Nurses completing a structured assessment will consider the neurological status of their patient. This is the ‘D’ for ‘disability’ in the ABCDE algorithm taught in professional health settings. That is, issues related to neurological function, which in turn disable the individual in some manner. Generally, this relates to consciousness, which is the earliest and most sensitive indicator of change in neurological status (Hickey, 2013). If concerns are raised, assessment will include observations that indicate the function and status of an individual's nervous system.
Neurological observations should only be performed by appropriately competent staff and must be recorded accurately (National Institute for Health and Care Excellence (NICE), 2017). The frequency of neurological observations will be informed by the condition of the patient and reviewed regularly by a registered practitioner (NICE, 2017). Professional knowledge, judgement and policy, will influence the frequency of this assessment, which can be as regular as every 15 minutes (Derbyshire and Hill, 2018). Any neurological deterioration must be reported promptly as support and intervention may be required.
To ensure family-centred care and accurate assessment, the patient and their family should have the need for and process of neurological assessment explained (Shields et al, 2012). This should include a rationale for the frequency.
Neurological assessment in children and young people may be required for a range of reasons (see Box 1 for examples). It is a necessary skill for all children and young people's nurses. If we consider head injuries alone it is estimated around 30 000 children are admitted to hospitals every year (Great Ormond Street Hospital, 2015).
NICE recently published a guideline on suspected neurological conditions (NICE, 2019), which goes into more detail on signs and symptoms that may raise concerns and prompt a referral for assessment.
Neurological structure and function
To understand the elements of a nursing neurological assessment it is necessary to first understand the structure and function of the nervous system. If there is clear understanding of how a system is formed and how it behaves normally, we are able to assess and identify change from this. The structure of the brain and spinal cord is complex; however, a visual overview can be helpful (see Figure 1). The Monro–Kellie hypothesis states that the skull is filled with non-compressible contents—the brain and interstitial fluid (80%), intravascular blood (10%), and cerebrospinal fluid (10%) (Karakis et al, 2017). These must be constant, or else a pressure change will occur, resulting in complications. However, this hypothesis applies only when the skull is fused, usually around the age of 2 years.
The nervous system is divided into the central and peripheral nervous system (Figure 2). The functions of the nervous system are vast and not yet fully understood by science (Woodward and Mestecky, 2011). They are further complicated by the age and stage of the child or young person being assessed. For example, an individual's emotional response to hunger differs between a 2-month-old and an 18-year-old. However, if we understand the functioning nervous system at different developmental stages our neurological assessment will be better informed. A nurse who knows the stages of motor development in an infant and child can recognise any impairment to this and clarify with family if the child has reached that developmental milestone (Table 1).
| Age | Developmental milestones |
|---|---|
| 0–6 months |
|
| 6–12 months |
|
| 18 months |
|
| 2 years |
|
| 3 years |
|
| 4 years |
|
| 5 years |
|
| 6 years |
|
Assessment
Neurological assessment may include the following forms of nursing observation:
AVPU
AVPU is a quick and common way to assess a person's nervous system (Nuttall et al, 2018). You will begin by waking the child. If a child or young person is fully alert and talking to you, they are ‘A’. For an infant this may be presented as a coo or a babble. Essentially the person presents how they normally would. This is where the role of the parents or carers is vital in allowing a comparison with the patient's usual state.
If the patient is not fully alert, check they respond to your voice. Then your assessment is a ‘V’. This may require a gentle touch. A response may be as simple as opening their eyes to look at the nurse.
If the patient does not respond to voice or touch, the health professional may need to apply a painful stimulus—if there is a response of any kind, they are ‘P’ for responding to pain. One example is the trapezius squeeze, but different stimuli are used in different contexts so you should refer to local policy.
Those individuals who do not respond at all are ‘U’ for unresponsive. If any concerns are highlighted they must be escalated rapidly.
If a more detailed assessment is needed then a nurse may assess using the Glasgow Coma Scale.
The Glasgow Coma Scale (GCS)
The GCS was developed in 1974 in Glasgow and is seen as a standardised tool for assessment of consciousness level (Teasdale, 2014). Various adaptations have been produced, including paediatric guidelines, which allow for the developmental age of the individual child. The scale is divided into three subscales: eyes, voice and movement (Table 2). Each of these subscales is given a score that is added together to give an overall score of between 3 and 15. For example, a person with a score of 15 would be fully alert whereas a score of 3 is indicative of deep coma (Hickey, 2013).
