1. Created by the provincial Neurosurgical Nurse Educators in 2013
Created by the provincial Neurosurgical Nurse Educators in Approved by Provincial Neurosurgery Ontario(PNO)and released in April 2014 by Critical Care Services Ontario ( CCSO) to serve as a educational tool and practice guideline for frontline nurses to follow when performing a neurological assessment. Although intended for non neurosurgical centers, the practice guideline gives best practice and criteria for nurses to follow when performing any neurological assessment, even if the cause of the neurological decline is not associated with a neurological( brain) injury. An example might be decreased Level of consciousness associated with hypoxia and CO2 Retention possibly associated with pneumonia, COPD, Lung injury etc…

2. WHY PERFORM A NEUROLOGICAL 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
Once a baseline neurological assessment has been established, successive assessments help to develop the trending and act in a predictive capacity in detecting changes to the neurological status. A consistent approach performed frequently can detect early changes to the assessment criteria. This alerts the nurse and team to early treatment options, medical or surgical management options and possibly improves the outcomes and prognosis for the patient. Changes are not always bad! Changes detecting improvement in status also can be seen indicating patient improvement progressing towards next in steps in recovery or discharge.
Guidelines for Basic Adult Neurological Observation,
CCSO 2014

3. WHY? PERFORM A NEUROLOGICAL ASSESSMENT
Evaluation of the patient’s neurological status
Record a baseline
Monitor & detect early changes
Successfully manage and treat
Trending of neurological changes allows the tester to track deterioration to be communicated to the physician or neurosurgeon. Progressive changes identifies progressive deterioration that may require medical and/or surgical intervention.
Guidelines for Basic Adult Neurological Observation,
CCSO 2014

4. WHAT’S INCLUDED? Assessment of the following:
Level of consciousness (LOC) using the Glasgow Coma Scale (GCS)
Pupillary response
Limb movement/ strength
Vital signs
GCS has been around since 1974 as an effectively consistent and reliable prediction tool in both assessing neurological status and predicting neurological deterioration. The patients level of consciousness and arousal state is tested and trended as part of their progress towards improvement or deterioration. Pupillary responses can be an early sign or late sign of deterioration depending on the injury. Limb movement may be to commands or to noxious stimuli such as a pain stimulus. Vital signs coupled with the other assessment criteria can indicate increasing intracranial pressure ( ICP) in response to injury or other factors that can cause neurological impairment and changes in neurological status.
The administration of continuous sedation may obscure the neurological assessment, and the accuracy of the assesment.
Guidelines for Basic Adult Neurological Observation,
CCSO 2014

5. GENERAL APPROACH Walk up to patient Talk to patient in normal voice
loud voice
Light touch
Painful stimuli
Continuum
The general approach can begin as early as entering the patient room. The patient should be aware of your presence and focus or look at you. If not, attempt to wake the patient first through voice commands, getting louder, repetitive, light touch such as touching, gently shaking an extremity moving to panful stimulus. The idea is to get the patient to WAKE UP! Focus on you as the nurse as you move to the components of the assessment.
Guidelines for Basic Adult Neurological Observation,
CCSO 2014

6. PAINFUL STIMULI Types Of Stimuli include:
Peripheral painful stimuli( LOC/eye opening)
Central painful stimuli( Movement/Motor)
Examples when to Use :
If patient is not waking and to obey verbal commands
In the absence of any purposeful spontaneous movements
Painful stimuli can often elicit a combination of responses in assessing the neurological status- arousal, movement and verbal.
If not obeying commands, or not spontaneously moving, a pain stimulus can produce an arousal or partial arousal state in an attempt to get the patient to wake up enough to obey commands and move, seen as a higher brain function. As deterioration continues the arousal state and use of pain can change showing deterioration. Moving from peripheral pain to central pain is seen as progressive deterioration.
NOTE: NOT TO USE: Applying pain to patients that are moving spontaneously and reaching for tubes, monitoring cables, IV lines, Foley catheters etc…shows localizing to a stimulus. There is no need to apply a deep pain stimulus to assess localizing pain if they are already reaching for an uncomfortable stimulus that is causing discomfort. A more appropriate assessment would be to observe and document the spontaneous localizing response and assess whether the patient can attempt to follow commands while spontaneously moving, indicating higher cognitive function. Applying pain to a extremity that is hemi-paretic will not get a response and is an inappropriate use of pain to assess their neurological status.
Examples when NOT to Use :
Obvious spontaneous movement that are purposeful in nature
Hemiparesis
Guidelines for Basic Adult Neurological Observation, CCSO 2014

