Download Neurological Observations in the Adult Patient

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1
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at least one randomised controlled trial
3a
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3b
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4
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5
expert committee reports or opinions and / or
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6
recommended best practise based on the clinical
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Consultation Process
Guidelines For Performing And
Recording Neurological Observations
In The Adult Patient
Gail Mackey
Nursing Development
June 2014
To monitor all adult patients in acute
hospital settings. The guidelines will
be used in all clinical areas where
adult patients require observations.
This includes patients in non-inpatient
areas who are undergoing treatment
or procedures and therefore have a
potential for deterioration. (E.g.
Interventional radiology and speciality
Day Case areas)
3
Guideline for Performing Neurological
Observations
Ward Sisters/Charge Nurses, PDMs,
Clinical Leads, Matrons, Nursing
Practice Guidelines Group (includes
University of Nottingham
representative), Clinical Quality, Risk
and Safety Manager, Trust Intranet.
Matron’s Forum
December 2013
All Clinical staff
December 2018
Ratified by:
Date:
Target audience
Review Date: (to be applied by the Integrated Governance Team)
A review date of 5 years will be applied by the Trust. Directorates
can choose to apply a shorter review date, however this must be
managed through Directorate Governance processes.
This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using
guidelines after the review date.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
NURSING PRACTICE GUIDELINES
GUIDELINES FOR PERFORMING AND RECORDING
NEUROLOGICAL OBSERVATIONS IN THE ADULT PATIENT
CONTENTS
Introduction: ............................................................................................3
Exclusion criteria: ................................................................................5
Background: ...........................................................................................5
Responsibility and accountability for performing clinical observations .....7
Neurological Observations: .....................................................................7
Glasgow Coma Scale: .........................................................................8
Limitations of the Glasgow Coma Scale ..............................................8
Painful Stimuli .....................................................................................9
Frequency of neurological observations: ...........................................10
Equipment ......................................................................................... 10
Eye Opening ......................................................................................... 11
Best Verbal Response ..........................................................................12
Best Motor Response ...........................................................................14
Pupil reaction to light: ........................................................................14
Other physiological observations .......................................................... 18
Level of consciousness – assessment using the AVPU scale ...........18
Provisions for audit ............................................................................19
References: .......................................................................................... 20
Further Reading .................................................................................... 21
Appendix 1 : Glasgow Coma Scale and Blood pressure scoring grid ....23
Appendix 2 : Motor Responses ............................................................ 24
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
GUIDELINES FOR PERFORMING AND RECORDING
NEUROLOGICAL OBSERVATIONS IN THE ADULT PATIENT
Guidance for performing and recording neurological observations
including the Glasgow Coma Scale in adult patients and ensuring timely
and appropriate escalation of care.
Introduction:
Patients admitted to hospital believe they are entering a place of safety
and they are in the best place to receive prompt and effective treatment
(NICE, 2007). In order to detect early changes in a patient’s condition it
is imperative that a full set of clinical observations are carried out on
admission and regularly throughout the patient’s stay. Neurological and
clinical deterioration can occur at any stage of a patient’s illness
(Waterhouse 2008). Assessment of a patient’s conscious level should
become a routine part of any set of observations in order to detect
change as promptly as possible.
The Glasgow Coma Scale (GCS) is the standard tool used for
assessing and recording neurological observation within the following
adult areas within NUH; Emergency Department, Neurosciences ward
and Critical care Units. It provides a detailed tool with which to assess a
patient’s conscious level.
