Monitoring and recording patients neurological observations

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1 art & science clinical skills: 25 Monitoring and recording patients neurological observations Dawes E et al (2007) Monitoring and recording patients neurological observations. Nursing Standard. 22, 10, Date of acceptance: July Summary This article provides a detailed account of how to monitor and record neurological observations. It outlines the importance of neurological observations in acutely ill patients and focuses on carrying out observations using the Glasgow Coma Scale. Authors Emma Dawes is practice development nurse, Hilary Lloyd is principal lecturer, Lesley Durham is nurse consultant in critical care, Sunderland Royal Hospital, Sunderland. emma.dawes@chs.northy.nhs.uk Keywords Clinical skills; Neurological observations; Vital signs These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at For related articles visit our online archive and search using the keywords. THE IMPORTANCE of undertaking neurological observations in acutely ill patients cannot be overstressed. Neurological status should be observed and recorded accurately in patients to monitor their level of consciousness for signs of deterioration, stability and improvement. The main methods for undertaking this are by: monitoring consciousness level; observing pupil reactions; assessing motor function; and observing vital signs. There are many possible neurological presentations that a nurse may encounter (Walsh 2006). The challenge for the busy nurse includes the quick recognition of acute events, for example, head injury, infection, haemorrhage or post-surgery complications and the monitoring and recording of neurological observations. The aim of this article is to provide nurses with knowledge to reliably and accurately monitor and record neurological status. It is important that nursing staff, particularly those working in the acute ward setting, are competent to monitor and record neurological observations and to keep up to date with the clinical skills required to ensure high levels of patient safety and quality care. As the acuity of ward-based patients continues to escalate, all ward staff need to develop knowledge and skills in both the recognition and management of at-risk and critically ill patients (Department of Health (DH) 2005a). Observation charts A validated observational chart is the most common method of monitoring and recording neurological observations. Although the layout may differ from chart to chart, in essence, all neurological observation charts measure and record the same clinical information, including the level of consciousness, pupil size and response, motor and sensory response and vital signs. It is only through consideration of all of these components that an accurate clinical assessment of the patient s neurological status can be obtained. Observational charts ensure a systematic approach to collecting and analysing essential information regarding a patient s condition. Such charts also act as a means of communication between nurses and other health professionals. The information collected is vital and can be used in the following ways: To aid diagnosis (Douglas et al 2005). As a baseline of observations (Crouch and Meurier 2005). To determine both subtle and rapid changes in an individual s condition (Crouch and Meurier 2005). To monitor neurological status following a neurological procedure (Mooney and Comerford 2003). To observe for deterioration and establish the extent of a traumatic head injury (Walsh 2006). To detect life-threatening situations (Alcock et al 2002). 40 november 14 :: vol 22 no 10 :: 2007 NURSING STANDARD

2 Nurses should be aware when taking initial observations that they are important as they may indicate that a patient requires immediate medical attention. Ongoing observations are just as important as they may indicate a change in the patient s condition. Often small changes in neurological status are not always obvious until compared with previous observations. A rapid decline in neurological observations will alert the nurse to seek urgent assistance. Glasgow Coma Scale The Glasgow Coma Scale (GCS) (Table 1), first developed by Teasdale and Jennett (1974), is a common way to assess a patient s conscious level. It forms a quick, objective and easily interpreted mode of neurological assessment. The GCS measures arousal, awareness and activity, by assessing three different areas of the patient s behaviour including: Eye opening. Verbal response. Motor response. Each area is allocated a score, therefore enabling objectivity, ease of recording and comparison between recordings. The total sum provides a score out of 15. A score of 15 indicates a fully alert and responsive patient, whereas a score of three (the lowest possible score) indicates unconsciousness. As well as an overall score, a score for each area of assessment should also be recorded and reported separately. Figure 1 provides TABLE 1 Glasgow Coma Scale Response NURSING STANDARD Score Best eye response Open spontaneously 4 Open to verbal command 3 Open to pain 2 No eye opening 1 Best