1. Guidelines for Basic Adult Neurological Observation, CCSO 2014

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

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

42. 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!

43. 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

44. 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