Pre‐procedure

ActionRationale

1. 1.Show
   Whether or not the patient is conscious, introduce yourself to the patient, and explain and discuss the procedure with them. If possible, gain their consent to proceed.
   Sense of hearing is frequently unimpaired even in unconscious patients. To ensure that the patient feels at ease, understands the procedure and gives their valid consent as far as possible (NMC [144], C).

Procedure

1. 2.Show
   Wash and dry hands and/or use an alcohol‐based handrub.
   To minimize the risk of cross‐contamination (NHS England and NHSI [124], C).

Assessment using the Glasgow Coma Scale (GCS) and AVPU

1. 3.Show
   Observe the patient without speech or touch.
   To assess eye opening as part of the GCS and level of consciousness as part of the AVPU (RCP [171], C).
2. 4.Show
   Talk to the patient. Note whether they are alert and giving their full attention, restless, or lethargic and drowsy. Ask the patient who they are, where they are and what day, month and year it is. Also ask them to give details about their family.
   To establish whether the patient's level of consciousness is deteriorating. If the patient is becoming disorientated, changes will occur in this order:

   1. disorientation as to time
   2. disorientation as to place
   3. disorientation as to person (Bickley [18], E).
3. 5.Show
   Ask the patient to squeeze and release your fingers (both sides should be assessed) and then to stick out their tongue or raise their eyebrows.
   To assess the patient's ability to follow commands, to evaluate their motor responses and to ensure that the responses are equal and not reflexive (Baumann [16], E).
4. 6.Show
   If the patient does not respond, apply painful stimuli, such as the trapezium squeeze (see the section above on application of painful stimuli).
   Responses grow less purposeful as the patient's level of consciousness deteriorates. As their condition worsens, the patient may no longer localize to pain (Baumann [16], E).
5. 7.Show
   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 the best arm in the GCS chart to reflect the best outcome (Baumann [16], E).

Pupil assessment

1. 8.Show
   Reduce any external bright light by darkening the room, if necessary, or shield the patient's eyes with your hands.
   To allow accurate monitoring of pupil reaction and enable a better view of the eye (Bickley [18], E).
2. 9.Show
   Ask the patient to open their eyes. If the patient cannot do so, hold their eyelids open and note the size and shape of both pupils simultaneously, and whether they are equal.
   To assess the size, shape and equality of the pupils as an indication of brain damage (Kerr et al. [92], E). Normal pupils are round and equal in size with a diameter ranging from 2 to 5 mm (Wilkinson et al. [215], E). See Figure 14.50.
3. 10.Show
   Hold each eyelid open in turn. Shine a bright light into the eye, moving from the outer corner towards the pupil. This should cause the pupil to constrict immediately, and there should be an immediate and brisk dilation of the pupil once the light is withdrawn.
   To assess the direct light reflex of the pupils (Kerr et al. [92], E).
4. 11.Show
   Hold both eyelids open but shine the light into one eye only. Both pupils should constrict immediately and then briskly dilate once the light is withdrawn.
   To assess the consensual light reflex (Baumann [16], E).
5. 12.Show
   Record pupillary size (in mm) and reactions on the observation chart. Brisk reaction is documented as ‘+’, no reaction as ‘−’, and sluggish response of one pupil compared to the other as ‘S’.
   Accurate recording will enable continuity of assessment and comply with Nursing and Midwifery Council (NMC) guidelines (NMC [144], C).
6. 13.Show
   Record unusual eye movements, such as nystagmus or deviation to the side.
   To assess cranial nerve damage (Kerr et al. [92], E).

Vital signs in relation to neurological assessment

1. 14.Show
   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 (Adam et al. [2], E; Baumann [16], E).
2. 15.Show
   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 (Adam et al. [2], E).
3. 16.Show
   Take and record the patient's blood pressure and pulse at specified intervals.
   To monitor for signs of increased intracranial pressure. Hypertension and bradycardia usually occur late, after the patient's level of consciousness has begun to deteriorate. Call for medical assistance as soon as it is evident that there is deterioration in the patient's level of consciousness (Adam et al. [2], E; Tortora and Derrickson [199], E).

