File Name: NG Gen FT POlO
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Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
EDITION NO: 3
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COPY: 45
(Full Text)
Every2Yean
AUTHORIZED BY:
Iv.. '
TITLE:
r, w.nL.'\,.(
JI;.~
Gerardine Kennedy
ADONlNlD'Se Practice Development Unit
).A.o. '4A. ~ 0. 0"",,-.
AlDirector ofNlD'Sing
Vo
Maura Fitzgerald
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TITLE:
Ann Reidy
Caroline Bridgeman
Sheila Sheehy
Clinical Placement Coordinator
Staff Nurse
Staff Nurse
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File Name: NG Gon FT P 010
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Feidhmeannaclll na Seirlhlse SWnte
Health Service Execulhc
TITLE:
1.0
HSEWest
Page2 0fll
Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Date Written: 9TH May
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
2008
(Full Text)
PURPOSE
1.1 This guideline is intended to give guidance to nursing staff on the assessment and monitoring of
patients who are potentially at risk of neurological deterioration. The guideline aims to provide
information on the correct use of the Neurological Observation chart and how to interpret the findings.
2.0
SCOPE
2. 1 The guideline applies to all Nursing Staff and Student Nurses Under supervision in order that
appropriate assessment and monitoring of patients who are potentially at risk of neurological
deterioration is performed
2.2 It is the Nursing staff's responsibility to assess, monitor and record neurological observations ,
and to liaise with medical team/s as appropriate
3.0
DEFINITION
3.1 The assessment and classification of patients who have sustained a head injury should be guided
by the adult version of the Glasgow Coma Scale (Please see appendix 1)
3.2
The Glasgow Coma Scale is a numerical grading system used to establish a patient's level of
consciousness following a head injury. This provides an essential baseline for comparison scores .Its
graphic, visual format ensures uniformity and gives a quick, concise, visual interpretation of the
patient's level of consciousness and neurological status over a period of time.
4.0 PRE PROCEDURE CONSIDERATIONS
4.1 For patients admitted with a head injury the minimum acceptable documented neurological
observations must include :The Glasgow Coma Scale: (GCS); pupil size and reactivity; limb
movements, respiratory rate, heart rate; blood pressure, temperature and blood oxygen saturation.
4.2 The GCS evaluates three key categories of behaviour that most closely refiect activity in the
higher centres of the brain.
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Feidhmeannadu na Seirtitist SWnte
Ifcalth ServIce ExccutM!
TITLE :
Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Date Written: gTH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
a. Eye opening
b. Verbal response
(Full Text)
c. Motor response.
The patient is assessed and scored in each area and the scores are added together to give the
patients Glasgow Coma Score- the maximum score is 15; indicating an awake, alert and fully
responsive patient and the lowest score is 3; indicating total unresponsiveness. A GCS score of 8 or
less defines coma in 90% of cases. (Robertson 2003).
4.3 Head injured patients who warrant admission should have neurological observations carried out
and recorded on a half hourly basis until GCS equal to 15 has been achieved or until discontinued by
the medical team.
4.4 The minimum frequency of neurological observations for patients with a GCS score equal to 15
is as fol lows
a. Half hourly for 2 hours
b. I-hourly for 4 hours
c.
2-hourly thereafter
(NICE 2007).
Should a patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period,
observations should revert to half hourly and follow the original frequency schedule
4.5 Important Factors for monitoring neurological observations
a. Use all parts of the neurological observation chart.
b.
Record only what you see
c.
Listen to family members and friends
d.
Report any changes in the patients
e.
Do not be influenced by previous observations
f.
Do not use nail pressure or sterna I rub
cond~ion
5.0 Procedure
Explain procedure to the patient and gain their consent where possible.
