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Monitoring and recording patients’
neurological observations
Dawes E et al (2007) Monitoring and recording patients’ neurological observations. Nursing Standard.
22, 10, 40-45. Date of acceptance: July 17 2007.
Summary
This article provides a detailed account of how to monitor and
record neurological observations. It outlines the importance of
neurological observations in acutely ill patients and focuses on
carrying out observations using the Glasgow Coma Scale.
Authors
Emma Dawes is practice development nurse, Hilary Lloyd is
principal lecturer, Lesley Durham is nurse consultant in critical care,
Sunderland Royal Hospital, Sunderland.
Email: emma.dawes@chs.northy.nhs.uk
Keywords
Clinical skills; Neurological observations; Vital signs
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.
THE IMPORTANCE of undertaking
neurological observations in acutely ill patients
cannot be overstressed. Neurological status
should be observed and recorded accurately in
patients to monitor their level of consciousness
for signs of deterioration, stability and
improvement. The main methods for
undertaking this are by: monitoring
consciousness level; observing pupil
reactions; assessing motor function; and
observing vital signs.
There are many possible neurological
presentations that a nurse may encounter (Walsh
2006). The challenge for the busy nurse includes
the quick recognition of acute events, for
example, head injury, infection, haemorrhage or
post-surgery complications and the monitoring
and recording of neurological observations.
The aim of this article is to provide nurses with
knowledge to reliably and accurately monitor
and record neurological status.
It is important that nursing staff, particularly
those working in the acute ward setting, are
competent to monitor and record neurological
40 november 14 :: vol 22 no 10 :: 2007
observations and to keep up to date with the
clinical skills required to ensure high levels of
patient safety and quality care. As the acuity of
ward-based patients continues to escalate, all
ward staff need to develop knowledge and skills
in both the recognition and management of
at-risk and critically ill patients (Department
of Health (DH) 2005a).
Observation charts
A validated observational chart is the most
common method of monitoring and recording
neurological observations. Although the layout
may differ from chart to chart, in essence, all
neurological observation charts measure and
record the same clinical information, including
the level of consciousness, pupil size and
response, motor and sensory response and vital
signs. It is only through consideration of all of
these components that an accurate clinical
assessment of the patient’s neurological status
can be obtained. Observational charts ensure a
systematic approach to collecting and analysing
essential information regarding a patient’s
condition. Such charts also act as a means of
communication between nurses and other health
professionals. The information collected is vital
and can be used in the following ways:
To aid diagnosis (Douglas et al 2005).
As a baseline of observations (Crouch and
Meurier 2005).
To determine both subtle and rapid changes
in an individual’s condition (Crouch and
Meurier 2005).
To monitor neurological status following a
neurological procedure (Mooney and
Comerford 2003).
To observe for deterioration and establish the
extent of a traumatic head injury (Walsh
2006).
To detect life-threatening situations (Alcock
et al 2002).
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Nurses should be aware when taking initial
observations that they are important as they may
indicate that a patient requires immediate
medical attention. Ongoing observations are just
as important as they may indicate a change in the
patient’s condition. Often small changes in
neurological status are not always obvious until
compared with previous observations. A rapid
decline in neurological observations will alert the
nurse to seek urgent assistance.
Glasgow Coma Scale The Glasgow Coma Scale
(GCS) (Table 1), first developed by Teasdale and
Jennett (1974), is a common way to assess a
patient’s conscious level. It forms a quick,
objective and easily interpreted mode of
neurological assessment. The GCS measures
arousal, awareness and activity, by assessing
three different areas of the patient’s behaviour
including:
Eye opening.
Verbal response.
Motor response.
