Guidelines for Basic Adult Neurological Observation, CCSO 2014

WHY PERFORM A NEURLOGICAL ASSESSMENT? The baseline neurological assessment and ongoing assessments are the most sensitive indicators of neurological change Early detection is important for successful treatment, management and prognosis Guidelines for Basic Adult Neurological Observation, CCSO 2014

WHAT’S INCLUDED? Assessment of the following: Level of consciousness (LOC) using the Glasgow Coma Scale (GCS) Pupillary response Limb movement/ strength Vital signs Note! The administration of continuous sedation of a patient, may obscure the neurological assessment, and the accuracy of the assesment. Guidelines for Basic Adult Neurological Observation, CCSO 2014

GENERAL APPROACH Walk up to patient Talk to patient normal voice loud voice Light touch Painful stimuli Continuum Guidelines for Basic Adult Neurological Observation, CCSO 2014

PAINFUL STIMULI WHEN TO USE TYPES OF STIMULI If patient is not obeying commands AND In the absence of any spontaneous movements TYPES OF STIMULI Peripheral painful stimuli Central painful stimuli Depending on the response being assessed Guidelines for Basic Adult Neurological Observation, CCSO 2014

PERIPHERAL PAINFUL STIMULI Used to elicit an eye-opening response The recommended method is an interphalangeal joint pressure (IPJ) Apply pressure with a pen/pencil to the lateral outer aspect of the proximal or distal interphalangeal joint (lateral aspect of the patient’s finger or toe) for 10 to15 seconds to elicit a response. Caution! a peripheral painful stimulus may elicit a spinal reflex, causing flexion of tested limb. A spinal reflex is not an indication of intact brain function Guidelines for Basic Adult Neurological Observation, CCSO 2014

CENTRAL PAINFUL STIMULI Used to elicit a motor response Done by stimulating a cranial nerve, thus avoiding the possibility of eliciting a spinal reflex Recommended methods are Trapezius twist (CN XI) Supra-orbital pressure (CN V) Jaw margin pressure (CN V) Guidelines for Basic Adult Neurological Observation, CCSO 2014

CENTRAL PAINFUL STIMULI Trapezius twist (CN XI): Using the thumb and two fingers as pincers Take hold of about two inches of the muscle located at the angle where the neck and shoulder meet Twist and gradually apply increasing pressure for 10 to 20 seconds to elicit a response. Note: High level spinal cord injuries may interfere with assessment using Trapezius twist. Note: Sternal rub is NOT recommended due to potential for severe bruising and residual pain and discomfort Guidelines for Basic Adult Neurological Observation, CCSO 2014

CENTRAL PAINFUL STIMULI Supra-orbital pressure (CN V) Place the flat of the thumb on the supra-orbital ridge (small notch below the inner part of eyebrow). While the hand rests on the head of the patient. Apply gradually increasing pressure for 10 to 20 seconds to elicit a response. Note: Supraorbital pressure is NOT to be used with orbital, skull, facial fractures, or frontal craniotomies. Note: Sternal rub is NOT recommended due to potential for severe bruising and residual pain and discomfort Guidelines for Basic Adult Neurological Observation, CCSO 2014

CENTRAL PAINFUL STIMULI Alternative method of applying central pain Jaw margin pressure (CN V): Place the flat of the thumb at the angle of the jaw at the maxilla-mandibular joint. Apply gradually increasing pressure for 10 to 20 seconds to elicit a response Note: Apply with caution in patient with increased intracranial pressure (ICP), as this may increase ICP if venous return is compromised due to compression of jugular vein Note: Sternal rub is NOT recommended due to potential for severe bruising and residual pain and discomfort Guidelines for Basic Adult Neurological Observation, CCSO 2014

LEVEL OF CONSCIOUSNESS Assessment LOC is the most sensitive indicator of neurological condition Consciousness consists of two components Consciousness: “A general awareness of oneself and the surrounding environment” (Hickey, 2003) Arousal or wakefulness: Reflects activity of the reticular activation system (RAS). Is a brainstem response Awareness & cognition: Reflects cerebral cortex activity Activated via the thalamic portion of RAS Guidelines for Basic Adult Neurological Observation, CCSO 2014

