neurological observations

NEUROLOGICAL OBSERVATIONS

Guidelines for assessment

March 2009

Assessment of Neurological Signs. Updated November 2008 Royal Free NHS Trust 1

CONTENTSSection1 Staff who may undertake the procedure2 Introduction3 Coma

3.1 Glasgow Coma Scale3.2 Consciousness Defined3.3 Procedure for using the Coma Scale

3.3.1 Best Eye Opening response3.3.2 Best Verbal Response3.3.3 Best Motor Response3.3.4 Diagrams of Best Motor Responses

4 Vital Signs5 Pupillary assessment6 Motor Function7 References 8 Acknowledgements9 Appendix 1: Royal Free Hospital Conscious Level Chart10 Appendix 2: Royal Free Hospital ICU Guidelines11 Appendix 3: Neurological observation frequency guidance12 Equality impact assessment


Validation Grid

Title of PolicyNeurological Observations – guidelines for assessment

Author/reviewerSean CarrollTrish Dale

Associate authors Hugh Passant

Target Audience All clinical and nursing staff

Commissioning body Clinical practice group

Stakeholders consulted

Clinical practice groupITU nursing and consultant staffNeurosurgeonsDirectorates:Surgery, anaesthetics and critical careClinical haematology, oncology & private practiceHepatology. Nephrology and transplantationNeurosciencesWomen’s and children’sRNTNE, ENT, audiology and ophthalmology

Clinical practice or Advanced practice

Clinical practice

Associated policies/guidelinesRFH guidelines for performing neurological observations in ITU

Are guidelines replacing existing guideline/policy

Yes, May 2004 version

Date of submission March 2009

Review Date March 2011

Key WordsGlasgow coma scale; consciousness; papillary assessment; motor function; vital signs


1. Staff who may undertake the procedureWithin this Trust carrying out assessment of neurological signs is regarded as a clinical practice. A clinical practice may be defined as an aspect of care which may be undertaken by registered nurses/midwives who accept accountability for their actions and feel competent to undertake the procedure. There is no formal assessment for these practices but they may be aspects of care which require a period of supervised, guided practice. They should form part of preceptorship or mentorship programmes.

Student nurses/midwives may undertake this practice under the supervision of a registered nurse/midwife who feels competent in this aspect of care and in the supervisory role.

Health care assistants should not carry out this practice

In line with guidelines laid down by the NMC (27), you must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been. You must also complete records as soon as possible after an event has occurred (The code NMC 2008)

2. IntroductionNurses carry out neurological assessment for a number of reasons:

As part of initial assessment to determine if the patient has a neurological problem

To establish a baseline assessment To determine changes in the patient’s neurological condition To detect life threatening situations which require medical

intervention (6, 16)

A comprehensive neurological assessment includes: Level of consciousness Pupillary reaction Vital signs Motor function Sensation Cranial nerves

Medical staff and nurses working in neuroscience specialist areas use this full assessment.

Nurses more commonly use an abbreviated assessment which includes critical components that are sensitive to change. This assessment includes:

Level of consciousness Vital signs Pupillary signs Motor function

This abbreviated assessment will be the focus of these guidelines. Vital signs must also be assessed at the same time as assessing the patient’s Coma Scale, pupillary response and motor function. The medical staff should provide information about the changes which are of significance to a patient's condition. The medical staff should be informed of any changes in the patient's condition


The frequency of assessment will vary depending on the stage of the patient’s illness. This should be discussed with the nursing and medical team. A set of observations should always take place during the nursing handover to ensure consistency of results (See appendix for further guidance)

EARLY WARNING CRITERIAThe Early Warning System criteria has been added to the `Royal Free Hospital Conscious level chart` (15), on the front and back of the chart. If the patient triggers any of these signs or symptoms bleep the Patient at Risk Team and the patient’s own medical team immediately.

Documentation of neurological signs should be made on the ‘Royal Free Hospital Conscious level chart’ (15).

Structural lesions of the CNS are not always the cause of a decreased level of consciousness. Altered consciousness may be attributable to metabolic causes and systemic disease (Table 1).

TABLE 1: DIFFERENTIAL DIAGNOSIS IN COMACause Examples

Abnormal serum levels

Hypoglycaemia or vitamin deficiency.

Diseases of organs excluding the brain

Non-endocrine organs:Kidneys - uraemic comaLiver - hepatic comaLungs - carbon dioxide narcosisPancreas - exocrine pancreatic encephalopathyEndocrine organs that are hypo or hyper-functioning:Thyroid - myxoedema or thyrotoxicosisParathyroid - hypoparathyroidism, hyperparathyroidism.Adrenals - Addison's disease, Cushing's

syndrome, phaeochromocytomaPancreas - diabetes mellitus

Pharmacological agents

Sedatives - barbiturates, opiates etcAcidic toxins - paraldehyde etcPsychotropic drugs - amphetamines, tricyclic