verbal response Orientated 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localises pain 5 Withdrawal from pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 (National Institute for Clinical Excellence 2003) instruction on how to use the GCS. Using painful stimuli Painful stimuli should be applied in a careful and purposeful manner once and for no longer than 30 seconds (Woodward 1997a). Under no circumstance should the sternal rub or nail-bed pressure methods be used as they may cause prolonged discomfort and bruising (Shah 1999, Crawford and Guerrero 2004, Waterhouse 2005). Table 2 provides a summary of the evidence base for different methods of applying painful stimuli. Before initiating painful stimuli it is important that the patient or family members are informed of the procedure and why it is necessary. Recording observations It is important that nursing staff record exactly what is being observed as changes to the patient s condition can be rapid and may require an urgent response. Waterhouse (2005) recommended picturing a photograph being taken of the patient that captures what is being seen at a particular point in time. It is important that nursing staff record individual findings rather than comparing and being influenced by a previous set of observations. Nursing staff should not seek conformity with previous recordings (Woodrow 2000). Any concerns about changes between the current and previous recording should be reported and appropriate action taken. There is no published consensus on how frequently observations should be documented (Mooney and Comerford 2003). For head injury patients, the NICE (2003) guidance recommended that a GCS of less than 15 necessitates 30-minute observations until the maximum score of 15 is reached. In addition, when a score of 15 is achieved, observations should then be performed every half hour for two hours, hourly for four hours and then two-hourly thereafter. For the unconscious patient, Walsh (2006) recommended 15-minute observations and suggested that these should be carried out more frequently if the level of consciousness is fluctuating. As with any assessment process it is essential to start by informing the patient of the procedure and where possible obtain verbal consent (Douglas et al 2005). When assessing neurological deficit it is important to record the best arm response. The reason for this is to ensure measurement of neurological status, rather than injury or disability. There is no need to record left and right differences, as the GCS does not aim to measure focal deficit, this should be completed in the limb assessment. Leg responses should not be measured because of the risk of a spinal rather than a brain-initiated response. november 14 :: vol 22 no 10 ::

3 art & science clinical skills: 25 It is important to note that a patient who is unable to open his or her eye(s) as a result of swelling or surgery does not necessarily indicate a low or falling conscious level. Likewise an absence of speech does not necessarily indicate a low or falling conscious level. Language difficulties or dysphasia will make it impossible to make an accurate assessment of consciousness (Crawford and Guerrero 2004) and should be taken into account in the overall assessment process. FIGURE 1 How to use the Glasgow Coma Scale Observation Score Method Eye opening: If the patient is unable to open his or her eye(s) as a result of trauma or surgery, the letter C indicating closed should be recorded in the first box. Otherwise this section should be completed as follows: The score indicates the 4 = Spontaneously The patient s eyes should open spontaneously as you approach. If the patient patient s state of arousal is asleep, wake the patient, ensuring he or she is fully roused and then complete the assessment. 3 = To speech The patient will respond to your voice. The best way to do this is to say his or her name. If there is no initial response, a raised voice should be used. 2 = To pain The patient opens his or her eyes to painful stimuli. The best way to do this is to apply peripheral painful stimuli. Avoid central painful stimuli as it may cause the patient to grimace. 1 = No response The patient s eyes remain closed despite painful stimuli. Best verbal response: The patient may have difficulty in speaking (dysphasia). If so, the letter D should be recorded in the none column. If the patient is intubated then the letter T should be recorded in the none column. This indicates the patient s 5 = Orientated The patient must be able to state his or her name, who he or she is, where orientation to time, place he or she is and the month of the year. and person 4 = Confused If the patient is able to hold a conversation but unable to answer the questions above correctly he or she should be considered to be confused. Correct wrongly answered questions, but change the order each time to avoid the patient just repeating them. 3 = Inappropriate words The patient will use random words that make little sense or are out of context, typically swearing and shouting. Painful stimuli may be required to gain a response. 