Nursing Assessment of the Neurological System: Theory and Glasgow Coma Scale (GSC)

00:01 So let's start off with our neurological system.

00:04 So this is where we're starting at the head, one of the first things that we're going to start doing.

00:09 And the neuro system tells you a lot about your patient.

00:12 So many times, that how we assess the neurological system, now, it's going to vary depending on the type of patient you have.

00:19 So for example, if I have a stroke patient, a head injury patient, I may deep dive a little bit more into this system, versus if my patient is awake, alert and oriented, and maybe they had a bowel obstruction, for example.

00:34 So we talked about the neurological system.

00:36 Mostly, the assessment that we're going to perform is, again, that level of consciousness.

00:42 I mean, I will tell you, the level of consciousness says so much about the patient.

00:48 This is one of the first indicators that if I walk into a room during my bedside shift report, my patient was awake and alert and talking to me, then I leave, I come back 30 minutes later, and the patient, we can't hardly arouse.

01:02 That's a big indicator for a rapid response or emergency intervention.

01:07 So a level of consciousness is really big indicator for the neurological system.

01:12 Then many times a general assessment, we'll look at pupils to see if they're light accommodating, looking at the size.

01:19 If the patient has feeling, and if the patient has any paralysis, meaning they can't move one of their limbs.

01:26 Now again, depending on what the patient's diagnosis is, what they came in for, we may move into more of a focus assessment such as looking at reflexes, including that sensation and coordination as well.

01:41 Cranial nerves, and we'll do more of a sensory evaluation.

01:45 So just note there's an expansive neurological deep detailed assessment if indicated for your patient.

01:53 Now, let's talk about some of the main ones of the neurological system that we would cover as a nurse.

01:58 So again, starting with that level of consciousness.

02:01 So we use something called the Glasgow Coma Scale, or you'll hear the term GCS a lot.

02:08 Now, this is a really common method and evidence based method to assess and document the neurological status of our patient.

02:16 And again, this is very widely used.

02:19 So this is actually you can start assessing this really easily.

02:23 Like when we enter the patient's room, we introduced ourselves.

02:26 We asked them even, "Hi, can you tell me your name, and date of birth? Can you tell me where you're at right now? And what brought you into the hospital? Just asking those orientation questions and assessing the patient response, you actually cover, believe it or not, a lot of the Glasgow Coma Scale.

02:43 and we'll talk about each one of these.

02:45 So to cover with the Glasgow Coma, know, it covers three main areas: eye opening, verbal response, and motor response.

02:56 So now let's dig into this GCS a little bit more on how we use it to assess our patient.

03:01 So first, we start with the eyes and the eye opening.

03:05 So just know when you're talking about this specific scale, you're going to rate each patient response, and then you're going to add all these numbers up, and you'll get a total.

03:16 Now, here's the key thing to know.

03:17 And this is why the GCS is so nice, that if it's a high functioning patient, you should have a 15, or a high level or a high number.

03:26 Such as me setting here talking to you today.

03:29 You could say that I'm a 15.

03:32 So I've got good eye, motor, and verbal responses right now.

03:36 So I should be higher on the GCS at a 15.

03:40 However, if a patient's very ill, and they aren't able to open their eyes, or they have mobility, motor issues, they may be lower at like an 8.

03:50 Now, if a patient's at like an 8 or lower, this could mean the patient could be potentially comatose, or really not responsive.

03:57 So again, GCS is great, because at a quick glance at a number, you have a good idea of the neurological status of your patient.

04:05 So let's start talking about the eyes in particular.

04:08 So if you look here on the GCS, and we talk about the eye opening, we're gonna start with the big numbers here on this image to orient you.

04:16 So number 4, if we write them in a 4, it's just like you see here that I'm opening my eyes spontaneously to noise.

04:23 I don't have any issues doing this just naturally.

04:26 Now, 3, if we have to score a patient at a three, it's they're only open them to verbal command.

04:32 So this can mean you walk into the patient's room, and you have to call a patient's name for them to open their eyes, for example.

04:41 Now 2, when we're talking about eye opening, this means the patient could be in bed, you walk in, they don't hear, even if you make a noise, opening the door.

04:51 You start calling their name, they don't respond, but maybe you have to put a painful stimuli or apply a painful stimulus.

04:59 Then the patient will open their eyes.

05:01 Then we rate them at a lesser score of two.

05:05 And then, of course, at the very lowest is the patient doesn't open their eyes at all and their score to one.

05:11 So that's how we evaluate eye opening.

05:15 So now let's move on to verbal response, which is just how your patient speaks to you.

05:20 So we're going to start with this higher number to orient you on that slide over here up to five, which is oriented.

05:26 Like, the patient knew their name and date of birth, they're answering appropriately, they knew what month, who the president is? All of those appropriate responses to orientation questions.

