Routine neuro assessments with every head to toe nursing assessment
- Assess every 4-8 hours per unit routine
- Level of Consciousness
- Glasgow Coma Scale
- Pupillary Assessment
- Extremity Strength
- Level of Consciousness
- Assess alertness
- Assess orientation
- Assess response to stimuli
- Start with verbal
- Then light touch
- Deep touch/shaking
- Painful (nail beds)
- Deep pain (sternal rub)
- Refer to LOC lesson for classifications
- Glasgow Coma Scale
- Best Eye Opening
- 4 – spontaneous
- 3 – to voice
- 2 – to pain
- 1 – no response
- Best Verbal Response
- 5 – oriented
- 4 – disoriented, converses
- 3 – inappropriate words
- 2 – incomprehensible speech
- 1 – no response / intubated
- Best Motor Response
- 6 – follows commands
- 5 – localizes to pain
- 4 – withdraws from pain
- 3 – abnormal flexion (“decorticate”)
- 2 – abnormal extension (“decerebrate”)
- 1 – no movement
- Best Eye Opening
- Pupil Assessment
- Equal, Round, Size
- Reactive to Light
- Should constrict briskly, equal on both sides, when light shined in eyes
- Should constrict when focusing from far to near
- Strength x 4 Extremities
- 5 – full strength
- 4 – overcomes some resistance
- 3 – overcomes gravity, no resistance
- 2 – cannot overcome gravity
- 1 – no movement at all
- Notify provider of any acute changes
- May need STAT CT or MRI to rule out possible stroke
- Clinical judgment
- Perform neuro exams per unit routing
- Perform PRN neuro exams if you suspect any changes
- Notify provider ASAP
- Purpose for detailed exam
- Especially if performing hourly – patients and families can get annoyed, but need to understand the importance.
So let’s talk about what neuro assessments you will need to do on a routine basis.
Now every facility and unit may vary, but typically you’ll do these neuro assessments with every head to do assessment, which could be every 4-8 hours. You may also do these q2 hours or hourly depending on what’s going on with your patient. The first is level of consciousness – you want to determine how alert they are, their orientation, and their response to stimuli. Refer back to the level of consciousness video for details for that. Then we’ll assess Pupils, strength, and the Glasgow Coma Scale or GCS. So let’s look at how to assess each one of those.
Along with level of consciousness, pupillary assessments are some of the most fundamental neuro assessments we perform. They say the eyes are the window to the soul, but I say the eyes are the window to the brain. So the acronym we use for things to assess is PERRLA. It stands for Pupils Equal Round and Reactive to Light and Accommodation. Here are a few examples of normal, unequal, constricted, and dilated pupils. The first thing we look at is whether the two pupils are equal left and right. Then we want to see that they are round. Sometimes patients have had cataracts or other surgeries that give them abnormally shaped pupils. Then we will shine a light in each eye to determine if they constrict briskly. Then we will measure size. The last thing we check is accommodation – I’ll be honest most people don’t check this. What we do is have the patient look at our nose, then put our finger closer to their face and have them shift their focus to our finger. That should cause both pupils to constrict equally – that is called accommodation. If all of these things are present, like in this image, you would document PERRLA 3mm, brisk. If one pupil is blown like in this image, they may have a stroke or bleed or lesion on that side of the brain.
We also want to assess strength. This is a quick way to determine if there are any neuromuscular issues or if the patient may have had a stroke. We test things like grip strength by asking them to squeeze and release our hands. We have them lift their legs and arms up against gravity and then against resistance. And we have them push against us and pull us towards them. Then we determine a score, with 5 being full strength. If they don’t move at all or make any effort, that gets a score of 0. We score each extremity individually, looking for differences from side to side. A one-sided weakness could be indicative of a stroke.
The Glasgow Coma Scale or GCS was initially designed to be an initial assessment of mental status. For example when first encountering the patient or when they arrive in the emergency room. These days, in clinical practice, it is actually used as a routine assessment. We look at their best response in these three categories – whether they open their eyes, how they respond verbally, and how they respond physically, or their motor response. Eyes can score from a 1 where their eyes don’t open at all to a 4 where they open their eyes on their own. Verbal scores from a 1, which indicates NO response. That means no sounds at all. If your patient is intubated, trached, or aphasic, they receive a 1 even if they can write their answers. That progresses based on what sounds they do make and how oriented they are up to a score of 5. Then motor response gets a 1 for no movement at all, 2 and 3 if their movements are abnormal, which we’ll look at in a second, 4 if they withdraw, which means they pull away from pain, 5 if they localize – meaning they reach across their body to try to stop it, and 6 if they follow commands on their own. Keep in mind, you don’t need to provide noxious stimuli multiple times – when you do it, look at their eyes and their motor response. So the total score ranges from 3 to 15. A patient with a GCS of 3 is considered comatose, while a GCS of 15 would be an alert, oriented, conscious person.
Real quick I want you to know the difference between abnormal flexion and abnormal extension. When a patient doesn’t follow commands, we administer some sort of noxious or painful stimulus to see how they respond. If they reach towards it, that’s localizing. If they pull away from it, that’s withdrawing. Below that is abnormal flexion and then abnormal extension. These two things are also known as posturing. Abnormal flexion is also called decorticate posturing. Patients will pull their arms in, their wrists, fingers, and elbows will flex. It’s almost as if they’re trying to protect their “core” – because that’s where the vital organs are. So Decorticate is towards the core. Decerebrate is our abnormal extension. Instead of drawing arms in and protecting themselves, you’ll see their wrists and elbows extend out away from the body. This is considered a worse finding because the patient is clearly not protecting themselves. These would score a 3 or a 2 for motor on the GCS scale and usually indicate a significant neurological issue.
So those are our basic neuro assessments that we’ll do for every patient. We assess their level of consciousness by checking alertness, orientation and response to stimulus, check their pupils with the acronym PERRLA, and assess their strength on a scale of 0 to 5. Then we perform a GCS assessment.
I remember I had a student once come to give me report on her patients. She told me all about her assessment and conversations she had with the patient. Then she said “oh no, I forgot to check a GCS!”. I was like “Hang on… I promise you that you know what their GCS score is… Did they have their eyes open when you went into the room?” She said “yes”. “Okay – were they oriented times 4?”. She started to giggle and said “yes”. And I said “did they follow commands? move and turn when you asked them to?”. And she laughed and said “yes – so I guess it’s a 15, huh?”. So moral of the story is that you can perform a lot of these assessments concurrently. You are gathering a LOT of information just by looking at the patient when you walk in the room. Practice these assessments, find your rhythm, and you’ll be able to catch any neuro changes really quickly.
So go out and be your best selves today. And, as always, happy nursing!!