The Glascow Coma Scale (GCS) is used to assess level of consciousness by evaluating eye opening, verbal response, and motor response on a scale of 3 to 15, with lower scores indicating a worse prognosis. A neurological exam assesses cranial nerves, motor function, coordination, reflexes, and sensation to identify abnormalities. Key tests include checking strength, tone, and range of motion before progressing to coordination, balance, reflexes, and sensory exams involving light touch, proprioception, and discrimination. Interpreting exam findings helps understand a patient's injury in relation to neurological function.

1. Glascow Coma Scale Glascow Coma Scale (GCS) is a scale used to assess LOC; used to monitor changes in assessment Criteria (always describe the greatest level of response) Best Eye opening Spontaneous (4) To Speech (3) To Pain (2) No Response (1) Best Motor Response Obeys verbal commands (6) Localizes to pain (5) Non-purposeful Movement [Withdraws] (4) Flexion [Decorticate posturing] (3) Extension [Decerebrate posturing] (2) No Response (1) Best Verbal Response Orientation X 4 (5) Confused (4) Speech [Inappropriate Words] (3) Sounds [Incomprehensible] (2) No Response (1)

2. Interpretation of GCS Highest Score obtainable 15 Lowest Score obtainable 3 Indications A score of 15 represents no deficit A score of 9-14 represents minor deficit A score of 8 or less represents major deficit (Less than 8 requires intubation due to the patient not able to protect airway)

3. Cranial Nerve Assessment I – Smell (not usually tested unless problem exists) II – Visual Acuity (Sight) III- Pupil Constriction, Inward movement, upward and out movement, Downward and out movement, Upward and in movement (Cardinal Directions) IV – Downward and in movement (Cardinal Directions) V – Sensation to face and chewing (Mastication) VI – Lateral (outward) movement of eye (Cardinal Directions) VII – Facial movements (smiling, frowning, facial expressions) VIII – Ability to hear and balance (Weber, Rhinne, and Rhomberg Test) IX – Ability to swallow and cough X – Ability to say “Ah”, swallow, and ability to Gag XI – Ability to shrug shoulders against resistance XII – Ability to move tongue out and side to side

4. Motor Exam Observation Involuntary muscle movement Voluntary muscle movement Check symmetry: Right and Left Strength of movement Monitor for muscle atrophy Monitor Gait Muscle Tone Monitor muscle tone by asking patient to relax and perform range of motion and note any resistance or passive movement Monitor for decreased tone: Flaccid Monitor for increased tone: Spastic or Rigid movement Strength Monitor range of motion against resistance Have patient push and pull with extremities, monitor flexion and extension of ankle (Dorsiflexion and Plantar flexion), and monitor grips

5. Coordination and Gait Exam Assess Rapid Alternating Movements Have patient tap palms and posterior hand to thighs in a fast alternating motion Have patient touch each finger to thumb starting from index finger to pinky finger in a fast sequential motion Have patient tap ball of each foot to clinicians hands in a fast motion Point to Point Discrimination Ask patient to touch end of clinicians finger to nose multiple times, during this process clinician should move finger around different locations Have patient stoke shin with opposite heel, have them do this with both feet

6. Coordination and Gait (cont.) Romberg Have patient stand with eyes closed and feet together for 20 secs; monitor for swaying or lack of balance If patient sways: Test is positive (This can indicate a vestibular or proprioception deficit) Gait If patient is able to walk, have patient walk across room and turn around then return (monitor for uncoordinated movements or swaying) Have patient walk in a straight line (heal-toe, just on toes, and just on heals); monitor for balance issues Have patient hop on each foot and monitor for balance issues Have patient perform a shallow knee bend Have patient arise from a sitting position