| Score | All children | Older than 5 years | Younger than 5 years | |
|---|---|---|---|---|
| Eyes | E4 | Spontaneous | ||
| E3 | To voice | |||
| E2 | To pain | |||
| E1 | None | |||
| C | Eyes closed (by swelling or bandage) | |||
| Verbal | V5 | Orientated (in person or place or address) | Alert, babbles, coos, words or sentences to usual ability (normal) | |
| V4 | Confused | Less than usual ability, irritable cry | ||
| V3 | Inappropriate words | Cries to pain | ||
| V2 | Incomprehensible sounds | Moans to pain | ||
| V1 | No response to pain | |||
| T | Intubated | |||
| Motor | M6 | Obeys commands | Normal spontaneous movement | |
| M5 | Localises to supraorbital pain (>9 months of age) or withdraws to touch | |||
| M4 | Withdraws from nailbed pain | |||
| M3 | Flexion to supraorbital pain (decorticate) | |||
| M2 | Extension to supraorbital pain (decerebrate) | |||
| M1 | No response to supraorbital pain (flaccid) |
However, the assessing nurse should not focus on the overall score alone. It is important to identify any change in the patient's presentation and escalate accordingly.
The process of completing a GCS and scoring is guided by the structure of the documentation. A nurse must select the relevant tool for the age of the child. However, it is important to understand the relevance of each aspect. The three key areas of the GCS are: eye opening (scoring 1-4), verbal response (scoring 1-5) and motor response (scoring 1-6). Eye opening is an assessment of arousal rather than awareness. The individual's verbal response is used to assess awareness and higher cerebral function.
Accurate assessment of the motor response is challenging, particularly with children, but is recognised as the most significant component of the GCS in predicting client outcome (Woodward and Mestecky, 2011). When assessing motor response, the nurse will assess the patient's ability to understand and respond to simple commands. For example, ‘can you place both hands against my palms and push me away?’ Conversely, in infants, observing their movement should give an indication of tone and strength (Great Ormond Street Hospital, 2015). Assessment of limb power and movement is not part of the GCS but is an accepted measure in neurological assessment. It is an important indicator as to the location and extent of the neurological difficulty (Derbyshire and Hill, 2018). Each limb is assessed individually as each side of the brain controls the opposite limbs.
Pupillary response
A brief assessment of the eyes allows information to be gained beyond whether the client is rousable. By observing pupil size and response to light a nurse is able to consider the cranial nerve function (Derbyshire and Hill, 2018). Normal function is indicated if both pupils are an equal size and reacting when a pen torch is shone. The size is compared with a printed scale on the neurological assessment chart or the pen torch itself (Figure 3). When recording the pupil size it is important that each pupil is assessed separately. If assessing the right eye; the pen torch should begin from the right side of the face, moving the beam into the pupil and then away in the direction it came. This will be repeated with the left eye. This overcomes the accommodation response, in which pupils constrict to a nearing object (Iggulden, 2006).
Pupil size should be recorded in millimetres and the reaction recorded as positive (+) for a brisk response, sluggish (S) for a slow reaction and negative (-) for no reaction or fixed pupil (Derbyshire and Hill, 2018). This process is challenging with children and young people, particularly if the nurse is asked to repeat observations throughout the night. Good explanation and distraction become essential techniques.
If one pupil is fixed, dilated and unreactive to light this could indicate injury or pressure on one side of the brain. However, it is more serious if both pupils are fixed and dilated. The nurse must consider factors that may influence pupil size or response: eye surgery, medication, a normal difference in pupil size and hormonal disorders (Waterhouse, 2005).
Vital signs
Vital signs are also an important aspect of the neurological assessment. Accurate recording of respiration is important as any deterioration or unusual patterns can indicate poor functioning of the vital centres of the brain. A raised temperature may indicate infection, but it can also indicate damage to the brain, because of its role in temperature regulation (Hickey, 2013). A slow pulse and rising blood pressure can indicate raised intracranial pressure.
With infants and young children there are some additional signs that indicate raised intracranial pressure: tense or bulging anterior fontanelle in infants, ‘sun setting’ pupils in infants (the eyes appear driven downward, and part of the lower pupil may be covered by the lower eyelid), high-pitched cry, irritability or lethargy, vomiting and headaches (Great Ormond Street Hospital, 2015).
Factors that may influence the score of a child or young person
There are many factors to consider when assessing the neurological function of a child or young person. Having a family-centred approach to care will be necessary to address or negate these factors. The input of family is vital in the assessment process. If they are not able to stay with the child then accurately recording their feedback regarding their child's presentation is key. The following is a list of suggestions to consider due to the range of ages and developmental stages of children:
The child or young person will usually benefit from having their parent or carer remaining with them during the period of assessment and observation. This is because they are most likely to respond to them and will also be comforted by their presence. The child and their family should be nursed in an environment that is as calm as possible but also where consistent access and monitoring can occur. This is because too much stimulation can cause distress but any deterioration in the child or young person needs to be identified quickly.
Conclusion
Accurate assessment and recording of neurological assessment and observations are essential to establish the status of the client's nervous system. Nurses play a vital role in monitoring, detecting and reporting any concerns so that prompt treatment can be provided. The role of family is of great importance in forming an accurate assessment of a child or young person.