Neuro Obs - Resident

Neurological Observation Chart Name of Resident:

Date TIme Spontaneously To speech To pain None

S C A L E

Best verbal response

Orientated Confused Inappropriate words Incomprehensible None

Best motor response

Obeys commands Localise pain Flexion to pain Extension to pain None

Eyes closed by swelling = C

Usually record the best arrival response

Blood Pressure and Pulse Rate

240 230 220 210

Pupil Scale (mm)

PUPILS

LIMB MOVEMENT

Left

Legs

200 190 180 170 160

150 140 130 120 110 100 90 80 70 60 50 40 30 20 Respirations 10 Right

Arms

40 39 38 37 36 35 34 33 32 31 30

Size Reaction Size Reaction

Temperature C

Eyes open

C O M A

+ reacts - no reaction c eyes closed

Normal power Mild weakness Severe weakness Spastic flexion Extension No response Normal power Mild weakness Severe weakness Extension No response

Record right (R) and left (L) separately if there is a difference between the two sides

Initials & Designation of person completing observations Please mark: Pulse with ‘X’;

Respirations with ‘ ’;

Blood Pressure with ------------ ; Temperature with a ‘ ’

Reference Card: Neurological Observations Frequency of observations depends on severity of injury. Following an incident where a head injury may have occurred: 1/2 hourly observations for 2 hours, hourly for 4 hours then daily for 4 days. If any abnormalities found in observations or if obvious head injury: ¼ hourly for 2 hours, ½ hourly for 2 hours or until transferred to hospital or reviewed by medical practitioner. A standard chart should be used to record and display neurological observations assessments and vital signs including the Glasgow Coma Scale, pupil size and reaction and movements of limbs [1]. Neurological observations include assessment of conscious level, vital signs, pupil size and reaction, motor response, and verbal response [1-3]. Glasgow Coma Scale The Glasgow Coma Scale uses objective observable characteristics and provides a scale by which to measure level of consciousness and response. The scale is used for assessment of eye opening, best verbal response and best motor response [1-3]. Eye Opening Assessing eye opening provides an indication of the resident’s arousal ability. Determine if the resident responds to speech (use a loud voice) or to touch. If the resident does not respond, apply pressure to the fingerbeds to determine if there is a response to painful stimuli. If the resident cannot open his or her eyes due to swelling, record “C”, or if the resident’s eyes remain continuously open this should be recorded as a non eye opening response [2]. Verbal Response This assessment determines appropriateness of the resident’s speech. The resident’s attention should be gained and a conversation attempted, allowing adequate time for the resident to respond. In assessing the resident’s best verbal response, consider the resident’s preferred language, any diagnosed medical problems that may influence the resident’s ability to respond, e.g. deaf, previous stroke, and level of confusion prior to the fall and determine if there are any changes to the resident’s pre-fall condition. Assess the resident’s response and record: Oriented: resident can respond appropriately to person/place/time; Confused: resident can talk but is not orientated; Inappropriate words: speaks only a few words, usually only in response to physical or painful stimuli; Incomprehensible sounds: unintelligible sounds such as moans; and None: no response after prolonged stimulation [1, 2]. Motor Response Assess the resident using simple commands to determine if the resident has the awareness / ability to repond by movement. If the resident does not respond to verbal commands such as “squeeze my hands” or “open your eyes” check the resident’s best motor response to painful stimuli by pressing the resident’s fingerbeds. In assessing the resident’s best motor response, consider the resident’s usual level of comprehension, usual ability to move his or her body and any existing medical diagnoses that may contribute to the resident’s ability to move, e.g. previous stroke, dementia. Record: Obeys command: follows your command; Localises pain: moves limb away from painful stimuli in a purposeful way or attempts to push painful stimulus away; Flexion to pain: responds to painful stimuli by bending arms up but does not localise pain; ND Extension to pain: responds to painful stimuli by straightening arms but does not localise pain [1, 2]. Assessment of Pupils Assessment of the resident’s pupil size and response to light can provide an indication as to presence and extent of head injury as a result of a fall. The neurological observation chart should provide a pupil scale on which to assess pupil size. An assessment should first be made as to whether the resident’s pupils are of equal size and then whether they react equally to exposure to light [1, 2]. Assessment of Limb Movement Assessment of the resident’s limb movement can give an indication as to the presence and extent of head injury as a result of a fall. Instruct the resident to move their limbs laterally or lift up against gravity or against resistance. If the resident does not respond to your request, assess limb movement in response to pain. Observe the type of movement the resident can perform, and compare the strength of limbs on both sides of the body. In assessing the resident’s limb movements and strength, consider the resident’s previous condition and any medical diagnoses that may preclude normal limb movement, e.g. previous stroke, musculoskeletal disorders. Consider whether the resident has sustained injuries to the limbs during the fall that may preclude normal movement, e.g. fractures. Record: Normal power – movements are within the resident’s normal power strength; Mild weakness – cannot fully lift limbs against gravity and struggles to move against resistance; Severe weakness – can move limbs laterally but cannot move against gravity or resistance; Spastic flexion – arms slowly bend at elbow and are stiff; and Extension – limbs straighten [1, 2]. References 1. 2. 3.

Network, Scottish Intercollegiate Guidelines, Early Management of Patients with a Head Injury. 1st ed. 2000, Edinburgh: SIGN. Institute, Joanna Briggs, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. Care, National Collaborating Centre for Acute, Clinical Guidelines 4: Head injury Triage, assessment, investigation and early management of head injury in infants, children and adults. 1st ed. 2003, London: National Institute for Clinical Excellence.