Assessment of maternal and neonatal vital signs: neurological assessment
the spinal accessory nerve (XI), although this is dificult on large or obese women. Waterhouse (2009) considers this to be the safer technique for inexperienced staff. Alterna-tively the supraorbital nerve, part of the trigeminal nerve (V), can be stimulated by applying pressure to the supraor-bital ridge provided there is no suspected or conirmed facial fracture or glaucoma (Palmer & Knight 2006) but bradycardia may occur. This is achieved by placing the thumb into the indentation below the eyebrow, close to the nose, and applying gradual pressure for up to 30 seconds (Okamura 2014). Sternal rubs are used with caution because they can cause bruising and the lat of the hand should be used, not the knuckles. It should not be used for repeated assessments (Edmunds et al 2011).
Waterhouse (2009) recommends central painful stimu-lus, rather than peripheral pain stimustimu-lus, is used as it can result in both an eye opening response and assess motor ability. The type and site of the stimulus used should be documented.
Verbal response
Assessing the verbal response is an assessment of the integ-rity of the higher, cognitive and interpretive centres of the brain (Okamura 2014). The midwife should ascertain the level of verbal response by asking questions that require answers to show clarity and understanding – What is your name? Where are you? What day is it? – an accurate answer scores 5. If the woman is able to speak using full sentences but the answers are incorrect, a score of 4 is given. If only words and incomplete sentences are given, the score is 3, regardless of whether the words are appropriate. A score of 2 is given if incomprehensible sounds (e.g. grunts, groans) are made. If no sound is made in response to verbal or painful central stimuli, 1 is scored.
It is important to take into account the language spoken by the woman; if she does not speak English, an interpreter should be used.
Motor ability
The response of the upper limbs is tested to determine the integrity of the motor strip within the cerebral cortex (Okamura 2014), as the lower limbs can also be affected by spinal function. The midwife should ask the woman to bend then hold out her arms and squeeze the midwife’s hands with both of her hands. The midwife can then deter-mine that both arms can be moved and the elbows lexed, the power and release of grip from each hand can be noted.
A score of 6 is given if the woman is able to complete these movements and 1 if there is no response despite painful central stimuli. Scores of 2–5 are given according to the degree of movement and lexion occurring as a result of painful stimulus: the arm moving towards the stimuli to try are totalled to score between 15 (fully conscious) and 3 (no
response) to provide a rapid assessment of the woman’s condition and response to treatment. NICE (2014) state that a GCS >12 indicates a normal or minimally impaired level of consciousness. The score should be recorded as a fraction using 15 as the denominator (e.g. 10/15). NICE (2014) recommend that information about the three sepa-rate GCS responses should also be recorded, e.g. a score of 12/15 based on scores of 3 on eye opening, 4 on verbal response, and 5 on motor ability should be recorded as E3, V4, M5.
Eye opening
Eye opening is the irst GCS measurement of consciousness, as without this cognition does not occur; however, it does not indicate the neurological system is intact (Iankova 2006).
Okamura (2014) states it is assessing the integrity of the reticular activating system found in the brainstem. It cannot be used if there has been damage to the eyes resulting in swelling, as it is unlikely the eyes will open easily, rendering this aspect of the assessment unreliable until the swelling subsides. Jevon (2008) recommends recording this as ‘C’.
The midwife should look at the woman to see if her eyes are opening spontaneously (score 4). If the eyes remain closed, the midwife should speak to the woman, which should provoke the eyes to open (score 3). Waterhouse (2009) suggests a greater response is achieved by asking the woman if she ‘wants a cup of tea’ rather than saying her name.
If the eyes continue to remain closed, a painful periph-eral stimulus is used – this may be a gentle shake but if no response a deeper stimulus is needed. Pressure is applied using a pen positioned just below the lateral outer aspect of the second or third interphalangeal joint for 10–15 seconds (Iankova 2006, Okamura 2014, Waterhouse 2009) (score 2). Painful stimulation should be applied slowly up to a maximum of 15 seconds. Pressure should not be applied to the nail bed because of the risk of bruising (Edmunds et al 2011).
If there is no response using a painful peripheral stimu-lus, a central painful stimulus is used. Central stimulation involves the application of a noxious painful stimulus to the core of the nervous system via the cranial nerves to elicit a complete motor response (Waterhouse 2009). However, the woman may grimace while keeping her eyes closed, and so it is not generally used unless the midwife has been appropriately trained. It is important to use the same stim-ulus on each assessment. A score of 1 is given if the eyes remain closed.
