Neurological Assessment and GCS

Symptoms of neurological changes often vary but can include sensory changes, motor changes, reflex changes, altered awareness and/or personality, altered level of consciousness and headaches (Koutoukidis et al. 2017).

Neurological observations collect data on the patient’s neurological status and can be used for many reasons, including in order to help with diagnosis, as a baseline observation, following a neurosurgical procedure, and following trauma.

Therefore, it is important that all healthcare professionals are efficient and accurate in assessing the neurological status of their patients.

It is also important to remember that these changes can be seen to occur rapidly over a short period of time, or more gradually taking place over days and weeks. This is why accurate neurological assessments and observations are vital in ensuring the early recognition of neurological deterioration in patients (Koutoukidis et al. 2017; Mooney & Comerford 2003).

The Neurological Assessment

A neurological assessment involves checking the patient in these main areas in which changes are most likely to occur:

• Level of consciousness
• Pupillary reaction
• Motor function
• Sensory function
• Vital signs

(Koutoukidis et al. 2017)

Glasgow Coma Scale (GCS)

There are many different assessment tools for neurological function, however, the most widely known and used tool is the Glasgow Coma Scale (GCS).

The patient is assessed and scored in three areas:

1. Eye opening
2. Verbal response
3. Motor response.

The highest possible score is a 15, which reflects an individual who is fully alert, aware and orientated, whereas the lowest possible score is a 3 and reflects an unconscious individual.

Although pupil reaction is not included as part of the GCS, it is often incorporated into the neurological assessment charts used in healthcare facilities in addition to the use of the GCS. Instead of pupillary reaction, the GCS area focuses on if the patient’s eyes are opening spontaneously or not (Majdan et al. 2015).

Because the GCS is widely known, it is a quick way to communicate a patients neurological status and provides a standardised assessment of an indivdual’s neurological functioning. However, there can be some inconstancies with its use.

In particular, there can be variations seen in the recording of pupil size as well as motor weakness between assessors. Therefore, it is important that nurses and health professionals are using the tool correctly to ensure these inconstancies do not affect patient care (Mooney & Comerford 2003; Reith et al. 2015).

Behaviour	Rating	Score
Eye Opening Response
Opens eyes spontaneously	Spontaneous	4
Opens eyes in response to speech and sound	Sound	3
Opens eyes in response to painful stimuli	Pain	2
Does not open eyes	None	1
Verbal Response
Oriented to time, person and place	Oriented	5
Confused and disoriented	Confused	4
Utters incoherent words	Words	3
Incomprehensible sounds	Sounds	2
Makes no sounds	None	1
Motor Response
Obeys 2-part requests	Obeys commands	6
Localises to painful stimuli	Localising	5
Flexion / withdrawal from painful stimuli	Normal flexion	4
Abnormal flexion from painful stimuli	Abnormal flexion	3
Extension to painful stimuli	Extension	2
Makes no movement	None	1

(Teasdale, G 2015; Rowlett, R 2001)

Assess Level of Consciousness

An individual’s level of consciousness can deteriorate due to many different reasons, such as head injuries, increased intracranial pressure, haemorrhage, or lesions and tumours.

Determining the level of consciousness depends on the individual you are assessing and can be easy or difficult.

Sometimes this will be obvious when you are talking to the patient, sometimes you may make note that they are not responding in an appropriate way or appear confused, and sometimes they may show no response at all.

Sound and pain are the most common stimuli used to assess an individual’s level of consciousness.

For example, sound is used by speaking to the patient, whilst pain is reserved for the patient with a decreased level of consciousness who is not responding when you are speaking to them (Koutoukidis et al. 2017; Mooney & Comerford 2003).

Painful stimuli can sometimes be necessary in order to rouse the patient who has a decreased level of consciousness. The response of the patient to painful stimuli can be classed as:

• Purposeful: When the individual pushes the assessor away, withdraws the affected body part or the individual winces
• Non-purposeful: When the application of the painful stimuli causes muscle contraction or the individual only moves the affected body part slightly
• Unresponsive: When there is no response to the painful stimuli

(Koutoukidis et al. 2017)

Eyes Opening and Pupillary Reaction

When we are assessing the patient’s pupils, we are gaining information regarding the brain and also if there has been an increase in intracranial pressure.