Assessment of strength and co‐ordination

1. 17.Show
   Ask the patient to close their eyes and hold their arms straight out in front, with palms upwards, for 20–30 seconds. Observe for any sign of weakness or drift.
   To detect any weakness and/or difference of strength in limbs (Baumann [16], E; Bickley [18], E).
2. 18.Show
   Stand in front of the patient and extend your hands. Ask the patient to push and pull against your hands. Ask the patient to lie on their back in bed. Place the patient's leg with knee flexed and foot resting on the bed. Instruct the patient to keep the foot down as you attempt to extend the leg. Then instruct the patient to straighten the leg while you offer resistance.
   To test arm strength. If one arm drifts downwards or turns inwards, it may indicate hemiparesis. To test flexion and extension strength in the patient's extremities by having the patient push and pull against resistance (Baumann [16], E).
3. 19.Show
   Flex and extend all the patient's limbs in turn. Note how well the movements are resisted.
   To test muscle tone (Baumann [16], E).
4. 20.Show
   Ask the patient to pat their thigh as quickly as possible. Note whether the movements seem slow or clumsy. Ask the patient to turn their hand over and back several times in succession. Evaluate co‐ordination. Ask the patient to touch the back of their fingers with the thumb of the same hand in sequence rapidly.
   To assess hand and arm co‐ordination. The dominant hand should perform better (Baumann [16], E; Bickley [18], E).
5. 21.Show
   Extend one of your hands towards the patient. Ask the patient to touch your index finger, then their nose, several times in succession. Repeat the test with the patient's eyes closed.
   To assess hand and arm co‐ordination and cerebellar function (Baumann [16], E).
6. 22.Show
   Ask the patient to place a heel on the opposite knee and slide it down the shin to the foot. Check each leg separately.
   To assess leg co‐ordination (Bickley [18], E).

Assessment of reflexes

1. 23.Show
   Ask the patient to look up, or hold their eyelid open. With your hand, approach the eye unexpectedly or touch the eyelashes.
   To test the corneal (blink) reflex – only if indicated (Bickley [18], E; Fuller [66], E).
2. 24.Show
   Ask the patient to open their mouth and hold down the tongue with a tongue depressor. Touch the back of the pharynx, on each side, with a low‐linting swab.
   To test the gag reflex – only if indicated (Bickley [18], E; Fuller [66], E).
3. 25.Show
   Ask the patient to lie on their back in bed. Place your hand under the knee, and raise and flex the leg. Tap the patellar tendon. Note whether the leg responds.
   To assess the deep tendon knee‐jerk reflex (Bickley [18], E; Fuller [66], E).
4. 26.Show
   Stroke the lateral aspect of the sole of the patient's foot. If the response is abnormal (Babinski's response), the big toe will dorsiflex and the remaining toes will fan out.
   To assess for upper motor neurone lesions (Baumann [16], E; Bickley [18], E; Fuller [66], E).
5. 27.Show
   Ask the patient to read something aloud. Check each eye separately. If their vision is so poor that they are unable to read, ask the patient to count your upraised fingers or distinguish light from dark.
   To test for visual acuity (Fuller [66], E).
6. 28.Show
   Occlude one ear with a low‐linting swab. Stand a short way away from the patient. Whisper numbers into the open ear. Ask for feedback. Repeat for the other ear.
   To test hearing and comprehension (Fuller [66], E).
7. 29.Show
   Ask the patient to close their eyes. Using the point of a neuro tip (a sharp instrument for applying pressure), stroke the skin. Use the blunt end occasionally. Ask the patient to tell you what is felt. See whether the patient can distinguish between sharp and dull sensations.
   To test superficial sensations to pain (Bickley [18], E; Fuller [66], E).
8. 30.Show
   Stroke a low‐linting swab lightly over the patient's skin. Ask the patient to say what they feel.
   To test superficial sensations to touch (Fuller [66], E).
9. 31.Show
   Ask the patient to close their eyes. Hold the tip of one of the patient's fingers between your thumb and index finger. Move it up and down and ask the patient to say in which direction it is moving. Repeat with the other hand. For the legs, hold the big toe.
   To test proprioception (Bickley [18], E). Proprioception is the receipt of information from muscles and tendons in the labyrinth, which enables the brain to determine movements and position of the body (Tortora and Derrickson [199], E).

Post‐procedure

1. 32.Show
   Record the findings precisely in the appropriate sections, noting the patient's best responses. Write exactly what stimulus was used, where it was applied, how much pressure was needed to elicit the response and how the patient responded. Do not be influenced by previous observations.
   Vague terms can easily be misinterpreted. Accurate recording will enable continuity of assessment and comply with NMC guidelines (NMC [144], C).
2. 33.Show
   Report any abnormal findings to medical staff.
   To prevent further deterioration and allow timely intervention (Adam et al. [2], E).
3. 34.Show
   Wash and dry hands and/or use an alcohol‐based handrub.
   To minimize the spread of cross‐infection (NHS England and NHSI [124], C).
4. 35.Show
   Clean the equipment after use.
   To prevent cross‐infection (NICE [127], E).