Title of Guideline (must include the word “Guideline” (not
protocol, policy, procedure etc)
O07 Paediatric Neurological Observation
Contact Name and Job Title (author)
Joseph Manning / Jennifer Davidson
Directorate & Speciality
Family Health / Nottingham Children’s Hospital
Date of submission
August 2014
Date on which guideline must be reviewed (this should be one to
five years)
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis)
August 2019
Abstract
This guideline describes the process for
assessing a child’s neurological status
Key Words
Neurological, observations, child, pupil
reactions, posture
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
6
Children requiring a neurological assessment
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
4
well –designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
5
expert committee reports or opinions and / or clinical
experiences of respected authorities
6
recommended best practise based on the clinical
experience of the guideline developer
Consultation Process
Expert panel
Target audience
Nurses caring for childen
This guideline has been registered with the trust. However,
clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using
guidelines after the review date.
Page 1 of 33
NOTTINGHAM CHILDREN’S HOSPITAL
Nursing Guidelines
O07 PAEDIATRIC NEUROLOGICAL OBSERVATIONS
Part A: Modified Paediatric Glasgow Coma Scale
Part B: Assessment of Limb Movement
Part C: Pupil Assessment
Part D: Vital Signs
Standard statement
Paediatric neurological observations are used to establish the neurological status of a child.
This involves; an assessment using the Modified Paediatric Glasgow Coma Scale, an
assessment of limb movement, a pupil assessment, and vital signs. All patients requiring
neurological observations will have the procedure carried out safely by a competent
healthcare professional to ensure an accurate and consistent assessment, and who will act
on the findings, appropriately.
Structure
Paediatric neurological observations should be performed by a Registered Children’s Nurse
who has the appropriate knowledge and skills to enable them to complete the procedure
safely and competently.
A student nurse can undertake this procedure but only under the direct supervision of a
Registered Children’s Nurse, furthermore it is the qualified Nurses responsibility to
understand and interpret the results of the neurological observations and ensure that the
appropriate action and escalation is completed.
Equipment










Sphygmomanometer OR Dinamap Monitor
Blood pressure cuff (appropriate size)
Stethoscope
Neurological observation chart - Modified Paediatric Glasgow Coma Scale (BCH
Model)
Pen torch
Millimetre scale for pupil measurement
Sure Temp Plus Thermometer (Axilla) OR Rectal temperature monitoring equipment
Procedure document O1- Recording Observations of Pulse and Respiration Rate
Procedure document O2b- Recording observations of body temperature (Axilla &
Rectal)
Procedure document B2- Blood Pressure Monitoring
Page 2 of 33
Procedure
Action
Rationale
1
Wash hands and apply alcohol gel.
An infection control precaution, in line
with hospital infection control policy (5
moments for hand hygiene).
2
Explain procedure to child and family, To prepare the child and family for the
and obtain consent.
procedure (Royal College of Nursing,
2003) and to comply with the NMC code
of professional conduct: standards for
conduct,
performance
and
ethics
(Nursing & Midwifery Council, 2004).
Part A: Modified Paediatric Glasgow Coma Scale
3
Eye opening
3i
Assess for eye opening and score as This directly assesses the functioning of
appropriate from the following list:
the brainstem, stimulation of the
Reticular Activating System, and the
child’s awareness of their environment.
These are indicators of arousal or
wakefulness (Shah, 1999).
Eyes open spontaneously- Score E4
The presence of spontaneous eye
opening ‘indicates that the arousal
mechanisms of the brainstem are active’
(Teasdale and Jennett, 1974)
3ii
Recorded when the child has their eyes
open and is seen to be awake without the
need for verbal or physical stimulus
(Waterhouse, 2005, Fairley and Pearce,
2006a).
Eyes open to voice- Score E3
Recorded when eyes open to a clear and
loud command (Waterhouse, 2005,
Fairley and Pearce, 2006a). The most
recognisable verbal stimulus is a child’s
name (Shah, 1999).