GLASGOW COMA SCALE (GCS) EYE-OPENING RESPONSE SCORE Spontaneously To speech To pain None 4 3 2 1 BEST VERBAL RESPONSE Oriented Confused Inappropriate words Incomprehensible sounds 5 BEST MOTOR RESPONSE Obeys commands Localizes to pain Flexion/withdrawal Abnormal flexion to pain Extension to pain 6 Most widely used tool to assesses LOC Developed in Glasgow 1974 Provides global measure of depth & duration of impaired consciousness/coma Guidelines for Basic Adult Neurological Observation, CCSO 2014

Glasgow Coma Scale: Assessing Eye Opening Response Eye opening assess the function of the reticular activating system extending from the brainstem through the thalamus to the cerebral cortex If eyes are closed by swelling or surgery and are unable to be opened, score 1 and indicate with a“1C” or a “C” in the “no response/none” section. If one eye is closed, document the response from the functioning eye. Guidelines for Basic Adult Neurological Observation, CCSO 2014

Eye Opening Response Feature Scale Response SCORE Behavior Spontaneously To Speech To Pain None 4 3 2 1 Patient’s eyes open spontaneously with no prompting from the nurse as he or she approaches the patient. Patient’s to a verbal stimulus only. • Speak in a normal voice initially, and then in a louder voice as needed to. Consider hearing impairments/medications/status fluctuations. Patient’s eyes do not open spontaneously or with verbal stimulation, but they do open to painful stimulation. Central pain stimulation for testing eye opening may cause the patient to grimace & confound the examination, if so use peripheral stimulation. There is no eye opening to any stimuli. * Navigating Neuroscience Nursing, 2012 Guidelines for Basic Adult Neurological Observation, CCSO 2014

Glasgow Coma Scale: Assessing BEST Verbal Response Verbal response help identify if the patient is orientated by verifying they are able to identify correctly: His/her identity Person Where they are located Place Current year/season/month /date Time x3 ****Verbal Responses CANNOT ACCURATELY be tested if an the person has an Artificial Airway In place. Patients should receive a score of 1T, the “T” indicating the reason for the score. If able to communicate through the writing/ mouthing of words, describe patient response in the nursing notes.**** Guidelines for Basic Adult Neurological Observation, CCSO 2014

Best Verbal Response (If the patient has a language or communication barrier and there is no interpreter or family present at the time of the assessment, document the language barrier across the section and expand in the nursing/interdisciplinary notes) Feature Scale Response SCORE Implications in Assessment Common Causes that can influence score Verbal Response Orientated Conversation Confused Speech Inappropriate Sounds Incomprehensible None 5 4 3 2 1 Information is getting to the cortex Information getting to the cortex, but jumbled confused answers Information getting to the cortex, but jumbled. No relation to questions asked Information getting through, less effective. No connection to questions or verbal Reponses No information is getting through. Needs to be correlated with other findings and may suggest brainstem injury NONE Temporal Lobe Receptive Aphasia Electrolyte imbalance Infection Post-op anesthetic Age Medications History of dementia or acute delirium Dysarthria Psychiatric disorders Alcohol/Drugs Deafness Mute Intubation Sedation Brainstem injury ( midbrain-medulla) * Navigating Neuroscience Nursing, 2012

Glasgow Coma Scale: Assessing BEST Motor Response Assesses area of brain, which identifies and translates sensory input into a motor response. Best response is documented If patient is localizing spontaneously i.e. attempting to remove invasive tubes or when suctioned, do NOT use painful stimuli If necessary, use central pain to avoid eliciting spinal reflex Guidelines for Basic Adult Neurological Observation, CCSO 2014