7. Reflexes Deep Tendon Reflexes These are only monitored for H&P assessment; not apart of a routine assessment unless issues are needing to be monitored Use Reflex Hammer and slightly strike each area and monitor for Reflex Biceps (C5, C6) Have patient relax arm, place thumb on tendon of bicep on the inside of the elbow, strike hammer against thumb on the elbow, monitor for movement Triceps (C6, C7) Hold patients arm and ask them to relax arm in a free hanging position, using broad side of reflex hammer, gently strike with hammer, and monitor for movement Brachioradialis (C5, C6) Have patient rest arm on abdomen, gently strike 2 inches above wrist and watch for flexion of forearm and wrist Abdominal (T8-T12) Stroke key or tongue blade inward towards umbilicus and monitor for abdominal flexion Knee (L2-L4) Have patient sit with feet off ground and free hanging, gently strike below the patella and monitor for kicking motion Ankle (S1, S2) Hold patients foot in dorsiflexion position, gently strike Archille’s Tendon and monitor for plantar flexion

8. Reflexes (cont.) Reflexes can be noted using the Tendon Reflex Grading Scale 0 – absent of movement 1 – hypoactive movement 2 – normal movement 3 – hyperactive movement without clonus 4 – hyperactive movement with clonus Clonus is repetitive movement after stimulation of reflex Babinski’s Sign Gently stroke bottom of patients foot from heel to big toe following lateral border of foot Monitor for movement of toes (flexion of toes or extension of toes) If toes extend (flare) in an adult that would be a positive babinski sign If toes flex (curl over) in an adult that would be a negative babinski sign

9. Sensory Exam Sensory Exams: Light Touch, Proprioception, Dermatomes, and Discrimination When assessing the sensory function, patients should have their eyes closed during this portion of the exam and explain each test prior to performing it.

10. Sensory Exam (cont.) Light touch: Map the body out into sections (Example: Head and neck, extremities, and trunk) Touch to areas simultaneously, asking the patient if the two areas feel different. (Example: Touch both arms and ask if one side feels different than the other) This exam compares symmetry of sensory function (Right and Left) Any deficits need to be documented

11. Sensory Exam (cont.) Proprioception: The ability to determine what are of the body is being touched Start off big such as an extremity and narrow the area to a specific point (touching a patients ring finger and asking the patient to identify where they are being touch, while the patients eyes are closed The patient should also be able to determine the direction of movement when you manually move the the toe or finger

12. Sensory Exam (cont.) Dermatomes: Sensation that correlates with level of spinal response. (see slide 11) Touch different areas of the body and ask patient when sensation changes Work in descending order (Head to Toe) Note where sensation changes Assess different senses: Pain, Temperature, and Light Touch

13. Sensory Exam (cont.) Discrimination: The ability to distinguish between different senses. (Sharp, dull, light touch) In order to perform this exam you will pick different area of the body and use a Q-tip with a wooden handle ( cotton end-soft, wooden end-sharp) Touch each area alternating between sharp and dull and have patient describe what end you touched them with while their eyes are closed Graphesthesia: Take your finger and write a number in the palm of the patients hand and have them say the number

14. Conclusion In order to get an idea of the patients injury related to the neurological function, you must be able to identify normal and abnormal values Competence with a neurological assessment will identify subtle changes with the patient and can prevent further deficits

15. Works Cited Barker, E. (2008). Neuroscience Nursing: A spectrum of care (3rd ed.). St. Louis, MO: Mosby Elsevier. Hickey, J. V. (1997). The Clinical Practice of Neurological and Neurosurgical Nursing (Fourth ed.). Philadelphia, PA: Lippincott-Raven Publishers. Jarvis, C. (2008). Physical Examination and Health Assessment (5th ed.). St. Louis, MO: Saunders Elsevier. Noah, P. (2004, September). Neurologic Assessment: A Refresher. Retrieved October 2, 2010, from http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=120796 Rathe, R. (2000, December 19). Neurologic Assessment. Retrieved October 8, 2010, from http://medinfo.ufl.edu/year1/bcs/clist/neuro.html Smirniotopoulos, J. G. (2000). Cranial Nerve Summary. Retrieved October 9, 2010, from http://rad.usuhs.mil/cranial_nerves/timrad.html