art & science clinical skills: 25

Monitoring and recording patients'neurological observationsDawes E e* af (2007) Monitoring and recording patients' neurological observations. Nursitig Statidard.22.10, 40-45. Date of acceptance: July 17 2007

SumniaryThis article provides a detailed account of how to monitor andrecord neurological observations. It outlines the importance ofneurological observations in acutely ill patients and focuses oncarrying out observations using the Glasgow Coma Scale.

AuthorsEmma Dawes is practice development nurse, Hilary Lloyd isprincipal lecturer, Lesley Durham is nurse consultant in critical care,Sunderland Royal Hospital, Sunderland.Email: emma.dawesCcDchs.northy.nhs.uk

KeywordsClinical skills; Neurological observations; Vital signs

These keywords are based on the subject headings from the BritishNursing Index. This article has been subject to double-blind review.Eor author and research article guidelines visit the Nursing Standardhome page at www.nurstng-standard.co.uk. For related articlesvisit our online archive and search using the keywords.

THE IMPORTANCE of iinderukingneurological observations in acutely ill patientscannot be overstressed. Neurological statusshould be observed and recorded accurately inpatients to monitor their level of consciousnessfor signs of deterioration, stability andImprovement. The main methods forundertaking this are by: monitoringconsciousness level; observingpupilreactions; assessing motor function; andobserving vital signs.

There are many possible neurologicalpresentations that a nurse may encounter (Walsh2006}. The challenge for the busy nurse includesthe quick recognition of acute events, forexample, head iniuryjnfection., haemorrhage orpost-surgery complications and the monitoringand recording of neurological observations.The aim of this article is to provide nurses withknowledge to reliably and accurately monitorand record neurological status.

It is important that nursing staff, particularlythose working in the acute ward setting, arecompetent to monitor and record neurological

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observations and to keep up to date with theclinical skills required to ensure high levels ofpatient safety and quality care. As the acuity ofward-based patients continues to escalate, allward staff need to develop knowledge and skillsin both the recognition and management ofat-risk and critically ill patients (DepartmentofHealth(DH)2065a).

Observation charts

A validated observational chart is the mostcommon iTiethod of monitoring and recordingneurological observations. Although the layoutmay differ from chart to chart, in essence, allneurological observation charts measure andrecord the same clinical information, includingthe level of consciousness, pupil size andresponse, motor and sensory response and vitalsigns. It is only through consideration of all ofthese components that an accurate clinicalassessment of the patient's neurological statuscan be obtained. Observational charts ensure asystematic approach to collecting and analysingessential information regarding a patient'scondition. Such charts also act as a means ofcommunication between nurses and other bealthprofessionals. The information collected is vitaland can be used in the following ways:

• Toaid diagnosis (Douglas ef a/2005).

• As a baseline of observations (Crouch andMeurier2005).

• To determine both subtle and rapid changesin an individual's condition (Crouch andMeurier2005).

• To monitor neurological status following aneurological procedure (Mooney andComerford2003).

• To observe for deterioration and establish theextentofa traumatic head injury (Walsh2006).

• To detect life-threatening situations (Alcocketal 2002).

NURSING STANDARD

Nurses should be aware when taking initialobservations that they are important as they mayindicate that a patient requires immediatemedical attention. Ongoing observations are justasiniportant as they may liulicLUeLi change in thepatient's condition. Often small changes inneurological status are not always obvious untilcompared with previous observations. A rapidttecline in neurological observations will alert theluirse Ct) seek tirgcnt assistance.Glasgow Coma Scale 1 he Glasgow Coma Scale(GCS) (Table 1), first developed byTeasdaleandjennett (1974)., is a common way to assess apatient's conscious level. It forms a quick,objective and easily interpreted mode ofneurological assessment. The GCS measuresarousal, awareness and activity, by assessingthree different areas of the patient's behaviourincluding:

• Eye opening.

• Verbal response.

• Motor response.

