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Summary
The primary tool used by nurses to assess a patient's neurological status is the neurological observation chart incorporating the Glasgow Coma Scale. This article explains the correct use of the chart and how to interpret the findings.
Keywords
Glasgow Coma Scale; Neurological assessment; Observations; Vital signs
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Aims and intended learning outcomes
This article aims to raise awareness of basic neurological observations, namely the Glasgow Coma Scale (GCS), pupil reaction, limb responses and vital signs. It should be of value to all nurses who care for patients at risk of neurological deterioration. It explains how to complete the neurological observation chart, which includes the GCS, accurately, safely and consistently. After reading this article you should be able to:
* Outline the rationale for using the GCS.
* Assess a patient's level of consciousness by evaluating three behavioural responses: eye opening, verbal response and motor response.
* Perform a neurological assessment, using the GCS, pupil reaction, limb responses and vital siens, and interpret the findings.
Introduction
Many patients are admitted to neurosurgical units from general clinical areas such as medical units or accident and emergency departments. Nurses working in these areas need to be able to perform a basic neurological assessment accurately and understand the significance of the findings. Accurate assessment and prompt action when needed can improve the eventual outcome, not just in terms of survival but also by minimising the degree of residual neurological deficit.
The neurological observation chart incorporating the GCS is well established both nationally and internationally (Teasdale and Jennett 1974) as the primary tool used by nurses to make quick, repeated evaluations of several key indicators of neurological status ( Auken and Crawford 1998):
* Level of consciousness (GCS).
* Pupil size and response to light.
* Limb movements (motor and sensory function).
* Vital signs.
Recently published guidelines for the management of patients with head injuries (National Institute for Clinical Excellence (NICE) 2003) stipulate the use of the GCS for assessment and classification of all head-injured patients.
Although there have been...