Jevon (2008) recommends squeezing the trapezium muscle using a thumb and two ingers and Edmunds et al (2011) advise twisting 3–5 cm of muscle from where the neck and shoulders meet for up to 30 seconds to stimulate
responses or 2 in motor responses, agitation or abnormal behaviour as these can indicate deterioration of the woman’s neurological status.
PROCEDURE: Neurological assessment
•
Gather equipment and take to the bedside:■ pencil torch
■ observation chart
■ thermometer
■ sphygmomanometer
■ pulse oximeter.
•
Wash and dry hands.•
Inform the woman of the procedure and gain consent if conscious and responsive.•
Complete vital signs: temperature, blood pressure, pulse, respiration and arterial oxygen saturation.•
Assess level of consciousness by talking with the woman and asking her who she is, what day it is and where she is; use peripheral or central painful stimulus if no response.•
Assess motor function by asking the woman to bend and lift her arms and to squeeze both your hands.•
Assess the size and shape of the pupils and movement of the eyes.•
Assess pupillary reaction by:■ darkening the room if necessary
■ holding one eyelid open, move the pen torchlight towards and across the eye, moving the light from side to side
■ assess the degree and speed at which the pupil constricts
■ repeat with the other eye
■ then with both eyelids held open, shine the light into one eye – the pupil in the other eye should also be observed to constrict
■ repeat with the other eye.
•
Ensure the woman is covered and comfortable.•
Document all indings on the observation chart.•
Wash and dry hands.•
Act on indings accordingly.to remove it (5), arm bends at the elbow without rotation of the wrist (4) or with wrist rotation and forearm rotation (3), the arm extends at the elbow while the wrist lexes (2).
Pupillary assessment
While this is not part of the GCS, it is a separate and impor-tant component of the neurological assessment. The size and shape of each pupil and reaction to light are assessed.
The midwife should look at the pupils to determine if they are the same shape and whether the eyes are working together. The diameter of each pupil is then measured – the normal range is 2–6 mm (Dawson 2000) – and they are usually equal in size (unequal pupils are a late sign associ-ated with raised intracranial pressure, but may be of little signiicance if the woman is alert and orientated and small differences in pupil size are often normal). Pupil reaction is assessed by shining a bright light from a pen torch into one eye, then the other – approach from the side rather than directly in front. The pupils should decrease in size and the speed at which this occurs is recorded. If there is no response, the pupil is ixed and suggests the midbrain may be suffer-ing from pressure as constriction and dilation of the pupils is controlled by the oculomotor nerve (cranial nerve III).
Pupils that are slow to respond or which dilate suddenly and unequally indicate that cerebral oedema or haematoma is worsening (Waterhouse 2005). The level of sedation administered to the woman will affect pupil reaction – pupils measuring 1–2 mm can occur when barbiturates or opiates have been used. Edmunds et al (2011) suggest that if the pupil size is equal but they are pinpoint in size, opiates or a Pontine lesion may be the cause whereas when they are equal but small and reactive, there be metabolic enceph-alopathy, equal-sized and ixed may be due to a midbrain lesion and equal, mid-sized pupils may be caused by a metabolic lesion. They also advise that when pupils are unequal, dilated, and unreactive, a cranial nerve III palsy may be responsible and unequal, small, reactive pupils may be a result of Horner’s syndrome (Edmunds et al 2011).
The indings of the neurological assessment should be recorded on a neurological observation chart (Fig. 7.1) in conjunction with the MEOWS, vital signs including tem-perature (see Chapter 3), pulse (see Chapter 4), blood pres-sure (see Chapter 5), and respiratory rate (see Chapter 6).
Blood oxygen saturation should also be monitored (NICE 2014) (see p. 65). While the total GCS score is recorded, it is also important to record separately the scores of the three different categories, as each one is assessing different areas of the brain. A decreasing score indicates the woman’s condition is deteriorating and referral is indicated.
The doctor should be informed if there is a severe or increasing headache, persistent vomiting, new or evolving neurological signs and symptoms (e.g. pupil inequality), a reduction to 3 or less points in eye opening or verbal
ROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:
• ensuring appropriate training in assessing neurological observation has been undertaken prior to performing the neurological assessment
• undertaking a competent examination in which all of the information is gained
• recognizing deviations from normal and instigating referral
• appropriate record keeping.
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7| Chapter
Assessment of maternal and neonatal vital signs: neurological assessment
categories of eye opening, verbal response and motor ability.
