Neuro Vital Signs
Neurological Assessment
● Neurological observations collect data on the patient’s neurological status and
can be used for many reasons, including in order to help with diagnosis, as a
baseline observation, following a neurosurgical procedure, and following
trauma.
● Therefore, it is important that all healthcare professionals are efficient and
accurate in assessing the neurological status of their patients.
● It is also important to remember that these changes can be seen to occur
rapidly over a short period of time, or more gradually taking place over days
and weeks. This is why accurate neurological assessments and observations
are vital in ensuring the early recognition of neurological deterioration in
patients (Koutoukidis et al. 2017; Mooney & Comerford 2003).
A neurological assessment involves checking the patient in
these main areas in which changes are most likely to occur:
01. 02. 03.
Level of
consciousness Pupillary reaction Motor function
04. 05.
Sensory function Vital signs
Glasgow Coma Scale (GCS).
There are many different
assessment tools for
neurological function,
however, the most widely
known and used tool is the
Glasgow Coma Scale (GCS).
The patient is assessed and scored in
three areas:
Eye opening Verbal response Motor response
Used as a reflection of the Index of higher cortical Knowing the integrity
intensity of impairment of function. of the nervous system in
activating functions. patients who are not
speaking.
Glasgow Coma Scale
● The highest possible score is a 15, which reflects an individual who is fully
alert, aware and orientated, whereas the lowest possible score is a 3 and
reflects an unconscious individual.
● Because the GCS is widely known, it is a quick way to communicate a
patient’s neurological status and provides a standardized assessment of an
individual’s neurological functioning. However, there can be some
inconstancies with its use.
● In particular, there can be variations seen in the recording of pupil size as
well as motor weakness between assessors. Therefore, it is important that
nurses and health professionals are using the tool correctly to ensure these
inconstancies do not affect patient care.
Interpretation.
Individual elements as well as the sum of the score are
important. Generally, brain injury is classified as:
Coma Severe Moderate Minor
GCS 3-8 GCS < 8–9 GCS 8 or 9–12 GCS ≥ 13
Reaction Level Scale (RLS).
● There is Neurological Assessment used in San Pedro
Hospital that is partnered with the Glasgow Coma
Scale (GCS) and this is the Reaction Level Scale.
This have lesser items and much easier to use and
the highest possible score is 1, which reflects that
the patient is alert, while the lowest possible score is
8 which means that the patient is in a coma.
● GCS and RLS are done simultaneously when getting
the Neuro Vital Signs in San Pedro Hospital and
results are put together in order to come up to score
is equal to RLS/GCS. The highest score combined is
1/15 and the lowest possible score is 8/3.
Reaction Level Scale (RLS).
Clinical Descriptor Responsiveness Score
Alert No delay in response 1
Drowsy or confused Responsive to light stimulation 2
Very drowsy Responsive to strong stimulation 3
Unconscious Localizes but does not ward of pain 4
Unconscious Withdrawing movement on pain stimulation 5
Unconscious Stereotype flexion movements on pain 6
stimulation (decortication)
Unconscious Stereotype extension movements on pain 7
stimulation (decerebration)
Unconscious No response on pain stimulation 8
Thank you.
