Groundwork

Explain and discuss the need for frequent observations, even through the night. Under no circumstances should observations be omitted and sleeping patients should be awakened to check that they are not in a coma.

Equipment Required:

• A small bright torch for pupil reactions
• Sphygmomanometer and stethoscope
• Thermometer
• Glasgow Coma Scale Chart (see here...) 
  

Procedure

A neurological assessment is used to detect a rise in intracranial pressure (ICP). This aids in detecting any rise which could lead to potentially life threatening complication due to brain becoming compressed. As a result the following should be assessed and any abnormalities reported to the appropriate personnel:

1. Orientation this assess the patient's response to questions such as, who they are, where they are, and date. If the patient is able to answer appropriately then they can be described as fully orientated. Questions should be kept simple and easy to understand. Also take into account barriers i.e. language, cognitive issues etc. An interpreter may be required. Confusion may indicate a rise in intracranial pressure.
2. Level of consciousness/eyes open this assesses the patient's response as you approach the bedside. Fully conscious patients will sense your approach and open their eyes spontaneously. Patients who are sleeping should be easily roused by light touch. If the patient does not respond to these then the next stage is to see if the patient responds to paid. The normal response when the body is inflicted with pain is to withdraw from the painful stimuli by flexing the limb. If the patient does not withdraw from painful stimuli and extends the limb, this can be an indicator of neurological damage. Pain response can be tested by pressing firmly on the patient's nail bed using bed or your nail. Another site to assess pain response is the earlobes, as they a sensitive when pinched. Finally, although rubbing the sternum is a good indicator of the patient's response to deep pain this area should be avoided as it causes bruising which can distress family. Although the process of inflicting pain on a patient may seem unkind; it is important to assess the patient's response to pain if the patient does not react to voice or light touch.
3. Pupil reaction this assesses the patient's response to light stimulus. Dim the lights in the patient's room, hold the patients eyelid open and bring the pen torch in from the side of the eye. Observe the reaction of the pupil. The pupil normally reacts quickly to light stimulus and constricts. If no reaction is observed or is slow to react then this may indicate damage/pressure on the optic nerve. 
4. Vital Signs
1. Temperature a rise in patient's body temperature increases the brains demand for oxygen which may already be suffering from an oxygen deficit due to damage or raise ICP. Therefore, it is important to maintain patients body temperature within normal limits. This can be achieved with the use of anti-pyretic drugs such as paracetamol.
2. Pulse Rate and Blood Pressure an indicator of ICP is a rise in blood pressure and a falling pulse rate, although this only present in the later stages.
   
3. Respiration Rate the respiration rate and pattern should be noted  and any irregular pattern of deep, sighing respirations with episodes of apnoea for several seconds may indicate a rise in ICP.
4. Motor activity strength this assesses the patient's motor activity and the ability of the nervous system to respond to verbal commands. To assess the upper limbs, ask the patient to grip your hands and make a comparison between the strength. To assess the lower limbs, ask the patient to push their foot against your hand as hard as possible. Upper and lower limbs are assessed separately, with the strength noted. 

References

Bavin, C., Bedford-Turner, S., Cronin, P., Nicol, M. and Rawlings-Anderson, K. (2002) Essential Nursing Skills. Edinburgh: Mosby.

Baxter, A., Dolan, S. and Gale, N. (2001) Observations. In: Dougherty, L. and Mallet, J. (eds.) The Royal Marsden Hospital: Manual of Clinical Nursing Procedures. 5th Edn. London: Blackwell Science.

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