A simplified scoring tool has been devised for use in all other clinical
areas. The AVPU scoring tool (refer to current NUH Early Warning
Scoring Chart, clinical guidelines, 2011) can be used to quickly assess a
patient’s conscious level. It is objective, easy to use and can be readily
used to communicate information. It is not a sensitive method for
assessing trends in neurological deterioration and patients who are not
alert require a further in-depth assessment by a registered practitioner
using the Glasgow Coma Scale (GCS). (See appendix 1)
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Neurological observations comprise of a combination of indicators and
are performed on patients who may be at risk of neurological
deterioration (Waterhouse 2005). The main purposes for recording the
observations are to determine a baseline, to identify changes and to
promptly detect life threatening situations. The Glasgow Coma Scale
(GCS) provides a simple, consistent method of neurological evaluation
(Waterhouse, 2005). It is an assessment of conscious level measuring
three indicators:
•
eye opening (E)
•
verbal response (V)
•
best motor response (M)
The GCS is incorporated into the NUH observation chart.
Other components and essential parameters; pupil reaction, vital signs,
limb movements and strength define the basic general neurological
condition of the patient and when monitored regularly, allow changes to
be detected early (Hickey, 2008). While other neurological assessment
tools exist, the GCS is recommended for use in all neurological patients
(Waterhouse, 2005) and specifically for people with head injuries (NICE,
2007). Generally, the 3 components of the GCS (E, V, M) are the most
sensitive indicator of neurological deterioration, compared to other
changes, (pupillary reactions and vital signs). The latter usually
occurring after the GCS has worsened (Waterhouse, 2005).
Nottingham University Hospitals (NUH) recognises the importance of
ensuring that adult patient neurological observations are appropriately
and promptly recorded by trained staff. NUH is committed to ensuring
that when observations are outside normal parameters or there are
signs of neurological deterioration that staff will take appropriate action
to monitor the patient more closely and seek advice and support from
other members of the multi-disciplinary team, with the aim to reverse or
prevent further deterioration and avoidable harm to the patient (NICE,
2007). In line with the NICE Clinical Guidance 50 (2007) NUH Adult
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Physiological Observation chart incorporates an Early Warning Scoring
system (EWS) which supports staff in recognising early clinical
deterioration. Provides guidance to the frequency and degree of
monitoring required as well as the actions that should be carried out in
order to prevent further deterioration occurring. A clear escalation
strategy on the chart ensures that nursing and medical staff can provide
effective clinical care. (Department of Health 2006, Patient Safety First
Campaign, 2010).
Exclusion criteria:
This guideline is not intended to be applied to the following patient
groups:
•
Paediatric patients (16 years and under) and neonates. Normal
physiological parameters are different in these patient groups.
Background:
NICE (2007) recommend that physiological observations, including
neurological observations and “track and trigger scoring” should be used
to monitor all adult patients in acute hospital settings. The guidelines will
be used in all clinical areas where adult patients require observations.
This includes patients in non-inpatient areas who are undergoing
treatment or procedures and therefore have a potential for deterioration.
(E.g. Interventional radiology and speciality Day Case areas)
Observations should be recorded at initial assessment (providing a
baseline) and thereafter at least every 12 hours as part of routine
monitoring (NICE 2007). All patients who are unscheduled admissions
with a recognised neurological event/assault/injury and/or are under one
of the following specialties: Neurosurgery, Neurology, Spinal and Stroke
medicine should have a GCS scored at least every 4 hours for the first
24 hours of their in-patient stay. Thereafter the frequency should be
reviewed by a senior member of the patients’ medical team and altered
as required.
Patients discharged from a critical care area under one of the following
specialities; Neurosurgery, Neurology, Spinal and Stroke medicine must
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
have a minimum of 4 hourly GCS recorded for at least 24 hours post
discharged. Thereafter the frequency should be reviewed by a senior
member of the patients’ medical team and altered as required.
