of problem, objectives, conceptual frame work, operational definition,
assumption.
Further the study report includes following chapters:-
Chapter-2 An overview of the review of literature.
Chapter-3 Describe the methodology used for the study which includes research
approach, research design, the setting, and sample, and sampling technique, description
of tool, procedure for data collection, and plan for data analysis.
Chapter-4 Describe and interpretation of data.
Chapter-5 Presents the discussion, summary, conclusion, implication, limitation and
Recommendation, followed by references.

23
 REVIEW

OF

LITERATURE

24
 CHAPTER- 2

REVIEW OF LITERATURE

The term “Review of literature” refers a survey of scholarly articles, books, and

other sources relevant to a particular issue, area of research, or theory, providing a

description summary, and critical evaluation of each work. In the development of

research project, review of literature is defined as a broad, comprehensive in depth,

system & critical review of scholarly publication, unpublished scholarly print material,

audiovisual material & personal communication.

A literature review helps to lay the foundation for a study, and can also inspire

new research ideas. It gives a new interpretation of old material or combine new with old

interpretations.

REVIEW ON GLASSGOW COMA SCALE AND NEUROLOGICAL

ASSESSMENT

Henneman EA, (1989) conducted a comparative study on Neurological

examination using the Glasgow Coma Scale to compare the assessment findings of

Registered General Nurses (RGNs), Enrolled Nurses and Student Nurses after viewing

videotaped neurological assessments of patients in a high dependency unit. The criterion

for judging the accuracy of subject's assessments was established by a panel of experts.

This study concluded, as expected, Registered General Nurses had the highest proportion

of correct assessments and students the least. Subjects were identified as having difficulty

25
in determining the relative amounts of weakness that a patient exhibited, and in correctly

distinguishing between flexion and extension.23

Stewart and Amedei C. (1991), conducted study on assessing the comatose

patient in the intensive care unit. Study showed detailed neurological assessment which

consist of evaluation of history, reactivity, eye, eye movement and respiratory patterns

predicting outcome and determining brain death is essential.30

Rowley G, Fielding K, (1991) conducted a study on the reliability and accuracy

of the GCS with experienced and inexperienced users to investigate whether the Glasgow

Coma Scale (GCS) can be used reliably and accurately by inexperienced observers,

ratings made by observers grouped by level of experience were examined for within-

group inter observer disagreements and for discrepancies with scores given by an expert.

The GCS was used accurately by experienced and highly trained users, but inexperienced

users made consistent errors. The errors were such that they would not be detectable by

studies that examine only inter observer agreement, and they were substantial, averaging

in some cases more than one point on the four-point and five-point scales of the GCS.

Also, the error rates were highest at the intermediate levels of consciousness, for which

the detection of changes in condition is vital. The findings support the continued use of

the GCS by appropriately qualified personnel, but call into question much of the

conventional wisdom about its reliability when used by untrained or inexperienced staff.

The findings also suggest that inter observer comparisons are insufficient for establishing

the viability of the GCS.33

Stephen J. Cavanagh (1992) conducted a Clinical trial study on Glasgow Coma

Scale among registered Nurses (RNs) in Critical care settings, in USA. GCS is used as an

26
assessment tool to measure the level of consciousness in coma patients. They selected the

General intensive care, neurological intensive care, coronary care emergency room and

post anesthetic recovery room. Seventy- five RNs viewed each of the GCS assessments

and rated each patient on the scoring sheet. Study shows that based on comparison with

export scores of the 75 participants, 38 responded correctly to eye opening responses;

only 26 responded correctly to the motor response ratings. However, a better accuracy

was achieved in the verbal response category with 67 participants responded correctly.

The study result shows, neurological experience were statically less regard to the nurse’s

accuracy of GCS assessment.11

Mengazzi JJ, Davis EA, Sucov AN, Paris PM, (1993) conducted a prospective

sequential trial on the reliability of GCS when used by emergency physicians and

paramedics. The objectives of the study was to determine the reliability of GCS when

used by emergency physicians and paramedics. The sample for this study included 19

universities affiliated physicians and 41 professional paramedics. The participants viewed

four videotaped scenes in which a patient assessed by a paramedic. The first 3 scenes

represented severity, intermediate and no/mild alteration in the LOC. The kappa statistic

was used to determine inter rater reliability. The study concluded that the GCS shows

statically significant reliability between emergency physicians and paramedics. It also has

a significant level of inter rater reliability.18

Muniz EC, Thomas MC et al (1997) was conducted a study on Use of the GCS

and Jouvet Coma Scale to assess the level of consciousness. The aim of the study was to

compare the results obtained from evaluation of consciousness level by the utilization of

two scales. The sample size was 48. The result revealed that 37.4% of the evaluation

27
done with the JCS indicated of alteration in the consciousness level, whereas with the

GCS the alteration was present in only 23.58% of the evaluations. Another important

observation about the utilization of both scales was that the people whose scores were

between 9 and 10 in GCS had a stronger indication of alteration of consciousness level by

the same scale, while those scores between 12 and 15 had a stronger indication of

alteration of consciousness level by JCS. However it was believed that the result as well

as specific characteristics of groups of the patients might favor the utilization of different

scales to evaluate the conscious level..17

Polit. DF and Hungler BD. (1999) was conducted a cross sectional study about

the knowledge of Neurological examination among Medical students at Teaching

Hospital, Mysore. A total of 137 students were randomly selected and included in the

study. Structured questionnaire was introduced for the purpose of the study. After the

intervention by structured teaching programme, the investigator evaluated the post-test

score. Study concluded that compare to pre-test level of knowledge post-test score of

neurological examination with Structured Teaching Programme was highest.22

Fischer J, Mathieson C (2001) conducted a study on the history of the Glasgow

Coma Scale: implications for practice in Pennsylvania, USA. The Glasgow Coma Scale

(GCS) has been the gold standard of neurologic assessment for trauma patients since its

development by Jennett and Teasdale in the early 1970s. The GCS was found to be a

simple tool to use. It became the method of choice for trauma care practitioners to

document neurologic findings over time and predict functional outcome. Although the

scale has been shown to be effective, many authors have cited weaknesses in the scale