2 = Incomprehensible The patient will only respond with moaning and groaning. Painful stimuli may sounds be required to gain a response. 1 = No response There is no verbal response despite painful stimuli. Best motor response: If the patient is receiving medicines to maintain muscle paralysis Glasgow Coma Scale observations should not be performed. Thisindicatesbrain 6 = Obeys commands Ask the patient to perform a couple of different movements such as sticking function out his or her tongue or lifting his or her arm. 5 = Localises to pain Apply a central painful stimulus using one of the recommended methods (Table 2). The patient should purposefully move the arm towards the site of pain to remove the cause of pain. (Shah 1999, Crawford and Guerrero 2004, Waterhouse 2005) 4 = Withdraws from pain The patient will flex his or her arms in response to pain but will not move towards the source of pain. 3 = Flexion to pain The patient will flex his or her arms in response to pain but the wrist will also rotate and the thumb may also flex and move across the fingers. 2 = Extension to pain Arms will straighten and the shoulder will rotate inwards when a painful stimulus is applied. The legs may also straighten with toes pointing downwards. 1 = No response There is no physical response despite painful stimuli. 42 november 14 :: vol 22 no 10 :: 2007 NURSING STANDARD

4 Recording other measurements Vital signs The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Crawford and Guerrero 2004) recommends that vital signs should be recorded in the order of respiration, temperature, blood pressure and pulse (Table 3). Raised intracranial pressure (ICP) will lower respiratory rate and alter the respiratory pattern (Crawford and Guerrero 2004). This is one of the clearest indicators of brain dysfunction. As ICP rises pressure will be exerted on the hypothalamus, the thermoregulatory part of the brain, resulting in fluctuating temperature (Woodrow 2000). The brain becomes hypoxic and ischaemic and as a result systemic blood pressure rises in an attempt to perfuse the brain (Shah 1999). Patients will also become bradycardic; this is known as Cushing reflex (Shah 1999, Crawford and Guerrero 2004). Both increases and decreases in blood glucose levels can occur in the patient with a head injury. Hyperglycaemia increases cerebral ischaemia, reducing blood perfusion in the brain, and hypoglycaemia results in a lack of available glucose to neurones which causes a reduction in function (Woodrow 2000). Pupil response Assessment of pupillary activity is an essential part of neurological observation and the only way to assess and monitor the neurological status of sedated patients (Waterhouse 2005). When examining pupil response it is important to position the patient so that there is enough light to see the pupils clearly but not so much light that the pupils constrict. Pupils should be assessed for size, shape and reaction to light (Table 4). Each pupil should be assessed and recorded individually. Pupils are measured in millimetres (normal range 2-6mm in diameter) and are normally round in shape. A bright light, preferably a bright pen torch, should be shone into each eye to assess the pupil s reaction to light. Abnormal pupil size and response together with other neurological symptoms, such as a reduced GCS and agitation, are an indication of raised ICP (Woodward 1997b). The anatomy of the skull means that any swelling or space-occupying lesion such as a bleed, haematoma or tumour, will raise ICP. If this persists or rapidly worsens the brain tissue will shift and become compressed. As a result the ocular motor nerve that controls pupil reaction may be affected resulting in changes to pupil responses. Sluggish or suddenly dilated pupils are an indication of deterioration and require urgent medical attention (Waterhouse 2005). This is why it is important to observe and record pupil size and reaction (Woodward 1997b). Other clinical indicators of deterioration such as a NURSING STANDARD falling GCS are likely to be found before a change in pupil response is observed. Altered pupils can be a response to a number of things, for example, pin-point pupils could indicate opiate use or metabolic disorders, a unilateral dilated pupil may indicate brain herniation or raised ICP and TABLE 2 Evidence base for methods of painful stimuli Central painful stimuli Method Action Evidence Trapezius pinch Using the thumb and Shah 1999, Woodrow or squeeze forefinger take hold of 2000, Mooney and approximately 5cm of Comerford 2003, the trapezius muscle Crawford and Guerrero and twist. 