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any subtle signs that may indicate deterioration, for example if the patient is incontinent, reluctant to eat, drink or initiate interaction. It should never be assumed that difficulty to rouse a patient is due to nighttime sleep as even a deeply asleep patient with no focal deficit should respond to pain. Therefore if the patient requires an increased amount of stimulus to achieve the same GCS score, this may also be a pointer to subtle deterioration (Table 12.13) (Aucken and Crawford 1998, Waterhouse 2005).

Table 12.13 Frequency of observations

Category Frequency Rationale

All patients diagnosed as suffering from neurological or neurosurgical conditions. Unconscious patients (including ventilated and anaesthetized) At least 4hourly, affected by the patient’s condition. Frequency indicated by patient’s condition To monitor the condition of the patient so that any necessary action can be instigated. To monitor the condition closely and to detect trends so that appropriate action may be taken

Preprocedural considerations

Equipment

The following equipment may be used as part of the neurological assessment.

Pen torch: used to assess the reaction of the pupils to light and consensual light reflex (Aucken and Crawford 1998).

Tongue depressor: device used to depress the tongue to allow for examination of mouth and throat (Fuller 2004).

Patella hammer: a tendon hammer used to strike the patella tendon below the knee to assess the deep knee jerk/reflex (Fuller 2004).

Neuro tips: sharp instrument used to apply pressure and test for superficial sensations to pain. Can be replaced by a safety pin or other suitable sharp object (Fuller 2004).

Snellen chart: an eye chart used to measure visual acuity.

Ophthalmoscope: instrument used to examine the eye.

Assessment and recording tools

The initial assessment of a patient should include a history (taken from relatives or friends if appropriate), noting changes in mood, intellect, memory and personality, since these may be indicators of a longstanding problem, for example brain tumour (Belford 2005).

The GCS, first developed by Teasdale and Jennett (1974), is a common way to assess a patient’s conscious level. It forms a quick, objective and easily interpreted mode of neurological assessment. The GCS measures arousal, awareness and activity, by assessing three different areas of the patient’s behaviour: eye opening, verbal response and motor response (Dawes and Durham 2007).

Each area is allocated a score, enabling objectivity, ease of recording and comparison between recordings. The total sum provides a score out of 15. A score of 15 indicates a fully alert and responsive patient, whereas a score of 3 (the lowest possible score) indicates unconsciousness (Dawes and Durham 2007). When used consistently, the GCS provides a graphical representation that shows improvement or deterioration of the patient’s conscious level at a glance (see Figure 12.30 and Table 12.14).

Figure 12.30 The Glasgow Coma Scale.

Table 12.14 Scoring activities of the Glasgow Coma Scale. Scores are added, with the highest score 15 indicating full consciousness

Category Score Response

Eye opening

Spontaneous 4 Eyes open spontaneously without stimulation

To speech 3 Eyes open to verbal stimulation (normal, raised or repeated)

To pain 2 Eyes open with painful/noxious stimuli

None 1 No eye opening regardless of level of stimulation

Verbal response

Orientated 5 Able to give accurate information regarding time, person and place

Confused 4 Able to answer in sentences using correct language but cannot answer orientation questions appropriately

Inappropriate words 3 Uses incomprehensible words in a random or disorganized fashion

Incomprehensible sounds 2 Makes unintelligible sounds, for example moans and groans

None 1 No verbal response despite verbal or other stimuli

Best motor response

Obeys commands 6 Obeys and can repeat simple commands, for example arm raise

Localizes to pain 5 Purposeful movement to remove painful stimuli

Normal flexion 4 Withdraws extremity from source of pain, for