Each area is allocated a score, therefore
enabling objectivity, ease of recording and
comparison between recordings. The total sum
provides a score out of 15. A score of 15
indicates a fully alert and responsive patient,
whereas a score of three (the lowest possible
score) indicates unconsciousness. As well as an
overall score, a score for each area of
assessment should also be recorded and
reported separately. Figure 1 provides
TABLE 1
Glasgow Coma Scale
Response
Best eye response
Open spontaneously
Open to verbal command
Open to pain
No eye opening
Score
4
3
2
1
Best verbal response
Orientated
Confused
Inappropriate words
Incomprehensible sounds
No verbal response
5
4
3
2
1
Best motor response
Obeys commands
Localises pain
Withdrawal from pain
Flexion to pain
Extension to pain
No motor response
(National Institute for Clinical Excellence 2003)
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6
5
4
3
2
1
instruction on how to use the GCS.
Using painful stimuli Painful stimuli should be
applied in a careful and purposeful manner once
and for no longer than 30 seconds (Woodward
1997a). Under no circumstance should the
sternal rub or nail-bed pressure methods be
used as they may cause prolonged discomfort
and bruising (Shah 1999, Crawford and
Guerrero 2004, Waterhouse 2005). Table 2
provides a summary of the evidence base for
different methods of applying painful stimuli.
Before initiating painful stimuli it is important
that the patient or family members are informed
of the procedure and why it is necessary.
Recording observations
It is important that nursing staff record exactly
what is being observed as changes to the
patient’s condition can be rapid and may
require an urgent response. Waterhouse (2005)
recommended picturing a photograph being
taken of the patient that captures what is being
seen at a particular point in time. It is important
that nursing staff record individual findings
rather than comparing and being influenced by
a previous set of observations. Nursing staff
should not seek conformity with previous
recordings (Woodrow 2000). Any concerns
about changes between the current and
previous recording should be reported and
appropriate action taken.
There is no published consensus on how
frequently observations should be documented
(Mooney and Comerford 2003). For head
injury patients, the NICE (2003) guidance
recommended that a GCS of less than 15
necessitates 30-minute observations until the
maximum score of 15 is reached. In addition,
when a score of 15 is achieved, observations
should then be performed every half hour for two
hours, hourly for four hours and then
two-hourly thereafter. For the unconscious
patient, Walsh (2006) recommended 15-minute
observations and suggested that these should be
carried out more frequently if the level of
consciousness is fluctuating.
As with any assessment process it is essential
to start by informing the patient of the procedure
and where possible obtain verbal consent
(Douglas et al 2005). When assessing
neurological deficit it is important to record the
best arm response. The reason for this is to ensure
measurement of neurological status, rather than
injury or disability. There is no need to record left
and right differences, as the GCS does not aim to
measure focal deficit, this should be completed in
the limb assessment. Leg responses should not be
measured because of the risk of a spinal rather
than a brain-initiated response.
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It is important to note that a patient who is
unable to open his or her eye(s) as a result of
swelling or surgery does not necessarily indicate a
low or falling conscious level. Likewise an absence
of speech does not necessarily indicate a low or
falling conscious level. Language difficulties or
dysphasia will make it impossible to make an
accurate assessment of consciousness (Crawford
and Guerrero 2004) and should be taken into
account in the overall assessment process.
FIGURE 1
How to use the Glasgow Coma Scale
Observation
Score
Method
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:
The score indicates the
patient’s state of arousal
4 = Spontaneously
The patient’s eyes should open spontaneously as you approach. If the patient
is asleep, wake the patient, ensuring he or she is fully roused and then
complete the assessment.
3 = To speech
The patient will respond to your voice. The best way to do this is to say his
or her name. If there is no initial response, a raised voice should be used.
2 = To pain
The patient opens his or her eyes to painful stimuli. The best way to do this is
to apply peripheral painful stimuli. Avoid central painful stimuli as it may
cause the patient to grimace.
1 = No response
The patient’s eyes remain closed despite painful stimuli.
Best verbal response:
The patient may have difficulty in speaking (dysphasia). If so, the letter ‘D’ 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 = Orientated
The patient must be able to state his or her name, who he or she is, where
he or she is and the month of the year.