28
including the inability to predict outcome, variation in inter-rater reliability, and the

inconsistent use by caregivers in the pre hospital and hospital settings.35

Bridge LJ. Wilson M.(2003). was conducted a Prospective study at the Keio

University UK, on usefulness of neurological examination for diagnosis of the affected

level in patients with cervical compressive myelopathy (CCM).Fifty patients who

underwent successful decompressive surgery for cervical myelopathy caused by single

level disc herniation (38 men & 12 women, mean age 60 yrs). One of the three surgeons

made a diagnosis of CCM, and the other two conducted the Neurological Examination

including deep tendon reflex, pinprick response, muscle weakness & numbness in the

hand only, knowing that the patient had CCM, & established the Neurological-level

diagnosis. The result of this study suggested that Neurological Examination in patients

with CCM is accurate.26

Gocan.S, Fisher.A, (2005) conducted a survey on neurological assessment

practices on acute stroke patients. The result of the study revealed that the nurse are

moving away from reliance on GCS towards more standard scale to facilitate assessment

for accurate implementation..19

Heron. R, Gillies. R, Davie.A, (2005) conducted a study on the inter-rater

reliability of GCS scoring among staff nurses in sub specialties of critical care. GCS is

used as an assessment tool to measure the level of conscious level in coma patient. This

research investigated the reliability of scoring the GCS among registered nurses working

in 5 different clinical areas of critical care. Study showed that based on comparison with

scores of 75 participants, 38 responded correctly to eye opening responses, 26 responded

correctly to the motor response ratings. However better accuracy was achieved in verbal

29
response category with 67 participants responding correctly. The result showed that

motor response rating was most problematic in relation to rate accuracy.20

Anderson NE, et, al.. (2005) was conducted a descriptive study in New Zealand,

to compare the clinical neurological examination with imaging studies. Investigator

selected 65 patients who were referred for investigation of neurological symptoms, such

as headache or transient neurological events, without obvious focal signs. Patients with

obvious focal signs, cognitive impairment, brain stem or cerebellar lesions, movement

disorders, non-neurological disorders that would affect assessment or a marked midline

shift on imaging were excluded. 46 patients aged 21-83 years (mean 51y, 61% men), had

a single cerebral hemisphere lesion and 19 patients had no lesion. The result shows that

Neurological Examination was very useful to detect focal hemisphere lesions than other

imaging Studies. 21

Tukaram (2006) conducted a descriptive study at Rajiv Gandhi University of

Health Science, Karnataka, to evaluate the Staff Nurse on Neurological Assessment on

the clients with altered sensorium. A descriptive approach was adopted for this study &

30 staff nurses selected in Neurosurgery Intensive Care Unit, Medical & Surgical ward of

K.L.E.S’ Hospital .The investigator used structured observational checklist. The practice

in the area of Glasgow Coma scale score was 56.66 at pre-test and post score 93.33%,

actual gain in score was 36.67%. The study concluded that knowledge regarding

neurological examination for staff nurse was Unsatisfactory.24

Hickey JV..conducted a comparative study regarding neurological examination

scores and quantitative sensory testing in diagnosis of diabetic polyneuropathy, at Andhra

Medical College, in India. Diabetic Neuropathy examination score, quantitative Sensory

30
Testing by Vibration Perception Threshold in the diagnosis of diabetic polyneuropathy

and seek an optimal screening method. The result shows that Seventy one of 100 subjects

had evidence of neuropathy confirmed by Nerve Conduction Studies, while 29 did not

have neuropathy. The DNE score gave a sensitivity of 83% and a specificity of

79%.Vibration Perception Thresholds yielded a sensitivity of 86% and a specificity of

76%. This Study Found that A Simple Neurological Examination score is as good as

Vibration Perception, in evaluation of polyneuropathy.25

Holdgate A, Ching N, Angonese L. (2006) conducted a prospective study on

Variability in agreement between physicians and nurses when measuring the Glasgow

Coma Scale in the emergency department limits its clinical usefulness. The objective of

this study was to assess the inter rater reliability of GCS between nurses and doctors in

the ED. Inter rater agreement was excellent for verbal scores(weighted kappa > 0.75) and

total GCS scores, and intermediate ( weighted kappa 0.4- 0.75) for motor and eyes scores.

Total GCS scores differed by more than two points in 10 of the 108 patients, the study

concluded that the level of agreement for GCS scores was generally high, a significant

proportion of patients had GCS which differed by two or more points. This degree of

disagreement indicates that clinical decisions should not be based solely on single GCS

scores.27

Waterhouse C an audit of nurses, conducted a study to explore nurses practice

and knowledge of the GCS in Jan. 2007. sixty questionnaires were used across six

clinical areas : neurosurgery, neuro intensive care, neuromedicine, general medicine,

accident and emergency and general intensive care. Observational studies compared

nurses’ performance, recording and documentation of GCS observations in each of these

31
units. The study resulted that there were several areas for improvement; including the use

and application of painful stimulus. It also suggested a lack of knowledge of the patho-

physiology underpinning the three components that make up the scale. Problems were

evident in the record keeping, with very few examples of documentation within nursing

records of the separate components of the GCS.28

Winkler JV, Rosen P, Alfry EJ conducted a study in Colorado, USA on the Pre

hospital use of the GCS in severe head injury to determine the prognostic value of pre

hospital GCS in severe blunt head injuries. the GCS at the scene of injury (INGCS) and

the GCS in emergency department (EDGCS) were compared. The sample size was 33

head injured patients, categorized in four groups according to the degree of head injury.

The study resulted that the mean EDGCS was significantly higher than INGCS and may

have prognostic value for severely head injured patients.29

Jaurez VJ, Lyons M conducted a study on the interrater reliability of the

Glasgow coma scale. The purpose of this study was to test the interrater reliability of the

Glasgow Coma Scale (GCS) when used in assessing neurologically impaired patients. In

order to control variables, a videotape was developed of seven patients with different

neurological impairments. A total of 57 nurses and physicians with varying degrees of

education and experience used the GCS to score the patient responses. These responses

were then compared for consensus and against a criterion standard. The comparison

showed a low disagreement rating and a moderate to high agreement rating

demonstrating that this tool has good interrater reliability (p = 0.000). Nurses may use

this tool with confidence as one measure of assessment in evaluating neurologically

impaired patients.31

32
 Prasad K. conducted a study on a critical appraisal of the GCS’s clinometric

properties to assess whether the scale possesses the requisite clinometric properties. The

properties were appraised by the methodological principles of sensibility, reliability,

validity and responsiveness. The scale has a good sensibility, reliability and cross

sectional construct validity. Its predictive validity in traumatic coma, when combined

with age and brainstem reflexes, was good in the generating sample (sensitivity, 79 to

97%; specificity, 84-97%) but has not been tested in an external validation sample. Its

longitudinal construct validity has not been studied adequately. Thus, the scale was an

established discriminative instrument but its validity as a predictive and an evaluative

instrument has not yet been studied adequately.32

The American Association of Neurological Surgeons, The Joint Section on

Neurotrauma and Critical Care conducted a study on the prognosis of Glasgow coma

scale score. When considering the use of the initial GCS for prognosis, the two most

important problems were the reliability of the initial measurement, and its lack of

precision for prediction of a good outcome if the initial GCS was low. If the initial GCS

was reliably obtained and not tainted by pre hospital medications or intubation,

approximately 20% of the patients with the worst initial GCS will survive and 8-10% will

have a functional survival (GOS 4-5).34

This chapter deals with review of literature. The next chapter dealt with

methodology of the research.