NB. This is not to be confused with the
waking of a sleeping child; such patients
receive a score of E4, not E3.
The eye opening in response to voice
implies that arousal has been caused by
non-specific auditory stimulation. This
indicates that the auditory sensory
pathway, which travels along the
Vestibulocochlear nerve (VIIIth cranial
nerve), through the medulla, midbrain,
thalamus, and cerebral cortex, is
functioning.
NB. However, this is an abnormal
response and indicates that the patient
Page 3 of 33
has a depressed level of consciousness.
3iii
Eyes open to pain- Score E2
If no response to a voice, then the
patients’ response to pain stimulus is
assessed.
Initially, simply touch or shake the child’s To avoid unnecessary distress.
shoulder gently.
If there is no eye
response, a deeper stimulation is
required. Before any stimulus is applied,
it is fundamental that the child and family
are informed of the need for a deeper
stimulus and an apology for the need to
hurt the child (even if the child is, or
seems,
unconscious)
(Waterhouse,
2005).
Pain is applied by using the Trapezius
muscle squeeze manoeuvre. This is
achieved by using your thumb and index
finger in a pincer grip, grabbing
approximately 2.5-5cm of the Trapezius
muscle where the head meets the
shoulder (Appendix 1). The muscle is
held and twisted for a maximum of 30
seconds with a gradually increasing
pressure.
NB. The Trapezius muscle has a sensory
and motor component and there is
therefore a risk of creating a spinal reflex
on stimulation (Waterhouse, 2005).
Sternal rub, supraorbital, jaw margin These can cause unnecessary bruising
and fingertip pressure are not and prolonged residual discomfort
(Fairley & Cosgrove, 1999). The use of
appropriate and should not be used.
supraorbital and jaw margin pressure is
contraindicated by facial fractures and
can make the patient grimace and lead to
eye closure rather than opening (Shah,
1999). Fingertip pressure response can
be misinterpreted due to factors such as
hemiparesis and high spinal cord injury
(Fairley and Pearce, 2006b).
3iv
If the child opens their eyes fully to a This is an abnormal response and
painful stimulus then a score of E2 is indicates that the patient has a
given.
depressed level of consciousness.
No eyes opening- Score E1
Despite voice and pain stimulus the child This indicates that the patients’ arousal
does not open their eyes they are scored mechanisms of the brainstem are
a E1.
inactive (Teasdale and Jennett, 1974)
Page 4 of 33
3v
4
5
If the child has their eyes open Eyes being continually open can be
continually, without blinking, this should contributed to flaccid ocular muscles
also be scored as E1.
(Fairley and Pearce, 2006b).
Eyes closed due to swelling or bandages
– mark ‘C’
May be the result of trauma (Shah, 1999)
or facial fracture (Fairley and Pearce,
2006b) to the occulomotor nerve and the
child may be unable to open their eyes.
Document eye opening findings clearly
on the Modified Paediatric Glasgow
Coma Scale (Appendix 2).
As it is impossible to perform an accurate
assessment of a patients level of arousal
(Waterhouse, 2005).
Allows for any trends or patterns to be
illustrated in line with previous findings,
and to enable findings to be
communicated to other members of the
multi disciplinary team (Nursing &
Midwifery Council, 2002).
Verbal/Grimace Response
Verbal/grimace
response
assesses
consciousness and determines the
child’s awareness of their environment,
which involves cognition (Shah, 1999).
Verbal responses yield information about
 Grimace response: Non-verbal / the child’s comprehension and their
ability
to
articulate
a
response
intubated patients.
(Waterhouse, 2005).
OR
 Child/Infant Verbal Response: Prelingual patients.
OR
 Adult/Child
Verbal Response:
Lingual patients.