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Mid Western Regional Hospital
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Feidhmeannacht na SeirItUse Si:iinle
Ik:!aIth Service Ea'CutiYe
TITLE:
Date Written: 9TH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
(Full Text)
5.1 Table 1 How to use the Glasgow Coma Scale
Eye Opening
If the patient is unable to open his or her eye/s as a result of trauma or surgery, the letter (C) indicating closed-should be
recorded in the first box. Otherwise this section should be completed as follows
Score
Method
Eyes open spontaneously as you approach. If the patient is asleep wake the patient,
4 = Spontaneously
ensuring he/she is fully roused and then complete the assessment
he patient will respond to your voice. The best way to do this is to say his/her name. If there
3 =
To Speech
is no initial response, a raised voice should be used.
The patient opens his/her eyes to painful stimuli. The best way to do this is to apply
2 =
,
To Pain
=
peripheral painful stimuli, see Table 2. Avoid central painful stimu li.
No Response
The patients eyes remain closed despite painful stimuli
Best verbal response
The patient may have difficulty in speaking (dysphasia).lf so the letter (0 ) should be recorded in the 'none' column. If the
patient is intubated then the letter (T) should be recorded in the 'none' column
This indicates the patient's orientation to Time, Place and person
5 =
4
Orientated
-
Confused
he patient must be able to state his/her name where he /she is and the month of the year
The patient is able to hold a conversation but is unable to answer the above questions
correctly he/she should be considered confused.( Correct any wrongly answered questions)
Change the order of questions to avoid the patient just repeating them
3
=
Inappropriate
The Patient uses random words rather than sentences, which make little
sense in the context of the questions asked sometimes these words are
words
communicated as obscenities.
-
2
he patient will only respond with moaning and groaning . Painful stimuli may be required to
Incomprehensible sounds
,
=
No Response
gain a response
There is no verbal response despite painful stimuli
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IleaIth SCrvicc £xccuU\>e
TITLE:
Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Date Written: 9TH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
(Full Text)
Best motor response- This indicates brain function
A Deterioration of 1 point in the motor response or an overall deterioration of 2 pOints in the GCS is clinically significant
and must be repotted immediately to medical staff (NICE, 2007)
6 -
Obeys commands
Ask the patient to perform a couple of different movements such as sticking out his/her
tongue or lift up his/her arm
5 =
Localises to pain
""pplya central painful stimulus using one of the recommended methods outlined in Table2
The patient should purposefully move his/her arm towards the site of pain to remove the
cause of pain.
4 =
3 -
Withdraws from pain
Flexion to pain
The patient will flex hisfher arm to pain but will not move towards the source of pain .
The patient will flex his/her arms in response to pain but the wrist will also rotate. Often th
thumb will also flex and move across or through the fingers
2
=
Extension to pain
Arms will straighten and the shoulder will rotate inwards when a painful stimulus is applie
The legs may also straighten with the toes pointed downwards.
1
=
No Response
There is no physical response despite painful stimuli.
(SHAH, 1999, Crawford and Guerrero, 2004, Waterhouse, 2005 Cited by Dawes E et al , 2007)
Table 2 METHODS OF APPLYING PAINFUL STIMULI
Central painful stimuli
Method
Action
Evidence
the thumb and forefinger take hold of Shah 1999, Wood row 2000, Mooney and
Trapezius pinch or
Using
squeeze
approximately 5cm of the trapezius muscle and twist
Comerford 2003, Crawford and Geurrero
2004, Waterhouse 2005
Jaw Pressure
Apply pressure with the thumb to the j aw, just in front
Woodward 1997a, Waterhouse 2005
of the earlobe. This method should not be used if the
patient has sustained any head or facial trauma
Supra - orbital
Feel along the medial aspect of the edge of the bone
Shah 1999, Wooddrow 2000. Mooney and
pressure
above the eye for a groove or notch; apply pressure
Comerford 2003, Crawford and Guerroro
here with the thumb. This method should not be used
2004, Waterhouse 2005
if the patient has sustained any head or facial trauma
Peripheral painful stimuli
Method
Action
Evidence
Lateral finger or toe
Using a pen apply pressure to the lateral aspect of a
Waterhouse 2005
pressure
finger or toe. Rotate the pen around the finger in
opposite direction to the nail. This should be
performed for no longer than ten seconds
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Mid Western Regional Hospital
Dooradoyle, Limerick, Ire land
I b1th SCrvicc Exi.'CutM!