antidepressants, etcOther drugs - e.g. steroids, cyclosporin, etc

Electrolyte and acid-base imbalance

E.g. Hyper/Hyponatraemia

Other causes Sepsis


3.Coma Scale

3.1.Glasgow Coma Scale (GCS)Teasdale & Jennet (19) developed the GCS in attempting to standardise observations for the objective and accurate assessment of level of consciousness. Three indicators of consciousness make up the Coma Scale; eye opening, best motor response and best verbal response. Originally designed as a surveillance tool with 14 criteria, a score was later incorporated for the purpose of a research trial amongst a population of head injured patients (10). The scoring system became 15 when the strongest predictor of outcome best motor response was allocated a score of 6 on the basis of its strength (10). The scoring system is unreliable in the eye opening and verbal response categories with the most reliable predictor of outcome being the best motor response (7, 22-26). The Coma Scale utilised on the RFH Conscious Level Chart does not include the scoring system but includes the 15 point criteria. (See Appendix 1 Neurological Observation Chart).

The tool has been shown to be reliable when used by experienced users (1, 21, 8, 4, 2, 17, 18, and 7). However, research has shown that inexperienced users made consistent and substantial errors (3, 8, and 14). The importance of accurate assessment and reporting of appropriate information is essential. Therefore written guidelines and education are recommended for all users of the GCS (12).

3.2.Consciousness DefinedConsciousness requires communication between the cerebral hemispheres and the brain stem (11). It involves the patient’s interaction with the environment, including awareness of various stimuli (e.g. speech, pain) and acting in response to the stimuli (6).

3.3.Procedure for Using the Coma ScalePrior to administration of the Coma Scale, the patient should be screened for pharmacological sedation and / or paralysis, spinal cord injury and language barriers. Firstly the Coma Scale cannot be used in a heavily sedated or paralysed patient due to the patient’s inability to respond to stimuli. (See Appendix 2: Guidelines on Performing Neurological Observations within Intensive Care.) In this situation deterioration is recognised by changes in pupillary reflex and vital signs.

Secondly the spinal cord injured patient needs to be carefully assessed prior to applying painful stimulus peripherally. If spinal cord injury is suspected as complete, incomplete or injury above the fifth cervical vertebrae then the medical staff should be consulted to determine if application of painful stimuli is appropriate. Care should be taken to ensure that a language barrier is not compromising the assessment. Patients, who are unable to understand a language may fail to comprehend your instruction, give an inappropriate response or remain silent (6).


3.3.1 BEST EYE-OPENING RESPONSEAssessment of eye opening shows that arousal mechanisms located in the brain stem are functioning

ACTIVITY RESPONSE RATIONALE

OPENS EYES SPONTANEOUSLY

• Eyes open without any stimulation from the nurse i.e. without speaking to the patient or touching him. Therefore, this response may be observed from the end of the bed or on approaching the patient's bedside.

• If the patient is unable to open an eye due to swelling, nerve palsy or eye dressing, document a ‘C’ in the ‘None’ box to denote closed.

• If the eyes are open and no blinking is apparent gently close the eyes and observe if they open.

• When the patient's eyes open spontaneously they may be considered to be awake & this will usually be associated with an aroused EEG pattern. However, awake indicates brainstem function but not necessarily cerebral cortical function. Reduced responsive states e.g. Persistent Vegetative State, Locked in Syndrome, should be distinguished from coma (6).

• Voluntary opening of the eyes will determine eye opening and intact brain stem function.

EYES OPEN TO VERBAL STIMULI

• If the patient's eyes do not open spontaneously, verbally stimulate the patient and note the response.

• Initially approach the patient in a normal voice, without any physical stimulation. At this point greeting the patient or introducing yourself may elicit a response.

• If not, proceed to directly and clearly asking the patient to open their eyes.

• If this is still insufficient, raise your voice and clearly ask the patient to open their eyes.

• To determine the patients response to stimuli.


3.3.1 BEST EYE-OPENING RESPONSE CONTINUEDAssessment of eye opening shows that arousal mechanisms located in the brain stem are functioning


EYES OPEN TO PAIN

• If there is no response from verbal stimulation, apply painful stimuli to the patient. Initially this should constitute some form of physical contact as opposed to actual pain. For example, touching the patient's hand or shoulder or gently shaking them.

• If there is still no response, deeper stimulus is required. Central stimulus using a trapezius pinch is all that is required at this stage in the assessment.

• If the patient does not respond to central stimulus then peripheral stimulus should be applied gradually to the side of the patient’s finger (see diagram 6 page 15) and withdrawn as soon as a response is noted. Care should be taken not to apply too much pressure to avoid tissue injury, e.g. bruising.

• Tactile stimulation follows a continuum of stimulation from light physical contact to pain (19).

• Using central painful stimulus e.g. Trapezius Pinch.

• Supraorbital pressure as a painful stimulus is not recommended as this may make the patient grimace and close their eyes (5).

NONE • Failure to open eyes regardless of the stimuli.

• May indicate injury to the oculomotor nerve or brain stem.


3.3.2 BEST VERBAL RESPONSEAssesses consciousness by determining whether a person is aware of themselves and the environment. It involves assessment of the cognitive aspect of consciousness.