Grimace Response
It is fundamental that the verbal/grimace
response is scored appropriately in line
with the child’s development and ability
using one of the following three scores:
5a
5ai
5aii
Assess grimace response and score The grimace score is used for non-verbal
appropriately:
adults, children and infants. This is
predominately used for intubated patients
(Tatman et al., 1997).
Spontaneous normal facial activity Score G5
Recorded when the patient has
spontaneous normal facial/oro-motor
activity.
Less than usual spontaneous facial
activity - Score G4
Recorded when the patient has less than
usual
spontaneous
facial/oro-motor
activity, or facial/oro-motor activity is only
evident after touch stimulus.
Page 5 of 33
5aiii
NB. Touch stimulus is applied by simply
touching or gently shaking the child’s
shoulder.
Vigorous grimace to painful stimulus Score G3
Recorded when the patient displays a
vigorous grimace to painful stimulus.
Initially, simply touch or shake the child’s To avoid unnecessary distress.
shoulder gently. If there is no grimace, a
deeper stimulation is required. Before
any stimulus is applied, it is fundamental
that the child and family are informed of
the need for a deeper stimulus and an
apology for the need to hurt the child
(even if the child is, or seems,
unconscious) (Waterhouse, 2005).
Pain is applied by using the Trapezius
muscle squeeze manoeuvre (refer to 3iii).
5aiv Mild grimace to painful stimulus - Score
G2
5av
Recorded when the patient displays a
mild grimace to painful stimulus.
No response - Score G1
5b
Recorded when the patient displays no
response to painful stimulus.
Child/Infant Verbal Response
Assess child/infant verbal response and The child/infant verbal score is used to
score appropriately.
assess pre-lingual patients (e.g. can
make noises but not form words or
sentences).
5bi
This relies upon the nurse having an
understanding of the child/infants’ ‘usual
ability’. For nurses unsure of the child’s
‘usual ability’ it is fundamental to gain the
parents/carers’ perception of the child’s
current verbal ability.
Usual verbal ability - Score V5
This is to reduce the subjective
measures as the help of the parents’ is
thought to increase the accuracy of the
results and decrease the chance of poor
inter- observer reliability (May,2001;
Worrall, 2004).
Recorded when the patient is alert, Indicates that the patients’ cognitive
babbles, coos to usual ability.
centres of the brain are functioning
correctly.
Page 6 of 33
5bii
5biii
Less than usual verbal ability- Score V4
Recorded when the patient displays a
less than usual ability or demonstrates a
spontaneous irritable cry.
Inappropriate crying - Score V3
Recorded when the patient displays an An Irritable cry is characterised by a very
irritable cry and cries inappropriately.
high-pitched whaling sound, which may
be attributed to irritation of the meninges.
NB. The child remains inconsolable
despite addressing all needs in activities
of daily living (e.g.; Is the child pain free?
Is the child hungry? Does the child need
changing? etc).
5biv Occasional whimper- Score V2
5bv
Recorded when the patient displays
occasionally whimpers or moans.
No response - Score V1
5c
Recorded when the patient displays no
response
Adult/Child Verbal Response
5ci
Assess the adult/child’s verbal response Verbal response provides information
and score appropriately.
about
the
patient’s
speech,
comprehension and functioning areas of
This is assessed by asking the patient the higher, cognitive centres of the brain,
three questions;
and reflects the patient’s ability to
(1) What is your name?
articulate
and
express
a
reply
(2) Where are you and why?
(Waterhouse, 2005).
(3) What is the current year or month?
(Waterhouse, 2005)
Orientated - Score V5
5cii
Recorded if the patient answers all three Indicates that the patient’s speech,
questions correctly.
comprehension and cognitive centres of
the brain are functioning correctly.
NB. If the patient has recently been
transferred from another hospital, some
degree
of
disorientation
is
understandable (Waterhouse, 2005).
Confused - Score V4
If the patient answers one or more of the
questions incorrectly then a score of 4 is
recorded as it is deemed that the patient
is confused.
Typically, patients who are deteriorating
will lose orientation of time, place and
person (in that order) (Shah, 1999).
