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Sphygmomanometer

Tongue depressor

Patella hammer

Neuro tips

Alcohol handrub

Optional equipment

Lowlinting swabs

Two test tubes

Snellen chart

Ophthalmoscope

Preprocedure

Action Rationale

1 Inform the patient of the procedure, whether conscious or not, and explain and discuss the observations. Sense of hearing is frequently unimpaired even in unconscious patients. It is important, as far as is possible, that the patient understands the procedure and gives their valid consent (NMC 2008b, C).

Procedure

2 Wash and dry hands. To minimize the risk of cross infection (Fraise and Bradley 2009, E).

3 Talk to the patient. Note whether they are alert and giving full attention or restless or lethargic and drowsy. Ask the patient who they are, the correct day, month and year, where they are and to give details about family. To establish whether the patient’s level of consciousness is deteriorating. If the patient is becoming disorientated, changes will occur in this order: (a) disorientation as to time

(b) disorientation as to place

(c) disorientation as to person (Aucken and Crawford 1998, R5).

4 Ask the patient to squeeze and release your fingers (include both sides of the body) and then to stick out their tongue. To evaluate motor responses and to ensure that the responses are equal and are not reflexive (Carlson 2002a, R5).

5 If the patient does not respond, apply painful stimuli. Suggested methods have been discussed earlier. Responses grow less purposeful as the patient’s level of consciousness deteriorates. As the condition worsens, the patient may no longer localize pain and respond to it in a purposeful way (Aucken and Crawford 1998, R5).

6 Record the findings precisely, recording the patient’s best response. Write exactly what stimulus was used, where it was applied, how much pressure was needed to elicit the response, and how the patient responded. Vague terms can be easily misinterpreted. Accurate recording will enable continuity of assessment and comply with NMC guidelines (NMC 2009, C).

7 Extend both hands and ask the patient to squeeze your fingers as hard as possible. Compare grip and strength. To test grip and ascertain strength. Record best arm in GCS chart to reflect best outcome (Carlson 2002a, R5).

8 Darken the room, if necessary, or shield the patient’s eyes with your hands. To enable a better view of the eye. E

9 Ask the patient to open their eyes. If the patient cannot do so, hold the eyelids open and note the size, shape and equality of the pupils. To assess the size, shape and equality of the pupils as an indication of brain damage. Normal pupils are spherical, usually at midposition and have a diameter ranging from 2 to 5 mm (Shah 1999, R5).

10 Hold each eyelid open in turn. Move torch towards the patient from the side. Shine it directly into the eye. This should cause the pupil to constrict promptly. To assess the reaction of the pupils to light. A normal reaction indicates no lesions in the area of the brainstem regulating pupil constriction (Aucken and Crawford 1998, R5).

11 Hold both eyelids open but shine the light into one eye only. The pupil into which the light is not shone should also constrict. To assess consensual light reflex. Prompt constriction indicates intact connections between the brainstem areas regulating pupil constriction (Scherer 1986, R5).

12 Record unusual eye movements. To assess cranial nerve damage (Aucken and Crawford 1998, R5).

13 Note the rate, character and pattern of the patient’s respirations. Respirations are controlled by different areas of the brain. When disease or injury affects these areas, respiratory changes may occur (Carlson 2002a, R5).

14 Take and record the patient’s temperature at specified intervals. Damage to the hypothalamus, the temperatureregulating centre in the brain, will be reflected in grossly abnormal temperatures (Fairley and McLernon 2005, R5).

15 Take and record the patient’s blood pressure and pulse at specified intervals. To monitor signs of increased intracranial pressure. Hypertension and bradycardia usually occur