NEUROLOGICAL ASSESSMENT

Why do a neurological assessment?

 Recognition of secondary brain injury caused by intercranial swelling or haemorrhage is important.

Changes to the neurological status can be dramatic or subtle and may occur over minutes or months depending on injury (Aucken&Crawford 1998)

NICE Guidelines June 2003

Minimum acceptable documented neurological observations are; GCS Pupil size and reactivity Limb movements RR, HR, BP, Temperature and SpO2

Frequency of observations
To be performed and documented on a halfhourly basis until GCS of 15 has been achieved Minimum frequency thereafter; Half-hourly for 2 hours Then 1 hourly for 4 hours Then 2 hourly

Who do we do neurological observations on?

Trauma Cerebral bleeds Sudden loss of consciousness Altering levels of consciousness Post cardiac arrest Overdose patients

The Glasgow Coma Scale(GCS)

Eye opening: indicates the functioning of the arousal mechanisms in the brain stem
Verbal Response:- assesses 2 areas of cerebral function, comprehension & transmission of sensory input. Ability to reply

Motor response:- damage to the patients motor nervous system may affect their ability to move

 By assessing the above in response to different stimuli, a decrease in the level of brain activity is reflected by the increased amount of stimuli required to produce a response.

Eye Opening
Score 4 3 2 1 Response Spontaneous To speech To pain None

Eyes opening spontaneously does not necessarily indicate awareness, but the functioning of the arousal mechanisms in the brain stem.

Painful Stimuli
The brain responds to central stimuli The spine responds to peripheral stimuli (Aucken & Crawford)

Painful Stimuli
Central Stimulation Trapezium squeeze Pressure at jaw margin Supra orbital pressure Sternal rub Peripheral Stimulation By squeezing patients finger between assessors thumb, gradually increasing pressure until a response is seen 3rd & 4th Fingers most sensitive

Points to note on painful stimuli

Pressure should not be applied to nail beds and pins should never be used.
Stimuli should only be applied once and for no more than 30 seconds

Motor response
Score 6 5 4 3 2 1 Response Able to move to command Localises to pain Normal flexion Abnormal flexion Extension None

Verbal Response
Score 5 4 3 2 1 Response Orientated Confused Inappropriate words Incomprehensible sounds None (ET Tube)

Pupil reaction
Should be 2-6mm diameter Shape- should be round Reaction should be brisk to light; sluggish or no reaction can indicate damage to cranial nerve III
NB: testing pupil reaction is not part of GCS, but is vital in neurological assessments

What are we testing?

Optic nerve II sensory nerve of visual activity Oculomotor nerve III nerve that controls pupillary response

Unequal pupils should be reported to medical staff

Limb responses
Test both arms and both legs to document any differences. Normal power Mild weakness Severe weakness Spastic flexion Extension No response

Vital Observations
Temperature Pulse Blood pressure Respiration

Accurate GCS Scoring

Highest total 15 - Lowest 3
COMA = GCS 8 or less Good practice on documentation GCS = 14/15 (E=4, M=5,V=5) Sharing at handover

The patient needs a medical review

Develops agitation or abnormal behaviour Drops one GCS point for half-hour or more Drops 2 or more GCS points Development of severe or increasing headache or persistent vomiting New or evolving signs