Neurological Observation Chart

Name of Resident:

Date
TIme
Spontaneously
To speech
To pain
None

S
C
A
L
E

Best
verbal
response

Orientated
Confused
Inappropriate words
Incomprehensible
None

Best
motor
response

Obeys commands
Localise pain
Flexion to pain
Extension to pain
None

Eyes
closed by
swelling
= C

Usually
record the
best
arrival
response

Blood Pressure and Pulse Rate

240
230
220
210

Pupil Scale
(mm)

PUPILS

LIMB MOVEMENT

Left

Legs

200
190
180
170
160

150
140
130
120
110
100
90
80
70
60
50
40
30
20
Respirations
10
Right

Arms

40
39
38
37
36
35
34
33
32
31
30

Size
Reaction
Size
Reaction

Temperature C

Eyes
open

C
O
M
A

+ reacts
- no
reaction
c eyes
closed

Normal power
Mild weakness
Severe weakness
Spastic flexion
Extension
No response
Normal power
Mild weakness
Severe weakness
Extension
No response

Record
right (R)
and left
(L)
separately
if there is
a
difference
between
the two
sides

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: hourly for 2 hours, 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 residents 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 residents eyes remain continuously open this
should be recorded as a non eye opening response [2].
Verbal Response
This assessment determines appropriateness of the residents speech. The residents attention should be gained and a conversation
attempted, allowing adequate time for the resident to respond. In assessing the residents best verbal response, consider the residents
preferred language, any diagnosed medical problems that may influence the residents 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 residents pre-fall condition. Assess the residents
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 residents best motor
response to painful stimuli by pressing the residents fingerbeds. In assessing the residents best motor response, consider the
residents usual level of comprehension, usual ability to move his or her body and any existing medical diagnoses that may
contribute to the residents 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 residents 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 residents pupils are of equal size and then whether they react equally to exposure to light [1, 2].
Assessment of Limb Movement
Assessment of the residents 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 residents limb movements and strength, consider the residents
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 residents 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.
2.
3.

Network, Scottish Intercollegiate Guidelines, Early Management of Patients with a Head Injury. 1st ed. 2000, Edinburgh: SIGN.
Institute, Joanna Briggs, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI.
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.