7. 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.
Peripheral pain at the phalangeal joint is used primarily to wake the patient, in response they should open their eyes, focus or partially be bale to focus on you or your voice as the nurse to obey commands. It can also cause a motor response, even in the unconscious or unresponsive patient that is not necessarily documented in the motor section of the GCS. The spinal cord reflex arc will cause withdrawal of the limb from pain, pressure and temperature, therefore peripheral pain as a pure motor assessment criteria is unreliable. Nail bed pressure is not used because it damages the cuticle of the nailbed making it also unreliable. More and more pressure may be needed to get a motor response as the damaged nailbed becomes numb to the stimulus or stimulates the reflex arc rather than assessing movement.
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

8. 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 (Cranial Nerve XI)
Supra-orbital pressure (Cranial Nerve V)
Jaw margin pressure (Cranial Nerve V)
A central pain stimulus as outlined by the 3 accepted areas for application show deep progression of neurological impairment, decline or deterioration, but avoids the question of spinal cord reflex arc and therefore the confusion between successive testers. The use of central pain in the performance of a neurological assessment is generally seen as a bad sign due to fact that direct stimulation to the cranial nerves is needed to get any response. Moving from peripheral to central pain is noted as deterioration in status, even if the same responses are met in moving from one to the other. The use of Central pain is regarded as a worsening patient care picture.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

9. CENTRAL PAINFUL STIMULI Trapezius twist (Cranial Nerve 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.
Direct stimulation to CN XI- Spinal Accessory- movement of shoulders up and down and neck to turn head from side to side.
Normal response- opens eyes, attempts to wake up, arouses enough to obey commands, or patient moves to identify the stimulus location and attempt to make the tester stop applying the stimulus, such as reach up to localize the area, crosses midline of body, crunch head to shoulder where the pain is being applied; May or may not have any verbal responses.
Abnormal response- not attempting to make the tester stop; facial grimacing with no attempt to stop the application; abnormal flexion, abnormal extension, posturing, no response.
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 Supra-orbital pressure (Cranial Nerve 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.
Direct stimulation of Cranial nerve sensation and movement of the upper portion of the face.
Application of this pain stimulus is usually reserved and/or indicates sever neurological decline as seen with those patients with sever traumatic brain injury and a GCS < 8. Application usually gets primarily motor response only ( abnormal flexion or extension). Often the patient is intubated and unarousable to get eyes to open.
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. CENTRAL PAINFUL STIMULI Alternative method of applying central pain Jaw margin pressure (Cranial Nerve 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
Direct Stimulation of Cranial Nerve alternate application area- sensation of the midsection of the face.
Application denotes severe or worsening neurological decline or impairment. Same indications may present as with Orbital notch application.
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

12. COMPONENTS OF A BASIC NEURO ASSESSMENT
Level of consciousness (LOC)
- using the Glasgow Coma Scale (GCS)
Pupillary response
Limb movement/ strength
Vital signs
Second part
Guidelines for Basic Adult Neurological Observation, CCSO 2014