MAKES ORIENTATED

SPEECH

• This category describes a person who is able to identify time, place and person. The following questions are used:

1. What is your name?

2. Where are you? (hospital & town)

3. What day of the week, date and year is it today?

• If ALL 3 questions are answered correctly (allowing for explainable error) then the patient is said to be orientated, even if other aspects of his conversation are inappropriate (5, 16).

• Incorrectly answered questions should be corrected at the end of each answer.

The order of the questions may be varied, but these 3 clear and simple questions are sufficient to provide a consistent and objective method of grading orientation.

• May help to orientate the patient.

MAKES CONFUSED

SPEECH

• At this level the patient is able to formulate sentences. They may also have a good attention span and may be able to engage in conversation. However, if the person answers one or more of the above questions incorrectly (allowing for explainable error) the response is recorded as confused.

• Clarity and consistency in assessment are paramount.


3.3.2 BEST VERBAL RESPONSE CONTINUDED Assesses consciousness by determining whether a person is aware of themselves and the environment. It involves assessment of the cognitive aspect of consciousness.


INAPPROPRIATE WORDS

• Differentiating between inappropriate words, confusion and mood i.e. anger can be difficult. The following help clarify this category:

o Conversational exchange is absent.

o There is a tendency to use words rather than sentences.

o Replies are often elicited following physical stimulation, i.e. painful stimuli rather than verbal.

o Associated with repetition of words / phrases or consistent loss of attention (5).

• Sets criteria for differentiation between the five categories.

INCOMPREHENSIBLE SOUNDS

• The person responds to verbal or painful stimuli with sounds rather than words. Examples may be groaning, mumbling, or screaming. These sounds may occur spontaneously or as a response to stimuli. These must not be confused with sounds associated with breathing e.g. snoring.

• Sets criteria for differentiation between the five categories.

NONE • No sounds at all are made by the patient in response to either verbal or painful stimuli.

• If the patient is unable to make any sounds due to the presence of an Endotracheal or Tracheostomy tube a 'T' should be place in the 'None' box.


3.3.3 BEST MOTOR RESPONSEAssess communication between the brain stem amd cerebral hemispheres, in interpreting environmental stimuli

ACTIVITY RESPONSE RATIONALEObeys commands • The best possible motor

response is being able to obey simple commands convincingly.

• Some recommended commands are:

o Put out your tongueo Move your toeso Lift up your arms (5)o Close your eyes

• The patient should be able to obey 2 different commands per assessment. These commands should be asked one at a time. One should assess peripheral motor function and another central function.For example stick our tongue and move your toes

• Consciousness is regained when a patient is consistently obeying commands (20)

• Asking patients to squeeze the assessors hands may result in a false response i.e. primitive reflex Using & varying the commands is a more reliable way of ascertaining whether the patient is aware of their environment and understands the instructions (5)

• Often central and peripheral muscle groups are affected differently. For example the patient may put out their tongue and shrug their shoulders but not move their arms and fingers

• Sets criteria for assessing best motor response

LOCALISING ARM TO PAIN

• If the patient does not obey commands a central pain stimulus should be applied. Painful stimulus is applied momentarily without any residual effects

• Localising to pain denotes intact sensory system, motor system and cortical processing. Peripheral stimulus (Diagram 6,page 15) any involve a spinal reflex and does


3.3.3 BEST MOTOR RESPONSE CONTINUEDAssesses communication between the brain stem and cerebral hemispheres, in interpreting environmental stimuli.


LOCALISING ARM TO PAIN (CONT)

• Localising to pain is said to occur when a patient raises their hand at least to chin level. (Diagram 1, page 12), in a response to painful stimuli above that level, i.e.Trapezius Pinch or Supraorbital Ridge pressure, (Diagram 2, page12)

• Involve cerebral function.

• Central painful stimulus (Diagram 1, page 12) is more accurate in ascertaining if the localising to the pain (5). This category should not be confused with flexing of arm as a reflex action. This is why the arm should reach at least the level of the chin and possibly try to remove the stimulus itself.

Recommended methods of applying central painful stimuli are:• Trapezius Pinch

Expose the shoulder and grossly pinch the trapezius muscle. Gradually increase the pressure until the best response is seen or maximum effort is used. Care should be taken when administering the trapezius pinch. With the painful stimulus at shoulder level the patient may reach for the shoulder and not achieve the chin level benchmark required for localising. When in doubt use a central stimulus above chin level. Continually squeezing of the trapezius muscle or applying supraorbital pressure can cause tissue damage.

• Supraorbital Ridge PressureThe nurse’s hand is rested on the head and the falt of her thumb placed on the supraorbital ridge or eyebrow. Pressure is gradually increased until the best response is gained or no further effort is possible

• Methods not to be used:o Sternal rubbing. Soft tissue in the sternal area bruises easily in most people

(6,13)o Twisting of nipples is NOT to be performed as it is undignifiedo Supraorbital orbital ridge pressure should not be used if there is damage to

the orbital structure or local facial/skull fractures.


3.3.3 BEST MOTOR RESPONSE CONTINUEDAssess communication between the brain stem and cerebral hemispheres in interpreting environmental stimuli.


