Neurological observations

Glasgow Coma Scale

Is used to assess patients state of consciousness that may have altered as a result of a hypoxic event or head trauma.

This assessment assesses the cerebral cortex and the brain stem.

It is repeated at intervals to detect improvement or deterioration in the patients level of consciousness.

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Neurological observations are done whenAn actual suspected LOC

An alteration to consciousness

Following a head injury

Following diagnostic or surgical procedures to the CNS

When requested to by the doctor

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The assessment includes

Mental statusLanguageOrientationMemoryAttention span and circulationJudgmentAbstract reasoningThe Glasgow coma scalePupil size and reaction to lightLimb responsesVital signs

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Glasgow coma scale

Measures the level of consciousnessAim Identify CNS dysfunctionEstablish a baseline for comparisonDetect early life – threatening changes or improvement in neurological conditionThree areas assessedEye openingVerbal responseMotor responseThese areas are graded and the values added7 or less indicates coma15 indicates optimal level of consciousness

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Eye opening

Spontaneous – eyes are open before or immediately they are aware of your presence (without you touching bed or verbalizing)

To speech – when greeted or in response to their name being called

To pain – in response to painful stimuli

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Painful stimulation

Peripheral – squeezing patient’s finger (over the nail bed) between a pen and the nurse’s thumb.

Central – trapezium squeeze; the trapezius muscle is twisted using the thumb and two fingers where the neck meets the shoulder

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Verbal response

Orientated to place, time and personConfused ; talking in sentences, but disorientated to place and time Inappropriate word; utters occasional words rather than sentences, often abusive words elicited, by inflicting pain rather than spontaneousIncomprehensible sounds , groans or grunts

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Motor response

Obeys commands, able to move on command.Localizes pain, locates and attempts to remove painful stimuli applied to the head or trunkNormal flexion , flexes arm at elbow without wrist rotation response to central stimulusAbnormal flexion. Flexes elbows and rotates wrist into a spastic posture in response to central painful A patient flexing to pain will not raise their hands above their shoulders in response to central stimulus

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Pupils

Size Should be equal in sizeDiameter approximately 2-6 mmShape Round Ovid pupils may be an early sign of tentorial herniationKeyhole pupils – cataract surgeryReaction Normal is a brisk reactionSluggish may indicate some compression of cranial nerve 111No reaction may indicate complete compression of cranial nerve 111

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Glasgow coma scaleEye Opening 4 Points Eyes open spontaneously 3 Points Eye opening to verbal command 2 Points Eye opening to pain (being pinched) 1 Points No eye opening Verbal Response 5 Points Oriented and speaks normally 4 Points Confused but speaks normally 3 Points Inappropriate words 2 Points Incomprehensible sounds 1 Points No verbal response Motor Response (movement of arms and legs) 6 Points Obeys commands to move arms and legs 5 Points Withdraws from pain locally (where pinched) 4 Points Withdraws from pain generally 3 Points Flexes limb in response to pain 2 Points Straightens limb in response to pain 1 Points No movement in response to pain

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