4 = Confused
If the patient is able to hold a conversation but unable to answer the
questions above correctly he or she should be considered to be confused.
Correct wrongly answered questions, but change the order each time to avoid
the patient just repeating them.
3 = Inappropriate words
The patient will use random words that make little sense or are out of
context, typically swearing and shouting. Painful stimuli may be required to
gain a response.
2 = Incomprehensible
sounds
The patient will only respond with moaning and groaning. Painful stimuli may
be required to gain a response.
1 = No response
There is no verbal response despite painful stimuli.
Best motor response:
If the patient is receiving medicines to maintain muscle paralysis Glasgow Coma Scale observations should not be performed.
This indicates brain
function
6 = Obeys commands
Ask the patient to perform a couple of different movements such as sticking
out his or her tongue or lifting his or her arm.
5 = Localises to pain
Apply a central painful stimulus using one of the recommended methods
(Table 2). The patient should purposefully move the arm towards the site of
pain to remove the cause of pain.
4 = Withdraws from pain
The patient will flex his or her arms in response to pain but will not move
towards the source of pain.
3 = Flexion to pain
The patient will flex his or her arms in response to pain but the wrist will also
rotate and the thumb may also flex and move across the fingers.
2 = Extension to pain
Arms will straighten and the shoulder will rotate inwards when a painful stimulus
is applied. The legs may also straighten with toes pointing downwards.
1 = No response
There is no physical response despite painful stimuli.
(Shah 1999, Crawford and Guerrero 2004, Waterhouse 2005)
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Recording other measurements
Vital signs The Royal Marsden Hospital Manual
of Clinical Nursing Procedures (Crawford and
Guerrero 2004) recommends that vital signs
should be recorded in the order of respiration,
temperature, blood pressure and pulse (Table 3).
Raised intracranial pressure (ICP) will lower
respiratory rate and alter the respiratory pattern
(Crawford and Guerrero 2004). This is one of the
clearest indicators of brain dysfunction. As
ICP rises pressure will be exerted on the
hypothalamus, the thermoregulatory part of the
brain, resulting in fluctuating temperature
(Woodrow 2000). The brain becomes hypoxic
and ischaemic and as a result systemic blood
pressure rises in an attempt to perfuse the brain
(Shah 1999). Patients will also become
bradycardic; this is known as Cushing reflex
(Shah 1999, Crawford and Guerrero 2004). Both
increases and decreases in blood glucose levels
can occur in the patient with a head injury.
Hyperglycaemia increases cerebral ischaemia,
reducing blood perfusion in the brain, and
hypoglycaemia results in a lack of available
glucose to neurones which causes a reduction
in function (Woodrow 2000).
Pupil response Assessment of pupillary activity
is an essential part of neurological observation
and the only way to assess and monitor the
neurological status of sedated patients
(Waterhouse 2005). When examining pupil
response it is important to position the patient so
that there is enough light to see the pupils clearly
but not so much light that the pupils constrict.
Pupils should be assessed for size, shape and
reaction to light (Table 4). Each pupil should be
assessed and recorded individually. Pupils are
measured in millimetres (normal range 2-6mm in
diameter) and are normally round in shape. A
bright light, preferably a bright pen torch, should
be shone into each eye to assess the pupil’s
reaction to light.
Abnormal pupil size and response together
with other neurological symptoms, such as a
reduced GCS and agitation, are an indication
of raised ICP (Woodward 1997b). The anatomy
of the skull means that any swelling or
space-occupying lesion such as a bleed,
haematoma or tumour, will raise ICP. If this
persists or rapidly worsens the brain tissue will
shift and become compressed. As a result the
ocular motor nerve that controls pupil reaction
may be affected resulting in changes to pupil
responses. Sluggish or suddenly dilated pupils are
an indication of deterioration and require urgent
medical attention (Waterhouse 2005). This is
why it is important to observe and record pupil
size and reaction (Woodward 1997b). Other
clinical indicators of deterioration such as a
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falling GCS are likely to be found before a change
in pupil response is observed. Altered pupils can
be a response to a number of things, for example,
pin-point pupils could indicate opiate use or
metabolic disorders, a unilateral dilated pupil
may indicate brain herniation or raised ICP and
TABLE 2
Evidence base for methods of painful stimuli
Central painful stimuli
Method
Action
Evidence
Trapezius pinch
or squeeze
Using the thumb and
forefinger take hold of
approximately 5cm of
the trapezius muscle
and twist.
