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.

                                                    

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

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

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

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

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

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

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

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

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