Each area is allocated a score, thereforeenabling obiectivity, ease of recording andcomparison between recordings. The total sumprovides a score out of 15. A score of 15indicates a fully alert and responsive patient,whereas a score of three (the lowest possiblescore) indicates unconsciousness. As well as anoverall score, a score for each area ofassessment should also be recorded andreported separately. Figure 1 provides

TABLE 1

Glasgow Coma Scale

Response

Best eye response> Open spontaneously> Open to verbal command> Open to pain• No eye opening

Best verbal response> Orientated• Confused• Inappropriate words• lncomprehensibie sounds• No verbal response

Best motor response> Obeys commands> Localises pain• Withdrawal from pain• Flexion to pain• Extension to pain• No motor response

Score

4321

54321

654321

(National Institute for Clinical Excellence 2003)

instruction on how to use the GCS.Using painful stitmtli Vainiul stimuli should beapplied in a careful and purposeful manner onceand for no longer than 30 seconds [Woodward1997a). Under no circumstance should thesternal rub or nail-bed pressure methods beused as they may cause prolonged discomfortand bruising (Shah 1999, Crawford andGuerrero 2004, Watcrhouse 2005). Table 2providesasummary of the evidence base fordifferent methods of applying painful stimuli.Before initiating painful stimuli it is importantthat the patient or family members are informedofthe procedure and why it is necessary.

Recording observations

It is important that nursing staff record exactlywhat is being observed as changes to thepatient's condition can be rapid and mayrequire an urgent response. Waterhouse (2005)recommended picturing a photograph beingtaken of the patient that captures what is beingseen at a particular point in time. It is importantthat nursing staff record individual findingsrather than comparing and being influenced bya previous set of observations. Nursing staffshould not seek conformity with previousrecordings (Woodrow 2000). Any concernsabout changes between the current andprevious recording should be reported andappropriate action taken.

There is no published consensus on howfrequently observations should he documented(Mooney and Comerford 2003). For headinjury patients, the NICE (2003) guidancerecommended that a GCS of less than 15necessitates 30-minute observations until themaximum score of 15 is reached. In addition,when a score of 15 is achieved, observationsshould then be performed every half hour for twohours, hourly for four hours and thentwo hourly thereafter. For the unconsciouspatient, Walsh (2006) recommended 15-minuteobservations and suggested that these should becarried out more frequently if the level ofconsciousness is fluctuating.

As with any assessment process it is essentialto start by informing the patient of the procedureand where possible obtain verbal consent(Douglas eif a/2005). When assessingneurological deficit it is important to record thebest arm response. The reason for this is to ensuremeasurement of neurological status, rather thaninjury or disability. There is no need to record leftand right differences, as the GCS does not aim tomeasure focal deficit, this should he completed inthe limb assessment. Leg responses should not bemeasured becauseoftherisk ofa spinal ratherthan a brain-initiated response.

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It is important to note that a patient who isunahle to open his or her eye(s) as a result ofswelling or surgery does not necessarily indicate a

low or falling conscious level. Likewise an absenceot speech does not necessarily indicate a low orfalling conscious level. Language difficulties ordysphasia will make it impossible to make anaccurate assessment of consciousness (Crawfordand Guerrero 2004) and should be taken intoaccount in the overall assessment process.

FIGURE 1

How to use the Glasgow Coma Scale

Observation i 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 inthe first box. Otherwise this section should be completed as follows:

Tlie score indicates thepatient's state of arousal

4 = Spontaneously The patient's eyes should open spontaneously as you approach. If the patient

is asieep, wake the patient, ensuring he or she is fully roused and thencomplete the assessment

3 = To speech Tlie patient will respond to your voice. T)ie best way to do this is to say hisor 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. Ttie best way to do this isto apply peripheral painful stimuli. Avoid central painful stimuli as it maycause the patient to grimace.

1 = No response The patient's eyes remain dosed despite painful stimuli.

Best verbal response:Tlie patient may have difficulty in speaking (dysphasia). I f so, the letter 'D' should be recorded in the 'none' column. I f the patient isintubated then the letter T shouid be recorded in the 'none' column.

