This document provides information on performing a neurological assessment for patients with altered levels of consciousness. It describes tools like the AVPU scale and Glasgow Coma Scale to assess a patient's consciousness. It outlines common causes of decreased consciousness like head injuries, infections, and metabolic disturbances. It also discusses nursing management considerations for patients with neurological injuries, focusing on airway protection, monitoring vital signs, managing seizures or increased intracranial pressure, and preventing secondary injuries.

1. NEUROLOGICAL
INJURY
ASSESSMENT &
MANAGEMENT
Shibu Chacko

2. Learning Outcomes
 Know when and why a neurological assessment
must be performed
 To be able to carry out a neurological
assessment on a patient with an actual/potential
altered level of consciousness using the AVPU
score and Glasgow Coma Scale
 Know common causes of altered conscious
level/neurological injury
 To understand & rationalise the nursing
management of patients with a neurological
injury

3. Your Amazing Brain
 Receives information – within a fraction of a second
 Acts on the external universe – allows you to cry, walk,
play a musical instrument
 Utilises language – one of your most advanced functions
 Possesses emotions – creates your affective universe
 Receives, processes and help you makes sense of your
world
 Thinks –is responsible for your memory, intelligence,
your thoughts
 Controls your autonomic functions – heart rate,
breathing, homeostasis
 Controls your immune system – protects you from

4. Nervous System
Central Nervous System
• Brain
• Spinal cord
Peripheral Nervous System
• Cranial nerves
• Spinal nerves

5. Common or Concerning Symptoms of the
Nervous System
 Headache
 Dizziness or vertigo
 Weakness
 Numbness
 Loss of sensations
 Loss of consciousness
 Seizures
 Tremors or involuntary movements
 Altered mental status, speech, and language
 Altered sensorium, memory, abstract thinking ability,
speech, mood, emotional state, perceptions, thought
processes, ability to make judgments

6. What is Consciousness?
 An awareness of surroundings and an ability
to interact with the environment
 Level of consciousness is the earliest and
most sensitive indicator of global brain
damage (Hickey, 1997)
 Various descriptive terminologies to describe
altered levels of consciousness

7. Altered states of Consciousness
(Haymore, 2004)
Description Characteristics
Normal consciousness Easily roused, wakefulness, awareness
of environment
Lethargy, obtunded Poorly defined terms. Need further detail
re: response to verbal and tactile stimuli
Confusion Subjective term. Again need further info
re: responses and deficits
Coma Completely unresponsive even to specific
stimuli
Persistent vegetative state Unaware of self & environment but
continues to have sleep-wake cycles
Locked in syndrome Normal consciousness with near
complete paralysis. Can usually answer
questions using eye movements
Brain Stem Death Irreversible loss of brain stem and
cortical functions

8. Common causes of a decreased
conscious level
 Intracranial haemorrhage
 Cerebral infarction
 Intracranial infection
 Hypothermia
 Hyperthermia
 Hypothyroidism
 Hepatic encephalopathy

9. Neurological assessment –Why &
When?
 Instigated for patients who have an acute or
potential neurological injury
 Inability to protect airway – loss of cough
and gag reflexes
 When used in conjunction with other
assessments eg haemodynamic parameters
can provide an early warning of drops in levels
of consciousness
 To prevent irreversible neurological damage
 Increased risk of aspiration

10. A Neurological Assessment should
achieve:
 The establishment of a baseline
 A determination of changes from the
baseline – progress or deterioration
 Changes in neurological status may be
slow eg. In the case of extension of
cerebral infarction or fast in the case of
herniation
 A common language for clinicians to
communicate

11. Assessment tools
 AVPU
 Glasgow Coma Scale
 NIHSS (National Institute of Health - Stroke
Scale)

12. AVPU
 Used for a quick assessment of neurological
status
 Included in many Early Warning Scores
 Any patient scoring less than Alert should have
a more detailed assessment
 Patients scoring P or U require immediate
medical attention
 Not intended for long term use