2004, Waterhouse Jaw pressure Apply pressure with the Woodward 1997a, thumb to the jaw, just in Waterhouse front of the earlobe. This method should not be used if the patient has sustained any head or facial trauma. Supra-orbital Feel along the medial aspect Shah 1999, Woodrow pressure of the edge of the bone 2000, Mooney and above the eye for a groove Comerford 2003, or notch; apply pressure Crawford and Guerrero here with the thumb. This 2004, Waterhouse method should not be used if the patient has sustained any head or facial trauma. Peripheral painful stimuli Method Action Evidence Lateral finger Using a pen apply pressure Waterhouse or toe pressure to the lateral aspect of a finger or toe. Rotate the pen around the finger in opposite direction to the nail. This should be performed for no longer than ten seconds. TABLE 3 Vital signs Observation Respiration rate Temperature Blood pressure and pulse Blood glucose Method Record respiratory rate and rhythm or pattern, observing for any decrease in rate and altered rhythm or pattern. Record and observe any increase in temperature. Record together observing for any increase in blood and pulse pressure and decrease in pulse. Record and observe for any deviation from normal parameters. Early warning score a Record and observe for any deviation from physiological scoring system normal parameters. with an identifiable trigger threshold (Morgan et al 1997) (Adapted from Crawford and Guerrero 2004) november 14 :: vol 22 no 10 ::

5 art & science clinical skills: 25 TABLE 4 Observation of pupil response Observation General observations Pupil size Pupil response (Adapted from Woodward 1997b) fixed pupils may indicate severe mid-brain damage or poisoning (Iggulden 2006). Limb movement Limb movements provide an Method Look at the shape of the pupils and their position. Is there any eye disease or medication that impairs either your view or the eyes response to light? Is the eye too swollen to open? Attempts should be made to open a mildly swollen eye but if it is too painful or the swelling is prolific the letter C for closed should be recorded on the observation chart. Does the patient have a false eye? The size of the eye is measured in millimetres a guide is given on the side of most neurological observation charts and some pen torches. Use this guide rather than estimation so that the results are objective rather than subjective. Record the size of the pupil at rest before any light is shone into the eye. To check the pupil response, move an illuminated pen torch from the outer aspect of the eye directly over the pupil. The pupil should constrict quickly. The pupil should dilate again when the bright light is moved away. Both eyes should constrict when a light is shone into one eye. This is called consensual reaction. These reactions are recorded as (+) for reaction, (sl) for a sluggish reaction and ( ) for no reaction. accurate indication of brain function (Crawford and Guerrero 2004). It is important to assess and record each limb separately (Waterhouse 2005). The observation chart should be marked with the letter L for left limbs and the letter R for right limbs. Table 5 demonstrates the process of limb observation. Assessment of limb responses provides information about motor function and is best carried out when the patient is lying down (Woodward 1997c). Any deficiencies in function may indicate a developing weakness or loss of movement caused by raised ICP (Woodward 1997c, Shah 1999). Limb assessment also assists the identification of local damage. Although it is usual for a hemiparesis or hemiplegia to occur on the opposite (contralateral) side to the lesion, it may occur on the same (ipsilateral) side, known as false localising. Particular consideration should be given to any limb weakness that may be the result of past medical history, for example, stroke, where there may be a difference in limb resistance, or general frailty which could influence the patient s ability to offer resistance. It is important to use clinical judgement as well as objective measurement, remembering to record any difference in resistance in each limb separately. Accountability Nurses are accountable and responsible for providing optimum care for patients. The Nursing and Midwifery Council s (NMC) Code of Conduct provides the main source of TABLE 5 Observation of limb movement Observation Result Method Normal power The patient will be able to push against To determine whether the patient has normal power, mild resistance with no difficulty. or severe weakness. Each limb is assessed and recorded separately. Mild weakness The patient will be able to push against Arms while holding the wrist ask the patient to pull you resistance but will be easily overcome. towards him or her and then push you away. Severe weakness The patient will be able to move his or her limbs Legs holding the top of the ankle ask the patient to lift his independently but will be unable to move against or her leg off the bed then holding the back of the ankle ask resistance. the patient to pull the leg towards him or her. Spastic flexion The patient s limbs will flex in response to painful To determine a response of spastic flexion or extension apply stimuli. Arms, wrists and possibly the thumb central painful stimuli. If no response is elicited use peripheral will bend inwards. Legs will pull upwards. painful stimulus. Extension No response The patient s limbs will extend in response to painful stimuli. Elbows, wrists and fingers will straighten stiffly down the side of the body. Legs will stiffen and feet will point downwards. There is no motor response despite central and peripheral painful stimuli. (Adapted from Woodward 1997c) 44 november 14 :: vol 22 no 10 :: 2007 NURSING STANDARD