This indicates the patient'sorientation to time, placeand person

5 = Orientated

4 = Confused

3 = Inappropriate words

2 = IncomprehensiblesoLinds

1 = No response

The patient must be able to state his or her name, who he or she is, wherehe or she is and the month of the year.

If the patient is able to hold a conversation but unable to answer thequestions above correctly he or she should be considered to be confused.Correct wrongly answered questions, but change the order each time to avoidthe patient just repeating them.

The patient will use random vi/ords that make little sense or are out ofcontext, typically swearing and shouting. Painful stimuli may be required togain a response.

Tlie patient will only respond with moaning and groaning. Painful stimuli maybe required to gain a response.

TTiere is no verbal response despite painful stimuli.

Best motor response:I f the patient is receiving medicines to maintain muscle paralysis Glasgow Coma Scale observations should not be performed.

Thisindicates brainfunction

6 = Obeys commands

5 = Localises to pain

4 = Withdraws from pain

3 = Flexion to pain

2 = Extension to pain

1 = No response

Ask the patient to perform a couple of different movements such as stickingout his or her tongue or lifting his or her arm.

Apply a central painful stimulus using one of the recommended methods(Table 2), The patient should purposefully move the arm towards the site ofpain to remove the cause of pain.

The patient will flex his or her arms in response to pain but will not movetowards the source of pain.

Tiie patient will flex his or her arms in response to pain but the wrist will alsorotate and the thumb may also flex and move across the fingers.

Arms will straighten and the shoulder will rotate inwards when a painful stimulusis applied. Tlie legs may also straighten with toes pointing downwards.

There is no physical response despite painful stimuli.

(Shah 1999, Crawford and Guerrero 2004, Waterhouse 2005)

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Recording other measurements

Vital signs The Royal Marsdcn Hospital Manualof Clinical Nursing Procedures (Crawford andCiuerrcro 2004) recommends that vital signsshould be recorded in the order of respiration,temperature, blood pressure and pulse (Table 3).

Raised intracranial pressure (ICP) will lowerrespiratory rate and alter the respiratory pattern(C'rawford and Guerrero 2004). This is one oftheclearest indicators of hrain dysfunction. AsICP rises pressure will be exerted on thehypnthalamus., the thermoregulatory part of thebrain, resulting in fluctuating temperature(Woodrow 2000). The brain becomes hypoxicand ischaemic and as a result systemic bloodpressure rises in an attempt to perfuse the brain(Shah 1999}. Patients will also becomebradycardic; this is known as Gushing reflex(Shab 1999, Crawford and Guerrero2004). Bothincreases and decreases in hlood glucose levelscan occur in the patient with a head injury.Hyperglycacmia increases cerebral ischaemia,reducing blood perfusion in the brain, andhypoglycaemia results in a lack of availableglucose to neurones which causes a reductionin function (Woodrow 2000).Pupil response Assessment of pupillary activityis aiicsscntial part of neurological observationand the only way to assess and monitor theneurological status of sedated patients(Watcrhciusf 2005). When examining pupilresponse it is important to position the patient sothat there is enough light to see the pupils clearlybut not so much lighr that the pupils constrict.Pupils should he assessed for size, shape andreaction to light (Table 4). Each pupil should beassessed and recorded individually. Pupils aremeasured in millimetres (normal range 2-6mm indiameter) and arc normally round in shape. Abright light., preferably a bright pen torch, shouldhe sht)ne into each eye to assess rhe pupil'sreaction to light.

Abnormal pupil size and response togetherwithotherneurological symptoms, such as areduced GCS and agitation, are an indicationof raised ICP (Woodward 1997b). The anatomyof rhe skull means that any swelling orspace-occtipying lesion such as a bleed,haemaroma or tumour, will raise ICP. If thispersists or rapidly worsens tbe brain tissue willshift and become compressed. As a result tbeocular motor nerve that controls pupil reactionmay be affected resulting in changes to pupilresponses. Sluggish or suddenly dilated pupils areLin indication of deterioration and require urgentmedical attention (Waterhouse 2005). This iswhy it is important to observe and record pupilsize and reaction (Woodward 1997b). Otherclinical indicators of deterioration such as a

falling GCS are likely to be found before a changein pupil response is observed. Altered pupils canbe a response to a number of things, for example,pin-point pupils could indicate opiate use ormetabolic disorders, a unilateral dilated pupilmay indicate hrain herniation or raised ICP and

Evidence base for methods of painful

Central painful stimuli

Method

Trapezius pinchor squeeze

Jaw pressure

Supra-orbitalpressure

Action

Using the thumb andforefinger take hold ofapproximately 5cm ofthe trapezius muscleand twist.

