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Evaluating the

neurologic status
of unconscious patients
Although overshadowed by CT and other
scanning methods, the neuro exam can help you
quickly gauge your patient’s condition.
By Elizabeth Anness, RN, CCRN, and Kelly Tirone, BSN, RN

ASSESSING THE NEUROLOGIC going and oncoming shifts should yourself: Is the airway patent? If so,
STATUS of unconscious or coma- evaluate the patient’s neurologic is the patient able to maintain it?
tose patients can be a challenge be- status together during shift changes Next, check vital signs: Are her res-
cause they can’t cooperate actively or care transfers (as well as with pirations adequate? Are her vital signs
with your examination. But once the medical team on rounds). Once stable? Is her blood pressure high
you become proficient in perform- you’ve completed the initial assess- enough to perfuse the brain and other
ing this exam, you’ll be able to de- ment, subsequent assessments vital organs? Be aware
tect early significant changes in a can be either basic or more that current or pro-
patient’s condition—in some cases, in-depth. gressive injury to
even before these show up on the brain and
more advanced diagnostic tests. Two types of neuro brain stem may
Subtle changes in findings may in- exams make vital signs
dicate the need for further testing. The type of neuro exam unstable, but this
Before the advent of computed you conduct depends on situation can be
tomography (CT) in the 1970s, the whether your patient can complex: Although
neurologic examination was the follow commands. If she unstable vital signs
main tool used to monitor a patient’s can, your exam can be more can reduce neurologic
neurologic condition. Although it’s comprehensive and should in- response, brain injury itself
still an integral assessment compo- clude evaluation of: may cause unstable vital signs.
nent for critically ill patients, many • level of consciousness (LOC) To appropriately assess the pa-
bedside nurses overlook or underuse • pupils tient’s peak neurologic status, be sure
it. One reason may be that, unlike • cranial nerves I through XII to evaluate oxygenation and circula-
CT scans and other diagnostic tools, • motor response tion. Ideally, you should conduct the
its results come in shades of gray, • sensation. neuro exam when the patient’s blood
not black and white. If your patient can’t follow com- pressure, temperature, heart rate, and
mands, you’ll be able to assess only heart rhythm are normal. Be aware
Quicker and easier than you the pupils, eye opening, motor re- that a temporary decline in neurolog-
might think sponse, and some of the cranial ic status caused by insufficient oxy-
The neuro exam can be conducted nerves. Yet despite the relative brevi- genation or circulation still represents
quickly and is easy to integrate into ty of this type of exam, it can yield a a neurologic change—and leads to
your daily assessment. It starts the significant amount of information. permanent neurologic loss unless the
moment you meet the patient. Per- underlying problem is corrected.
forming it early is crucial because First step: Evaluate ABCs and
this helps you establish a baseline vital signs Assess LOC, eye opening, and
for later comparison. As with any patient, give top priori- motor response
For accurate interpretation of as- ty to assessing the ABCs—airway, Once you’ve established that your
sessment findings, nurses on the off- breathing, and circulation. Ask patient is stable enough to assess,