•
The midwife who has been appropriately trained can undertake the GCS and recording of vital signs as part of the woman’s neurological assessment to determine any changes to her condition.•
Additionally, the doctor will evaluate motor and sensory function as required.SUMMARY
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Neurological assessment is undertaken where there are actual or potential altering levels of consciousness.•
The GCS determines the level of consciousness by assessing the woman’s response to the three Figure 7.1 Neurological observation chart.(Adapted with kind permission from Jamieson et al 2002)
OBSERVATION CHART NAME
HOSP. No:–
AGE:–
C O M A
S C A L E
Eyes open
Best verbal response
Best motor response
Spontaneously To speech To pain None Orientated Confused Inappropriate words Incomprehensible sounds None
Obey commands Localise pain Flexion to pain Extension to pain None
240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 Blood pressure and Pulse rate
Respiration
Size Reaction Size Reaction right
left
Normal power Mild weakness Severe weakness Spastic flexion Extension No response Normal power Mild weakness Severe weakness Spastic flexion Extension No response
+ reacts – no reaction c. eye closed
Record right (R) and left (L) separately if there is a difference between the two sides 40 39 38 37 36 35 Temperature
°C 34 33 32 31 30 Usually record the best arm response Endotracheal tube or tracheostomy = T Eyes closed by swelling = C
CONSULTANT:-PUPILS 1 2 3 4 5 6 7
8
Pupil scale (mm)
A R M S
L E G S L I M B
M O V E M E N T
DATE:–
TIME:–
SELF-ASSESSMENT EXERCISES
The answers to the following questions may be found in the text:
1. What are the three categories of the Glasgow Coma Scale?
2. What observations should you undertake in conjunction with the Glasgow Coma Scale?
3. How does the midwife assess eye opening?
4. If there is no response, how is central stimuli applied?
5. How can the midwife determine the verbal response?
6. How does the midwife assess motor response?
REFERENCES
Dawson, D., 2000. Neurological care. In:
Sheppard, M., Wright, M. (Eds.), Principles and practices of high dependence nursing. Baillière Tindall, Edinburgh, pp. 145–182.
Edmunds, S., Hollis, V., Lamb, J., Todd, J., 2011. Observations. In: Dougherty, L., Lister, S. (Eds.), The Royal Marsden Hospital manual of clinical nursing procedures, eighth ed. Wiley-Blackwell, Oxford, pp. 699–802.
Iankova, A., 2006. The Glasgow coma scale. Emerg. Nurse 14 (8), 30–35.
Jamieson, E., McCall, J., Whyte, L., 2002. Clinical nursing practices,
fourth ed. Churchill Livingstone, Edinburgh.
Jevon, P., 2008. Neurological assessment part 3 – Glasgow Coma Scale. Nurs.
Times 104 (29), 28–29.
NICE (National Institute for Health and Care Excellence), 2014. CG 176 Head injury triage, assessment, investigation and early management of head injury in infants, children and adults.
Available online: <www.nice.org.uk>
(accessed 2 March 2015).
Okamura, K., 2014. Glasgow coma scale low chart: a beginner’s guide. Br. J.
Nurs. 23 (20), 1068–1073.
Palmer, R., Knight, J., 2006. Assessment of altered conscious level in clinical practice. Br. J. Nurs. 15 (22), 1255–1259.
Waterhouse, C., 2005. The Glasgow coma scale and other neurological
observations. Nurs. Stand. 19 (33), 56–64, 66–67.
Waterhouse, C., 2009. The use of painful stimulus in relation to the Glasgow Coma Scale observations. Br. J.
Neurosci. Nurs. 5 (5), 209–214.
Principles of infection control: standard precautions
Chapter
•
identify speciic situations in which personal protective equipment (PPE) should be used•
describe source and protective isolation nursing.Healthcare professionals are widely exposed to large numbers and varieties of microorganisms. This poses a threat both to the practitioner and to the women and babies in her care. The term ‘standard precautions’ (previously having incorporated ‘universal precautions’) refers to the measures taken universally, i.e. by all health professionals for all women and babies, all the time, (whatever the clini-cal environment, whether infection is known or suspected or not) to achieve mutual protection. The ultimate aim of standard precaution use is to prevent the transfer of infec-tion. As an important area of care, the reader is required to keep up-to-date with developing protocols. The cost of infection to individuals (service users and staff), the NHS, and the community as a whole is large and the increasing incidence of healthcare-associated infections (HCAIs) all mean that the use of standard precautions has to be correct every time. This chapter reviews the nature and use of stand-ard precautions and the principles of isolation nursing.