13. 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
Consciousness can fluctuate from moment to moment, hour to hour. The reticular activation system ( RAS) in the brainstem region of the brain coordinates the stimulation necessary to arouse and respond the our environment around us, keeping us awake and able to respond to commands. Awareness and cognition identifies the cerebral interaction of the lobes of the brain to the information being presented or asked, then coordinates appropriate responses as part of the interaction with the environment, a higher brain function. Ability to become awake and appropriate is the goal of assessing the LOC.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

14. 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 Level of Consciousness ( LOC)
Developed in Glasgow 1974
Provides global measure of depth & duration of impaired consciousness and/or coma
GCS is proven as a reliable predictor of neurological status. Once a baseline has been established, successive consistent approaches to the 3 components of Eye opening, Verbal and Motor responses to obtain the BEST SCORE in these areas can accurately identify neurological changes, detect neurological deterioration and predict impending neurological compromise in a patient. As a snapshot at the time of assessment, successive snapshots produce the trend needed to detect neurological compromise.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

15. GCS: Eye Opening Response
Eye opening assesses the function of the reticular activating system(RAS) extending from the brainstem through the thalamus to the cerebral cortex.
Opening the eyes = Awake, Arousal, focusing on the tester (.i.e. Registered Nurse) Patients who are hard to arouse, hard to keep awake, difficult to wake , slow to respond are having fluctuations in the Level of Consciousness ( LOC). Closed due to injury or post surgery is not associated with not opening the eyes. Document appropriately if this is the case.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

16. 4 3 2 1 Eye Opening Response GCS: Eye Opening Response Spontaneously
Feature
Scale Response
SCORE
Behavior
Eye Opening Response 4
Patient’s eyes open spontaneously
no prompting from the nurse as he or she approaches the patient.
Spontaneously 3
Patient’s eyes open to a verbal stimulus only
Use normal to louder voice. Consider hearing impairments/medications/status fluctuations
To speech
NOTE: go through each section individually.
Spontaneous eye opening scores 4 section complete
Speech- calling the patient’s name, arouses to verbal stimulus, easy , difficult or deterioration. deterioration may indicate patient still wakes up with loud repetitive speech and commands “ open your eyes, keep them open, wake up.” giving the same score, but the patient picture is changing indicating the level of consciousness and arousal are becoming more difficult. Not opening eyes or progressive deterioration means the tester must now use pain stimulus. Pain stimulus, peripheral first then central can elicit a noted response in the remaining sections as well. With deterioration, opening the eyes even to pain becomes increasing difficult for the patient to perform. 2
Patient’s eyes open to a painful stimulus only
Use peripheral stimulation
Interphalangeal joint pressure is recommended
To pain 1
Patient’s eyes do not open to any stimuli
None
Guidelines for Basic Adult Neurological Observation, CCSO 2014
* Navigating Neuroscience Nursing, 2012

17. GCS: Eye Opening Response
If eyes are closed due to 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.
C= closed due to swelling
Guidelines for Basic Adult Neurological Observation, CCSO 2014

18. GCS: Best Verbal Response
Helps identify if the patient is orientated
Verify that the patient is able to correctly answer ALL the following:
His/her identity/Name Person
Where they are located Place
Current year/season/month /date Time x3
Confusion states may be one of the first aspects that point to deteriorating status. Assessing orientation as part of the baseline and detecting fluctuations or changes in the verbal responses can indicate a disconnection between long term memory, short term memory, and being in the here and now. Early identification of forgetting ,fluctuations, or worsening fluctuations of an already confused state in any verbal responses is the goal. If not orientated to all parameters then the patient is confused and should be documented as such to avoid inconsistences in verbal responses.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