13. AVPU
A - Alert Conscious and able to answer
correctly: name, date, location
V - Responds to Voice Not Alert, semi-conscious but
responds to shouting (may
just be moans & groans)
P - Responds to pain Moves or groans in
response to painful stimuli
U – Unresponsive No response elicited

14. AVPU
Start by checking to see if patient is awake
↓
If not  talk to them, if still no response
↓
Inflict a painful stimuli (centrally)
↓
If still no response = UNRESPONSIVE

15. Glasgow Coma Scale
 Created in 1974 by Jennett & Teasdale to assess a patient’s level of
consciousness
 Made up of 3 components
1. Eye opening
2. Motor response
3. Verbal response
 A score of 15 denotes a fully conscious patient,
8 denotes a coma
 Lowest score possible is 3
 For a more accurate handover, score should be
communicated in three components. E, V, M

16. Glasgow Coma Scale

17. Assessing Eye Opening
 The level of stimulation required to elicit an eye
opening response
 Tests awareness of environment and brainstem
function
 Patient may have eyes open spontaneously
prior to you approaching or open on hearing you
approach. Should stay open for duration of
assessment
 May open to command or you calling name
 Eyes open in response to pain or nursing
procedure
 Eyes remain closed despite all of above
stimulation

18. Assessing Verbal Response
 To elicit state of orientation/confusion
 Provides information about speech,
comprehension & functioning areas of the
cognitive centres of the brain
 Orientated – Pt knows where he is & why, the
year, date & month
 Confused – Converses in sentences with
varying degrees of disorientation
 Inappropriate words – Random words, no
conversational exchange
 Incomprehensible sounds – Groaning, grunting
– no recognisable words
 None

19. Assessing Motor Response
 To test brain areas that identify sensory input and
translate it to a motor response
 To establish patients ability to obey command,
localise, withdraw, or assume abnormal body
positions in response to any noxious stimuli or
command
 Best arm response noted
 Ask patient to do something above level of spinal
cord. Poke out tongue – not squeeze hand (reflex
grasp)
 Painful stimuli must be elicited centrally not
peripherally. You are trying to assess higher brain
function. Nail bed pain can elicit spinal reflex giving
false impression

20. Motor Response contd.
 If patient able to obey commands – Assess power
and equality by :
Raising both feet off bed, pushing down with feet,
pulling up with feet, pushing up with knees, holding
both hands in the air with eyes closed
 If localising to pain – Assess power by speed &
general movement of the limbs
 Flexion to pain indicates disruption in pathways
between motor area in cortex & brain stem
 Extension – Elbow extended, arms held tightly
against body, internal rotation of shoulders, wrist
flexed, fist may be made

21. DECORTICATE
 Decorticate posturing is also called
decorticate response, decorticate rigidity,
flexor posturing

22. DECEREBRATE
 Decerebrate posturing : typically the head is
arched back, the arms are extended by the
sides, and the legs are extended

24. Pupil Response
 Oculomotor response (Cranial nerve III)
 Assess pupils for
Reaction to light
Size measured in mm (normal range 2-6mm in
diameter)
Shape (abnormalities are ovoid, keyhole, irregular)
Symmetry
 Assess each pupil individually using a narrow beamed
torch
 Record reaction as brisk, sluggish or fixed (non reactive)
 Sluggish or suddenly dilated unequal pupils are an
indication of worsening occular nerve compression
 Bilateral dilatation and fixation represents
decompensation – indicates serious brainstem

25. Pupillometer

26. Classification of Brain Injury
According to Glasgow Coma Scale
(GCS) (HICKEY 2003)
MILD
GCS 13-15
MODERATE
GCS 9-12
SEVERE
GCS 3-8