Shah 1999, Woodrow
2000, Mooney and
Comerford 2003,
Crawford and Guerrero
2004, Waterhouse 2005.
Jaw pressure
Apply pressure with the
Woodward 1997a,
thumb to the jaw, just in
Waterhouse 2005.
front of the earlobe. This
method should not be used
if the patient has sustained
any head or facial trauma.
Supra-orbital
pressure
Feel along the medial aspect
of the edge of the bone
above the eye for a groove
or notch; apply pressure
here with the thumb. This
method should not be used
if the patient has sustained
any head or facial trauma.
Shah 1999, Woodrow
2000, Mooney and
Comerford 2003,
Crawford and Guerrero
2004, Waterhouse 2005.
Peripheral painful stimuli
Method
Action
Evidence
Lateral finger
or toe pressure
Using a pen apply pressure
to the lateral aspect of a
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.
Waterhouse 2005.
TABLE 3
Vital signs
Observation
Method
Respiration rate
Record respiratory rate and rhythm or
pattern, observing for any decrease in rate
and altered rhythm or pattern.
Temperature
Record and observe any increase in
temperature.
Blood pressure and pulse
Record together observing for any increase
in blood and pulse pressure and decrease in
pulse.
Blood glucose
Record and observe for any deviation from
normal parameters.
Early warning score – a
Record and observe for any deviation from
physiological scoring system
normal parameters.
with an identifiable trigger
threshold (Morgan et al 1997)
(Adapted from Crawford and Guerrero 2004)
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fixed pupils may indicate severe mid-brain
damage or poisoning (Iggulden 2006).
Limb movement Limb movements provide an
TABLE 4
Observation of pupil response
Observation
Method
General
observations
Look at the shape of the pupils and their position. Is
there any eye disease or medication that impairs either
your view or the eyes’ response to light?
Is the eye too swollen to open? Attempts should be made
to open a mildly swollen eye but if it is too painful or the
swelling is prolific the letter ‘C’ for closed should be
recorded on the observation chart.
Does the patient have a false eye?
Pupil size
The size of the eye is measured in millimetres – a guide is
given on the side of most neurological observation charts
and some pen torches. Use this guide rather than
estimation so that the results are objective rather than
subjective.
Record the size of the pupil at rest before any light is
shone into the eye.
Pupil response
To check the pupil response, move an illuminated 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.
Both eyes should constrict when a light is shone into one
eye. This is called consensual reaction.
These reactions are recorded as (+) for reaction, (sl) for
a sluggish reaction and (–) for no reaction.
(Adapted from Woodward 1997b)
accurate indication of brain function (Crawford
and Guerrero 2004). It is important to assess
and record each limb separately (Waterhouse
2005). The observation chart should be marked
with the letter ‘L’ for left limbs and the letter ‘R’
for right limbs. Table 5 demonstrates the process
of limb observation.
Assessment of limb responses provides
information about motor function and is best
carried out when the patient is lying down
(Woodward 1997c). Any deficiencies in function
may indicate a developing weakness or loss of
movement caused by raised ICP (Woodward
1997c, Shah 1999). Limb assessment also assists
the identification of local damage. Although it is
usual for a hemiparesis or hemiplegia to occur
on the opposite (contralateral) side to the lesion,
it may occur on the same (ipsilateral) side,
known as false localising. Particular
consideration should be given to any limb
weakness that may be the result of past medical
history, for example, stroke, where there may
be a difference in limb resistance, or general
frailty which could influence the patient’s ability
to offer resistance. It is important to use clinical
judgement as well as objective measurement,
remembering to record any difference in
resistance in each limb separately.
