Author: Kristi Hudson RN MSN CCRN

Glasgow Outcome Scale (GOS)

The Glasgow Outcome Scale (GOS) was commonly used before other scales were developed. Differing from the Glasgow Coma Scale, which is still a frequently used assessment tool in the early stages of trauma, the Glasgow Outcome Scale was used to determine the rehabilitation potential of brain-injured patients. Although The Glasgow Outcomes Scale continues to be referred to in the literature, especially in studies investigating early acute medical predictors of gross outcome, it is being frequently replaced with the DRS (Disability Rating Scale). The five categories of the original Glasgow Outcome Scale are: dead, vegetative, severely disabled, moderately disabled, and good recovery. The following gives greater detail to each of these categories.

1	DEAD
2	VEGETATIVE STATE Unable to interact with environment; unresponsive Patients who show no evidence of meaningful responsiveness. Patients who obey even simple commands, or who utter any words, are assigned to the better category of severe disability. Vegetative patients breathe spontaneously, have periods of spontaneous eye-opening when they may follow moving objects with their eyes, show reflex responses in their limbs (to postural or painful stimuli), and they may swallow food placed in their mouths. This non-sentient state must be distinguished from other conditions of wakeful, reduced responsiveness--such as the locked-in syndrome, akinetic mutism and total global aphasia.
3	SEVERE DISABILITY Able to follow commands/ unable to live independently This indicates that a patient is conscious but needs the assistance of another person for some activities of daily living every day. This may range from continuous total dependency (for feeding and washing) to the need for assistance with only one activity--such as dressing, getting out of bed or moving about the house, or going outside to a shop. Often dependency is due to a combination of physical and mental disability--because when physical disability is severe after head injury there is almost always considerable mental deficit. The patient cannot be left overnight because they would be unable to plan their meals or to deal with callers, or any domestic crisis, which might arise. The severely disabled are described by the phrase "conscious but dependent."
4	MODERATE DISABILITY Able to live independently; unable to return to work or school These patients may be summarized as "independent but disabled," but it is perhaps the least easily described category of survivor. such a patient is able to look after himself at home, to get out and about to the shops and to travel by public transport. However, some previous activities, either at work or in social life, are now no longer possible by reason of either physical or mental deficit. Some patients in this category are able to return to certain kinds of work, even to their own job, if this happens not to involve a high level of performance in the area of their major deficit.
5	GOOD RECOVERY Able to return to work or school This indicates the capacity to resume normal occupational and social activities, although there may be minor physical or mental deficits. However, for various reasons, the patient may not have resumed all his previous activities, and in particular may not be working.

Disability Rating Scale (DRS)

The Disability Rating Scale (DRS) was developed and tested with older juvenile and adult individuals with moderate and severe traumatic brain injury (TBI) in an inpatient rehabilitation setting. One advantage of the DRS is its ability to track an individual from coma to community. The maximum score a patient can obtain on the DRS is 29 (extreme vegetative state). A person without disability would score zero. In order to assure the reliability of this assessment tool, it must be completed on patient’s who are free from sedatives, anesthesia or other mind-altering medications. The scale is intended to accurately measure general functional changes over the course of recovery. It is an easy assessment tool to complete, and scoring is very simple and clear. Another advantage of the DRS is that expertise in the field is not needed to complete it accurately. The following is the rating system that is used when completing a DRS.

EYE OPENING:

0 Spontaneous
1 To Speech
2 To Pain
3 None

COMMUNICATION ABILITY:

0 Oriented
1 Confused
2 Inappropriate
3 Incomprehensible
4 None

MOTOR RESPONSE:

0 Obeying
1 Localizing
2 Withdrawing
3 Flexing
4 Extending
5 None

FEEDING (Knows how and when):

0.0 Complete
0.5
1.0 Partial
1.5
2.0 Minimal
2.5
3.0 None

TOILETING (Knows how and when):

0.0 Complete
0.5
1.0 Partial
1.5
2.0 Minimal
2.5
3.0 None

GROOMING (Knows how and when):

0.0 Complete
0.5
1.0 Partial
1.5
2.0 Minimal
2.5
3.0 None

LEVELS OF FUNCTION (Physical and Cognitive):

0.0 Completely independent
0.5
1.0 Independent in special environment
1.5
2.0 Mildly dependent - Limited assistance (Non-resident helper)
2.5
3.0 Moderately dependent - Moderate assistance (Person in home)
3.5
4.0 Markedly dependent (Assistance with all major activities, at all times)
4.5
5.0 Totally dependent (24 hour Nursing Care)

EMPLOYABILITY (Full time worker, homemaker, student):

0.0 Not restricted
0.5
1.0 Selected jobs, competitive
1.5
2.0 Sheltered workshop, noncompetitive
2.5
3.0 Not employable

(GOS) AND (DRS) COMPARISONS

Given the same data, the following is a comparison between the Glasgow Outcome Scale and the Disability Ranking Scale. Note that the Glasgow Outcome Scale ranks both of these cases the same (3), and though the patient falls in the 8-21 range on the DRS, the range of deficit is much more defined.

National Institute of Health Stroke Scale:

The NIH Stroke Scale is a Clinical Stroke Scale based on the clinical examination. It can be used to assess patients following an acute cerebral infarction. Instruction for implementing the NIH Stroke Scale is as follows:

1.      To be most effective, administer stroke scale items in the order they are listed.

2.      Record performance in each category after each subscale exam.

3.      Do not go back and change scores.

4.      Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do.

5.       The clinician should record answers while administering the exam and work quickly.

6.      Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).