A neurologic vital sign assessment is done in order to know the level of consciousness of the patients. By obtaining it, the nurse can determine if the cortical function is still normal. It will also provide an early sign of central nervous system (CNS) deterioration if assessed correctly.
- Sterile cotton ball or cotton tipped applicator
- Pupil size chart
- Pencil or pen
Special considerations: Notify the physician immediately if a previously stable patient suddenly develops a change in neurologic status.
- Introduce yourself to the client and explain well the procedures.
- Perform hand washing and provide privacy to the patient.
I. Assessing level of consciousness and orientation
- Use the Glasgow Coma Scale
- Ask the patient for his complete name.
- Assess his orientation in regards to date, time, and place.
- Assess the quality of responses given.
- Assess his ability in acknowledging your questions and if he can follow one-step commands which requires a motor response.
- Increase the intensity of stimulus if the patient doesn’t respond to the previous ones.
II. Examining pupils and eye movement
- Tell the patient to open his eyes.
- lift his upper eyelids if the patient doesn’t respond.
- Inspect each pupil’s size and shape, and compare for equality.
- Note if the pupils are positioned in, or deviate from the midline.
II A. Testing Direct Light Response
- Be sure to darken the room before testing.
- Keep one eye covered as you hold both of his eyelids.
- Start to move the penlight from the patient’s ear toward the midline of his face.
- Next, shine it directly into his eye. The pupil should constrict immediately.
- When the penlight is removed, the pupil should dilate immediately.
- Wait for about twenty seconds (20) before testing the other eye.
II B. Testing Consensual Light Response
- As you hold both of his eyelids, shine the light into one eye only.
- Watch for the constriction of the other pupil. Positive constriction means there is a proper nerve function of the optic chiasm.
- Now, brighten the room and tell the patient to open his eyes.
- Observe for signs of drooling effect or ptosis.
- Check extraocular movements.
II C. Checking Accommodation
- Hold up one finger midline to the patient’s face and several feet away.
- Tell the patient to focus only to your finger.
- Gradually move your finger toward his nose while he focuses on your finger. His eyes should converge and both pupils to constrict equally.
- Using a wisp of cotton, touch his cornea. You should notice an immediate blink reflex. Repeat for the other eye.
- If the patient is unconscious, test for oculocephalic reflex (doll’s eye).
Warning: Never test a patient with doll’s eye if you suspect that the patient has a cervical spine injury. Permanent spinal cord damage may result.
III. Evaluating motor function
- If the patient is conscious, test his grip strength in both hands at the same time.
- Test arm strength.
- Test leg strength.
Warning: If decerebrate (extension; the patient’s arms are adducted and extended with wrists pronated and fingers flexed; one or both legs may be stiffly extended with plantar flexion of the feet.) or decorticate (abnormal flexion; the arms are adducted and flexed with wrists and fingers flexed on the chest.) posturing develops in response to stimuli, notify the physician immediately.
- To evaluate the muscle tone on both sides, flex and extend the extremities.
- Be sure to test plantar reflex in all patients.
- If a positive Babinski reflex happens, it indicates an upper motor neuron lesion.
- Check if there is a widening pulse pressure. If present it indicates an increasing ICP.
- Make a detailed documentation for your baseline data.
- Record patient’s level of consciousness and orientation, motor function, routine vital signs and pupillary activity.
- Note patient’s behavior throughout the procedure.
Photo credit: missouribaptist
Reference: Nurse’s Quick Check: Skills by Lippincott Williams & Wilkins