33
METHODOLOGY

34
 CHAPTER -3

RESEARCH METHODOLOGY

Research methodology refers to control investigations of the ways of

obtaining, organizing, and analyzing data. Research methods are the steps, procedures

and strategies for gathering and analyzing the data in research investigation.

This chapter deals with the methodological approach to assess the

knowledge of staff nurses regarding Glasgow coma scale as a part of neurological

assessment of patients with neurological disorders.

RESEARCH APPROACH

The research approach adopted for this study was Quantitative research approach.

RESEARCH DESIGN

The research design refers to the researchers overall plan for obtaining answers to

the research questions and for testing hypothesis. The research design spells out the

strategies that the researcher adopts to develop information that is accurate, object and

interpretable.

For the present study the design was a Descriptive research design

VARIABLES

Variables are the qualities, properties or characteristics of person, things or

situation that change or vary.

35
 The variables are mainly included in this study are independent variable and

dependent variable. Dependent variable explains the effect of independent variable.

Independent variable

An independent variable is that stands alive or not dependent on any other. In this

study the independent variables refers to the staff nurses working in critical areas.

Dependent variable

Dependent variable is the variable that the researcher is interested in

understanding, explaining or predicting. In this study the dependent variable refers to the

knowledge of staff nurses.

POPULATION

TARGET POPULATION

The population of the present study consists of staff nurses who are willing to

participate, working in neuro and emergency ward.

ACCESSIBLE POPULATION

The population of the present study consists of staff nurses working in critical

care units in selected hospitals in Haryana.

SAMPLE AND SAMPLING TECHNIQUES

Sample consists of a subset of a population selected to participate in research

study. Sampling refers to the process of selecting a portion of the population, to represent

the entire population.

In this study the sample were staff nurses who are working in neuro and

emergency ward in selected hospitals in Kaithal.

36
SAMPLE SIZE

The sample size of the study consists of 80 staff nurses

SAMPLING TECHNIQUE

In this study the purposive sampling technique was used.

SAMPLING CRITERIA

INCLUSION CRITERIA

 Staff nurses who are working in critical care units.

 Staff nurses who are willing to participate in the study.

 Staff nurses who are available in the time of study.

 Staff nurses who can read and write English.

EXCLUSION CRITERIA

 Staff nurses working in other wards.

 Staff nurses who are not willing to participate in the study.

SETTING

The study was conducted at various hospitals in Kaithal district of Haryana. Shri

BalaJi hospital, Shah hospital, Kaithal Nursing hospital, Jaipur hospital and Kirti

hospital. All these hospitals provides emergency and trauma care to the clients and also

provided physiotherapy to the clients.

TOOLS FOR DATA COLLECTION

Self Administered Questionnaire used for data collection. The tool for the data

collection consists of two sections:

37
Section A: Section A consists of selected demographic variables such as age, sex, year

of experience, educational status, years of experience in critical care units, source of

information.

Section B: Section B consists of Structured questionnaire to assess the knowledge on

Glasgow coma scale among staff nurses working in neuro and emergency ward..

DURATION OF DATA COLLECTION:-

The duration of the study was 4 weeks.

DELIMITATION

This study is delimited to the staff nurses working in critical care units

of selected hospitals.

DESCRIPTION OF TOOL

The structured knowledge questionnaire is of 30 items. MCQ type

knowledge questionnaire that is completed by staff nurses. Each item had four options.

Each right and wrong answers score for right answer 1 and for wrong answer 0. Total

score is calculated and recorded.

Maximum score: - 30

Minimum score: - 0

Each right answer: - 1

Each wrong answer: - 0

Categorization and interpretation

Poor knowledge = <14 correct response

Average Knowledge = 15-22 correct response

Good Knowledge = 23-30 correct response

38
Reliability

An instrument’s reliability is the consistency with which it measures the target

attribute. Reliability of the tool was assessed by administering the tool to 5 staff nurses.

Reliability was tested by using Karl Pearson’s Coefficient of correlation. The reliability

computed was r = 1.00

Ethical clearance

1. The research was ethically approved by institutional ethical committee.

2. Formal approval was taken from the Chairperson of every hospital for the data

collection.

3. Consent sheet were developed and informed written consent was obtained from

staff before enrolling to the study

Pilot study

A pilot study is a small scale version, or trial run, done in preparation for a major

study. In order to test the feasibility of the research study a pilot study was carried out at

Haryana Institute of medical sciences (HIMS) Hospital from 17-12-13 to 18-12-13 on 10

staff nurses.

Data collection Technique

Data collection was carried out on Jan. 2014 at the hospitals of Kaithal. After

obtaining permission major steps taken to collect data were as follows :-

1. Good rapport was established with staff nurses and purpose of the study was told

to the staff nurses.

2. Informed consent was taken from staff nurses and instruction were given about

how to respond.

39
 3. Self rapport and structured knowledge questionnaire method was used to correct

regarding socio demographic variables.

4. Knowledge of the staff nurses about Glassgow Coma Scale was obtained by

structured knowledge questionnaire.

During data collection procedure participants queries were answered.

Data analysis

Statistically analysis was carried out using SPSS software 17 version.

Descriptive Statistics

Mean, standard deviation, mean percentage.

Inferential Statistics

Chi Square were used to find out the association between staff nurses skills with

selected socio demographic variables.

40
 Purpose Setting Target Sampling
population technique

To assess CCUs of Kirti Staff Purposive

the hospital, Shri nurses sampling
knowledge balaji hospital, working in
regarding Kaithal nursing Critical
GCS home, Shah care units
among staff hospital, Jaipur
nurses. hospital.

RESEARCH PROCESS

Variables
Analysis
Instrument Sample size

Dependent
Descriptive variables:
statistics: Structured 80 staff knowledge of the
Frequency, questionnair nurses staff nurses.
Percentage, e on
Mean, Median, Glasgow Independent
Standard Coma scale variables: staff
deviation and nurses working
Chi-square test. in CCUs.

Fig 2: SCHEMATIC PRESENTATION OF RESEARCH PROCESS.

41
 This chapter dealt with research methodology. The next chapter will highlight the

analysis and interpretation of data.