In specialist areas where an accurate neurological assessment is
required, the Glasgow Coma Scale rather than the ‘AVPU’ tool must
always be used. A decision to increase or decrease the frequency of
observations should be made by a Registered Nurse depending on the
individual patient’s clinical condition. The frequency of observations
MUST increase if abnormal physiology is detected (Goldhill et al 2004,
McQuillan et al 1998). The EWS chart incorporates a clear escalation
and monitoring plan, to give guidance about ensuring timely intervention
by appropriately trained personnel (NICE, 2007). Refer to current NUH
Early Warning Scoring Chart, clinical guidelines, 2011)
These guidelines are designed to work in conjunction with the Policy for
the use of the Adult Observation Chart and Early Warning Scoring
(EWS) tool in the monitoring, recognition and management of the sick
and / or deteriorating Adult patient (2011).
It is the responsibility of the Registered Nurse/Practitioner to ensure that
a complete set of observations is recorded on every episode unless
directed by senior medical staff. In these circumstances it should be
clearly documented within the medical notes what observations should
be recorded and parameters. In line with the Adult EWS chart each set
of observations must include the recording of the following: temperature,
respiratory rate, oxygen saturations, blood pressure, pulse rate, urine
output. In addition the following should also be documented: oxygen %,
oxygen delivery device, pain and conscious level (AVPU or GCS).
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Responsibility
observations
and
accountability
for
performing
clinical
Throughout the NHS, professional groups are promoting more flexible
ways of working to deliver patient–centred care (Spilsbury and Meyer,
2005). NUH permits appropriately trained and competent non-registered
nurses to undertake the task of taking physiological observations. If the
GCS is utilised, it must only be performed by a Registered Nurse or
other competent practitioners. The assessment should include pupil
reactions and limb power, as well as the physiological observations
detailed above.
Please see Policy for the use of the Adult Observation Chart and Early
Warning Scoring (EWS) tool in the monitoring, recognition and
management of the sick and / or deteriorating Adult patient (2011) which
clearly states roles and responsibilities of registered and non-registered
nurses in NUH.
Neurological Observations:
A Registered Nurse/Practitioner must review each patients observation
chart a minimum of once per shift to review and indicate the frequency
with which the observations should be recorded. They should document
and sign the observation chart accordingly. Throughout their shift this
frequency should be reviewed and altered in accordance with the
monitoring plan if the patient’s condition deteriorates.
It is the Registered Nurse/Practitioners responsibility to ensure that a full
set of observations and accurately scored EWS is recorded a minimum
of 12 hourly on all patients in line with the NICE guidance (2007). This
includes up to and on the day of discharge. (Exception – are those
patients on the care of the dying pathway).
The following observations will be recorded:
•
Glasgow Coma Scale (GCS)
•
Pupil reactions to light
•
Limb power
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
•
Physiological observations as outlined in Guidelines for performing
and Recording of Physiological Observations in the Adult Patient (NUH,
2011)
Glasgow Coma Scale:
The GCS has 15 points. A GCS of 15 equates to an orientated person
who is able to obey commands and open his/her eyes spontaneously.
The lowest score obtainable is a GCS 3. The scoring system allocates a
number to each of three responses (see below), which are added
together to give a total score (Waterhouse 2005). When assessing the
GCS, hearing, language and speech difficulties need to be taken into
account.
Medical staff must be informed if a patient’s Glasgow Coma Score drops
by 2 points or more as this may indicate a neurological emergency. A
drop of one point must also be considered as a significant change /
deterioration and the assessor should seek a second opinion from an
experienced competent practitioner.
For example if an orientated patient becomes disorientated or a patient’s
motor response changes by one point this could be indicative of rapid
deterioration.
Limitations of the Glasgow Coma Scale
While the GCS has been shown to be a useful tool when assessing
neurological function it also has limitations. Other factors can affect the
GCS. These include:
•
analgesia / sedation
•
ventilation / intubation
•
other medications
•
alcohol and other drug intoxication
•
spinal cord injury (Fischer and Mathieson, 2001).
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
In addition, the GCS may be difficult to use with people who:
•
can only speak or understand a different language
•
are children
•
have learning difficulties
•
have speech difficulties e.g. dysphasia or are dysarthric
Painful Stimuli
The Glasgow Coma Scale may require the application of a painful
stimulus. However, there is disagreement in the literature regarding:
•
The nature of painful stimuli:
Painful stimuli can be central (evoking a response from the brain), or
peripheral (evoking a primary reflex response from the spine) (Edwards,
2001).
