What are the three components of a neuro check?
- Glasgow Coma Scale
- Pupil size and reaction
- Extremity strength
A neuo check can be done quickly, recorded on a flow sheet and is usually ordered at a set frequency, ie q2 hours. The RN must be aware that if a client's neurologic status is changing, a more complete neurologic assessment must be done.
Glasgow Coma Scale
This looks at a client's ability to respond to the environment. Three types of responses are assessed: eye opening, verbal response, and motor response. The client's responses are graded and a score is obtained. This information tells the health care team about the client's level of consciousness, if they are simply arousable ( a function mediated by the reticular activating system in the brain) or if they are aware of the environment (which requires some degree of higher level cortical functioning). 15 is the highest score possible, 3 is the lowest.
Pupil size and reaction to light
If the pupils are equal and briskly reactive to direct and indrect light, the nerves (CN III oculomotor) that controls pupil constriction/dilation is working normally.
Hand grasp and limb movement is assessed. This assesses basic motor function in all 4 extremities with serial exams (muliple exams over time). Changes in motor function in all four extremities can be detected. If asymmetry is noted, describe in detail and notify the health care provider if the change is a recent finding.
Normal GCS values
Coma GCS value
7 or less
Use the minimum stimulus which causes one or both eyes to open and score from 1-4. If client's eye is closed due to swelling indicate C in the appropriate column
Spontaneous (opens eyes spontaneously): 4
To sound (opens eyes in response to speech): 3
To pain (opens eyes in response to pain): 2
None (does not open eyes when painfully stimulated): 1
Record the client's best verbal response to commands and/or to painful stimuli. If client has dysphasia "D" or endotracheal tube or tracheostomy "T," indicate (D) (T) in the appropriate column. Non-verbal communication is acceptable.
Speech: Client is oriented to person, place, and time: 5
Speech: Client is not oriented to person, place, time, but can converse: 4
Speech: Client speaks in words or phrases that make little or no sense : 3
Speech: Client responds with incomprehensible sounds: 2
Speech: Client does not respond verbally: 1
Record the client's best response to command or to painful stimuli and score from 6 to 1.
Requests simple command: Client obeys command such as "lift up your hands" : 6
Pain: Client purposely tries to remove painful stimuli: 5
Pain: Client purposely flexes arms in response to pain: 4
Pain: Client flexes arm in response to pain, but not purposefully: 3
Pain: Client's elbow extends and wrist internally rotates in response to pain, but not purposely: 2
Pain: Client has no motor responses to pain in any limb: 1
Pupil size and reaction test
Record left and right pupil size in millimeters using regular lighting. A normal size will be dependent on the amount of light in the room , but left and right should be equal in most normal cases. Shines a direct beam of light into one eye at a time, bringing the light beam down from above the client's head to shine into the pupil. This works best, especially for darker colored eyes. Observe pupil reaction. Record left and right reaction as B (brisk) or NR (non-responsive) or C (eyes closed)
Extremity Strength Test
Record client's best response for each extremity (start with handgrasp in UE and plantar flexion in LE) and score from 5 to 1.
5: Normal Strength
4: Lifts and holds
3: Lifts and falls back
2: Moves on bed
1: No movement