19. Best Verbal Response GCS: Best Verbal Response 5 4 3 2 1 Orientated
Feature
Scale Response
SCORE
Behavior
Best Verbal Response 5
Patient correctly answers questions to person, place & time
Orientated 4
Patient incorrectly answers 1 or more questions to person, place & time
Confused
Orientated- Information is getting to the Cerebral cortex, being understood and responded to appropriately. Score 5
Confused- Information getting to the cerebral cortex but answers are jumbled, confused, missing or not able to remember. Incorrect 1 or more aspects of person, place or time- Score 4
Inappropriate- Information getting to the cerebral cortex, jumbled answers, no relation to questions asked. Not in the here and now, eyes may be wide open and speech clear. Score 3
REASONS for confused or inappropriate answers might include Temporal Lobe injury, Receptive Aphasia, Electrolyte imbalance, Infection, Post-op anesthetic ,Age, Medications, History of dementia or Acute Delirium, Dysarthria, Psychiatric disorders
Alcohol/Drugs
Incomprehensible- moans, groans, guttural sounds, inappropriate. Information getting through to cortex is not effective. No connection to questions or verbal responses. Score 2
No Response- No verbal response at all. No information is getting through or person may not be able neurologically to wake up enough to respond with and verbal effort. Need to be correlated with other findings and may suggest brainstem injury. Score 1
Reasons for groans or no response include, Mute/Deafness but neurologically might be attributed to speech center involvement, expressive aphasia, intubation/Trach placement, sedation, brainstem injury. Score 1
NOTE 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) 3
Patient answers to the questions are not relevant. Speech is still intact and understandable.
Inappropriate 2
Patient answers by moaning or groaning
Incomprehensible 1
No response
None
Guidelines for Basic Adult Neurological Observation,
CCSO 2014
* Navigating Neuroscience Nursing, 2012

20. GCS: Best Verbal Response
If a patient has an artificial airway, verbal responses cannot be accurately tested:
Score 1 and indicate with a“1T” or a “T” in the “no response/none” section.
Document in your notes
If a patient is able to communicate though writing or mouthing of words
Describe the response in the notes
Still document as 1- writing does not qualif\y as orientated verbally.
Verbal Responses CANNOT ACCURATELY be tested if an the person has an Artificial Airway In place such as an Endotracheal tube (ETT) or Tracheostomy tube. 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

21. GCS: Best Motor Response
Assesses area of brain, which identifies and translates sensory input into a motor response.
Use central pain if needed to elicit a response & avoid a spinal reflex
DO NOT use pain if patient localizing spontaneously
e.g. attempting to remove tubes or triggers such as suctioning
Assessing the motor response and the ability to follow verbal commands is a higher brain function utilizing the RAS and the lobes of the brain to comprehend, understand, formulate and complete responses to a command. Commands should be respective of the patients ability to respond,. For example, asking a quadriplegic patient to move his toes would not be accurate or appropriate, but asking the patient to stick out their tongue or blink their eyes would identify their ability to obey commands indicating their cerebral functioning is intact. Using pain to get a motor can be indicative of deterioration, especially central pain. In patients that are moving, restless, agitated and not following commands but reaching for ETT, Foley, IV lines, suctioning, oral care, restraints etc…this is a localizing response to and irritation and can be categorized as localizing to a stimulus
Guidelines for Basic Adult Neurological Observation,
CCSO 2014

22. Best Motor Response GCS: Best Motor Response 6 5 4 3 2 1 Obey commands
Feature
Scale Response
SCORE
Behavior
Best Motor Response 6
Patient understands/obeys verbal/written/gestured commands: i.e. stick out your tongue
Obey commands 5
Purposefully moves limb to locate/remove source of pain: example-to chin or across the midline.
Localize pain 4
flexes at the elbow/knee with the limb drawn away from the trunk (recoil).
Withdrawal
Limb movement is what the tester is looking to observe. Purposeful movement to remove the stimulus is the next highest brain function. Flexion in recoil motion without actually attempting to remove the stimulus indicates withdrawal. Flexion ( decorticate posturing) or Extension ( Deceberate posturing) identifies worsening brain injury, and/or increasing Intracranial pressure and deterioration. 3
Flexes at the elbow with shoulder adduction, wrist flexion and the making of a fist. Slow movement
Flexion to pain 2
Extends limb with shoulder adduction, wrists flexion & fingers either in a fist or extended
Extension to pain 1
No response or movement
None
Guidelines for Basic Adult Neurological Observation, CCSO 2014
* Navigating Neuroscience Nursing, 2012