The pupils are assessed for their size and shape, as well as how they react to the presence of light. They should be round and equal in size.

Their size can vary but they are generally 3.5mm in diameter, and then constrict briskly to a smaller size when exposed to a light shone in their eyes.

The reactions to light can be described as brisk, sluggish or non-reactive/fixed.

Both eyes are checked and compared against each other. Generally, any change that occurs during your assessment of the pupils can indicate a change in the individual’s intracranial pressure and may signify a neurological emergency.

Acute pupillary dilation in patients who have suffered a head injury is thought to be caused from compression of the third cranial nerve from brain oedema and herniation or alternatively from a decrease of blood flow to the brain stem resulting in brain stem ischaemia (Koutoukidis et al. 2017; Majdan 2015).

Assess Motor Function

Assessing the motor function of the patient during a neurological assessment needs to be individualised, and the techniques used are dependent on the patient’s condition.

For example, if the patient is conscious, the assessment is made by observing their motor response to commands such as squeeze my hands. If they are unconscious or unable to provide accurate responses, you may only be able to assess motor function by observation.

You will also be taking note of the strength of their limbs, if they are experiencing any weakness, and if these effects are bilateral or unilateral.

Limb strength can be describe as either being of normal power, mild weakness, severe weakness, extension, or no response.

Generally, this assessment focuses on the arms and legs and will look for any improvement or deterioration in function. However, it must be noted that lower limb function can impact on spinal function in some patients and this can then disrupt the assessment findings (Koutoukidis et al. 2017; Mooney & Comerford 2003).

Assess Vital Signs

Vital signs are also assessed in conjunction with neurological observations in order to gain a full picture of the patient’s current health status.

Changes in vitals can indicate a deterioration of the neurological condition of the patient and can also provide clues to any other medical problems the individual may be experiencing. Depending on the findings of the assessment, further neurological examinations and diagnostic tests may be required.

Overcoming Challenges in Neurological Assessments

As mentioned, there have been concerns raised about the consistency of neurological assessments, especially in regards to assessing pupil size and motor function.

This remains one of the major challenges in regards to neurological assessments. To ensure reliability of neurological assessment and use of the GCS, it is important that all health professionals conducting these assessments are:

1. Fully educated and competent in the use of the GCS and neurological observation tools being used within their health service, and;
2. Generating discussion together regarding their patient’s neurological condition.

References

• Koutoukidis, G, Stainton, K & Hughson, J (eds) 2017, Tabbner’s Nursing Care: Theory and Practice, 7^th edn, Elsevier, Chatswood.
• Majdan, M, Steyerberg, EW, Nieboer, D, Mauritz, W, Rusnak, M & Lingsma, HR 2015, ‘Glasgow Coma Scale motor score and pupillary reaction to predict six-month mortality in patients with traumatic brain injury: Comparison of field and admission assessment’, Journal of Neurotrauma, vol. 32, no. 2, pp. 101-108, viewed 27 March 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291088/
• Mooney, GP & Comerford, DM 2003, ‘Neurological observations’, Neurology, vol. 99, no. 17, pp. 24, viewed 27 March 2018,  https://www.nursingtimes.net/clinical-archive/neurology/neurological-observations/205473.article
• Reith, FCM, Brennan, PM, Maas, AIR & Teasdale, GM 2015, ‘Lack of standardization in the use of the Glasgow Coma Scale: Results of International Surveys’, Journal of Neurotrauma, vol. 33, no. 1, pp. 89-94, viewed 27 March 2018, http://online.liebertpub.com/doi/abs/10.1089/neu.2014.3843
• Rowlett, R 2001, Glasgow Coma Scale, University of North Carolina, viewed 27 March 2018, http://www.unc.edu/~rowlett/units/scales/glasgow.htm
• Teasdale, G 2015, Glasgow Coma Scale: Do it this way, GCS, viewed 27 March 2018, http://www.glasgowcomascale.org/