TITLE :
Date Written: 9TH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
(Full Text)
POINTS OF NOTE
5.2 A good sensitive indicator of neurological change is the patient's level of consciousness
Is the patient becoming more difficult to rouse? Patients will often become more restless, or a
previously restless patient will become atypica lly quiet.
5.3 Painful stimuli should only be carried out by experienced professionals and should not be applied
to the lower limbs when assessing consciousness as any response elicited may be the result of a
spinal reflex and could be confused with an appropriate response
5.4 Painful stimuli should only be used if the patient does not respond to firm and clear commands.
5.5 Only use the least amount of pressure to elicit a response to avoid bruising.
6.0 Vital Signs
It is recommended that vital signs should be assessed in the following order:
•
Respirations
•
Temperature
•
Blood pressure
•
Pulse
•
P02
6. 1 Note that Respiratory patterns give the clearest indication of how the brain is functioning because
the process of respiration is controlled by more than one area in the brain. (Oougherty and Lister
(eds), 2004).
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licalth SCoice EJccutM!
TITLE:
Mid Western Regional Hospital
Dooradoyle, limerick, Ireland
Date Written: 9TH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
(Full Text)
7.0 Observation of pupil response
a. Inform the patient and explain what you are going to do,
b. Reduce the light from overhead lights
Table 3
Observation of pupil response
Observation
Method
General Observation
Look at the shape of the pupils and their position.
(Consider any underlying disease or medication)
Is the eye too swollen to open? Attempts should be made to open a mildly swollen eye but if it too
painful or the swelling is prolific the letter 'C' for closed should be recorded in the observation
chart
Pupil Size
The size of the eye is measured in millimetres- a guide is given on the side of the neurological
observation chart (Appendix 1). Use this guide so that the results are objective
Record the size of the pupil at rest before any light is shone into the eye
Pupil response
To check the pupil response, move a bright pen torch from the outer aspect of the eye directly
over the pupil. The pupil should constrict quickly. The pupil should dilate again when the bright
light is moved away
Repeat the test in the other eye
Both eyes should constrict when a light is shone into one eye .This is called consensual reaction.
These reactions are recorded as (+) for reaction (SI) for a sluggish reaction and (-) for no
reaction
Any changes in pupil reaction, shape or size are a late sign of raised intracranial pressure. Sluggish or suddenly dilated
unequal pupils are an ind ication that oedema or haematoma is worsening and the oculomotor cranial nelVe is being
compressed . Urgent intervention is required at this stage.
File Name: NG Gen FT POlO
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Fekihme:annachl. Ra Sei.rt:Wse SWnre
lie2lth Service ExccullYe
Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Date Written: 9TH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
TITLE:
(Full Text)
8.0 Limb Response
a. Assess and record each limb separately (Waterhouse 2005).
b. The observation chart should be marked with (L) for left limbs and (R) for right limbs
c. Assessment of limb responses are best performed when the patient is lying down
d. Carry out limb response as detailed below
Table 4
Observation of limb movement
Observation
Result
Method
Normal power
The patient will be able to push against resistance
To determine whether the patient has
with no difficulty
normal power, mild or severe weakness.
The patient will be able to push against restraints but
Each limb is assessed and recorded
will be easily overcome
separately.
Mild weakness
Severe weakness
Spastic flexion
The patient will be able to move his/her limbs
independently but will be unable to move against
Arms -wh ile holding the wrist ask the
resistance
patient to pull you towards him/her towards
The patient's limbs will flex in response to pain
you and then push you away.
painful stimuli. Arms wrists and possibly the thumb
Extension
will bend inwards. Legs will pull upwards
Legs - holding the top of the ankle ask the
The patient's limbs will extend in response to painful
patient to lift his Iher leg off the bed then
stimuli. Elbows ,wrists and fingers will straighten
holding the back of the ankle ask the
stiffly down the side of the body. Legs will stiffen and
patient to pull the leg towards him/her
feet will point downwards
No response
There is no motor response despite central and
To determine a response of spastic f1exion
peripheral painful stimuli.
or extension apply central painful stimuli. If
no response is elicited use peripheral
painful stimuli.