Apply pressure wittl thethumb to the jaw, just infront of the earlobe. Thismethod should not be usedif the patient has sustainedany head or facial trauma.

Feel along the medial aspectof the edge of the boneabove the eye for a grooveor notch; apply pressurehere with the thumb. Thismethod should not be usedif the patient has sustainedany head or facial trauma.

Peripheral painful stimuli

Method

Lateral fingeror toe pressure

Action

Using a pen apply pressureto the lateral aspect of afinger or toe. Rotate thepen around the finger inopposite direction to thenail. Tliis should beperformed for tio lotigerthan ten seconds.

stimuli

Evidence

Shah 1999. Woodrow2000, Mooney andComerford 2003,Crawford and Guerrero2004, Waterhouse 2005,

Woodward 1997a,Waterhouse 2005.

Shah 1999, Woodrow2000, Mooney andComerford 2003,Crawford and Guerrero2004, Waterhouse 2005.

Evidence

Waterhouse 2005.

Vital signs

Observation

Respiration rate

Temperature

Blood pressure and pulse

Blood g luco^

Early warning score - aphysiological scoring systemwith an identifiable triggerthreshold (Morgan et al 1997)

Method

Record respiratory rate and rhythm orpattern, observing for any decrease in rateand altered rhythm or pattern.

Record and observe any increase intemperature.

Record together observing for any increasein blood and pulse pressure and decrease inpulse.

Record and observe for any deviation fromnormal parameters.

Record and observe for any deviation fromnormal parameters.

(Adapted from Crawford and Guerrero 2004)

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fixed pupils may indicate severe mid-braindamage nr poisoning (Iggulden 2006).Limb movement Limb movements provide an

TABLE 4

Observation of pupil response

Observation

Generalobservations

Method

Look at the shape of the pupils and their position. Isthere any eye disease or medication that impairs eitheryour view or the eyes' response to light?

Is the eye too swollen to open? Attempts should be madeto open a mildly swollen eye but if it is too painful or theswelling is prolific tbe letter 'C for closed sbould berecorded on the observation chart.

Does the patient have a false eye?

The size of the eye is measured in millimetres - a guide isgiven on the side of most neLjralocjical observation chartsand some pen torches. Use this guide rather thanestimation so tbat the results are objective rather tbansubjective.

Record the size of the pupil at rest before any light isshone into the eye.

Pupil response To check the pupil response, move an illuminated pen; torch from the outer aspect of the eye directly over the

pupil. Tbe pupil should constrict quickly. The pupil shoulddilate again when the bright light is moved away.

Both eyes should constrict when a light is shone into oneeye. This is called consensual reaction.

These reactions are recorded as {+) for reaction, (si) fora sluggish reaction and (-) for no reaction.

(Adapted from Woodward i997b)

accurate indication of brain function (Crawfordand Guerrero 2004). It is important to assessand record each limb separately (Wnterhouse2005). The observation chart should be markedwith the letter 'U for left limbs and the letter 'R'for right Hmhs. Table 5 dciiioiistriucs the processof limb observation.

Assessment of limb responses providesinformation about motor function and is bestcarried out when tbe patient is lying down(Woodward 1997c). Any deficiencies in functionmay indicate a developing weakness or loss ofmovementcau.sed by raised ICP (Woodward1997c, Shah 1999). Limb assessment also assiststbe identification of local damage. Altbimgh it isusual for a hemiparesis or hemiplegia to occuron the opposite (contralateral) side to tbe lesion,itmay occur on the same (ipsilateral}side,known ns false localising. Particularconsideration shouid be given to any limbweakness that may be tbe result of past medicalhistory, for example, stroke, where there maybe a difference in linib resistance, or generalfrailty wbicb could influence the patient's abilityto offer resistance. It is important to use clinicaljudgement as well as objective measurement,remembering to record any difference inresistance in each limb separately.