6 professional accountability for nurses (NMC 2004). It is essential that nursing staff examine objectively the information gathered from assessments and observations as well as the information previously recorded. Neurological observations contribute to the overall patient assessment, which then forms the basis for the individualised plan of care (Crouch and Meurier 2005). Nursing staff should ensure that the patient has an appropriate care plan in place and know how and when to take action should a change occur in the patient s condition. Accurate record keeping and documentation is important. The NMC (2007) states that the quality of record keeping is also a reflection of the standard of the individual s professional practice. All records must be contemporaneous, accurate and unambiguous. It is important always to act in a way that safeguards the patient s best interests and this includes the prompt reporting of abnormal findings when monitoring and recording neurological observations. It is also important to remember that observation charts, while important, are only one of the many tools available to gather information regarding a patient s condition. It is often useful to listen to the patient s family or close friends when carrying out neurological observations as they can provide invaluable information about the patient s normal state and can often give an accurate history of the onset and symptoms. This is important in situations where patients may not be able to communicate their medical history. Accountability also involves being up to date with new developments, best practice and ensuring consistency. Nurses should be fully aware of relevant, credible research and ensure that any patient care given is safe. Guidelines and protocols should be in place in healthcare organisations to ensure that care is in line with best practice. Head injury guidance is available from NICE (2003) and the DH (2005b). It is important to ensure best practice when monitoring and recording neurological observations. Box 1 presents a quick reminder of factors that need to be considered. Conclusion Monitoring and recording neurological observations that are reliable and accurate are important clinical skills. There are a number of tools, including the GCS, which can be used to perform neurological assessments. Nurses should ensure that they are competent to undertake these observations and use the tools available to achieve the best outcomes for patients. The importance of using clinical judgement and taking appropriate action when changes in the patient s neurological status occur are paramount NS BOX 1 Monitoring neurological observations: important factors Use all parts of the neurological observation chart. Record only what you see. Listen to family members and friends. Report any changes in the patient s condition. Do not be influenced by previous observations. Do not use nail-bed pressure or sternal rubs. References Alcock K, Clancy M, Crouch R (2002) Physiological observations of patients admitted from A&E. Nursing Standard. 16, 34, Crawford B, Guerrero D (2004) Observations: neurological. In Dougherty L, Lister S (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth edition. Blackwell Science, Oxford, Crouch A, Meurier C (Eds) (2005) Vital Notes for Nurses: Health Assessment. Blackwell Publishing, Oxford. Department of Health (2005a) Quality Critical Care: Beyond Comprehensive Critical Care : A Report by the Critical Care Stakeholder Forum. The Stationery Office, London. Department of Health (2005b) The National Service Framework for Long-term Conditions. The Stationery Office, London. Douglas G, Nicol F, Robertson C (Eds) (2005) MacLeod s Clinical Examination. Eleventh edition. Churchill Livingstone, London. Iggulden H (2006) Care of the Neurological Patient. Blackwell Publishing, Oxford. Mooney GP, Comerford DM (2003) Neurological observations. Nursing Times. 99, 17, Morgan RJM, Williams F, Wright MM (1997) An early-warning scoring system for detecting developing critical illness. Clinical Intensive Care. 82, National Institute for Clinical Excellence (2003) Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. Clinical guideline 4. NICE, London. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC, London. Nursing and Midwifery Council (2007) Record Keeping Guidelines. NMC, London. Shah S (1999) Neurological assessment. Nursing Standard. 13, 22, Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness: a practical scale. The Lancet. 2, 7872, Walsh M (Ed) (2006) Nurse Practitioners: Clinical Skills and Professional Issues. Second edition. Butterworth-Heinemann, Edinburgh. Waterhouse C (2005) The Glasgow Coma Scale and other neurological observations. Nursing Standard. 19, 33, Woodrow P (2000) Head injuries: acute care. Nursing Standard. 14, 35, Woodward S (1997a) Neurological observations: 1. Glasgow Coma Scale. Nursing Times. 93, 45, Suppl 1-2. Woodward S (1997b) Neurological observations: 2. Pupil response. Nursing Times. 93, 46, Suppl 1-2. Woodward S (1997c) Neurological observations: 3. Limb responses. Nursing Times. 93, 47, Suppl 1-2. NURSING STANDARD november 14 :: vol 22 no 10 ::