GCS – BEST MOTOR RESPONSE Obeying Commands: score of 6 The patient is able to understand and obey verbal/ written/gestured commands. Acceptable commands include: “show me a thumb/two fingers”; “stick out your tongue”. Note: It is not acceptable to ask a patient to squeeze one’s hand unless he/she is also asked to release it. Hand grasping, without a release, may be merely a reflex. If the patient is unable to obey commands, place the patient in a supine position with hands positioned at the groin area, if possible, and proceed through the assessment by applying a central painful stimulus. If applicable, loosen any limb restraints while performing assessment. Guidelines for Basic Adult Neurological Observation, CCSO 2014

GCS – BEST MOTOR RESPONSE Localizes pain: score of 5 The patient purposefully moves a limb in an attempt to locate and remove the source of the applied central painful stimulus. The hand must move toward the source in an attempt to remove the painful/noxious stimulus i.e. to the chin or across the midline of the body. Guidelines for Basic Adult Neurological Observation, CCSO 2014

GCS – BEST MOTOR RESPONSE Flexion/withdrawal: score of 4 The patient withdraws the limb in response to a central painful stimulus by flexing at the elbow/knee with the limb drawn away from the trunk (recoil)There is no direct attempt to remove the source of the painful stimuli. Guidelines for Basic Adult Neurological Observation, CCSO 2014

GCS – BEST MOTOR RESPONSE Abnormal Flexion to Pain: score of 3 The patient flexes the limb at the elbow in response to central painful stimuli. Accompanying this movement is shoulder adduction, wrist flexion and the making of a fist. Flexion to pain is usually a slow movement, with no attempt to remove the painful stimuli. Guidelines for Basic Adult Neurological Observation, CCSO 2014

GCS – BEST MOTOR RESPONSE Extension to pain: score of 2 The patient extends the limb at the elbow in response to central painful stimuli. Accompanying this movement is adduction of the shoulder; flexion of the wrist while the fingers either make a fist or extend. Guidelines for Basic Adult Neurological Observation, CCSO 2014

GCS – BEST MOTOR RESPONSE None: score of 1 No movement of the limbs occurs in response to painful central stimuli. Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Pupil Assessment Shape Size Reaction Pupil assessment: Assess pupil size, shape and reaction Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Shape Why Assess Pupil Shape? Many neurosurgical patients are at risk of increased ICP. Early detection of the signs and symptoms may make interventions more effective. The baseline neurological assessment and ongoing assessments are the best indicators of changing ICP Subtle neurological changes, such as changes in pupil shape, may indicate rising ICP Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Shape Assessing Pupil Shape Normal Pupils should be circular and even in size Normal Variations Older people may have irregular pupil margins Shape Pupils should be circular and even in size 20% of people have pupil inequality (but pupils will still react normally) Cataracts and cataract surgery distorts pupils Age related changes to pupils include Small size Slightly irregular margins Slowed reaction times Sluggish accommodation (contraction) Usual size 2-6mm smaller with narcotics, Horner’s syndrone larger with topical anticholinergics, CN III palsies, migraine, amphetamines Dilated is always abnormal— and can mean there is increased intracranial pressure Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Shape Assessing Pupil Shape Abnormal Oval Ovoid pupils possibly indicate: Sign of increased intracranial pressure Sign of brain herniation Usually seen on the same side as the mass (ipsilateral) The intermediate phase between normal and fully dilated and fixed Shape Pupils should be circular and even in size 20% of people have pupil inequality (but pupils will still react normally) Cataracts and cataract surgery distorts pupils Age related changes to pupils include Small size Slightly irregular margins Slowed reaction times Sluggish accommodation (contraction) Usual size 2-6mm smaller with narcotics, Horner’s syndrome (a rare condition that results from disruption of the sympathetic nerves supplying the eye. There is the triad of: •Partial ptosis (upper eyelid drooping). •Miosis (pupillary constriction). •Hemifacial anhidrosis (absence of sweating). larger with topical anticholinergics, CN III palsies, migraine, amphetamines Dilated is always abnormal— and can mean there is increased intracranial pressure Guidelines for Basic Adult Neurological Observation, CCSO 2014