•
The methods of applying painful stimuli:
The trapezius squeeze is regarded as the most favourable method of
applying central painful stimuli (Waterhouse 2008). To do this, the
trapezius muscle is located by palpating the area superior to the clavicle
and medially to the shoulder. Using the thumb and forefinger hold the
muscle and apply gradually increasing pressure for a maximum of 30
seconds while noting any verbal and non-verbal responses
(Waterhouse, 2005).
Other methods of applying central pain include supraorbital pressure
and sternal rub. Each of these has associated contraindications or
complications (Lowry, 1998; Fairley and Cosgrove 1999) and if used,
should only be used by practitioners trained in these techniques and in
areas which have a local policy to reflect this.
•
The need for painful stimuli:
The actual need to apply pain as part of a neurological assessment has
been challenged (Lowry, 1998). However, this remains an accepted and
valuable component of the GCS (Waterhouse, 2005; Palmer and Knight
2006).
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Frequency of neurological observations:
The frequency of neurological observations should ultimately be
determined by the practitioner’s professional judgement (Edwards,
2001). There are recommendations in the literature, ranging from every
5 – 10 minutes to 4 hourly (Stewart, 1996) and in the head injured
patient, every 15 minutes (NICE, 2007) but as the evidence and
rationale is unclear, the condition of the patient, combined with clinical
judgement, should determine frequency.
Equipment
Pen Torch and equipment for recording vital signs.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Eye Opening
This assesses arousal or wakefulness, largely a function of structures
within the brainstem (Waterhouse, 2005).
Spontaneously
Eyes open To speech
To pain
None
1.
4
Eyes closed
by swelling =
C
3
2
1
Action
Rationale
Assess for eye opening by
observing the patient as you
approach him/her – if he/she opens
eyes spontaneously, score 4. (Note
that if the person has hearing
difficulties, gently touch him/her – if
eyes open, score 4).
Spontaneous eye opening is an
indication
that
the
arousal
mechanisms within the brain are
functioning.
2.
If the patient’s eyes remain closed,
say something to elicit a response
(e.g. his/her name). If eyes open,
score 3.
3.
If there is no response to speech,
touch the patient on his/her hand,
arm or shoulder and shake gently. If
eyes open, score 3.
If the neurone pathways that make
up these mechanisms are impaired
due to trauma or because of rises in
intracranial pressure, a greater
sensory stimulus is needed to evoke
eye opening (Edwards, 2001). Thus
speech, then touch and as a last
resort, pain, is utilised.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Action
Rationale
4.
If there is no response, exert a
painful peripheral stimulus: using
the side of a pen or pencil, apply
gradually increasing pressure to the
side of the finger, (the lateral outer
aspect of the finger) for a short time.
If eyes open, score 2.
Some commentators suggest that
peripheral pain should be applied if
there is no response to speech or
touch. This is because a central
painful stimulus may result in the
patient grimacing and thus closure
of the eyes will occur (Waterhouse,
2005). When applying peripheral
If there is still no response, exert
pain, the side of the finger, rather
painful central stimulus. If eyes
than the actual nail bed, is used in
open, score 2.
order to minimize damage (Fairley
and Cosgrove 1999). It is important;
however, to elicit the best response,
so central pain may be applied.
5.
If there is no eye opening following
the application of painful stimulus,
score 1
6.
If eye opening is not possible due to
swelling, write ‘C’ against ‘none’.
Best Verbal Response
This examines comprehension and reflects the ability to express
thoughts into words, expression of speech
V
Orientated
Best
Disorientated
Inappropriate
verbal
response Incomprehensible
None
sounds
5
4
3
2
1
Endotrache
al tube or
tracheostom
y=T
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
1.