ARM FLEXION TO PAIN

• If the patient does not obey

commands and fails to respond to central pain, peripheral pain stimulus (see eye opening to pain) should be applied. The response to stimuli should be observed in the arms not the legs. Both arms are assessed and the best response documented

• Flexion/Abnormal Flexion There are two types of flexion in the motor response of the 15-point coma scale. Correct interpretation is vital when assessing the patient (3)

• FlexionFlexion at the elbow in response to central pain. (Diagram 3, page 14)

• Motor response should be assessed using the `best arm response`, as a response in the legs is both inconsistent and inaccurate and may only be a spinal reflex. By assessing the upper limbs this category is easier to distinguish and a more reliable response is obtained. (16) Flexion may indicate cerebral damage and an interruption of Corticospinal pathways from the brain’s cortex. e.g. hemispherical or brainstem lesion

ARM ABNORMAL FLEXION TO PAIN

• An abnormal flexion of the elbow and wrist (Diagram 4, Page 14)

• Abnormal flexion may indicate severe damage to the cerebral cortex

EXTENSION TO PAIN

• Straightening of the elbow joint in response to central pain (Diagram 5, page 15)

• Abnormal response that emanates from the brain stem. Information cannot be sent to and from the cerebrum due to the damaged midbrain and pons

NONE • There is no response following application of central or peripheral painful stimuli

• Absence of motor response may be due to paralysis from a high cervical spine injury or inadequate reversal of chemical muscular paralysis. The longer this state persists the poorer the outcome

DIAGRAMS OF BEST MOTOR RESPONSE


DIAGRAM OF APPLYING PERIPHERAL PAINFUL STIMULI


3. Flexing to pain using trapezius pinch

4. Abnormal flexing to pain using trapezius pinch

1. Localising to pain using central stimulus- trapezius pinch

5. Extending to pain using trapezius pinch

2. Localising to pain using central stimulus - Supra orbital ridge pressure

6. Peripheral

NBUse a syringe to apply painful stimuli to reduce risk of cross infection in isolation rooms

Clean pens after use to reduce risk of cross infection

4. Vital SignsIt is important to remember that neurological function is dependent on adequate temperature, pulse, respiratory function and blood pressure. During periods of raised intracranial pressure this relationship is even more important. Therefore the patient’s vital signs must be recorded at the same time as Coma Scale, pupillary response and limb assessment. Abnormalities in vital signs should be reported to the medical staff in conjunction with other neurological parameters, be they normal or abnormal.

Control centres for blood pressure, heart rate & respiration are situated in the brain stem, and the temperature control centre situated in the midbrain. Any pressure that builds up inside the brain will eventually effect these control centres.

When brain herniation occurs in an acute period of raised intracranial pressure this indicates that all the adaptive mechanisms for accommodating intracranial pressure have been exhausted. The following changes are late signs and should not be relied upon to anticipate changes in neurological status. If any alteration in vital signs outside normal parameters does occur then they should be reported to medical staff.

• Blood pressure will rise in an attempt to perfuse the brain. As intracranial pressure (ICP) rises the brain becomes hypoxic and ischaemic.

• Heart rate will usually fall although tachycardia and arrhythmias may be seen in some cases.

• Respiratory rate will fall and become deep and irregular when ICP rises causing pressure on brain stem

• Body Temperature will become high if the temperature control centre is compressed or damaged.

5. Pupillary assessmentCompression of the oculomotor (3rd cranial) nerve caused by rising intracranial pressure will cause changes in pupillary response. This is a late sign of rising pressure, and indicates a very emergent situation of impeding irreversible brain damage. Only significant changes in size, response and equality are recorded. It should be noted that the shape of pupils is an unreliable indicator of deterioration. Shape can be altered by previous surgery, infections, trauma and pre existing congenital conditions.

Assessment Criteria

Normal Abnormalities Action

SizeLook at the size of pupils before direct light is applied

Normally 2-6 mm in diameter

Dilated or pinpoint pupils may suggest abnormality

NB some drugs effect pupil size –atropine dilates,

Document on chart

Report any abnormal


morphine constricts changes immediately

EqualityCompare the size of the pupils

Pupils should be equal in size

Dilated pupils occur when intracranial pressure rises. This will usually be seen first in the pupil on the side of injury

Document on chart

Report any abnormal changes immediately

Reaction to lightUsing a light of pen torch strength, dim the lighting if necessary and whilst viewing the pupil gradually expose the pupil to light

Each pupil should constrict as the light is directed momentarily into the eye

Non reactive pupils suggest compression of the oculomotor nerve due to rising intracranial pressure.

Document on chart Reacts: +No reaction: -

Report any abnormal changes immediately

6. Motor FunctionChanges in motor function can provide vital information about a developing hemiparesis which can result from increasing intracranial pressure due to a expanding lesion, such as a extradural haematoma or post operation brain swelling (16).

Upper Limbs• Conscious patient

Hold the patient’s hands and ask him/her to push you away, or pull you towards him/her. Whilst the patient is pulling apply some resistance. The movement should be assessed for power and equality and documented using the categories below. Test the proximal and distal part of the limb. If part of a limb is weak then this should be recorded as a weakness.