23. Best Motor Response GCS: Best Motor Response 6
It is not acceptable to ask a patient to squeeze one’s hand unless
he/she is also asked to release it.
Feature
Scale Response
SCORE
Behavior
Best Motor Response 6
Patient understands and obeys verbal/ written/gestured commands: stick your tongue out
Obey commands
If unable to obey commands:
Place the patient in a supine position
Hands at the groin area, if possible
Apply a central painful stimulus
If applicable, loosen any limb restraints while performing assessment.
Localize pain
Withdrawal
Obeying commands can be show me 2 fingers, show me your thumb, wiggle fingers and toes, lift up your arms or legs, blink your eyes, stick out your tongue. An attempt to complete the task appropriately is the goal. The strength of an extremity is not the driving factor, but whether the patient can understand and comprehend enough to compete the task. Extremity Strength is scored differently. Here the goal is can they perform the function. Squeezing the testers hand also has to be accompanied with the command to release it to avoid the grasping reflex that can occur in some brain injured patients similar to a baby's grasp reflex during infancy when something is placed in the palm of their hand. If the patient is not obeying commands, then move to identifying response to pain stimulus by laying the patient in a supine position, untie restraints , arms to sides, hands to groin area and apply painful stimulus.
Flexion to pain
Extension to pain
None
Guidelines for Basic Adult Neurological Observation,
CCSO 2014
* Navigating Neuroscience Nursing, 2012

24. 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.
Purposeful movement towards the stimulus in an attempt to remove it.
Guidelines for Basic Adult Neurological Observation CCSO 2014

25. 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.
General flexion nut no attempt to remove the stimulus. May or may not see facial grimacing in some cases, possibly moans or groans if not intubated, however progressive deterioration will make keeping the airway open difficult where intubation may be required to keep the airway open and assist with breathing.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

26. 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.
Identify each section in relation to the picture and movement.
Guidelines for Basic Adult Neurological Observation CCSO 2014

27. 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

28. GCS: Best Motor Response
Away from trunk
Flexion Withdrawal
Flexed
Fist
Ask group to guess- animation to slides in identification- click for picture to be shown then click for definition to populate on slide to corresponding picture.
Abnormal Flexion to pain
adduction
Flexed
Abnormal Extension to pain
adduction
Flexed
extension
Guidelines for Basic Adult Neurological Observation, CCSO 2014

29. GCS – BEST MOTOR RESPONSE None: score of 1
No movement of the limbs occurs in response
to painful central stimuli.
No explanation needed. No response is still a scored response=1
Guidelines for Basic Adult Neurological Observation,
CCSO 2014

30. COMPONENTS OF A BASIC NEURO ASSESSMENT
Level of consciousness (LOC)
- using the Glasgow Coma Scale (GCS)
Pupillary response
Limb movement/ strength
Vital signs
Second part
Guidelines for Basic Adult Neurological Observation, CCSO 2014

31. Guidelines for Basic Adult Neurological Observation, CCSO 2014
Pupil Assessment
Shape
Size
Reaction
Pupil assessment includes assessment and documentation of pupil size, shape and reaction
Guidelines for Basic Adult Neurological Observation, CCSO 2014

32. 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
Self explanatory
Guidelines for Basic Adult Neurological Observation, CCSO 2014

33. Pupil Assessment: WHY? Indication of changes in ICP:
Compression of the oculomotor nerve results in changes in pupillary size, shape and reaction to light
May be related to increasing intracranial pressure (ICP) brainstem damage, cerebral anoxia, cerebral ischemia or oculomotor nerve compression.
Monitor & detect for early changes to allow for early management or treatment of the cause
Cranial Nerve 3- Oculomotor Nerve- controls the pupil response. Pupil changes can be early or late signs of impending problems. Early detection is the goal for frequent assessments. Changes in size shape and reaction can indicate increasing intracranial pressure and herniation.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

