Neurological assessment

•Frontal lobe –voluntary motor activity –speech –thought •Temporal lobe –processes sound / speech •Occipital lobe –processes visual input •Parietal lobe –processes sensations ( touch, pressure, heat, cold) –proprioception; awareness of body position.        

•To determine if someone’s level of consciousness and general neurological condition is: –static –improving –deteriorating

Examples may include……...

•          Direct causes: head / spinal injury, brain damage (hypoxia, CVA, etc), neuromedical conditions, trauma, metabolic changes

•          Secondary causes: drugs (sedatives / opiates / anaesthetics), environmental factors, homeostatic changes

  A standardised and practical method of assessing impaired consciousness

 Allows a baseline of neurological function to be established

 Determines any changes in the patients neurological condition over a period of time

 Detects life threatening situations & those which need medical intervention

 Establishes the impact a condition has on the patients independence.

Determining the degree of stimulation required to elicit a response. 

•Three components •Eye opening (max. 4 points) •Best verbal responses (max. 5 points) •Best motor response (max 6 points)

The maximum score is 15

•Fully alert, orientated  and responsive

•Closely linked to being awake, and that arousal mechanisms are functioning •Relates to function of brain stem, hypothalamus and thalamus (RAS) •Eye opening does not always indicate intact neurological function

4  Patient opens eyes spontaneously when nurse approaches bedside

3  Patient opens eyes in response to speech (normal, then increase volume if necessary)

2  Patient opens eyes in response to pressure (painful stimuli) (touch normally before using painful stimuli)

1  There is no response from the patient at all following sufficient stimuli

NT  To be recorded if patients eyes are closed due to peri-orbital swelling

•       Examines comprehension (understanding) of sensory input & verbal stimuli

•       Reflects patients ability to articulate and express a reply

•       Involves cognition of stimuli

•       May be affected if there has been damage to speech centres i.e. dysphagia

5             Patient is orientated to time (month), place (where they are & why) + person (their name).  Allowances are made for minor inconsistencies.

4              Patient is confused (able to converse but gives wrong answers)

3              Patient speaks only (inappropriate) words (minimal verbal response, no structure or sentence)

2              Patient makes only (incomprehensible) sounds (grunts or moans to verbal or painful stimuli)

1              Patient makes no response

NT          Factor interfering with communication i.e. endo- or tracheal tube in situ

•Testing ability to identify sensory input & translate into motor response

•Focuses on performance of limbs

•Scores from highest level of brain involvement to lowest

•Purposeful response excludes automatic or reflex reaction. 

6   Patient can obey commands which have 2 parts of instruction, such as ‘raise and lower your arm’.

5   Localises to pain (moves hand to remove a source of irritation). Needs to be specific response to source of sensory stimulation, usually to head or neck.

4   Attempts to withdraw (normal flexion) from the source of pain; flexion of arm towards pain but not localising.

3(Abnormal) flexion to pain (decorticate posturing). Pt will flex arm & rotate wrist. Legs may extend

2  Extension to pain (decerebrate posturing).    Arms extend – elbow straight, arm rotates inwards. Legs may extend

.

1    No response, even to painful stimuli, in any limb

NT  Factor ie. Patient paralysed 

In abnormal flexion the arms are flexed at the elbow and wrists rotate outwards.  Legs are extended.

In extension the body can become rigid, with the arms externally rotated and toes pointing down, legs extended.

•Central stimuli: •Trapezium squeeze

  -  advocated best   practice

•Supraorbital pressure

But not…….

•Jaw margin pressure •Sternal rub     

•Peripheral Stimuli: •Finger pressure

Clinical test for brain stem function

The light reflex tests two cranial nerves.

1. Optic Nerve (II) - the sensory nerve of visual acuity
2. Oculomotor nerve (III) - the motor nerve that controls pupillary response

Light shone into eyes causes

•      direct reflex response to light falling on retina

•      Consensual constriction of both pupils.

•      Involves the autonomic nervous system

•      sympathetic- pupil dilation

•      parasympathetic- pupil constriction

•Size – look before shining light in. 

•Pupils size can be affected by certain drugs for eg….

Atropine

Opioids

•Be aware of any pre-existing eye problems. 

•Check each pupil reacts equally, or are unequal?

•Are they mishapen?

•Notice how sluggish, or briskly each pupil reacts to this light.

•Pupil size should be noted before proceeding to test pupil response to direct light.

•Score pupil size 1-6mm

•+ is used to indicate a brisk response

•- is used to indicate no response

•SL is used to indicate a ‘sluggish’ response

•C is used to indicate closed eyes due to perirobital oedema.

•      Pupils should remain round throughout.

•      If pupils are sluggish, oval or unequal may be a sign of raised ICP, haemorrhage or compression of cranial nerves

•      However some people do have unequal pupils and are healthy

•      Raised ICP constricts oculomotor (parasympathetic) nerve so eye remains dilated in response to light

•      Abnormalities can include either constriction or dilation of pupils

•      Neuro obs should be carried out thoroughly and frequently until GCS =15

•      half hourly for 2 hours

•      Then 1-hourly for 4 hours

•      2 hourly thereafter

•Time of day •Is the patient usually asleep? •Pain •individual response to pain •Pain induced increased BP, HR, RR •Medication •Sedatives, anticonvulsants, opiates. •Individual interpretation

-    Assessment is subjective, seek second opinion when unsure.

•Other factors

- Glucose

•Consistency important; do GCS at handover •New or evolving neurological signs need to be reported immediately •GCS of 8 or below indicates coma; immediate help is required. A, B, C. •Helpful to note scores for each component as well as total •i.e. GCS 10/15 (E=4, V=T, M=6) •Pupil changes are often a late sign of deterioration 

•Ensure the patient airway is patent –adjuncts as necessary

•Place patient horizontally in the lateral recovery position

•Oxygen therapy

•If patients breathing is inadequate, provide assisted ventilation using a manual resuscitator / bag-valve-mask

•Administer intravenous fluids to maintain adequate systolic BP

•Measure blood glucose & treat hypoglycaemia

•Advantages: •Universal scale •Relatively simple to use •Aims to ensure changes in patients condition are detected and acted upon at the earliest opportunity 

•Disadvantages:

•Can be misused / misunderstood

•GCS score not always helpful

•Some patients could score lower i.e. if intubated/ tracheostomy, or if on sedation etc