ANALYSIS

AND

INTERPRETATION

42
 CHAPTER-IV

ANALYSIS AND INTERPRETATION

This chapter deals with the analysis and interpretation of data collected from 80

staff nurses to assess the knowledge regarding Glassgow Coma scale as a part of

neurological assessment. .The analysis was based on the objectives of the study.

The results were computed using descriptive and inferential statistics based on

assumptions and the objectives of the study. The main objectives of the study were:-

 To assess the knowledge regarding the glassgow coma scale among staff

nurses in a selected hospital.

 To identify the association between knowledge score of Glasgow Coma

Scale with their selected socio demographic variables

Organization and representation of data

The data was first coded and entered in a master data sheet. The data have been organised

and presented in various sections.

Section 1: Sample characteristics

Section 2 : Mean, median, standard deviation and range of knowledge scores of staff

nurses regarding Glasgow Coma scale.

43
Section 3 : Association between the knowledge scores with selected socio - demographic

variables.

Section 1: Sample characteristics

This section shows age, gender, educational qualification, years of

experience in Critical Care Units and total years of experience in clinical areas.

Table 2: Socio- demographic characteristics of staff nurses: Frequency and

Percentage

N=80

Frequency Distribution Percentage(%) Frequency

· 23-25years 69 55
Age
· 25-27years 31 25
· Male 20 16
Gender
· Female 80 64
· G.N.M 95 76
Educational Qualification
· B.Sc(N) or P.B.Bsc (N) 5 4
1-2(Yrs) 84 67
Exp. In CCU 3-4(Yrs) 15 12
5 and Above(Yrs) 1 1
1-2(Yrs) 65 52
Total yrs exp 3-4(Yrs) 30 24
5 and Above(Yrs) 5 4

Table 2 represents that the majority of staff nurses i.e. 55(69%) out of 80 were

between the age group 23-25, rest of the staff nurses i.e. 25(31%) were in the group of

44
25-27years. Sixty four staff nurses (80%) out of 80 were females and sixteen (20%)

staff nurses were males.

Out of 80 staff nurses, 76 (95%) of the nurses were diploma holder and remaining

i.e. 4(5%) were graduate nursing. 67 (84%) staff nurses had the experience in CCU

between 1-2 years and 12 (15%) staff nurses had 3-4 years experience and only one (1%)

out of 80 had more than 5years experience in CCU.

Maximum staff nurses i.e. 52(65%) had total years of experience between 1-2

years and remaining i.e 24(30%) had 3-4 years total experience and only 4(5%) had more

than 5 years total experience in their clinical areas.

Figure3 showing the distribution of staff nurses according to age group.

45
Figure 4 showing the distribution of staff nurses according to their gender.

46
Figure 5 showing the distribution of staff nurses according to their educational

qualification.

47
Figure 6 showing the distribution of staff nurses accordind to the experience in

Critical Care Units.

Figure 7 showing the distribution of staff nurses according to their total years of

experience.

Section-2: Mean, median, standard deviation and range of knowledge scores of staff

nurses regarding Glassgow Coma scale.

Objective no. 1: To assess the knowledge regarding the GLASGOW COMA SCALE

among staff nurses in a selected hospital.

Table 3: Descriptive Statistics includes Mean, median, standard deviation and range

of knowledge scores of staff nurses

N=80
Descriptive Mean + S.D Median Min. Range of Range of
statistics score obtained possible obtained score
score

48
Knowledge 17.94+ 4.524 18 7 30 20
scores

Table3 shows the total mean of knowledge score regarding to the GCS among staff

nurses was 17.94+ 4.524 and the range of obtained score was 20.

Figure 8 showing mean and median of knowledge scores among staff nurses.

Table 4: Frequency and percentage(%)distribution of knowledge scores of Staff

nurses on Glassgow Coma Scale

N=80
Category Score Percentage Percentage Frequency

Good (23-30) ≥75% 19 15

Average (15-22) 50%-74% 65 52

Poor (0-14) < 50% 16 13

49
 Table 4 reveals that the maximum i.e 52(65%) staff nurses had average

knowledge scores i.e. between 15-22 (50%-74%) whereas 15(19%) staff nurses had good

knowledge scores i.e between 23-30(>75%) scores and rest of them had poor knowledge

score i.e <50%.

Figure 9 showing the frequency and percentage of knowledge scores of staff nurses.

Section-3: To find the association between the knowledge scores among staff nurses with

selected socio - demographic variables.

Objective no.2:- To identify the association between knowledge score of

GLASSGOW COMA SCALE with their selected socio demographic variables

Table 5 : Association between the knowledge scores with selected socio -

demographic variables.

Demographic Data Association with Knowledge Score

50
 DEMOGRAPHIC Chi Table
P Value df Result
VARIABLES Test Value

· 23-25years
Age 4.065 0.131 2 5.991 Not Significant
· 25-27years

Male
Gender 0.729 0.695 2 5.991 Not Significant
· Female

· G.N.M
Educational
· B.Sc(N) or 0.837 0.658 2 5.991 Not Significant
Qualification
P.B.Bsc (N)

1-2(Yrs)

Exp. In CCU 3-4(Yrs) 14.563 0.006 4 9.488 Significant

5 and Above(Yrs)

1-2(Yrs)

Total yrs exp 3-4(Yrs) 9.421 0.051 4 9.488 Not Significant

5 and Above(Yrs)

p<0.05*

In Table5..the findings suggest that there was significant association between the

knowledge score and experience in CCU of staff nurses. But at the same time, there was

no significant association between with selected variables like age, gender, educational

qualification and total years experience in clinical of staff nurses.

This chapter dealt with analysis and interpretation of data. The next chapter will deal with

discussion.

51
DISCUSSION
52
 CHAPTER-V

DISSCUSSION

This chapter deals with summary of the study, its major findings, discussion and

conclusion. The implications for nursing administration, nursing practices, nursing

education and nursing research have been followed by limitation of the study. The

chapter ends with recommendation for research on future.

53
The study is a descriptive research and aimed to assess the knowledge regarding GCS

among staff nurses.

Objectives of the study were:

 To assess the knowledge regarding the Glassgow Coma Scale among staff

nurses in a selected hospital.

 To identify the association between knowledge score of Glassgow Coma

Scale with their selected socio demographic variables

The research approach adopted for the study was with descriptive research design.

The independent variable in the study were staff nurses working in CCU and dependent

variable was knowledge of staff nurses. The study was conducted at district Kaithal with

80 staff nurses and purposive sampling was used to collect data with the help of

structured questionnaire. Structured questionnaire was divided into two sections:

 Demographic variables

 Knowledge Questionnaire on GCS

Content validity of the tool was established with the help of nine experts included

four nursing experts and five doctors. Reliability coefficient for structured questionnaire

was calculated by the method of karl pearson which was highly significant.