8 American Nurse Today Volume 4, Number 4


Testing your patient’s response to pain
begin the neuro exam itself. To de- Testing response to a central painful stimulus is the most reliable way to evaluate
motor response in an unresponsive patient. If your patient doesn’t respond to a cen-
termine if the patient is unconscious
tral stimulus, you may want to use a peripheral stimulus. Be aware, though, that a
and unable to follow commands, peripheral stimulus may elicit a reflex response, which isn’t a true indicator of a mo-
use the Glasgow Coma Scale (GCS) tor response. This chart lists both central and peripheral testing sites and methods.
to test eye opening, best motor re-
sponse, and best verbal response. Central testing
An unconscious patient is likely to
open her eyes only in response to Trapezius squeeze: Firmly pinch or
pain, if at all; obviously, you can’t grasp the trapezius muscle (as shown
test her best verbal response at all. in photo).
To assess motor response using
the GCS, apply a painful or other Earlobe: Pinch the earlobe.
noxious stimulus to a central part of
Supraorbital: With your thumb, apply
the body; for instance, use trapezius firm pressure to the upper inner aspect Peripheral testing
squeezing, supraorbital pressure, ear- of the orbital wall. (Don’t use this
lobe pinching, or a sternal rub. (See method if the patient has suspected Nail bed: Using a penlight or similar item,
Testing your patient’s response to facial fractures.) apply firm pressure to the nail bed for
pain.) Then watch for specific motor 10 to 30 seconds.
responses, as specified in the GCS. Sternum: Using your knuckle, rub the
In an unconscious patient, the best sternum firmly or apply firm pressure Inner arm or thigh: Pinch or twist the
response is localization, in which to it. (This method isn’t recommended sensitive tissues of the inner arm or thigh.
because it may cause bruising.) (Use caution if the patient has frail or
she reaches across the midline to-
friable skin.)
ward the stimulus site as though try-
ing to stop the pain. In a semipur-
poseful (withdrawal) response, she the letter “T” (for endotracheal before and after exposure to light.
recoils as though attempting to with- tube) or “ETT” on the GCS form, Normally, pupils are equal in size
draw or escape from the pain. indicating the patient might be able and about 2 to 6 mm in diameter,
A flexion motor response (decorti- to verbalize if not intubated. If the but they may be as large as 9 mm.
cate posturing) is marked by inward patient was sedated during the ex- Also, the pupils may be pinpoint,
flexion of the elbows, wrists, and am, write the letter “S” (for seda- small, large, or dilated. Normal pupil
hands accompanied by extension and tion), acknowledging that sedation shape is round; variations include ir-
plantarflexion of the feet. An exten- may have decreased the GCS score. regular, keyhole, and ovoid. (See
sion motor response (decerebrate pos- If your patient has a GCS score Visualizing a keyhole pupil.)
turing) is straightening or stiff exten- of 8 or less, follow the steps below To assess the patient’s pupils,
sion of the arms, with wrists rotated to complete the neurologic assess- hold both eyelids open and shine a
outward, knees and ankles rigidly ment of the unconscious patient. light into the eyes. The pupils
straight, and plantarflexion of the feet. should constrict immediately and
After assessing eye opening and Evaluate pupils equally bilaterally; after you remove
verbal and motor responses, assign Pupil evaluation includes assessment the light, they should immediately
a GCS score. The best possible of pupil size, shape, and equality dilate back to baseline. Document
score is 15, which indicates the pa- the response: Is it brisk, sluggish,
tient is awake, oriented, and fol- nonreactive, or fixed? Immediately
lowing commands. The lowest pos- Visualizing a keyhole pupil report any changes from baseline.
sible score is 3, which means the In many cases, a change in pupil-
patient doesn’t open the eyes and lary response, such as unequal or
has no motor or verbal response to dilated pupils, results from a pro-
a central stimulus. gressive neurologic condition.
Usually, a GCS of 8 or less indi- A pupil with a keyhole shape (patient’s Fixed and dilated pupils are an
cates severe brain insult; the patient left eye above) may indicate early com- ominous sign that warrant immedi-
may be unable to maintain an air- pression of cranial nerve III. It’s also seen ate physician notification (unless
in diabetic patients and those who’ve un-
way, may require airway protection the patient’s pupils have just been
dergone eye surgery. Although a base-
or even intubation, and may need line finding of a keyhole pupil usually is
dilated chemically). For true
to go to the intensive care unit for benign, later development suggests neuro- changes in pupillary response, ex-
airway monitoring. logic deterioration. pect the physician to order further
If the patient is intubated, write diagnostic tests, such as a CT scan.