Subtle orientation loss can be an early
indicator of neurological deterioration
Page 7 of 33
5ciii
NB. It is important to attempt to re- (Frawley, 1990).
orientate patients by correcting all wrong
answers. Reassure them, and ask them
to try to remember for the next time you
ask (Waterhouse, 2005).
Inappropriate words- Score V3
5civ
If the patient responds with extremely
limited or the absence of completely
understandable conversation then a 3 is
recorded. These can include the offer of
words rather than sentences, which make
little sense in the context of the questions
(Waterhouse, 2005).
Inappropriate sounds - Score V2
5cv
If the patient displays incomprehensible This basic vocalisation does not require
sounds then they will score 2. These awareness and is thought to depend
refer to moaning and groaning without upon subcortical functioning.
any recognisable words.
No response - Score V1
6
7
When the patient displays no response a A total inability to articulate and express
score of 1 is given.
a reply.
Indicates malfunction of the
cognitive
centres
of
the
brain
(Waterhouse, 2005).
Document appropriate Verbal/Grimace Allows for any trends or patterns to be
Response findings clearly on the Modified illustrated in line with previous findings,
Paediatric
Glasgow
Coma
Scale and to enable findings to be
(Appendix 2).
communicated to other members the
Multi disciplinary team (Nursing &
Midwifery Council, 2002).
Motor Response
Assess for motor response and score as The motor response assesses the area
appropriate from the following:
of the brain that processes a sensory
input
into
a
motor
response
(Waterhouse, 2005).
NB. When assessing the patients’ best
motor response it is important to score in
line with the child’s development to
ensure an accurate assessment.
7i
Obeys commands - Score M6
The best possible motor response is
being able to obey simple commands
convincingly (Frawley, 1990). Therefore
M6 is scored.
Page 8 of 33
From the following list, the patient should
be asked to perform two different
movements, which should be repeated
twice;




“Stick out your tongue”
“Raise your eyebrows”
“Show me your teeth”
“Hold up your thumb”
If the patients’ motor skills are restricted
(e.g.
due
to
age/physical
disability/underlying condition), making
them physically unable to obey simple
commands, then the patient should be
assessed by observing for normal
spontaneous movements. If evident then
a score of M6 is awarded.
7ii
It is good practice to have patients obey
two different commands, and at the very
least they should obey the same
command twice (Lower, 1992), as to
ensure a reliable assessment of motor
response.
This is to reduce the subjective
measures as the help of the parents is
thought to increase the accuracy of the
results and decrease the chance of poor
inter- observer reliability (Worrall, 2004).
NB. This relies upon the nurse having an
understanding of the child/infants’ ‘usual
ability’. For nurses unsure of the child’s
‘usual ability’ it is fundamental to gain the
parents/carers’ perception of the child’s
current motor ability.
Motor response - Score M5
If no response to verbal commands then
a painful stimulus should be applied.
A score of M5 is awarded when the
patient locates and attempts to remove
the painful stimulus (Appendix 3) (from a
neutral position (Appendix 4)).
Initially, simply touch or shake the child’s To avoid unnecessary distress.
shoulder gently. If there is no localising
and attempting to remove painful stimulus
then a deeper stimulation is required.
Before any stimulus is applied, it is
fundamental that the child and family are
informed of the need for a deeper
stimulus and an apology for the need to
hurt the child (even if the child is, or
seems,
unconscious)
(Waterhouse,
2005).
Pain is applied by using the Trapezius
muscle squeeze manoeuvre (refer to 3iii).
If the patients’ motor skills are restricted
(e.g.
due
to
age/physical
disability/underlying condition), making
them physically unable to localise to
Page 9 of 33
7iii
7iv
painful stimulus, then they are assessed
by touching a limb and observing for a
withdraw response.
If a withdraw
response is evident, then a score of M5 is
awarded.