Data analysis was done by using descriptive and inferential statistics.

DISCUSSION-

The findings of the study were discussed in terms of objectives of the study and

assumptions. The data was collected from 80 staff nurses who are working in the critical

54
care units in selected hospitals in district Kaithal. The findings of the present study

compared with other studies.

In the present study, the staff nurses were in the age group of 23-27 years.

55(69%) out of 80 were between the age group of 23-25years, rest of the staff nurses i.e.

25(31%) were in the group of 25-27years. Bagi D reported the similar findings as the

staff nurses participated in the study were in the age group of 20-35 years where 65.45%

of staff nurses were in the age group of 20-30 years41.

In the present study the majority of the subjects were females 64(80%) while only

16(20%) were males. The findings related to another study conducted by Bagi D in

which majority 38(69.10%) were females41.

In the present study majority 95% completed their diploma of nursing and similar

findings were found in a study conducted by Sibhala S in which majority 70% were

holding the diploma of nursing42.

In the present study majority of staff nurses 84% had 1-2 years experience in

CCU and similar findings were reported in a study conducted by Dessai S in which the

majority 82% had 0-2 years experience in CCU43.

In the present study majority 65% of staff nurses had 1-2 years experience and the

similar findings were reported by Dessai S in his study in which majority 56% of the

subjects had 0-2 years experience43.

In the present study 65% staff nurses having average level of knowledge whereas

only 19% having good knowledge regarding GCS but they face difficulties while they

practiced the Glassgow Coma Scale in patients with neurological disorders.

55
MAJOR FINDINGS OF THE STUDY

 Majority 69% of the subjects belonged to the age group of 23-25 years.

 Majority 80% of the subjects were females.

 Majority 95% of the subjects were diploma holder in nursing.

 Majority 84% of the subjects had 1-2 years experience in CCU.

 Majority 65% of the subjects had 1-2 years total experience.

 Majority 65% of the subjects had average level of knowledge.

NURSING IMPLICATIONS

The study findings have several implications in nursing. They can be categorized

under nursing practice, nursing education and nursing administration.

Nursing Practice:

Nursing practice can be improved by regular upgrading of the knowledge via in

service education. Periodic neurological assessment via the Glasgow Coma Scale can

help to improve the survival rate of the patients by early detection of the neurological

disorders. To undertake this task staff nurses should be equipped with adequate

knowledge and skill on Glassgow Coma Scale.

Nursing education:

It is essential for all the staff nurses to have adequate knowledge and skills on

Glasgow coma scale. The structured knowledge questionnaire used in the study should be

56
employed by the nurses and students to refine their knowledge and skills on the topic

from time to time to render the effective patient care.

Nursing Research:

Nurses are the key personnel who provide health care to the patients extensively.

Therefore these nurses should conduct various projects and research studies in the

hospital to provide an evidence based care to the patients. The nurse can take up

researchers on different teaching strategies to improve the knowledge and practice on

Glassgow Coma scale.

Nursing administration:

The nurse administrators can conduct in-service education Glasgow coma scale

based on the result of the present study.

LIMITATIONS

 The study was limited to staff nurses working in intensive care units and

emergency departments in selected hospitals in Kaithal.

 The staff nurses who are willing to participate.

 The study was confined to a small sample selected by purposive sampling

technique which restricts the generalization.

RECOMMENDATIONS

Keeping in view the findings of the study the following recommendation are made for the

further study.

57
  A similar study can be replicated with a large sample in order to generalize the

data.

 A study can be done on the effectiveness of self instructional module or video

instruction on the knowledge and skills regarding Glassgow Coma Scale.

 Comparative study can be conducted in different settings.

 The research tool can be updated and can be used as evaluation criteria for the

nursing working skills in the CCUs.

CONCLUSION

Major conclusions drawn from the study during administration of questionnaire

are the most of the staff nurses had average knowledge regarding Glassgow Coma scale.

The socio demographic variables of nurses having experience in CCUs were found to

have significant association with knowledge scores of staff nurses. Conversely, age,

qualification, gender, and total years of experience did not have association with

knowledge scores. The association of the knowledge scores of staff nurses with the

experience in CCUs indicated that the nurses knowledge on Glassgow Coma Scale were

influenced by working in Critical Care Units.

Considering above findings of the study it may be recommended that a short training

course with teaching program is needed to improve the staff nurses knowledge as well as

their practice.

58
59
REFERENCES

60
 REFERENCES

1. Lewis S, Heitkemper M, Dirksen S, Medical Surgical Nursing: Assessment and

Management of Clinical Problems.7th edition., Missouri: Elsevier; 2007:1442.

2. Dowsen S. Brain and Nervous System.2010.Available from:

http://kidshealth.org/parent/general / body basics /brain_nervous_system.html

3. Edwards S.., Using the Glasgow Coma Scale: analysis and limitations. British

Journal of Nursing; 2001.10(2): 92-101. Available from:

http://www.mpdgp.com.au/files/docs/laos%20recommendations/using

%20glasgow%20scale%20analysis%20and%20limitations.pdf

4. Palmer R, Knight J, Assessment of altered conscious level in clinical practice.

British Journal Of Nursing; 2006.15(22):1255-59.Available from:

http://www.mpdgp.com.au/files/docs/laos%20recommendations/assessment

%20of%20altered%20conscious%20level%20in%20clinical%20practice.pdf

5. Teasdale G, Murray G, Parker L, Jennett B "Adding up the Glasgow Coma

Score". Acta Neurochir Suppl (Wien) 1979. 28 (1): 13–6. PMID 290137.

6. Bordini A L, Luiz T F, Fernandes M, Arruda W O, Teive H A G, Coma Scales :

Historical Review., 2010;68(6):930-37. Available from:

http://www.scielo.br/pdf/anp/v68n6/19.pdf.

7. Traumatic Brain Injury Information Page., National Institute of Neurological

Disorders and Stroke.2001.[Updated 2012 Jan 20]. Available from :

http://www.ninds.nih.gov/disorders/tbi/tbi.html

8. Black J M, Hawks J H., Medical Surgical Nursing: Clinical Management for

61
 positive outcomes. 7th edition., Missouri: Elsevier; 2005:2051

9. Matis G, Birbilis, The Glasgow Coma Scale-- A Brief review..Past, present,

future.2008. Available from:

http://www.mendeley.com/research/theglasgowcoma-scale-brief-review-past-

present-future

10. Heim C, Schoettker P, Spahn DR, Glasgow Coma Scale in traumatic brain injury.,

Anesthetist. 2004 Dec;53(12):1245-55. Available from :

http://www.ncbi.nlm.nih.gov/pubmed/15597166

11. Geraghty M., Nursing the Unconscious Patient. 2005. Available from :

http://www.redorbit.com/news/health/255016/nursing_the_unconscious_patient.