If you are unsure of the equality, assess for pronator drift which is a more sensitive technique (6). Ask the patients to extend both arms palms up in front of him and close his/her eyes; the weaker arm will pronate (rotate palm downwards) and drift to downwards within 30 seconds.

• Unconscious patientApply central stimuli (see Coma Scale motor response – localizing to pain). Record the response. If no response occurs apply peripheral stimuli (see eyes open to pain). Document using the categories below (6,16).


Lower Limbs• Conscious patient

Place resistance on the patient’s knees and ask the patient to lift their knees up whilst assessing the power against resistance and differences between each limb. Document using categories below

• Unconscious patient Apply central painful stimuli. Assess response. If no response occurs, apply peripheral painful stimuli. Document using categories below. Please note the sensitivity of the legs to flexion in response to painful stimulus is a normal response and not of pathological significance. Therefore it is not included in the assessment of the lower leg.

• Categories for assessment of motor function (6, 16)

Normal power Ability to match resistance applied by the assessor allowing for age and build

Mild weaknessAbility to move the limb against resistance but is easy overcome

Severe Weakness Patient is unable to move the limb against resistance.

Flexion (Not for the lower limb)

See diagram 3

Abnormal flexion See diagram 4Extension See diagram 5No response

Document right (R) and left (L) separately.


7. References

1. Addison C; Crawford B. 1999 Not bad, just misunderstood. (Arguments for retaining the Glasgow coma scale rather than replacing with Lowry Coma Record). Nursing Times, 95:43:52-3

2. Crosby L; Parson L.C. 1989 Clinical neurological assessment tool: development and testing an instrument to index neurological status. Heart and Lung 18 (2): 121-129

3. Ellis A, Cavanagh S. 1992 Aspects of Neurosurgical assessment using the Glasgow Coma Scale, Intensive and Critical care Nursing, 8: 94-99

4. Feilding K; Rowley G. 1990. Reliability of assessments by skilled observers using the Glasgow coma scale. Australian journal of advanced nursing, 7:4:13-17.

5. Frawley P. 1990 Neurological Observations. Nursing Times August 29, Vol. 86, No35, 29-34.

6. Hickey J. 1997 The Clinical Practice of Neurological and Neurosurgical Nursing 4th Edition. JB Lippincott, Philadelphia

7. Jagger J; Jane J.A; Rimel R. 1983 The Glasgow Coma Scale: to sum or not to sum? Lancet 2: 1: 97

8. Janosik M, Fought S. 1992 The Glasgow Coma Scale: observer variability and correctness of scores, Heart & Lung, 21(3): 291

9. Janosik M; Fought, S. 1992. The Glasgow coma scale: observer variability and correctness of scores. Heart and Lung: Journal of critical care. 21:3:291.

10.Jennet B; Teasdale G. 1974 Assessment of coma and impaired consciousness, Lancet, 2:81-84

11. Lindsay and Bone 1997 Neurology and Neurosurgery Illustrated; Harcourt Brace, Edinburgh.

12.Macrina D; Macrina N; Horvath C; Gallapsy J; Fine P. R. 1996 An educational intervention to increase use of the Glasgow coma scale by Emergency department personnel. International journal of trauma nursing, 2:1:7-12.

13.Proehl J.A. 1992 The Glasgow coma scale: Do it and do it right. Journal of Emergency Nursing. Vol. 18, No. 5, October.

14.Rowley G; Fielding K. 1991Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced user, Lancet, 337: 535-38

15.Royal Free Hospital Conscious level chart. RF65A. HHA 567.16. Shah S. 1999 Neurological assessment; Nursing Standard. February 17,

Vol. 13, No. 22, 49-54.17. Stanczak D.E; White III J.G; Gouview W.D; Moehle K.A; Daniel M. Novack

T; Long C.J. (1984) Assessment of loss of consciousness following severe neurological insult. Journal of Neurosurgery. 60: 955-960

18. Sugiura K; Muracka K; Chishiki T; Baba M. (1983) The Edinburgh 2 Coma Scale: a new scale for assessing impaired consciousness. Neurosurgery.


12: 411-41519.Teasdale G; Jennet B. 1976 Assessment and prognosis of coma after

head injury. Acta Neurochir. 34, 45-55.20.Watson M; Horn S; Curl J. 1992 Searching for signs of revival: Uses and

abuses of the Glasgow coma scale. Professional Nurse July, 670-674.21.Way C; Segatore M. 1994 Development and preliminary testing of the

neurological assessment instrument. Journal of Neuroscience Nursing. 26: 5: 278-287

22. Zafonte R. D; Hammond F. M; Mann N. R; Wood D. L; Black K. L; Millis S. R. 1996. Relationship between Glasgow coma scale and functional outcome. American journal of physical medicine and rehabilitation, 75:5:364-369, 380-383.

23. Meredith W; Rutledge R; Fakhry S. M; Emery S; Kromhout-Schiro S. 1998. The conundrum of the Glasgow coma scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. Journal of trauma, injury, infection and critical care, 44:5:839-845.