34. Pupil Assessment: Size
Assess size after the eyes have opened & the pupils have accommodated to room light
Size is documented in mm with normal range from 2-6 mm
A difference of 1.5 mm between pupils should be reported to MD
Direct eye injury, past surgery, drugs or medications can affect pupil 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

35. Pupil Assessment: Size
Size of the pupil can denote changes in neurological status. Sizes can be described as:
Pinpoint
Small
Midposition
Large
Dilated
Pinpoint: May be 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 an 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
NOTE: Pupil changes in size may be LATE sign of rising intracranial pressure and neurological deterioration
Guidelines for Basic Adult Neurological Observation, CCSO 2014

36. Pupil Assessment: Shape
Abnormal
Normal
Elderly patients may have irregular 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 syndrome
larger with topical anticholinergics, CN III palsies, migraine, amphetamines
Dilated is always abnormal— and can mean there is increased intracranial pressure, impending brain herniation and brain death.
May indicate ICP
Usually same side (ipsilateral)
Sign of impending brain herniation
Fixed + dilated
Signs of ICP
Cranial Nerve 3 compression
Brain herniation and brain death
Abnormal variations in pupil shapes may be related to:
Cataracts and cataract surgery may distort pupil shape
Disease processes: glaucoma
Trauma or iris inflammation
Congenital defects
Guidelines for Basic Adult Neurological Observation, CCSO 2014

37. Pupil Assessment: Reaction
Inform patient to look forward & dim room lights
Move a concentrated light source from the outer aspect of the eye inwards:
Direct constriction: pupil with light source constricts
Repeat for other eye
Consensual constriction: Pupil constricts in response to light directed in opposite eye
Record a “+” symbol if the pupil reacts, a “–“symbol if the pupil does not react
Read the screen for proper procedure for assessing the pupils.
Uncooperative patients or patients that do not open their eyes such as in the case of head trauma, open the eyes by lifting the eyelids and perform the same procedure watching for reaction and consensual reaction in the other eye.
If eyes are closed by swelling, open gently otherwise record a “C”
Guidelines for Basic Adult Neurological Observation, CCSO 2014

38. Pupil Assessment: Reaction
Pupil response can be described as:
Brisk
Sluggish
Nonreactive
Fixed
Dilated
BRISK: Normal Finding
Opposite pupil should have a consensual reaction to the light source. Brisk is the normal response to be maintained or to return to.
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
SLUGGUSH: Sluggish Pupils amy also accompany changes in size or shape and indicate increasing intracranial pressure in cranial nerve 3 delaying or blocking the normal constrictive response
Constriction occurs but slower than expected
Found in conditions that cause oculomotor nerve compression Cranial Nerve 3
Can be caused by increased intracranial pressure, brainstem damage, anoxia or ischemia
NONREACTIVE/FIXED/DILATED:
Abnormal response and must be communicated immediately.
No reaction to light source
Fixed in shape, size and position denotes no function to cranial nerve 3 to constrict the pupil.
Found in conditions that cause oculomotor nerve compression such as severe traumatic brain injury, or conditions that cause rapidly increasing Intracranial pressure such as Subarachnoid hemorrhage.
Other conditions may be associated with increased intracranial pressure, brainstem damage or anoxia such as stroke or post cardiac arrest.
May be a sign of brain death if bilateral
Guidelines for Basic Adult Neurological Observation, CCSO 2014

39. Pupil Assessment Steps
Direct Consensual 1
Note pupil size and shape in ambient lighting 2
Sweep light onto the pupil, note reaction of the pupil the light is on 3
Repeat action noting the reaction of pupil the light is not shining on
This is the consensual reaction … IT’S IMPORTANT TOO! 4
Repeat for the other eye 5
Document your assessment
Alert team if concerned
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 Cranial nerve 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