12. Ellis A, Cavanagh S J. Aspects of neurosurgical assessment using the Glasgow

Coma Scale. Intensive and Critical Care Nursing. 1992 Jun; 8(2): 94-99.

Available from :

http://www.intensivecriticalcarenursing.com/article/0964-3397(92)90037-K/

abstract

13. Glasgow Coma Scale. Wikipedia: The Free Encyclopedia. Available from :

http://en.wikipedia.org/wiki/Glasgow_Coma_Scale

14. Jennet. B., Development of Glasgow Coma and Outcome Scales, 2005. Available

from: http://www.sbn- neurocirurgia.com.br/site/download/14j.pd

15. McNett M.A, Review of the Predictive Ability of Glasgow Coma Scale Scores in

Head-Injured Patients. Journal of Neuroscience Nursing. 2007 Apr; 39(2):68-75..

Available from : http://www.medscape.com/viewarticle/5561702

62
16. Injuries in India: A national perspective. NCMH Background Papers, Burden of

Disease in India. Available from :

http://whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_

P2__Injury_in_India.pdf

17. Gowda N.K et.al; Technetium Tc-99m Ethyl Cysteinate Dimer Brain Single-

Photon Emission CT in Mild Traumatic Brain Injury: A Prospective Study,

American Journal Of Neuro radiology. 2006 Feb;27(2):447-51. Available from:

http://www.ajnr.org/cgi/reprint/27/2/447.pdf.

18. Henneman EA, (1989) clinical assessment and neuro-diagnosis. Critical Care

Nurse Clinic North Am. p:131-42.

19. Stewart – Amideic, Assessing the comatose patient in the intensive care unit,

AAGS Clinical issues., Critical care nurses 1991 Nov; 2(4) : 613-622

20. Rowley G, Fielding K, Reliability and accuracy of Glassgow Coma Scale with

experienced and inexperienced users. Lancet 1991 March2; 337(8740) : 535-8.

21. Menegazzi J J, Davis E A, Sucov AN, Paris PM.., Reliability of the Glasgow

Coma Scale when used by emergency physicians and paramedics. The Journal of

trauma, 1993 Jan; 34(1):46-8..Available from:

http://www.ncbi.nlm.nih.gov/pubmed/8437195

22. Muniz EC, Thomaz MC, Kubota MY, Cianci L, de Sousa RM.., Use of the

Glasgow Coma Scale and the Jouvet Coma Scale to evaluate the level of

consciousness. Revista da Escola de enfermagem da USP. 1997 Aug; 31(2):287-

303. Available from: www.ncbi.nlm.nih.gov/pubmed/9411580

63
23. Polit DF and Hungler BD.. Nursing Research: Principles and Methods.. 5th

edition.. New York: J.B Lippincott Company; 1999; 97-106.

24. Fischer j, Matheison C.. The history of GCS: implications for practice.. Journal of

Critical Care Nursing 2001 feb; 23(4): 52-8.

25. Bridge LJ, Wilson M (2003).. Description of assessment practice.. Journal of

neurology..p- 72.

26. Gocan S, Fisher A. Ontario regional stroke centre: survey of neurological nursing

assessment practices with acute stroke patients. Axone. 2005 Jun; 26(4): 8-13.

27. Heron R, Davie A, Gillies R, Courtney M. Interrater reliability of the Glasgow

Coma Scale scoring among nurses in sub-specialties of critical care.. Australian

Critical Care. 2001 Aug;14(3):100-5. Available from :

http://www.ncbi.nlm.nih.gov/pubmed/11899634

28. Anderson NE, (2005) Dec.76; Detection of with focal cerebral hemisphere lesion

using the neurological examination. Pg 545-549.

29. Zagade T B, (2006); An observational study of the neurological assessment on the

clients with altered sensorium with a view to prepare a learning package and to

evaluate the efficacy of the staff nurses in terms of gain in practice in KLES Dr.

Prabhakar Kore Hospital and MRC, Belgaum, Karnataka.[Unpublished MSc

Theses].Belgaum: Rajiv Gandhi university of health sciences.

64
30. Hickey JV.. the critical practice of neurological nursing; 4th edition- 227; East

Washington square, Philadelphia Newyork J.B Lippincott company; 1997;

p: 33-161.

31. Holdgate A, Ching N, Angonese L. Variability in agreement between physicians

and nurses when measuring the Glasgow Coma Scale in the emergency

department limits its clinical usefulness. Emergency Medicine Australasia. 2006

Aug;18(4):379-84.

Available from: http://www.ncbi.nlm.nih.gov/pubmed/16842308

32. Waterhouse C. An audit of nurses’ conduct and recording of observations using

the Glasgow Coma Scale. British Journal of Neuroscience Nursing.2008 Oct; 4

(10): 492-93.

33. Winkler JV, Rosen P, Alfry EJ. Pre hospital use of the Glasgow Coma Scale in

severe head injury. Journal of Emergency Medicine. The Journal of Emergency

Medicine. 1984; 2(1):1-6.Available from:

http://www.ncbi.nlm.nih.gov/pubmed/6520365

34. Jaurez VZ, Lyons M.. Interrater reliability of GCS. Journal of neuroscience

nursing 1995 Oct; 27(5): 283- 286

35. Prasad K.. The GCS: a critical appraisal of its climacteric properties. Journal of

clinical epidemiology 1996 Jul; 49(7): 755-763

36. The Brain Trauma Foundation. The American Association of neurological

surgeons. The Joint Section on Neuro trauma and Critical Care. GCS Score;

Journal of Neuro Trauma; 2000 Jun-July; 17(6-7): 563-71.

37. www.medtrng.net/efmb..../Glasgow%20coma%20scale%20Quiz...html...

65
38. www.gobookee.net/multiple-choice-questions-for Glasgow coma scale

39. http://en.wikipedia.org/wiki/glasgow_coma_scale.

40. Laureys et al. 2002..Glasgow coma scale comments.. pdf..

41. Bagi D.. A study to evaluate the effectiveness of Self Instructional Module(SIM)

on knowledge of Arterial Pressure Monitoring(APM) among the nurses working

in critical care units of KLES’ Dr. Prabhakar Kore Hospital and MRC, Belgaum,

Karnataka.[Unpublished MSc Theses]. Belgaum: Rajiv Gandhi university of

health sciences;2009

42. Sibbala S.. The effectiveness of a self instructional module on selected obstetric

drugs among staff nurses working in Jayanagar general hospital, Bangalore, south

Karnataka.[Master Theses].Banglore:Karnataka.2005 JUN. Available from:

http://119.82.96.198:8080/jspui/bitstream/123456789/2684/1/Sabitha

%20Sibbala.pdf.