24. Ross S.E; Leipold C; Terregino C; O’Malley K. F. 1998 Efficacy of the motor component of the Glasgow coma scale in trauma triage. Journal of trauma – injury infection and critical care, 45:1:42-44.

25. Cifu D.X; Keyser-Marcus, L; Lopez E; Wehman P; Kreutzer J.S; Englander J; High W. 1997.Acute predictors of successful return to work 1 year after traumatic brain injury: a multi-centre analysis. Archives of physical medicine and rehabilitation, 78:2:125-131.

26. Buechler C. M; Blostein P. A; Koestner A; Hurt, K; Schaars M; McKernan J. 1998. Variation amongst trauma centres calculation of Glasgow coma scale score: results of a national survey. Journal of trauma, injury, infection and critical care, 45:3:429-32

27. The code 2008 nursing and midwifery Council NMC London

8. Acknowledgements:Contributors and designers of first draft: Jane Nicholson PDN and Sally Dootson CNMReviewed by: Staff on Thorne and King Edward ward, Mr Colin Shieff and Mr Neil Dorward Consultant NeurosurgeonsCoordinated by: Mark Clements PDN

Reviewed and Updated: January 2004By Sean Carroll Senior Charge Nurse ITU Eileen Roberts Practice Development Nurse Clinical Neurosciences.

Reviewed and updated: June 2008By Sean Carroll Senior Charge Nurse ITU Trisha Dale Matron NeurosciencesHugh Passant Practice Education Nurse, Neurosciences.


9. Appendix 1: Royal Free Hospital Conscious Level Chart


10. Appendix 2: Royal Free ITU Guidelines


The Royal Free Hampstead NHS Trust - Intensive Care Unit (ICU)

Guideline on performing neurological observations within the Intensive care area

The purpose of this guideline is to ensure that neurological observations are carried out appropriately and do not cause unnecessary harm or suffering to patients. Any concerns as to the requirements of a patient's need for neurological observation should always be discussed with the neurosurgical team or the ICU nurse in charge/registrar.

This guidance document should be read in conjunction with the Trust's document Neurological Observations; guidelines for assessment (November 2008).

Neurological observations are important aspects of the critical care nurse's role. Observation methods include assessment of the:

• Glasgow Coma Scale (GCS)• Pupillary reaction • Limb responses

The combination of all these methods allows the nurse to detect deterioration in the patient's neurological status and to take appropriate action. However, in certain circumstances assessing the GCS and limb movement is inappropriate. Even where this is so, monitoring the pupil response is always appropriate and should always be assessed.

1. Patients receiving sedative or neuromuscular blocking agentsPatients who are sedated and paralysed should NOT have their GCS or limb assessment performed1. An accurate reflection of the patient's neurological status cannot be obtained when receiving either:

• Sedation agents, as they cause a depression of the central nervous system2. • Neuromuscular blocking agents (NMBAs) as they create a block at the

synaptic junction of the neurone preventing impulses passing from nerves to muscles3. Therefore, the patient is totally unable to respond to command or pain.

This includes: Patients receiving sedatives or NMBAs with known/suspected elevated ICP.

In addition to the above contraindications, painful stimuli may increase intracranial pressure (ICP) 5. The pupil responses should always be assessed.

Patients receiving sedatives or NMBAs with an known/suspected elevated ICP undergoing hyperventilation to maintain their ICP below a set level should also not have GCS or limb assessment performed. Hyperventilation, i.e. low pCO2, causes reduced cerebral blood flow to the brain6, if painful stimuli were then applied it may result in an increased ICP7 and blood flow to the cerebral tissue would be further compromised. The pupil responses must always be assessed.

THE PUPIL RESPONSE MUST ALWAYS BE ASSESSED


2. Monitoring pupillary responsesSedative agents or NMBAs do not influence abnormalities (in size, equality, reaction to light) of pupils caused by raised intracranial pressure. Therefore, assessing pupillary response should always be carried out even when GCS and limb assessment are contraindicated.

3. ICU patients who should have a GCS score and limb movement assessment include: Patients who are being woken up after a period of sedation. This group of

patients must have full neurological observations performed, i.e. GCS, limb assessment and pupillary reactions. It is important to assess the patient once the sedation is reduced1 to establish their neurological status. An accurate reflection of the patient's neurological status can only be obtained once sedative agents have been withdrawn.

4. Frequency of Neurological ObservationThere is little evidence to guide the frequency of performing neurological observations9. The purpose of carrying out neurological observations is to monitor the patient’s condition. Therefore, the frequency of neurological observations should depend on the individual patient's status10. For example, acute neurological changes in the patient's condition are frequently seen during the first 72 hours following neurosurgery. Hence the need for intense monitoring of this group during the post-operative period. Below are examples illustrating the need to use clinical judgement when deciding on the frequency of carrying out neurological assessment:

Following admission of a patient who has sustained an acute neurological injury, ½ hourly observations should be carried out for the first 6 hours. Then the need for frequency should be reviewed. If the patient is stable, 1-hourly observations should be carried out for a minimum of 6 hours, then reviewed.