Withdraws to painful stimulus- Score M4
If no localising to pain is observed /
child does not withdraw to touch then the
patient is observed for withdrawal (normal
flexion) to painful stimulus.
If the patient responds to the painful
stimulus by rapidly bending their arms at
the elbow and displaying shoulder
abduction (Appendix 5) (Fairley and
Pearce, 2006b) then a score of M4 is
awarded.
Abnormal flexion to painful stimulusScore M3
A score of M3 is awarded if a slower
internal rotation, adduction of the
shoulder and flexion of the elbow is
observed in response to painful stimulus.
7v
7vi
This collection of movements is
categorised as abnormal flexion or
decorticate posturing (Appendix 6)
(Fairley and Pearce, 2006b).
This is an abnormal response and
indicates severe cerebral damage and an
interruption of nerve pathways from the
brain's cortex to the spine.
Abnormal extension to painful stimulus Score M2
A score of M2 is awarded if there is no This collection of movements is
abnormal flexion to painful stimulus and categorised as extension or decerebrate
the following is observed:
posturing (Appendix 7) (Fairley and
Pearce, 2006b).
 straightening of the elbow joint,
 adduction, internal rotation of the This is an abnormal response and
emanates from the brain stem. It shows
shoulder,
 inward rotation, spastic flexion of that information cannot be transferred,
via neural pathways, to and from the
the wrist,
cerebrum due to damage to the brain.
NB. Jaw clenching, and arching of back
with backward flexion of head and feet
may also be present.
No response to painful stimulus - Score
M1
If there is no response to painful stimulus
then a score of 1 is given.
Page 10 of 33
8
9
Document Motor response findings Allows for any trends or patterns to be
clearly on the Modified Paediatric illustrated in line with previous findings,
Glasgow Coma Scale (Appendix 2).
and to enable findings to be
communicated to other members of the
multi disciplinary team (Nursing &
Midwifery Council, 2002).
Calculate the sum of eye opening To calculate a Modified Paediatric
response, grimace/verbal response and Glasgow Coma Scale score. This
motor response scores and document on information can indicate, quantitatively, if
the Modified Paediatric Glasgow Coma the patient’s neurological status is
Scale (Appendix 2).
improving or worsening.
The maximum score a patient can
achieve is 15/15 and the minimum score
is 3/15.
NB. The phrase 'Modified Paediatric
GCS of 11' is essentially meaningless, as
it is important to break the figure down
into
its
components,
such
as
E3+V/G3+M5 = Modified Paediatric GCS
11.
Part B: Assessment of Limb Movement
10
Assessment of Limb
Conscious patient
Movement:
Assess limb movement in a conscious
patient by asking the patient to perform
the following tasks independently and
then again with the addition of the
assessor applying an opposing force to
the direction that the limb is moving.
NB. Ensure each limb is assessed
separately.
10a
Limb movement evaluation provides the
assessor with an understanding of the
geographical
distribution
of
any
dysfunction, and is an important
consideration when performing a full
neurological assessment of the patient
(Lower, 1992). This assessment aims to
establish; grading of limb strength, and
level of stimulation required to initiate a
limb response.
For infants assess normal spontaneous
movement of limbs, the perception of NB. This assessment requires the
parents is useful. (Worrall 2004).
cooperation of a conscious patient to
elicit an accurate view of the patient’s
limb movement ability.
Upper Limbs

Ask the patient to lift each upper limb Normal movements include being able to
move limbs against gravity and
independently.
resistance.
Page 11 of 33

10b
Apply a resistant force (your hand) to
the patient’s upper limb and ask them A difficulty or total inability in performing
the movements indicates that there
to push and pull against it.
could be muscle/nerve damage.
Grade each upper limb appropriately To establish ability of limb and detail the
using the following categories:
geographical
distribution
of
any
dysfunction.
 Limb strength;

o Normal power
Full movement against both gravity and
resistance.
o Mild weakness
Limb moves against gravity but not
against resistance.
o Severe weakness
Limb is unable to move against gravity
and resistance.