43. Desai S V.A study to evaluate the effectiveness of Self Instructional

Module(SIM) regarding the knowledge and practices of management of clients on

ventilator among the nurses working in KLES’ Dr. Prabhakar Kore Hospital and

MRC, Belgaum, Karnataka.[Unpublished MSc Theses].Belgaum: Rajiv Gandhi

university of health sciences;2005

66
ANNEXURES

67
68
 Annexure I

REQUISITION LETTER TO EXPERTS FOR VALIDATION OF THE

TOOL

From
Ms. PRIYANKA
M.Sc. Nursing II year student
Ved Nursing College
Baroli, Panipat

To
……………….………………

………………………………

……………………………….

Sub: Requisition for acceptance to validate the tool

Respected Madam/ Sir

I wish to inform you that my title of study is, “A descriptive study to assess the
knowledge of staff nurses regarding glassgow coma scale as a part of neurological
assessment among the patients with neurological disorders in selected hospitals at
Haryana”.

I would be grateful to you if you would validate my tool and provide me your valuable
guidance.

Yours sincerely
PRIYANKA

69
 Annexure II

CERTIFICATION OF VALIDATION OF TOOL

Title of the study: “A Descriptive Study to Assess the Knowledge of Staff nurses
regarding Glassgow Coma Scale as a Part of Neurological Assessment among the
Patients with Neurological Disorders in Selected Hospitals at Haryana”.

I
________________________________________________________________________
___

Would /would not agree in validating the Tool prepared for the above mentioned
study.

Name
Designation
Date

70
 ANNEXURE- III

List of Experts

1. Mrs. Santosh Hooda

Professor,
College of Nursing
Pt. B.D. Sharma, PGIMS
Rohtak.

2. Mrs. Vinay Kumari

Lecturer (Med-Surg Nursing)
M.M.C.O.N
Mullana, Ambala.

3. Mr. Sujith Chandran

Assistant Professor
Ved nursing college
Panipat.

4. Ms.Manju
H.O.D (Medical Surgical Nursing)
Ved Nursing College
Panipat .

5. Dr. Purushottam
Neurosurgeon
Hyderabadi Hospital,
Panipat.

6. Dr. Vijay Kumar

Neurosurgeon
Jindal Institute of Medical Sciences and Research Centre,
Hissar.

7. Dr. Navdeep Khurana

Neurologist
Jindal Institute of Medical Sciences and Research Centre,
Hissar.

71
8. Dr. Sanjay Aggarwal
Neurosurgeon
Prem Hospital,
Panipat.

9. Dr. Narender Ahlawat

Neurosurgeon
CMAH,
Panipat.

72
Annexure IV

73
Annexure V

74
Annexure V(a)

75
Annexure V(b)

76
Annexure V(c)

77
Annexure V(d)

78
 ANNEXURE-VI

SCREENING SHEET

Section –A Code

Inclusion criteria:-

a) Staff nurses who are working in CCU.

Yes/No
b) Staff nurses who are willing to participate in the study.
Yes/No
c) Staff nurses who can understand Hindi or English.
Yes/No
Section -B

Exclusion criteria:-

a) Staff nurses who are not working in CCU.

Yes/No
b) Staff nurses who are not available at the time of data collection.
Yes/No

79
 Annexure VII

SUBJECT INFORMATION SHEET

Study title: A Descriptive Study to Assess the Knowledge of Staff nurses regarding
Glassgow Coma Scale as a Part of Neurological Assessment among the Patients with
Neurological Disorders in Selected Hospitals at Haryana”.

Principal : Prof. Mrs. Rita Sarkar

Investigator: Priyanka Gupta

Chief Guide: Ms. Manju

Co-Guide: Mrs. Minal Sharma

Purpose of the study:

The purpose of this study to assess the knowledge of staff nurses regarding Glasgow

Coma Scale.

Study Plan: You will be given two questionnaires:-

Questionnaire for socio-demographic profile.

Structured knowledge questionnaire to assess the knowledge of staff nurses

regarding Glasgow Coma Scale.

You are requested to give information by answering the questions given in the
questionnaire. It will take 30 minutes of your time. Please do not hesitate to give the
necessary information.

Potential risks and discomforts:

There is no risk associated with the study.

80
Benefits by participating in the study:

You will gain knowledge on Glasgow Coma Scale and that may help to managing the

patients with neurological disorders.

Alternative to participation:

The study is for research purpose. You are willing to decide about the participation in the

study.

Confidentiality:

I assure you that information given by you will be kept confidential and will be used

Only for the research purpose.

Question:

I will try to answer your entire questions regarding study up to your satisfaction before

you give your consent for participation in the study.

Voluntary Consent:

You have the freedom to participate or withdraw from the study anytime without penalty

or loss of benefits.

Thanking you for the co-operation,

Yours faithfully,

Priyanka Gupta

Contacts:

In the event that at any time during the course of the study you feel that you have not

been adequately informed about the study or feel under stress to continue against your

wishes you can contacts.

81
Guide:
Ms. Manju
Lecturer
(H.O.D Medical Surgical nursing)
Ved Nursing College
Baroli , Panipat

Co-guide:
Mrs. Minal Sharma
Lecturer, Medical Surgical nursing
Ved Nursing College
Baroli, Panipat

82
 Annexure VIII

CONSENT FORM

Code No.

I agree to participate in the study “A descriptive study to assess the knowledge

regarding Glassgow Coma Scale as a part of neurological assessment of patients with

neurological disorders among staff nurses in a selected hospital in Haryana.”

 I have had the study explained to me.

 I have been given opportunity to ask question and have been answered to my
satisfaction.

 I voluntarily give consent to participate in this study.

