Neurological Observation Chart

Name of Resident: Date

TIme
Spontaneously
Eyes
Eyes To speech closed by
C open
To pain swelling
O = C
M None
A Orientated
Best Confused
S
C verbal Inappropriate words
A response Incomprehensible
L None
E
Obeys commands
Usually
Best Localise pain record the
motor Flexion to pain best
response Extension to pain arrival
response
None

240
230 40
220 39
210 38

Temperature C
200 37
Blood Pressure and Pulse Rate

190 36
180 35
170 34
160 33
150 32
140 31
130 30
120
110
100
90
80
70
60
50
40
30
Pupil Scale 20
Respirations
(mm) 10

Size + reacts
Right - no
Reaction
PUPILS reaction
Size
Left c eyes
Reaction closed
Normal power
Mild weakness Record
LIMB MOVEMENT

Severe weakness right (R)

Arms and left
Spastic flexion
(L)
Extension separately
No response if there is
Normal power a
difference
Mild weakness
between
Legs Severe weakness the two
Extension sides
No response

Initials & Designation of

person completing
observations

Please mark: Pulse with ‘X’; Respirations with ‘’; Blood Pressure with ------------; Temperature with a ‘’
 Reference Card: Neurological Observations
Frequency of observations depends on severity of injury. Following an incident where a head injury may
have occurred: 1/2 hourly observations for 2 hours, hourly for 4 hours then daily for 4 days.
If any abnormalities found in observations or if obvious head injury: ¼ hourly for 2 hours, ½ hourly for 2
hours or until transferred to hospital or reviewed by medical practitioner.
A standard chart should be used to record and display neurological observations assessments and vital signs including the Glasgow
Coma Scale, pupil size and reaction and movements of limbs [1]. Neurological observations include assessment of conscious level,
vital signs, pupil size and reaction, motor response, and verbal response [1-3].
Glasgow Coma Scale
The Glasgow Coma Scale uses objective observable characteristics and provides a scale by which to measure level of consciousness
and response. The scale is used for assessment of eye opening, best verbal response and best motor response [1-3].
Eye Opening
Assessing eye opening provides an indication of the resident’s arousal ability. Determine if the resident responds to speech (use a
loud voice) or to touch. If the resident does not respond, apply pressure to the fingerbeds to determine if there is a response to painful
stimuli. If the resident cannot open his or her eyes due to swelling, record “C”, or if the resident’s eyes remain continuously open this
should be recorded as a non eye opening response [2].
Verbal Response
This assessment determines appropriateness of the resident’s speech. The resident’s attention should be gained and a conversation
attempted, allowing adequate time for the resident to respond. In assessing the resident’s best verbal response, consider the resident’s
preferred language, any diagnosed medical problems that may influence the resident’s ability to respond, e.g. deaf, previous stroke,
and level of confusion prior to the fall and determine if there are any changes to the resident’s pre-fall condition. Assess the resident’s
response and record:
Oriented: resident can respond appropriately to person/place/time;
Confused: resident can talk but is not orientated;
Inappropriate words: speaks only a few words, usually only in response to physical or painful stimuli;
Incomprehensible sounds: unintelligible sounds such as moans; and
None: no response after prolonged stimulation [1, 2].
Motor Response
Assess the resident using simple commands to determine if the resident has the awareness / ability to repond by movement. If the
resident does not respond to verbal commands such as “squeeze my hands” or “open your eyes” check the resident’s best motor
response to painful stimuli by pressing the resident’s fingerbeds. In assessing the resident’s best motor response, consider the
resident’s usual level of comprehension, usual ability to move his or her body and any existing medical diagnoses that may
contribute to the resident’s ability to move, e.g. previous stroke, dementia. Record:
Obeys command: follows your command;
Localises pain: moves limb away from painful stimuli in a purposeful way or attempts to push painful stimulus away;
Flexion to pain: responds to painful stimuli by bending arms up but does not localise pain; ND
Extension to pain: responds to painful stimuli by straightening arms but does not localise pain [1, 2].
Assessment of Pupils
Assessment of the resident’s pupil size and response to light can provide an indication as to presence and extent of head injury as a
result of a fall. The neurological observation chart should provide a pupil scale on which to assess pupil size. An assessment should
first be made as to whether the resident’s pupils are of equal size and then whether they react equally to exposure to light [1, 2].
Assessment of Limb Movement
Assessment of the resident’s limb movement can give an indication as to the presence and extent of head injury as a result of a fall.
Instruct the resident to move their limbs laterally or lift up against gravity or against resistance. If the resident does not respond to
your request, assess limb movement in response to pain. Observe the type of movement the resident can perform, and compare the
strength of limbs on both sides of the body. In assessing the resident’s limb movements and strength, consider the resident’s
previous condition and any medical diagnoses that may preclude normal limb movement, e.g. previous stroke, musculoskeletal
disorders. Consider whether the resident has sustained injuries to the limbs during the fall that may preclude normal movement, e.g.
fractures. Record:
Normal power – movements are within the resident’s normal power strength;
Mild weakness – cannot fully lift limbs against gravity and struggles to move against resistance;
Severe weakness – can move limbs laterally but cannot move against gravity or resistance;
Spastic flexion – arms slowly bend at elbow and are stiff; and
Extension – limbs straighten [1, 2].
References
1. Network, Scottish Intercollegiate Guidelines, Early Management of Patients with a Head Injury. 1st ed. 2000, Edinburgh: SIGN.
2. Institute, Joanna Briggs, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI.
3. Care, National Collaborating Centre for Acute, Clinical Guidelines 4: Head injury Triage, assessment, investigation and early management of head injury in infants, children and adults. 1st ed. 2003, London:
National Institute for Clinical Excellence.