April 2009 American Nurse Today 9


Assessing cranial nerves in the unconscious patient
Each of the 12 pairs of cranial nerves (CNs) is assigned a name and Roman numeral. The nerves are numbered in descending order
from their origin points in the central nervous system. Three pairs are sensory, five are motor, and four have mixed sensory and
motor functions. In an unresponsive patient, you can assess only five CNs—III, V, VII, IX, and X—as described below. (Note: This
chart addresses CN testing in the unconscious patient only.)

Cranial nerve and function What to test for Testing method and normal response

III (Oculomotor): Motor Pupillary response Shine a light into patient’s eye to assess pupil size, shape,
equality, and reaction. (Normal response: see “Evaluate
pupils,” page 9.)

V (Trigeminal): Mixed motor Corneal reflex Hold eye open and gently touch sclera or lower eyelashes
and sensory with a sterile cotton swab, taking care not to touch cornea.
Normal response: forceful eye closure. Any movement is a
positive response; document it as strong or weak
accordingly.

VII (Acoustic): Mixed motor Facial grimace Observe for facial grimace after applying noxious
and sensory stimulus or touching a sterile cotton swab to inside of
nostril. Normal response: grimace of entire face; compare
results bilaterally for equal or nearly equal response.

IX (Glossopharyngeal): Coughing Touch back of pharynx, soft palate, or uvula with tongue
Mixed motor and sensory blade, cotton swab, or Yankaur suction catheter. Normal
response: coughing.

X (Vagus): Mixed motor Gag reflex Touch back of pharynx, soft palate, or uvula with tongue
and sensory blade, cotton swab, or Yankaur suction catheter. Normal
response: gagging.

Assess cranial nerves stationary. This exam is contraindi- can quickly and easily perform a
Findings from cranial nerve (CN) cated in patients with suspected neuro exam on the unconscious
assessment can tell much about the cervical spinal cord injury. patient. Establish your patient’s
patient’s midbrain, pons, and Oculovestibular testing also evalu- baseline early, and make sure you
medullary functions. Although some ates CNs III and VI, along with CN know how to differentiate normal
nurses find this assessment intimi- VIII. The physician instills iced saline and abnormal neurologic findings.
dating, it’s not that difficult. (See solution into the ear canal and ob- Remember that changes can be
Assessing cranial nerves in the serves for nystagmus (involuntary subtle and should be documented
unconscious patient.) rapid eye movements). In a normal and reported promptly. Most im-
response, the eyes show conjugate portantly, use your nurse’s “sixth
Physician’s examination movement and nystagmus in the di- sense”—that gut feeling most of us
The oculocephalic (doll’s eye) and rection of the irrigated ear, indicating have when something just isn’t
oculovestibular (cold caloric) tests, an intact brain stem. Absence of nys- right. ✯
which reveal brain stem function, tagmus is an abnormal response sig-
are performed only by physicians nifying a decrease in consciousness Selected references
on patients who don’t respond to with severe brain stem injury. The Barker E. Neuroscience Nursing: A Spectrum
of Care. 3rd ed. St. Louis, MO: Elsevier/Mos-
the exam methods described above. oculovestibular test is contraindicated
by; 2008.
These tests aid prognosis of severe- in patients with ruptured tympanic
Hickey J. The Clinical Practice of Neurologi-
ly brain-injured patients. membranes or otorrhea; results may
cal and Neurosurgical Nursing. 6th ed.
The oculocephalic test evaluates be false-positive in patients who are Philadelphia, PA: Lippincott Williams &
extraocular muscle movements on ototoxic drugs (including pheny- Wilkins; 2008.
(controlled by CNs III and VI). The toin) or who have Ménière’s disease.
examiner moves the patient’s head Both authors work in the Neurosciences Intensive
from side to side forcefully and Document and follow up on Care Unit at Harborview Medical Center in Seattle,
quickly; in an abnormal response findings Washington. Elizabeth Anness is a staff nurse; Kelly
(an ominous sign), the eyes remain By following these guidelines, you Tirone is an assistant nurse manager.

10 American Nurse Today Volume 4, Number 4