Name of the staff nurse ______________

Signature of the staff nurse ______________

Address ______________

Date ______________

Name of the investigator ______________

Signature of the investigator ______________

Address _______________

Date _______________

83
 Annexure IX

STRUCTURED QUESTIONNNAIRE ON
GLASGOW COMA SCALE

Instructions
 Kindly read carefully
 Attempt all the questions with appropriate answers
 Tick ( ) mark the appropriate answers

A. DEMOGRAPHIC VARIABLES

1. Age(in years): _____________

2. Gender
 Male _____
 Female _____
3. Qualification:-
 Diploma nursing- ____________
 Degree nursing- _____________

4. Years of experience in Critical care unit: ____________

B. QUESTIONNAIRE ON KNOWLEDGE ASSESSMENT OF GLASGOW

COMA SCALE

1. The functional unit of the nervous system is _____

a. Neuron
b. Nephron
c. Neurogilia
d. Gilial cells

2. The long projection of the neuron that carries impulses away from the cell body is
________
a. Synapse
b. Axon
c. Myelin sheath
d. Dendrite

3. The Glasgow coma scale used to assess the status of the _________
a. Autonomic Nervous System
b. Central Nervous System
c. Peripheral Nervous System
d. All of above

84
4. The Glasgow coma scale was formulated by _______
a. Teasdale and Jennets
b. Marion
c. Carlier
d. Laureys

5. The original Glasgow coma scale was a _________

a. 15 point scale
b. 14 point scale
c. 13 point scale
d. 12 point scale

6. The three aspects of orientation are ___________

a. Sensation, person and place
b. Time, place and person
c. Memory, time and place
d. Place, memory and person

7. The GCS is used to assessing the patient’s ______

a. Neurological status
b. Mental status
c. Orientation
d. Cognition

8. The elements of GCS are________

a. Temperature, pulse, respiration
b. Eye opening, Motor response, Verbal response
c. History taking, physical assessment
d. Head circumference, chest circumference, midarm circumference

9. The best possible score for a Glasgow coma scale is __________

a. Eye opening 4;Verbal response 5; Motor response 6
b. Eye opening 6; Verbal response 5; Motor response 4
c. Eye opening 5; Verbal response 5; Motor response 5
d. Eye opening 3; Verbal response 4; Motor response 5

10. The Glasgow coma scale is used for _______

a. Children
b. Adults
c. Elders
d. All of above

85
11. The least score in Glasgow coma scale is _________
a. 3
b. 2
c. 1
d. 0

12. The highest score in GCS is __________

a. 12
b. 13
c. 14
d. 15

13. Scoring of GCS for a head injured patient between 9-12 indicates that patient
have ____________
a. Mild brain injury
b. Moderate brain injury
c. Severe brain injury
d. No brain injury

14. In mild brain injury, the Glasgow coma score would be ________
a. 3-8
b. 8-10
c. 9-12
d. 13-14

15. Below 8 Glasgow coma score is an indicator of ________

a. Mild brain injury
b. Moderate brain injury
c. Severe brain injury
d. No brain injury

16. An oriented conversation implies __________

a. Awareness of self
b. Awareness of environment
c. Awareness of self and environment
d. Unawareness of self and environment

17. The GCS score represented as the response to pain with abnormal flexion with
spontaneously opening eyes and making moaning sounds_______
a. E4V2M3 – GCS9
b. E2V3M2 – GCS7
c. E3V3M4 – GCS10
d. E2V4M5 – GCS11

86
18. The patient who does not respond to internal and external environmental stimuli
is ______
a. Obtunded
b. Lethargic
c. Confused
d. Comatose

19. Moaning and groaning without any recognizable words refers ______
a. Inappropriate words
b. Incomprehensible sounds
c. Confused speech
d. None of above

20. The patient obeys simple command in a motor response, getting score
a. 6
b. 5
c. 4
d. 3

21. The patient awakened from coma but remain completely unaware of their self and
environment, the condition referred as ________
a. Stupurous
b. Vegetative state
c. Obtunded
d. Lethargic

22. When the patient is capable of producing language, for instance phrases and
sentences, but is unable to answer the question about orientation in a condition
called __________
a. Confused speech
b. Inappropriate speech
c. Incomprehensible speech
d. Stereotype speech

23. A rapid flexion of the elbow associated with abduction of the shoulder, in
response to painful stimuli, known as _________
a. Abnormal flexion
b. Withdrawal flexion
c. Extensor posturing
d. Stereotyped flexion

87
24. Stereotyped flexion responses are the most common of the motor reactions
observed in _________
a. Mild brain injuries
b. Moderate brain injuries
c. Severe brain injuries
d. No any injury
25. Decorticate or decerebrate posturing indicates the presents of_______

a. Co-ordinated and localized responses to stimulation

b. Irreversible brain damage
c. A high spinal cord lesion
d. A significant brain injury

26. Which of the following statement about the use of GCS is false?

a. Highest score obtainable is 15

b. The scale can be used for children and adults
c. Lowest possible score is 0
d. To obtain total score of GCS, add the scores for eye opening, best verbal and best
motor response
27. The score given for internal rotation of the shoulders and pronation of the forearm
with adducted shoulder is _____________
a. 2
b. 3
c. 4
d. 5

28. The score given for the incomprehensible sounds in speech is _______
a. 4
b. 3
c. 2
d. 1

29. The score given for the patient when he is unable to open his eyes due to swelling
of the eyelid, is _______
a. 4
b. 3
c. 2
d. 1

30. An abnormal posture includes straightening of the limbs, pointing downward of

the toes and arching backward of the neck (extensor posturing) is ________

88
a. Decorticate
b. Decerebrate
c. Opisthotonus
d. Moribund

89
 Annexure X

ANSWER KEY OF QUESTIONNAIRE

Item no. Correct Response Scoring

1 a 1
2 b 1
3 b 1
4 a 1
5 b 1
6 b 1
7. a 1
8 b 1
9 a 1
10 d 1
11 a 1
12 d 1
13 b 1
14 d 1
15 c 1
16 c 1
17 a 1
18 d 1
19 b 1
20 a 1
21 b 1
22 a 1
23 b 1
24 c 1
25 b 1
26 c 1
27 a 1
28 c 1
29 d 1
30 b 1

90
 Annexure XI

Blueprint of structured questionnaire

Sr. Items to elicit the Knowledge Comprehension Application Total no. Total %
no. knowledge Item No. of Item No. of Item No. of of
concerning no. question no. question no. question questions
Glassgow Coma s s
Scale
1. Anatomy and 1,2 2 - - - - 2 6.7%
physiology of
nervous system

2. History of 4,5 2 10 1 - - 3 10%

Glassgow Coma
Scale

3. Elements of 3,6,7 4 16,18 9 - - 13 43.3%

Glassgow Coma ,8 19,21
Scale 22,23
24,25
30
4. Scoring of 26 1 - - 9,11, 11 12 40%
Glassgow Coma 12,1
Scale 3,14,
15,1
7,20,
27,2
8,29
Total questions 9 10 11 30

Total % 30% 33.3% 36.7% 100

91
 Annexure XII

Coding sheet

Sr. Demographic Code Abbreviation

no. variables no.

1. Age AG

1
 23-25years
2
 25-27years

2. Gender GD

1
 Male
2
 Female

3. Educational E.Q

Qualification

1
 G.N.M
2
 B.Sc(N) or

P.B.Bsc (N)

92
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94