Abnormal Pupil Variations Shape Abnormal Pupil Variations Some Abnormal Variations in pupil shapes occur related to: Cataracts and cataract surgery may distort pupil shape Disease processes: glaucoma Trauma or iris inflammation Syndromes, congenital defects May indicate clinically significant intracranial hypertension Compression of the oculomotor nerve from mass effect results in changes in pupillary size, shape and reaction to light The changes to response to light, and pupil shape and size may be observed with increasing pressure on the optic nerve {CN lll} as the ICP increases As the pressure increases the increasing pressure on the optic nerve results in both pupils becoming dilated and fixed Oval pupils represent the intermediate phase between a normal pupil and fully dilated and fixed pupil Usually seen ipsilateral (occurring on the same side of the body) to the mass but is transitory, quickly becoming round, midsized or dilated and fixed Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Assessing Pupil Size Size documented in mm Normal range from 2-6 mm Assess after the eyes have opened and the pupils have accommodated to room light A difference of 1.5 mm between pupils should be reported to MD Direct eye injury or past surgery can affect size 17% of population have unequal pupil size and this is a normal finding for them (Critical Care Concepts, 2006) Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Assessing Pupil Size Pinpoint: Seen with opiate overdose and pontine hemorrhage Small: Normal if person is in bright room. May also be seen with Horner’s syndrome, pontine hemorrhage, ophthalmic drops, metabolic coma Midposition: Seen normally. If pupils are midposition and nonreactive the cause is midbrain damage Large: Seen normally when the room is dark. May be seen with drugs and some orbital injuries Dilated: Always and abnormal finding. Anticholinergic drugs can dilate pupils. Bilateral fixed and dilated pupils are seen in the terminal stage of severe anoxia-ischemia or at death Guidelines for Basic Adult Neurological Observation, CCSO 2014

Assessing Pupil Reaction Tests the function of cranial nerve lll Changes in the pupil reaction may be an indicator of a change in intercranial conditions Direct constriction: Pupil constricts in response to direct light Consensual constriction: Pupil constricts in response to light directed in opposite eye Guidelines for Basic Adult Neurological Observation, CCSO 2014

Assessing Pupil Reaction Brisk Normal finding Rapid constriction when light source is introduced Pupils should return to original size when light source removed There should be a consensual reaction to the light source in the opposite eye Opposite pupil should have a consensual reaction to the light source Guidelines for Basic Adult Neurological Observation, CCSO 2014

Assessing Pupil Reaction Sluggish Constriction occurs but slower than expected Found in conditions that cause oculomotor nerve compression (CN lll) Can be caused by increased intracranial pressure, brainstem damage, anoxia or ischemia Guidelines for Basic Adult Neurological Observation, CCSO 2014

Assessing Pupil Reaction Nonreactive or Fixed Pupils do not react to bright light Found in conditions that cause oculomotor nerve compression (CN lll) Can be caused by increased intracranial pressure, brainstem damage or anoxia May be a sign of brain death if bilateral Guidelines for Basic Adult Neurological Observation, CCSO 2014

Assessing Pupil Reaction Documentation: Record “+” symbol if the pupil reacts Record “-” symbol if the pupil does not react Record “C” for closed if the eyelid is swollen shut If the pupils change from baseline or no reaction is observed this may indicate a deterioration in a patient’s condition. Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Shape Reaction When to be concerned??? Changes from baseline Increased ICP and progression in signs and symptoms of herniation Early signs – interventions may still be effective Decreased briskness to light (sluggish or no response) Changes in size or shape of one pupil (or both) Round to ovoid pupils Late signs – may be too late for effective interventions Fully dilated Nonreactive to light Bilaterally fully dilated and fixed Many neurosurgical patients are at risk of ICP. Early detection of the signs and symptoms may make interventions more effective. The baseline neurological assessment and ongoing assessments are the best indicators of changing ICP Subtle neurological changes may indicate rising ICP When late signs appear – brainstem signs of change in vital signs or respiratory pattern it may be too late for effective interventions to reverse cerebral deterioration, herniation or death Guidelines for Basic Adult Neurological Observation, CCSO 2014

