Neurological Assessment

Glasgow Coma Scale

- Tool for assessing all patients at potential risk of neurological
deterioration
- 2 aspects of consciousness
o Arousal
o Cognition
- Physiology
-

Responses and scoring

o Best eye response
Max score 4
o Best Verbal response
Max score 5
o Best motor response
Max Score 6
o GCS

o GCS

o GCS

of 8 or less
Severe Injury
of 9 12
Moderate Injury
of 13 15
Minor Injury

Neurological Assessment

Problems with GCS

Misuderstood
Misused
General nurses vs neuroscience nurses
Research of 3rd year nursing students
Implication for practice

Motor Response
- Sensory Input and translation into motor
- Response within the brain
o Motor and sensory function
- Total Score: 6
o 6: Obeys commands
Highest level of motor response
Accurate response to instruction (twice)
e.g. Raise eyebrows, stick out tongue, squeeze and let go
o 5: Localizing pain
Response to pain stimulus
Moves hand to the point of stimulation
o Sternal rub
3 Stimuli recommended by the National Neuroscience
Benchmarking group
Supra orbital pressure
Jaw margin pressure
Trapezius squeeze
o Score 4: Withdrawal from Pain
Normal flexion in response to central pain stimuli, but
failing to locate source of pain
Pulls limb away from painful stimulus
o Score 3: Flexion to pain
Decorticate posturing
Occurs due to a block in motor pathway between
cerebral cortex and brain stem
Slower response
Flexing upper arm and rotating of wrist an thumb
through fingers
o Score 2: Extension to Pain
Decerebrate posturing
Occurs due to blockage/damage within brainstem
Straightening of elbow and internal rotation of
shoulder and wrist; leg extension with toes pointing
downwards
o Score 1: No Motor Response

Neurological Assessment

Brain incapable of processing any sensory input and motor

activity
Rigid to all pain stimuli
Check not unresponsive due to local disease injury
Neurological examination of limbs
o Pattern and power of movement
Identify site and severity of brain
damage

Warning Score (NICE (2003) Guidelines)

- GCS < 15 (impaired consciousness)
o Assessed immediately by a trained member of staf
e.g. Triage Nurse
- GCS < or = 8
o Early involvement of an anesthetist or critical care physician to
provide appropriate airway management and to assist with
resuscitation
- GCS < 15
o 30 mins obs till recovery of maximum score
Assessing the reflexes
- Deep tendon reflexes
o Biceps
Rest clients elbow in nondominant hand with thumb over
biceps tendon
Strike percussion hammer to own thumb
o Triceps
Abduct clients arm at the shoulder, flexing at the elbow;
support upper arm with nondominant hand, letting forearm
hang loosely
Strike the triceps tendon 2 inches above the olecranon
process
o Brachioradialis
Rest clients arm on his leg
Strike with percussion hammer 1-2 inches above the bony
prominence of the wrist on the thumb site
o Patellar
Position client in seated position with legs dangling
Strike the tendon directly below the patella with a
percussion hammer
o Assessing the sensory function Achilles
Position client in the supine or seated position with legs
dangling
Hold clients foot slightly dorsiflexed

Neurological Assessment
Strike the Achilles tendon about 2 inches above the heel
with the percussion hammer
o Plantar Superficial Reflex
Strike the sole of the clients foot in an arc from the lateral
heel to medially across the ball of the foot
Reflex hammer with triangular rubber head
o A proper tool for testing reflexes
Grading
o 0 Absent
o 1 Diminished
o 2 Normal
o 3 Increased, brisker than average
o 4 Markedly hyperactive with clonus

Pathological Reflexes
- Babinskis Reflex
o Stroking the lateral aspect of the sole of the foot with a
thumbnail or another moderately sharp
- Kernigs Reflex
o With the patient in the supine position, flex his hip and knee to
form a 90 angle. Then attempt to extend hid leg
- Brudzinskis Sign
o With the patient in the supine position, place your hand under his
neck and flex it forward, chin to chest
Cranial Nerves
I.

II.

III.

Olfactory
o Check first for the patency of the nose
o Instruct to close the eyes
o Occlude one nostrils at a time
o Hold familiar substance and asks for the identification
o Repeat with the other nostrils
o Problem: Anosmia Loss of smell
Optic
o Check the visual acuity with the use of the snellen chart
o Check for visual field by confrontation test
o Check for pupillary reflex
Direct and consensual
o Fundoscopy to check for papilledema
Oculomotor
o Assess simultaneously the movement of the extra-ocular
muscles
o Deviations
Opthalmoplegia

Neurological Assessment
Inability to move the eye in a direction
Diplopia
Complaint of double vision
Trochlear
o Assess simultaneously the movement of the extra-ocular
muscles
o Deviations
Opthalmoplegia
Inability to move the eye in a direction
Diplopia
Complaint of double vision
Trigeminal
o Sensory portion
Assess for sensation of the facial skin
o Motor portion
Assess the muscle of mastication
o Assess corneal reflex
Abducens
o Assess simultaneously the movement of the extra-ocular
muscles
o Deviations
Opthalmoplegia
Inability to move the eye in a direction
Diplopia
Complaint of double vision
Facial
o Sensory portion
Prepare salt, sugar, vinegar and quinine
Place each substance in the anterior 2/3 of the tongue,
rinsing the mouth with water
o Motor portion
Ask the client to make facial expressions
Ask to forcefully close the eyelids
Vestibulocochlear
o Test patients hearing acuity
o Observe for nystagmus and disturbed balance
Glossopharyngeal
o Together with CNX: Vagus
o Assess for gag reflex
o Watch the soft palate rising after instructing the client to say
AH
Vagus
Accessory

IV.

V.

VI.

VII.

VIII.
IX.

X.
XI.

Neurological Assessment

XII.

o Press down the patients shoulder while he attempts to shrug

against resistance
Hypoglossal
o Ask patient protrude the tongue and note for symmetry