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