27. Frequency of Assessment
 NICE RECOMMENDATIONS (2007)
 Minimum documented observations
 For patients admitted for head injury observation the minimum acceptable
documented neurological observations are: GCS; pupil size and reactivity; limb
movements; respiratory rate; heart rate; blood pressure; temperature; blood oxygen
saturation.
 Frequency of observations
 Observations should be performed and recorded on a half-hourly basis until GCS
equal to 15 has been achieved. The minimum frequency of observations for patients
with GCS equal to 15 should be as follows, starting after the initial assessment in the
emergency department:
 half-hourly for 2 hours
 then 1-hourly for 4 hours
 then 2-hourly thereafter.
 Should a patient with GCS equal to 15 deteriorate at any time after the initial 2-hour

28. Brain Injuries
 Two broad categories
 Primary – Sustained at the time of insult or
accident, include lacerations or contusions of
brain parenchyma
 Secondary – Result of a complex process that
develops hours or days after impact- Due to a
decreased cerebral oxygen delivery as a result
of Hypertension, Hypoxia, cerebral oedema,
intracranial hypertension, infection etc
 Damage can be Focal or Diffuse

29. Herniation & brain stem death
 Persistent rise in ICP  Loss of Autoregulatory
mechanisms (regulation of blood flow)  Further rises in
ICP  Herniation (displacement of portions of the brain)
 There are three types of herniation
 Central or transtentorial herniation results in brain stem
death
 Brain Stem death = the absence of all brain function
shown by coma, fixed pupils, apnoea & absence of all
brain stem reflexes
 Brain stem tests can be carried out at the bedside to
confirm death
 Consider organ donation/early referral to SNOD

30. Other causes of Altered Conscious
level
Hypoxia
 Reduced 02 delivery to the brain
• Airway obstruction
• Primary respiratory problem
• Shock
Metabolic disturbances
 Chemical depression of the brain
• Alcohol, opiates, sedatives, anaesthesia, CO2, Methane
• Hypo/hyperglycaemia, liver failure, renal failiure, Electrolyte
imbalance
Psychological causes , dementia (Often dealt with very differently)

31. Nursing Management of neurological
Injury
 Exact management will vary dependent on
the specific cause/type of injury/condition
 ABCDE!-Pertinent to the care of patients
with an altered level of consciousness.

32. Nursing Management & Considerations
Actual/potential problems Actions
Airway Compromise with reduced GCS
Reduced ability to cough and clear secretions
Aspiration pneumonia
Consider using recovery position
Consider use of airway adjuncts/suctioning. Pre-oxygenation
Anaesthetic assistance
Definitive airway
Always ensure airway secure for transfer
Breathing pattern may be altered (Cheyne stokes) if raised ICP
(respiratory control centres are located in pons and medulla of
brain stem)
Low RR may indicate drop in conscious level secondary to
opiates
Reduced Vital capacity/ability to cough in GBS patients
Risk of further neurological injury due to hypoxia
Risk of ↑cerebral blood flow and thus ICP IF paCO2 high
(vasodilatory effects of CO2)
Use of ( CPAP) PEEP ↑ ICP
Excessive coughing may cause transient ↑ in ICP and or re-bleed
in patients with heamorrhagic CVA’S
Close observation of RR, Depth and pattern. If changes
accompanied by ↑BP and ↓HR call for help (sign of herniation)
Monitor all patients receiving opiates closely
Administer 02 and monitor 02 Sats closely to reduce the risk
of further hypoxic brain injury. ABG’s if GCS deteriorating
Consider mechanical ventilation if unable to maintain PaO2
>10 kPa on maximal 02 therapy
Avoid Hypercarbia. Maintain normal PaCO2
Do not use without outreach/Anaesthetic involvement
May require ITU Care and sedation to manage this