05:37 Now, 4 is a little bit different. So they're a little bit confused.

05:40 So they can talk to you, but maybe they think their birthday is in December, when really it's in March.

05:47 Maybe they think they're in Hawaii, and really, they're in Oklahoma.

05:52 So these are things to where we would score them into 4 that the patient's confused.

05:58 Now, here's where it gets a little bit different and we've got to discern as the nurse.

06:02 Now 3, is inappropriate words.

06:05 So sometimes, we'll say this kind of like a word salad or something like that.

06:09 And here's a great example of that.

06:12 Let's say you have a patient and you've got a bedside table, and there's a pencil laying on the bedside table.

06:19 Let's say you talk to your patients say, "Okay, Mr. Jones, this is an object laying on the table.

06:25 Can you tell me what this is?" Now most everybody can tell you, it's a pencil, right? But what if he says, baseball instead of pencil? Well, this is an appropriate.

06:35 Now, this could be because of a stroke, a specific area of the brain that's been damaged.

06:40 Now, moving down into a lesser score is 2, which is incomprehensible sounds.

06:46 So this is going to be more like noises, or grunts, or maybe mumbles.

06:52 Now, you're not going to get really formed words, or anything that you can technically comprehend here.

06:59 And one, of course, is a no verbal response.

07:02 So this could mean the patients ventilated.

07:06 It could mean that they're sedated, or they're in a coma.

07:10 Now finally, let's look at the last part of this scale.

07:14 Now, here we're talking about motor response.

07:17 Now, this is something that we ask the patient to actively engage with us physically.

07:23 So if you start here on the slide at the bottom, and we're looking at this big number of obey commands.

07:28 This is going to look at something like okay, so means that I need you to raise your left arm.

07:34 So I would raise my arm.

07:35 So per the verbal command, I can obey and I can respond quickly, and I would score about a 6.

07:42 Now, when we're talking about moving down the scale at a 5, this is purposeful movement to painful stimuli, such as, I applied pain, and the patient appropriately moves.

07:53 Now, 4 is going to be a little bit different, where maybe the patient's not purposely moving every time when we apply painful stimuli.

08:02 You have to apply the painful stimulus to see if they withdraw from you.

08:07 This is a little bit less of a response and coordinated at a 4.

08:12 Now, moving down this, if you see number 3, and number 2, this is not a positive sign.

08:18 This is usually meaning a bad outcome in your patient.

08:21 So if you see a patient with their flexion to pain, meaning they go what we called decorticate, meaning inward and flexing inward towards their core, that is an ominous and a sign with your patient neurologically, and needs to be reported.

08:36 Now, the same thing here with 2, we call it decerebrate or extension to pain where the patient may be extends out.

08:43 This is also a negative sign in your patient and also needs to be reported.

08:47 And 1, of course, is no motor response.

08:51 So we just talked a lot about the Glasgow Coma Scale or the GCS and its components.

08:56 Now seems pretty complex, but it's actually quite easy to apply it to a patient case.

09:02 So let's take a look and apply it to a patient scenario here.

09:06 So this is Mr. Hering, and he's a 49-year-old client.

09:10 Now he experienced a loss of consciousness and he was found down this morning by a co-worker.

09:16 Now upon our assessment, we see that Mr. Herings, lethargic.

09:20 Now, his eyes are closed most of the time, but actually, when we asked him, he will open his eyes to verbal commands.

09:27 Now, when we ask the orientation questions with Mr. Hering, he's not oriented to time or place, but when we ask and assess his motor response, he can indeed follow simple commands and move his extremities or grip the hands of the nurse.

09:43 So now let's take a look at the graph next to him in the coma scale and see how he scores.

09:48 So, if you recall here in the middle, now Mr. Hering was lethargic, eyes were closed most of the time, but upon verbal command, he opens his eyes.

09:58 So if you take a look here on the graphic he's going to score a 3 that he opens to verbal command.

10:04 Now when we're talking about orientation and verbal response, when we ask those very, very typical orientation questions, he actually wasn't oriented to time or place.

10:16 So we actually deam this confusion and here on the Glasgow Coma Scales, he would be scored a four at confused.

10:24 Now, assessing the motor response, if you are called now he can follow simple commands like Mr. Hering, raise your arm or grip the hands of the nurse.

10:33 Now, because he was easily and appropriately able to obey commands, we score him here at a 6.

10:40 So if we sum up all those numbers of a 3 to verbal, of 3 to eye opening, a 4 to verbal, and a 6 to motor, that scores is 13 on the Glasgow Coma Scale.

10:53 So know on the Glasgow Coma Scale, the highest number you have is a 15.

10:59 So that means he has a great GCS score.

11:02 Now, if Mr. Hering was closer down to an 8 or lower, this could mean that he has severely impaired eye opening or verbal or motor response issues.