Following the postoperative admission of a patient who has undergone neurosurgey ½ hourly observations should be carried out for the first 6 hours. Then the need for frequency should be reviewed. If the patient is stable, 1-hourly observations should be carried out for a minimum of 12 hours, then reviewed.

5. Neuromuscular conditionsPatients with neurological conditions causing neuromuscular weakness, e.g. Guillain-Barré syndrome or Myasthenia Gravis, must have a full neurological assessment performed once a day. More frequent assessment is not necessary, as neurological conditions are often degenerative8, consequently deterioration and improvements in neurological status occur over long periods of time.

THE PUPIL RESPONSE MUST ALWAYS BE ASSESSED


References1. Mass AIR, et al (1997) European Brain Injury Consortium - Guidelines for

Management of Severe Head Injury. Acta Neurochir (wien) 139:286-292. Menon DK (1997) Monitoring the central nervous system. Current anaesthesia

and Critical Care, 8:254-263.3. British medical Association and Royal Pharmaceutical Society (2001) British

National Formulary 42: September 2001.4. Hickey J. (1997) Clinical Practice Neurosurgical / Neuromedical Nursing. J.B.

Lippincott, UK.5. Geraci E. (1996) A look at recent hyperventilation studies. Journal of

Neuroscience Nursing, 28:4 : 222-233.6. Matta B. (1997) Monitoring the Central Nervous System. Current Anaesthesia

and Critical Care, 8: 254-263.7. Lindsay K> (et al (1994) Neurology and Neurosurgery Illustrated. Churchill

Livingston, UK.8. McMahon-Parkes, et al (1997) Guillain-Barré syndrome: basis , treatment and

care. Intensive and Critical Care Nursing, 13: 42-48.9. Price T. (2002) Painful stimuli and the Glasgow Coma Scale. Nursing in Critical

Care, 17 (1): 19-2310. Addison C., Crawford B. (1999) Not bad, just misunderstood. Nursing Times,

95:52-53

This guideline has been agreed with the following:

Dr Shaw Lead Consultant Critical CareSean Carroll Senior Charge Nurse, Critical CareCarol Ball Nurse Consultant critical careAndrew Roche Practice Development Nurse, Critical CareTracy Pearse Practice Development Nurse, Critical care

Mr N Dorwood Consultant NeurosurgeonMr C Shieff Consultant NeurosurgeonMr L Thorne Consultant Neurosurgeon

Implementation date: November 2008 Review date: November 2010


Appendix 3 Neurological observation frequency guidanceThis is intended only to provide a reference guide for a variety of conditions and operations. If you have concerns about a patients condition you must make a referral to another practitioner when it is in the best interests of your patient (NMC the code 2008) and also use your discretion regarding increasing the frequency of observations you carry out. These time frames are a required minimum for patient’s safety. Unless otherwise stated full neurological observations should to be performed.

Subarachnoid Haemorrhage

2 hourly full neurological observations until operation Patient to be on flat bed rest Minimum of 3 litres of fluid every 24 hours

Embolisation of an aneurysm

½ hourly observations for 4 hourshourly observations for 6 hours2 hourly observations for 12 hours 4 hourly observations until dischargePedal pulses and groin wound checks to carried out at the same time for the first 24 hours post surgery. Patient must remain on bed rest until told to mobilise by medical staff and continue with 3 litres of fluid every 24 hours.

Craniotomy and clipping of an aneurysm

½ hourly observations for 6 hourshourly observations for 6 hours 2 hourly observations for 12 hours4 hourly observations until discharge or reduction agreed by Medical and Senior Nursing Staff due to stable conditionAll patients are to remain on bed rest until told to mobilise by medical staff To have 3 litres of fluid/day post surgery.

Acute and Chronic Subdural Haematomas

1/2hourly full neurological observations for acute subdural and 2 hourly full neurological observations for chronic subdural haematoma prior to surgery.

Post surgery, ½ hourly observations for 6 hours, hourly observations for 6 hours, 2 hourly observations for 12 hours, if patient’s condition stable. 4 hourly observations until reduced by doctors or senior nursing staff. If any deterioration return to 2 hourly observations and contact doctors. Consult with doctors before mobilising.

Head Injury (post ITU)

2 hourly full neurological observations for 24 hours 4 hourly observations until discharge or condition stabilised and permission to reduce observation given by Medical or Senior Nursing Staff

Hydrocephalus: Pre surgery ½ hourly to hourly full neurological observations depending on GCS on admission. For post surgery care, see EVD or VPS depending on treatment.


