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Type Pattern Significance

Cheyne–Stokes Rhythmic waxing and waning of both rate and depth of respirations, alternating regularly with briefer periods of apnoea. Greater than normal respiration, that is 16–24 breaths per minute May indicate deep cerebral or cerebellar lesions, usually bilateral; may occur with upper brainstem involvement

Central neurogenic hyperventilation Sustained, regular, rapid respirations, with forced inspiration and expiration May indicate a lesion of the low midbrain or upper pons areas of the brainstem

Apneustic Prolonged inspiration with a pause at full inspiration; there may also be expiratory pauses May indicate a lesion of the lower pons or upper medulla, hypoglycaemia or druginduced respiratory depression

Cluster breathing Clusters of irregular respirations alternating with longer periods of apnoea May indicate a lesion of lower pons or upper medulla

Ataxic breathing A completely irregular pattern with random deep and shallow respirations; irregular pauses may also appear May indicate a lesion of the medulla

Constant reevaluation of the patient’s ability to maintain and protect their airway is a concern when there is evidence of reduced consciousness or coma (GCS score is less than 8). At this stage, muscles often become flaccid and the use of the recovery position may need to be considered. Patients who have deteriorated may require adjuncts to protect the airway and possibly artificial ventilation (Resuscitation Council 2006). Close working liaison with physiotherapists and speech and language therapists is important to minimize the danger of chest infections.

Temperature

Damage to the hypothalamus, the temperatureregulating centre, may result in grossly fluctuating temperatures (Fairley and McLernon 2005).

Blood pressure, pulse and respirations

Observations of blood pressure, pulse and respirations will provide evidence of increased intracranial pressure. When intracranial pressure is greater than 33 mmHg for even a short time, cerebral blood flow is significantly reduced. The resulting ischaemia stimulates the vasomotor centre, causing systemic blood pressure to rise. The patient becomes bradycardic and the respiratory rate falls. Abnormalities of blood pressure and pulse usually occur late, after the patient’s level of consciousness has begun to deteriorate. This change in the blood pressure was first described by Cushing and is known as the Cushing reflex (Carlson 2002b).

Evidencebased approaches

Rationale

Indications

An accurate neurological assessment is essential in planning patient care. The information gained from a neurological assessment can be used in the following ways.

To aid diagnosis (Douglas et al. 2005).

As a baseline for observations (Crouch and Meurier 2005).

To determine both subtle and rapid changes in an individual’s condition (Crouch and Meurier 2005).

To monitor neurological status following a neurological procedure (Mooney and Comeford 2003).

To observe for deterioration and establish the extent of a traumatic head injury (Walsh 2006).

To detect lifethreatening situations (Alcock et al. 2002).

Frequency of observations

The frequency and type of neurological observation are matters of much debate (Price 2002). It is therefore not possible to be prescriptive, as the frequency will depend on the underlying pathology and possible consequences. For example, in a patient with a head injury and a skull fracture, there may be bruising to the brain (contusion), cerebral oedema and an extradural haemorrhage which may increase in size. The bruising and oedema may develop over a couple of days and gradually give rise to subtle neurological changes, whilst the extradural haemorrhage can develop very quickly and cause profound neurological changes over a matter of a few hours. Therefore such a patient may require frequent 30minute GCS observations for the first 6 hours followed by 1–2hourly observations for a further 48 hours. The nurse must be competent and take appropriate action if changes in the patient’s neurological status occur, as well as reporting