Neurological observations

1. 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.

3. Neurological observations are done when • An 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

4. The assessment includes • Mental status • Language • Orientation • Memory • Attention span and circulation • Judgment • Abstract reasoning • The Glasgow coma scale • Pupil size and reaction to light • Limb responses • Vital signs

5. Glasgow coma scale • Measures the level of consciousness • Aim • Identify CNS dysfunction • Establish a baseline for comparison • Detect early life – threatening changes or improvement in neurological condition • Three areas assessed • Eye opening • Verbal response • Motor response • These areas are graded and the values added • 7 or less indicates coma • 15 indicates optimal level of consciousness

6. 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

7. 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

8. Verbal response • Orientated to place, time and person • Confused ; 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 spontaneous • Incomprehensible sounds , groans or grunts

9. Motor response • Obeys commands, able to move on command. • Localizes pain, locates and attempts to remove painful stimuli applied to the head or trunk • Normal flexion , flexes arm at elbow without wrist rotation response to central stimulus • Abnormal 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

10. Pupils • Size • Should be equal in size • Diameter approximately 2-6 mm • Shape • Round • Ovid pupils may be an early sign of tentorial herniation • Keyhole pupils – cataract surgery • Reaction • Normal is a brisk reaction • Sluggish may indicate some compression of cranial nerve 111 • No reaction may indicate complete compression of cranial nerve 111

12. Glasgow coma scale • Eye 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