Action
Rationale
Ask questions to assess orientation
to time, place and person, e.g. ask
the patient if he/she knows what the
month or year is, where he/she is
and who he/she is. Avoid questions
that elicit a yes/no response. If
correct answers are elicited to all 3
questions, score 5.
Orientation is defined as the ability
of a person to know the current year
/ season and month (time); where
she / he is (place); and his / her
identity (person). It is not essential to
know the day and date as events
such as a prolonged hospital stay or
recent transfer from a different
hospital can have a disorientating
effect (Waterhouse, 2005).
If the patient is expressively Dysphasic patients cannot be
dysphasic, write ‘D’ instead
assessed accurately for orientation
2.
If the patient cannot answer the
above questions correctly but is able
to sustain some conversation, score
4.
3.
If single-worded answers are given
or if the patient is unable to make a
sentence of words, this is classed as
inappropriate words; score 3.
4.
Deterioration may be typically
manifested by a loss of orientation to
time, place and person – in that
order (Shah, 1999 cited in
Waterhouse, 2005).
If only noises such as moaning or At this stage responses may not be
groaning sounds are made, score 2. elicited by talking to the patient and
central stimuli may be required.
(Waterhouse 2005)
5.
If the patient makes no attempt to
speak and no sounds are made,
score 1.
6.
If no verbal response is possible due Intubated patients cannot speak
to an endotracheal tube or although they may be conscious.
tracheostomy (without a speaking
valve) write ‘T’ against ‘none’.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Best Motor Response
This assesses areas of the brain that identify sensory input and translate
this into a motor response (Waterhouse, 2005) and is an indicator of
how well the brain is functioning as a whole (Edwards, 2001).
Obey
commands
M
6
Best
Localise
to 5
Normal
Flexion 4
motor
pain
3
response Abnormal
Extension
2
Flexion
None
1
Usually
record the
best arm
response
Pupil reaction to light:
The pupils are assessed for size, shape and equality and reaction to
light. Abnormal reactions can indicate raised intracranial pressure and/or
damage to the optic nerve(s).
NB If the eye/eyes are closed through swelling or trauma
(facial/orbital fractures) this procedure may not be appropriate and
should be recorded as ‘C’ on the chart.
Size
Right
Reaction
PUPILS
+ reacts
Size
reaction
Reaction
C
closed
no
Left
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
eye
Action
Rationale
1.
Ascertain any significant patient
history that may affect pupil
reactions e.g. cataracts or recent If such issues are not known, pupil
drug therapy that may dilate or reactions could be misinterpreted.
constrict the pupil.
2.
Note the size, shape, equality and Where possible, both pupils should
position of the pupils in normal be assessed at the same time to
lighting.
ensure equal bilateral reaction and
consensual response.
3.
Using a pen torch, shine the light
moving from the outer towards the
inner aspect of the eye. Observe the
size (see pupil scale diagram –
appendix 1), shape and reaction of
the pupil and record brisk reactions
as + and sluggish reactions as ‘S’.
4.
Progressive dilatation and loss of
pupil reaction on one side can be
due to pressure on the occulomotor
nerve on that side. Pressure can be
caused by a variety of lesions, but if
it continues to build, the occulomotor
nerve on the other side can also be
compressed, resulting in unreactive,
Allow a few moments to pass before dilated pupils – a sign of severe
(Edwards,
2001;
repeating the procedure in the other damage
Waterhouse, 2005).
eye.
To allow the pupils to adjust to
normal lighting.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Limb Power:
Damage to any part of the motor nervous system can affect the ability to
move (Dougherty and Lister, 2004). Limb responses may give clues to
the geographical distribution of neurological dysfunction (Waterhouse,
2005). The power of each limb should be recorded separately.
1
Arm strength. Ask the patient to To identify limb weaknesses.
close their eyes and hold their
In
some
specialist
areas
arms out in front of them.
