Performing a Neurological Assessment
When performing a neurological assessment, one would be assessing the nervous system for the purpose of identifying abnormalities affecting the activities of daily living. The Glasgow Coma Scale (GCS) is an assessment tool which can objectively describe the extent of consciousness impairment incurred by acute medical and trauma patients. Similarly, pupillary reaction is assessed as an attempt to trigger a normal physiological response to the size of the pupil via the optic and oculomotor cranial nerve.
The Glasgow Coma Scale GCS Neurological Assessment
Through the use of the Glasgow Coma Scale GCS the nurse assesses the patient’s level of consciousness in a way that determines the degree of stimulation required to elicit a response.
- the GCS is based on 3 modes of behaviour, namely Eye Opening, Verbal Response, and Motor Response
- the GCS’s overall score should not be used alone in determining clinical findings, and must be combined with Pupillary Reaction and Vital Signs
- the patient can score from 3 to 15, with 15 being the best score possible, and 3 being the least score possible; a patient with a score of <9 is considered to be severe, requiring an ETT
- repeated observations indicate static, improving, or worsening of the patient’s neurological condition
- action must be taken even if minor changes are noted
Structured GCS Assessment
#1 – CHECK
- identify factors which may interfere with assessment such as pre-existing factors (eg. language barrier, intellectual deficits), effects of current treatment (eg. sedation or tracheostomy), and effects of pre-incurred injuries (eg. cranial fracture or spinal cord damage)
- if any of the above factors are determined, NT (Not Testable) should be recorded, and no total score should be listed
#2 – OBSERVE
- observe patient for evidence of spontaneous behaviour
- if no spontaneous behaviour is noted, observe behaviour in response to stimulation
#3 – STIMULATE
- try to illicit a response by increasing the stimulus intensity gradually
- for auditory stimulus, speak, and if needed, shout, using the patient’s preferred name
- for physical stimulus to illicit eye opening, use a peripheral method by pressing on the distal part of the patient’s fingernail, increasing the intensity for up to 10 seconds
- for physical stimulus to illicit localisation, use central methods such as the trapezius pinch or the supra-orbital notch pressure
- AVOID sternal rub since this method can cause bruising to the patient!
#4 – RATE
- if during your initial ‘check’ you determine that certain domains are not testable, document as NT and do not list total score
- determine if top criteria is met based on observation – if yes, document appropriately; if no, attempt to illicit a response through stimulus as mentioned above
- in relation to motor response, different responses between the left and right side (arms or legs) of the patient, document the best response
- different responses between the peripheral stimulus and central stimulus, document the response stimulated centrally
NOTE:
- EYE OPENING aim is to assess brain stem function
- VERBAL RESPONSE aim is to assess interpretative speech and language area in the temporal lobe within the brain
- MOTOR RESPONSE aim is to ascertain whether the cerebral cortex can interpret sensory messages and translate them to a motor response
For more information about the Glasgow Coma Scale please visit https://www.glasgowcomascale.org/
Pupillary Reaction
In the Critical Care setting, the eyes are considered to be a ‘window to the brain’.
- pupillary reaction to light may be brisk, sluggish, or fixed
- sluggish, suddenly dilating, or unequal pupils may indicate compression of oculomotor cranial nerve (3rd), and/or compressed brain stem due to oedema or haematoma worsening; urgent intervention may improve outcome
- pinpoint pupils may indicate narcotic/opioid use
NOTE: certain eye drops such as Atropine may dilate pupils.
Additional Signs & Symptoms
- Autonomic Dysfunction a.k.a. Dysautonomia – happens when the autonomic nervous system, which controls functions responsible for wellbeing and maintaining balance, does not regulate properly; signs include hypertension and hyperpyrexia
- Persistent Vegetative State – a state of ‘eyes-open unresponsiveness’ in patients in a coma for 30 days or more; it is considered to be a chronic disorder in which a patient with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings
- Prolonged Unconsciousness a.k.a. Coma – a prolonged state of unconsciousness during which a person is unresponsive to their surrounding environment; while the patient is alive and looks like they are sleeping, they cannot be awakened by any stimulation, including pain
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Claire Galea is a mum of three currently in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta, as a mature student.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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