40. Guidelines for Basic Adult Neurological Observation, CCSO 2014
Shape
When to be concerned???
Reaction
Changes from baseline pupil assessment size shape and/or reaction
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 fixed and fully dilated
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

41. COMPONENTS OF A BASIC NEURO ASSESSMENT
Level of consciousness (LOC)
- using the Glasgow Coma Scale (GCS)
Pupillary response
Limb movement/ strength
Vital signs
Second part
Guidelines for Basic Adult Neurological Observation, CCSO 2014

42. 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’
The best indication of movement strength is with the patient that can follow commands. Testing left and right is important for comparison and to detect a worsening issue. Those that cannot or will not obey commands, observing the spontaneous movement can give indications of the strength of the extremity or extremities. Abnormal flexion and extension is movement and must be considered as such, weak or strong. This can be documented in the nurses notes or neurological record. Spinal cord injury motor assessments are performed and documented differently,. Even though movement is being assessed, if there is a spinal cord injury, the proper movement and sensory assessments are performed using the ASIA scoring or acceptable version. Peripheral and or Central pain stimulus is not an appropriate method to test motor strength of an extremity, Pain only assesses the response level. Assessing strength requires ability to obey command.
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

43. 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 inability 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

44. Not Applicable for:
Spinal Cord Pathology – Use ASIA scoring or facility specific policy and procedure and associated documentation
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
Spinal cord assessments and documentation are not part of this assessment. Document exceptions in the nursing or Interprofessional notes related to trauma, traction, fractures, deformities etc…
New Spinal cord guidelines from NEON/CCSO possible released in 2016.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

45. Some examples of applying Gravity and Resistance1
Resistance 2
Push down
Resistance
Have the patient pull arms in, bending form the elbow ( biceps flexion)- tester offers resistance in opposite direction.
Have the patient push down with their foot/feet while tester pushes back form the bottom of the foot.
Patient lifts their leg while the tester pushes down.
Flex up; pull in
Lift up 3
Resistance
Bring Limb off surface for gravity - then apply counter resistance
Lift up
Guidelines for Basic Adult Neurological Observation, CCSO 2014

46. COMPONENTS OF A BASIC NEURO ASSESSMENT
Level of consciousness (LOC)
- using the Glasgow Coma Scale (GCS)
Pupillary response
Limb movement/ strength
Vital signs
Second part
Guidelines for Basic Adult Neurological Observation, CCSO 2014

47. Guidelines for Basic Adult Neurological Observation, CCSO 2014
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 intracranial pressure.
This can be a emergency and should be communicated and addressed IMMEDIATELY by a physcian.
Vital signs of Blood pressure, heart rate, respiratory rate ( as well as breathing pattern and oxygen saturation) are important aspects of the Cushing's response to increasing intracranial pressure and pressure being exerted on the brain stem from impending herniation and/or cerebral edema. Deterioration of the neurological status coupled with increasing blood pressure values, widening of the pulse pressure ( difference between systolic and diastolic), increasing heart rate changing to bradycardia, increasing alterations in respiratory depth, rate, pattern and oxygen saturation are all signs and symptoms of rising Intracranial pressure ( ICP) that can be fatl if not treated immediately. Brain death can occur if left untreated.
Guidelines for Basic Adult Neurological Observation, CCSO 2014

48. 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
Review in summary. A complete assessment includes all these components. Identify each one…. Together these can accurately detect, identify neurological deterioration and predict neurological decline; if performed accurately and with increased frequency.
Frequency can be adjusted based on the last clinical assessment. Increasing the frequency of the assessments does not require a physicians order. Increasing the frequency of assessments in patients with fluctuations in neurological status may detect subtle changes that when added to the complete clinical picture and trend show increasing neurological decline and possible emerging or emergent patient situation.
Guidelines for Basic Adult Neurological Observation CCSO 2014