External Ventricular Drain (EVD)

Post surgery ½ hourly observations for 6 hours hourly observations for 6 hours 2 hourly observations until drain removedDrain to be emptied every hour Maintain bed rest unless the doctors allow patient to mobilise

Ventricular Peritoneal Shunt (VPS)

Same observations as acute/chronic subdural haematoma post operative care

Cerebral Space Occupying Lesions (SOLs)

Twice daily full neurological observations until surgery, unless neurologically impaired If neurologically impaired maintain 4 hourly observationsPost surgery see acute/chronic subdural haematoma post operative care

Pituitary SOL’S Pre surgery patients can be on twice daily full neurological observationsPost surgery, see acute/chronic subdural haematoma post operative care. Post surgery maintain a strict fluid balance chart record specific gravity and urine volume every time the patient passes urineIf catheterised empty catheter every 2 hours, check specific gravity, urine volume and record on fluid chart.If excess bleeding from nose which cannot be dried with a tissue, use a nasal bolster. Check nasal bolsters are worn correctly and changes recorded if in use.Check and immediately report if patient has any salty fluid trickling down their throat

Anterior Cervical Discectomy

Twice daily full neurological observations until operationPost surgery ½ hourly neurological observations for 4 hourshourly observations for 6 hours2 hourly observations for 10 hours4 hourly observations until dischargeObserve wound site for signs of swelling report occurrenceCheck and report any new swallowing or breathing problemsIf any concerns, contact doctors immediately

Spinal Laminectomies

Post surgery ½ hourly observations for 2 hourshourly observations for 4 hours2 hourly observations for 8 hours 4 hourly observations until dischargeEach level of spine needs different assessments as well as routine observations:Upper Cervical Spine (C1-4):

Full neurological and limb assessments


Lower Cervical Spine (C5-8): Full limb assessment

Thoracic Spine (T1-12): Full limb assessment

Lumbar Spine (L1-5): Lower limb assessment

Sacral Spine (S1-5): Lower limb assessment

All spinal surgery patients to have regular laxatives and daily recording of bowel movements. If patient has a CSF leak or opening of the Dura full neurological observations need to be performed.

Cauda Equina Syndrome (L1-S5):

Lower limb assessmentsBowel assessment Patient should be catheterised to prevent further complicationsIf bowels not opened on their regular cycle will need to start Stanmore Bowel Regime

Lumbar Drains: Post surgery treat as spinal mounted EVD for observationsThe drain to be in line with the top of the mattress when lying down or turned off when mobilising.


Full Equality Impact Assessment Matrix

Name of policy/serviceNeurological observations guidelines for assessment

Name of Manager responsible for completing impact assessment Hugh PassantIs this a new policy/service or a review of an existing policy/service? ReviewWhat is the purpose of the policy/service? To provide guidance for staff for the safe and effective

assessment of neurological observationsWho is intended to benefit from the policy and in what way?

Staff and patients

Date commenced March 2009 Date completed March 2009Policy/service review date March 2011Using the matrix below, review the policy/service under consideration, in relation to the six equality strands, for differential impact upon service users or trust staff and identify what these might be:Group (highlight relevant groups)

Age Race/ethnicity Gender Disability Religion/belief Sexual orientation

1.Is there any evidence that groups have different needs, experiences or priorities in relation to this policy and if so, what?

Guidance is for Adults Appropriate communication should be employed to ensure consent and understanding is gained.

Appropriate communication should be employed to ensure consent and understanding is gained. The trust has a robust interpreting service, enabling patients to access information in different languages.Language and communication requirements are routinely recorded in the nursing documentation

No evidence seen Appropriate communication should be employed to ensure consent and understanding is gained. Language, communication and comprehension requirements are routinely recorded in the nursing documentation

No evidence seen No evidence seen

2. The policy promotes The policy promotes The policy promotes The policy promotes The policy promotes The policy promotes


Is the any evidence/ concern that this proposal could result in a qualitative or quantitative differences in impact on any group and if so what?

principles of good care and safety for all groups






3. Does the proposal promote equality of opportunity/ access/good relations within the organisation and the wider community and how is this evidenced?

The policy promotes equality of access and opportunity for all groups






4.Who are the key stakeholders in relation to this policy and how are they being consulted?

Clinical practice group, clinical directorates and ITU.






5.Are there any concerns that the policy/service development could have a differential impact on any group(s) and how might this be evidenced?

The guideline promotes equality of opportunity and access for all groupsThis guideline promotes best practice based on the available evidence






6.Do you anticipate any areas where there may be inconsistencies in application and are there alternative arrangements that could

No evidence of inconsistencies found



ITU additional guidance in the appendix




reduce/eliminate impact?

Using the information from the matrix complete the following action plan:

Area of concern Groups likely to experience differential

Action planned to minimise discrimination/promote equality of access

Monitoring arrangements Review date

1. Provision of accessible information for patients and

staff

Patients and staff with a disability the impacts on vision or comprehensionPatients and staff for whom English is not the first languagePatients and staff who are unable to or have difficulty with reading

Staff to read and explain the guidance to patients, carers and colleagues as requiredInterpreting service to be accessed through the PALS team as required

Audit of referrals to PALS for interpreting services

April 2010

Name/signature of manager completing assessment Hugh PassantDate assessment sent to Equality and Diversity Manager March 2009Name/signature of Equality and Diversity Manager Jenny KenwardDate of publication of Impact assessment April 2009


neurological observations

Documents

guidelines assessment

pupillary assessment

baseline assessment

initial assessment

formal assessment

guided practice

neurological problem

aspect of care