Accountability

Nurses are accountable and responsible forproviding optimum care for patients.

Tbe Nursing and Midwifery Council's (NMC)Code of Conduct provides the main source of

Observation of limb movement

Observation

Normal power

Miid weakness

Severe weakness

Spastic flexion

Extension

No response

Result

Ttie patient will be able to push againstresistance with no difficulty.

The patient will be able to push againstresistance but will be easily overcome.

The patient will be able to move his or her limbsindependently but wil) be unable to move againstresistance.

The patient's limbs will flex in response to painfulstimuli. Arms, vt^rists and possibly the thumbwill bend inwards. Legs will pull upwards.

Tiie patient's limbs will extend in response topainful stimuli. Elbows, Vi'rists and fingers Vi illstraighten stiffly down the side of the body.Legs will stiffen and feet will point downwards.

There is no motor response despite central andperipheral painful stimuli.

Method

To determine whether the patient has normal power, mildor severe weakness. Each limb is assessed and recordedseparately.

Arms - while holding the wrist ask tbe patient to pull youtowards him or her and then push you away.

Legs - holding the top of the ankle ask the patient to lift hisor her leg off the bed then holding the back of the ankle askthe patient to pull the ieg towards him or her.

To determine a response of spastic flexion or extension applycentral painful stimuli. If no response is elicited use peripheralpainful stimulus.

(Adapted from Woodward 1997c)

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professional accountability for nurses (NMC2004). It lsfssfntial that nLirsinfisratt examineobjectively the information gathered fromassessments and observations as well as theinformation previously recorded. Neurologicalt)bservationscontrihiite to the overall patientassessment, which then forms the basis tor theindividualised plan ofcare (Crouch and Meurier2005). Nursingstaff should ensure that thepatient has an appropriate care plan in place andknow how and when to take action should achange occur in the patient's condition.

Accurate record keeping and documentationis important. The NMC (2007) states that thequality of record keeping is also a reflection ofthestandard ofthe individual's professional practice.All records must be contemporaneous, accurateand unamhiguous. Iris important always to act ina way that safeguards the patient's best interestsand this Includes the prompt reporting ofabnormal findings when monitoring andrecordnig neurological observations. It is al.soimportant to remember that observation charts,while important, are only one of the many tooisavailable togather information regarding apatient's condition. It is often useful to listen t(]the patient's family or close friends whencarrying out neurological observations as theycan provide invaluable information about thepatient's normal state and can often give anaccurate history of the onset and symptoms. Thisis important in situations where patients may notbe able to communicate their medical history.

Accountability also involves being up to datewith new developments, best practice andensuring consistency. Nurses should be fully

aware of relevant, credible research and ensurethat any patient care given is safe. Guidelines andprotocols should be in place in healthcareorganisations to ensure that care is in line withbest practice. Head injury guidance is availablefrom NICE (2003) and thJoH (2005b).

It is important to ensure best practice whenmonitoring and recording neurologicalobservations. Box 1 presents a quick reminderof factors that need to be considered.

Conclusion

Monitoring and recording neurologicalobservations that are reliable and accurate areimportantclinical skills. There are a number oftools, including the CICS, which can be used toperform neurological assessments. Nursesshould ensure that they are competent toundertake these observations and use the toolsavailable to achieve the best outcomes forpatients. The importance of using clinicaljudgement and taking appropriate action whenchanges in the patient's neurological status occurare paramount NS

Monitoring neurological observations: important factors

U 5 e a l l p a r t s • • • • . , • • i •! > • ••' • i

Record only what you see.

Listen to family members and friends.

Report any changes in ttie patient's condition.

Do not be influenced by previous observations.

Do not use nail-bed pressure or sternal rubs.

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