Pupil Assessment Steps Direct Consensual Assessment STEPS Note pupil size and shape in ambient lighting (Ambient lighting is a general illumination that comes from all directions in a room that has no visible source). Once you have noted the pupil baseline, darken the room if necessary to assess reactivity Choose an eye Sweep light onto the pupil, Note the reaction of pupil the light is on Repeat noting the reaction of pupil the light is not shining on This is the consensual reaction … IT’S IMPORTANT TOO! Lack of consensual pupil response can indicate compression of CN III, if this was new this would be concerning. Now repeat for these steps with the other eye. Observe for direct and consensual reactions Document your findings & take next steps as necessary (e.g.: alerting team to concerning changes) Guidelines for Basic Adult Neurological Observation, CCSO 2014

Limb Movement and Strength Test legs and arms Compare left and right sides Can’t obey or non-compliant? Observe spontaneous movement or central pain response Grade the movement and strength 0 to 5 Abnormal flexion ‘F’ Extension to pain ‘E’ NOTE: Assessing Limb movement & strength as part of a Neurological Assessment is NOT considered a replacement for Spinal Cord Assessment in a patient with a suspected Spinal Cord Injury. Guidelines for Basic Adult Neurological Observation, CCSO 2014

What the movement means What the movement looks like Grade Description What the movement means What the movement looks like 5 Limb moves against full resistance Normal Power The patient has normal limb power 4 Limb moves against moderate resistance, but strength is diminished Contraction- against Gravity and Resistance The patient is able to lift the limb off the bed against resistance (pushing on your hand), but is not normal limb power 3 Limb may move against minimal resistance or gravity. E.g., If the patient lifts the arm off a surface and it immediately drops back down Contraction- against Gravity The patient is able to lift the limb off the bed (against gravity) 2 Limb moves on a horizontal surface with the ability to lift against gravity Contraction- Gravity eliminated The patient is able to move the limb but cannot lift it off the bed 1 Limb or muscle flickers Flicker of muscle contraction The patient is attempting to move the limb No movement is observed Test the strength of the prime mover muscle groups for each joint. Repeat the motions you elicited for active ROM. Now ask the person to flex and hold as you apply opposing force. Muscle strength should be equal bilaterally and should fully resist your opposing force. (Note: Muscle status and joint status are interdependent and should be interpreted together. ) A wide variability of strength exists among people. You may wish to use a grading system from no voluntary movement to full strength, as shown. Guidelines for Basic Adult Neurological Observation, CCSO 2014

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Not Applicable for: Spinal Cord Pathology – Use ASIA scoring If unable to assess limb movement/strength due to limb Fractures/Limb Traction. Document not applicable on patient care record, and document reason in interdisciplinary notes Guidelines for Basic Adult Neurological Observation, CCSO 2014

Some examples of applying Gravity and Resistance Bring Limb off surface for gravity - then apply counter resistance

Vital Signs Increasing fluctuations in vital signs including blood pressure, heart rate and respiratory rate coupled with a deteriorating GCS and Neurological status can indicate rising intercranaial pressure. This can be a emergency and may need to be addressed IMMEDIATELY!

Guidelines for Basic Adult Neurological Observation, CCSO 2014 Vital Signs Documentation of the vital signs with GCS, pupil response, and limb movement completes the patient picture and should be documented as frequently as the performing of the neurological assessment. Guidelines for Basic Adult Neurological Observation, CCSO 2014

Level of consciousness (LOC) using the Glasgow Coma Scale (GCS) In Summary….. A complete Neurological Assessment includes the assessment and documentation of the following: Level of consciousness (LOC) using the Glasgow Coma Scale (GCS) Pupillary Response Limb Movement/ Strength Vital signs Guidelines for Basic Adult Neurological Observation, CCSO 2014