(Neurosurgery,
ITU,
HDU)
If the patient can maintain this practitioners are competent in
position, record the power as assessing strength and tone of
normal.
limbs by employing a method
which involves the patient
If an arm drifts downwards or the squeezing, pushing and pulling
patient cannot maintain this the assessors hands. Care to
position, record the relevant limb protect the individuals back must
as mildly weak.
be recognized.
If the patient is unable to lift their
arms but can make some
movement (e.g. move fingers) Central painful stimuli is used as
record as severely weak.
peripheral pain may evoke a
spinal reflex action (Aucken and
If the patient is unable to move Crawford, 1998).
their arms, apply central pain
and record the response as
indicated in Appendix 2. If there
is no response to central painful
stimuli, apply peripheral painful
stimuli: using the side of a pen
or pencil, apply pressure to the
side of the nail bed on the finger
for a short time and record any
response as above.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Action
2
Rationale
Leg strength. Ask the patient to Lower
limb
response
to
raise their legs off the bed
peripheral painful stimuli is not
completely reliable due to
or
involvement of spinal reflexes
place hand on the sole of the (Aucken and Creawford, 1998).
foot and ask the patient to push,
then place hand on top of the
patient’s foot and ask them to
pull their foot towards them.
Record whether the power of
each leg is normal or mildly
weak if observed.
If the patient cannot lift their legs
off the bed but can make some
movement (e.g. move toes),
record as severely weak.
If the patient cannot move their
legs, apply central painful
stimulus as above and record
the response as indicated in
appendix 2.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
ARMS
LIMB MOVEMENT
Normal power
Mild weakness
Severe
weakness
Abnormal flexion
Extension
No response
LEGS
Normal power
Mild weakness
Severe
weakness
Record
right (R)
and
left
(L)
separately
if there is
a
difference
between
the
two
sides
Extension
No response
Other physiological observations
While a drop in Glasgow Coma Score is usually an early sign of
neurological deterioration, changes in vital signs can also indicate a
worsening condition. It is therefore important that vital signs are
recorded at the same time as other neurological observations: see
Physiological observations as outlined in Guidelines for performing and
Recording of Physiological Observations in the Adult Patient (NUH,
2011).
Level of consciousness – assessment using the AVPU scale
All patients admitted to hospital have the potential to develop a
neurological deficit. In order to detect and promptly act upon changes a
simplified scoring tool has been devised. The AVPU scoring tool (see
below) can be used to quickly assess a patient’s conscious level. It is
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
objective, easy to use and can be readily used to communicate
information. It is not a sensitive method for assessing trends in
neurological deterioration and patients who are not alert require a further
in-depth assessment by a registered practitioner using the Glasgow
Coma Scale (GCS). Please refer to guidelines for “Performing
Neurological Observations including the use of the Glasgow Coma
Scale”.
A
Alert, conscious and able to correctly answer name, date, time and
location.
V
Responds to voice. Not alert, is semi-conscious but responds to a
raised voice even if only groans or moans. Ensure patient is not deaf.
P
Responds to pain.
U
Unresponsive.
Record best AVPU response on patient’s observation chart. If response
is anything other than “alert”, or there is any new change in patient’s
conscious level, this should be reported to a registered practitioner
immediately, and Glasgow Coma Scale rechecked by them. Frequent
EWS and neurological observations should be commenced and medical
staff informed immediately as per escalation plan.
Provisions for audit
Monitoring of the implementation and effectiveness of these guidelines
are undertaken via the auditing of the physiological observations / EWS
chart. Currently 81 wards out of 90 are productive wards and regularly
audit the standard of physiological observation recording.