File Name: NG Gen FT P 010
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FeidJureannachllll Selrbhfse SWnIe
Health Smicc Exccume
TITLE:
8.0
HSEWest
Page 9 of 11
Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Date Written : gTH May 2008
Nursing Service
Neurological Observations - Adult (Over Age 16Yrs)
(Full Text)
POST PROCEDURE
8.1 The results of all assessments and any action taken should be recorded as per current Hospital
Policy on documentation
8.2 Dots (.) not ticks or numbers must be used to fill out the Glasgow Coma Scale. The dots
may be joined to fonn a graph ( Appendix 1 )
8.3 Monitoring and exchange of infonnatlon about individual patients should be based on the three
separate responses on the GCS. For example. a patient scoring 13 based on scores of 4 on eye
opening. 4 on verbal response and 5 on motor response should be communicated as (E4. V4. and
MS)
8.4 If a total score is recorded or communicated it should be based on a sum of 15. and to avoid
confusion the denominator should be specified (for example 13/15).
8.5 The individual components of the GCS should be described in all communications and should
always accompany the total score (for example E4. V4. MS. 13/15).
9.0Any of the following examples of neurological deterioration should prompt urgent
reappraisal by the supervising doctor
a Development of agitation or abnonnal behaviour
b Any drop of three or more points in the eye-opening or verbal response scores of the
Glasgow Coma Scale, or two or more points in the motor response score
c Development of severe or increasing headaches or persisting vomiting
d New or evolving neurological symptoms or signs. such as pupil inequality or asymmetry of
limb or facial movement.
10.0
It is important to identify report and document any changes however subtle.
(NICE 2007).
11 .0
Nurses should initiate the Neurological Observations Chart wherever they deem
necessary for the appropriate care of patient
12.0
Consultation Trail
This Guideline has been reviewed by the following:
Consultant Anaesthetist Or. O'Dea
Pauline Chapman AlCPC
File Name: NG Gen FT POlO
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Feidhrneannachl n Sei.1ti!ise SI:1in1e
Heallh SCrvX:e Exccutlw:
TITLE:
HSEWest
Page 10 of IJ
Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
Date Written: 9TH May 2008
Nursing Service
Neurological Observations - Adu lt (Over Age 16Yrs)
(Full Text)
REFERENCES
Crimlisk Janet T. Grande Margaret M. (2004). Neurological Assessment Skills for the Acute
Medical Surgical Nurse Orthopaedic Nursing
Dawes E. et al (2007). Monitoring and record ing patients neurological observations
Nursing Standard Vol22 No 10 40-45
Dougherty, I, & Lister, S., (eds.), The Royal Marsden Hospital Manual of Clinical Procedures,
61h edition, The Royal Marsden NHS Foundation Trust.
Edwards L (200 1). USing the Glasgow Coma Scale analysis and limitations British Journal of
Nursing 2001. Vol19 No 2 92-101
National Institute for Health and Clinical Excellence (2007) .Head Injury NICE clinical guideline
56 developed by the National Collaborating Centre for Acute Care
Mooney G.P. (2005) Neurological Observations Nursing Times Vol.99 No 1725
Waterhouse C. (2005). The Glasgow Coma Scale and other neurological observations
Nursing Standard. Vol 19 No 23 56-62
File Name: NG Gen FT P 010
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Mid Western Regional Hospital
Dooradoyle, Limerick, Ireland
feidhmeannadl1 ll2 Sdrbh!se SWrue
Date Written: 9lH May 2008
Health ServIce ExecuU\le
TITLE :
Nursing Service
Neurological Observations· Adult (Over Age 16Yrs)
(Full Text)
12,0 APPENDIX 1
NEUROL.OGICAi.
OBSERvAnoN CHART
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