33. Nursing Management & Considerations
Actual/Potential Problems Actions
Cardiovascular instability – either due to brain stem
dysfunction (Cushings Triad)
Associated trauma/sepsis also  hypovolaemia real
or relative
Hypertension in ischaemic stroke
Hyperpyrexia (either due to head injury damage to
hypothalamus or as a result of infection eg
meningitis). Will cause ↑ metabolic rate and
therefore cerebral 02 consumption
Electrolyte imbalances (May be the cause or result of
neurological injury)
Risk of SIADH
Risk of VTE due to immobility
Monitor BP, HR & rhythm closely for early signs of
decompensation
Maintain adequate BP (map) to ensure good cerebral
perfusion pressure
Good CVS assessment and assessment of fluid status
Administer fluid boluses to maintain BP. Avoid dextrose
containing solutions and avoid hypernatraemia
Consideration of ITU care if inotropic support required
Monitor BP and administer anti-hypertensives
Actively cool patient. Aim for Temp <37.5. Administer
antipyretics
Administer appropriate antibiotics
Assist with further investigations eg Lumbar puncture
Monitor levels of K+, mg, and Na closely. Maintain
normal levels.
Monitor quality and volume of urine closely. May need
rehydration to maintain circulating volume. May need
DDAVP.
Consider serum and urine osmolarity measurements
Monitor for signs of VTE. Teds, VTE prophylaxis.(as
appropriate), encourage limb movements

34. Nursing Management & Considerations
Actual/Potential Problems Actions
Disability
Deterioration in GCS due to secondary damage or
extension of original damage.
Risk of further strokes in CVA patients
Changes in pupil size & reactivity
Worsening cerebral oedema
Headaches (early signs of meningitis and sign of
intracerebral haemorrhage)
Seizures (caused by any cerebral irritation)
Analgesia and sedative requirements
Hypo/Hyperglycaemia
Regular monitoring of GCS & pupil reaction (NICE
guidelines for Head Injury, 2007). Early recognition
will improve outcome
Monitor for changes in limb movement & strength.
Consider use of osmotic diuretics (Mannitol).
Call for help if deterioration is observed and
increase frequency of obs. CT SCAN/Transfer
to tertiary centre may be required
Monitor for signs of severe headache
Airway manoeuvres as appropriate, maintain safety,
Control of seizures with medication and or sedation
to prevent further neurological damage
Ensure pain well controlled to reduce agitation
which would increase ICP
Sedation & neuromuscular blocking agents in ITU
setting only with controlled ventilation
Aim for normal BMs. Hyperglycaemia will cause
vasospasm. Consider use of Insulin infusion.

35. Other Nursing Management & Considerations
Actual/Potential Problems Actions
Nutrition. Level of consciousness will affect ability to
take oral nutrition
Risk of aspiration in patients with impaired swallow
secondary to neurological injury
Risk of aspiration in patients who are vomiting
secondary to neurological injury
Unable to pass NG tube in patients with basal skull
fractures
Constipation will raise Intra-abdominal pressure and
thus ICP
Early enteral feeding and maintain hydration as head
injury increases demand of brain for O2 and glucose
Assessment of swallow
Anti-emmetics and or NG drainage
Oro -gastric tube must be considered
Bowel assessment & management. Aperients as
indicated
Incorrect positioning and neck rotation and hip flexion
can cause rises in ICP as fluid drainage from brain is
impeded
Internal jugular CVC’S/ ETT ties - impede venous
drainage and ↑ ICP
Complications of immobility – pressure sores etc.
Clustering of activities cause cumulative rise in ICP
Sensory overload causing ↑ ICP
Photophobia (In meningitis)
Psychological/psychosocial issues
Ensure head elevation of 30° (to facilitate venous
drainage. Avoid flexion and rotation
Femoral lines or good peripheral IV accesss. Secure
ETT with elastoplast
Reposition regularly, encourage mobility etc
Avoid this. Consider boluses of sedation prior to
activities eg suctioning (in ITU setting)
Reduce lighting
Address fears & anxieties

36. Further Reading/useful websites
 National Institute for Health & Clinical Excellence (2007)
Head Injury. Triage, assessment, investigation and early
management of head injury in infants, children and
adults
 National Institute for Health & Clinical Excellence.
Stroke. Diagnosis and initial management of acute
stroke and transient ischaemic attack
Available at www.nice.org.uk
 Headway: The Brain Injury Association
www.headway.org.uk

37. Any Questions?