Accountability
Nurses are accountable and responsible for
providing optimum care for patients.
The Nursing and Midwifery Council’s (NMC)
Code of Conduct provides the main source of
TABLE 5
Observation of limb movement
Observation
Result
Method
Normal power
The patient will be able to push against
resistance with no difficulty.
To determine whether the patient has normal power, mild
or severe weakness. Each limb is assessed and recorded
separately.
Mild weakness
The patient will be able to push against
resistance but will be easily overcome.
Arms – while holding the wrist ask the patient to pull you
towards him or her and then push you away.
Severe weakness
The patient will be able to move his or her limbs
independently but will be unable to move against
resistance.
Legs – holding the top of the ankle ask the patient to lift his
or her leg off the bed then holding the back of the ankle ask
the patient to pull the leg towards him or her.
Spastic flexion
The patient’s limbs will flex in response to painful
stimuli. Arms, wrists and possibly the thumb
will bend inwards. Legs will pull upwards.
To determine a response of spastic flexion or extension apply
central painful stimuli. If no response is elicited use peripheral
painful stimulus.
Extension
The patient’s limbs will extend in response to
painful stimuli. Elbows, wrists and fingers will
straighten stiffly down the side of the body.
Legs will stiffen and feet will point downwards.
No response
There is no motor response despite central and
peripheral painful stimuli.
(Adapted from Woodward 1997c)
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professional accountability for nurses (NMC
2004). It is essential that nursing staff examine
objectively the information gathered from
assessments and observations as well as the
information previously recorded. Neurological
observations contribute to the overall patient
assessment, which then forms the basis for the
individualised plan of care (Crouch and Meurier
2005). Nursing staff should ensure that the
patient has an appropriate care plan in place and
know how and when to take action should a
change occur in the patient’s condition.
Accurate record keeping and documentation
is important. The NMC (2007) states that the
quality of record keeping is also a reflection of the
standard of the individual’s professional practice.
All records must be contemporaneous, accurate
and unambiguous. It is important always to act in
a way that safeguards the patient’s best interests
and this includes the prompt reporting of
abnormal findings when monitoring and
recording neurological observations. It is also
important to remember that observation charts,
while important, are only one of the many tools
available to gather information regarding a
patient’s condition. It is often useful to listen to
the patient’s family or close friends when
carrying out neurological observations as they
can provide invaluable information about the
patient’s normal state and can often give an
accurate history of the onset and symptoms. This
is important in situations where patients may not
be able to communicate their medical history.
Accountability also involves being up to date
with new developments, best practice and
ensuring consistency. Nurses should be fully
aware of relevant, credible research and ensure
that any patient care given is safe. Guidelines and
protocols should be in place in healthcare
organisations to ensure that care is in line with
best practice. Head injury guidance is available
from NICE (2003) and the DH (2005b).
It is important to ensure best practice when
monitoring and recording neurological
observations. Box 1 presents a quick reminder
of factors that need to be considered.
Conclusion
Monitoring and recording neurological
observations that are reliable and accurate are
important clinical skills. There are a number of
tools, including the GCS, which can be used to
perform neurological assessments. Nurses
should ensure that they are competent to
undertake these observations and use the tools
available to achieve the best outcomes for
patients. The importance of using clinical
judgement and taking appropriate action when
changes in the patient’s neurological status occur
are paramount NS
BOX 1
Monitoring neurological observations: important factors
Use all parts of the neurological observation chart.
Record only what you see.
Listen to family members and friends.
Report any changes in the patient’s condition.
Do not be influenced by previous observations.
Do not use nail-bed pressure or sternal rubs.
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