Auditing of the physiological observations / EWS response will be
undertaken using continuous audit by all productive wards. Analysis of
clinical incidents and audits will be coordinated by Patient safety team,
Practice Development Matron and the Critical Care Outreach Team.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
References:
Aucken and Crawford (1998) Neurological Observations in Guerro, D
(Ed) Neuro-oncology for Nurses London: Whurr
Dougherty, L and Lister, S (Eds) (2004) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures 6th Ed London: Blackwell
Edwards, S L (2001) Using the Glasgow Coma scale: analysis and
limitations British Journal of Nursing Vol. 10 No. 2 pp. 93-101
Emergency-Nurse.Org (2005) Neurological Observations Tutorial – Pupil
Reaction and Vital Signs [Online] Available: http://emergencynurse.org/tutorials/neuro/pupil.htm (Accessed October 18th 2005)
Fairley DF and Cosgrove JA (1999) Glascow Coma Scale: improving
nursing practice through clinical effectiveness. Nursing in Critical Care
Vol. 4 No. 6 pp. 276-279
Fischer, J and Mathieson, C (2001) The history of the Glasgow Coma
Scale: implications for practice. Critical Care Nursing Quarterly Vol. 23
No. 4 pp. 52-57
Hickey, J V (2008) The Clinical Practice of Neurological and
Neurosurgical Nursing 6th Edition Philadelphia: Lippincott-Raven
Lowry, M (1999) The Glasgow Coma Scale in clinical practice: a critique
Nursing Times Vol. 95 No. 22 pp. 40-42
National Institute for Clinical Excellence (2003) Head Injury: Triage,
Assessment, Investigation and Early Management of Head Injury in
Infants, Children and Adults Clinical Guideline 4 London: NICE
National Institute for Health and Clinical Excellence – NHS. (2007)
Acutely ill patients in hospital. Recognition of and response to acute
illness in adults in hospital. NICE clinical guideline. Department of
Health.
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
NUH (2011) Guidelines for performing and Recording of Physiological
Observations in the Adult Patient (NUH, 2011)
Palmer, R and Knight, J (2006) Assessment of altered conscious level in
clinical practice. British Journal of Nursing Vol. 15 No.22 pp. 1255-1259
Shah, S (1999) Neurological Assessment Nursing Standard Vol. 13 No.
22 pp. 49-56
Stewart, N (1996) Neurological Observations Professional Nurse Vol. 11
No. 6 pp 377-378
Waterhouse, C (2005) The Glasgow Come Scale and other neurological
observations. (Learning zone: neurological assessment)
Nursing
Standard Vol. 19 No. 33 pp. 56
Waterhouse, C (2008) An audit of nurses’ conduct and recording of
observations using the Glasgow Coma Scale. British Journal of
Neuroscience Nursing Vol. 3 No. 10 pp 2-9
Further Reading
Dootson, S (1990) Critical Care: Sensory Imbalance and Sleep Loss
Nursing Times Vol. 86 No. 35 pp. 26-29.
Ellis, A and Cavanagh, SJ (1992) Aspects of Neurological Assessment
using the Glasgow Coma scale Intensive Critical Care Nursing Vol. 8
No.2 pp 94 - 99
Hudak, C, Gallo, B, Morton, P (1998) Critical Care Nursing Philadelphia:
Lippincott
Mooney, G and Comerford, DM (2003) Neurological Observations
Nursing Times Vol. 99 No. 17 pp. 24-25
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Price, T (2002) Painful stimuli and the Glasgow Coma Scale Nursing in
Critical Care Vol. 7 No. 1 pp. 19-23
Teasdale, G M and Murray, L (2000) Revisiting the Coma Scale and
Coma Score Intensive Care Medicine Vol. 26 No. 2 pp 153-154
Woodward S (1997) Practical Procedures for Nurses. Neurological
Observations Nursing Times Vol. 93 Nos. 45-48 parts 5.1 – 5.4
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Appendix 1 : Glasgow Coma Scale and Blood pressure scoring grid
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014
Appendix 2 : Motor Responses
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Guidelines For Performing And Recording Neurological Observations In The Adult Patient Final GM June 2014