Level of stimulation;
o Spontaneous
o Painful stimulus
o No response
10c
NB. It is important to consider any
previous disability that the patient had
prior to the neurological impairment as
this may impact upon the findings and
subsequent actions that need to be
taken.
Lower Limbs


10d
Any brain injury may lead to weakness to
one side of the body or to certain limbs
and therefore requires close observation
for any worsening or improvement of
condition.
Ask the patient to lift each lower limb A difficulty or total inability in performing
these movements indicates that there
independently.
could be muscle/nerve damage.
Apply a resistant force (your hand) to
the patient’s lower limb and ask them
to push and pull against it.
Grade each lower limb appropriately To establish ability of limb and detail the
using the following categories:
geographical
distribution
of
any
dysfunction.

Limb strength;
o Normal power
Full movement against both gravity and
resistance.
Page 12 of 33

o Mild weakness
Limb moves against gravity but not
against resistance.
o Severe weakness
Limb is unable to move against gravity
and resistance.
Level of stimulation;
o Spontaneous
o Painful stimulus
o No response
11
Assessment of Limb
Unconscious patient
Any brain injury may lead to weakness to
one side of the body or to certain limbs
and therefore requires close observation
for any worsening or improvement of
condition.
NB. It is important to consider any
previous disability that the patient had
prior to the neurological impairment as
this may impact upon the findings and
subsequent actions that need to be
taken.
Movement:
Assess
limb
movement
in
an Limb movement evaluation provides the
unconscious patient by performing the assessor with an understanding of the
following.
geographical
distribution
of
any
dysfunction, and is an important
NB. Ensure each limb is assessed consideration when performing a full
separately.
neurological assessment of the patient
(Lower, 1992). This assessment aims to
establish; grading of limb strength, and
level of stimulation required to initiate a
limb response.
NB. When undertaking this assessment
it is important to recognise that certain
medicines, such as sedatives and
paralyzing agents will impact on the
findings.
11a
11ai
11aii
Upper Limbs
Assess the ability of the patients’ upper
limbs by completing the following tasks.
Observe
the
patient
for To establish strength of limb.
spontaneous/involuntary movements.
If evident, the assessor should apply an
opposing force to the direction that the
limb is moving.
If no spontaneous movements, apply
central painful stimulus to elicit a motor
response.
Page 13 of 33
Before any stimulus is applied, it is
fundamental that the child and family are
informed of the need for a deep stimulus
and an apology for the need to hurt the
child (even if the child is, or seems,
unconscious) (Waterhouse, 2005).
Central stimulation produces an overall
body response and is more reliable than
peripheral stimulation for this purpose. In
an unconscious patient, peripheral
stimulation, such as nail bed pressure,
can elicit a reflex response, which is not
a true indicator of motor activity.
Pain is applied by using the Trapezius
muscle squeeze manoeuvre (refer to
3iii).
11aiii If no response to painful stimulus, lift This assesses for limb paralysis. A
both arms into the air to a maximum paralysed limb will fall more rapidly than
height of 30cm. Then release both limbs the non-paralysed limb.
together.
11b
NB. The patients’ environment must be
safe to ensure they will not injure
themselves by allowing their arms to fall
independently from a height.
Grade each upper limb appropriately To establish ability of limb and detail the
using the following categories:
geographical
distribution
of
any
dysfunction.
 Limb strength;

o Normal power
Full movement against both gravity and
resistance.
o Mild weakness
Limb moves against gravity but not
against resistance.
o Severe weakness
Limb is unable to move against gravity
and resistance.
Level of stimulation;
o Spontaneous
o Painful stimulus
o No response
11c
Any brain injury may lead to weakness to
one side of the body or to certain limbs
and therefore requires close observation
for any worsening or improvement of
condition.
NB. It is important to consider any
previous disability that the patient had
prior to the neurological impairment as
this may impact upon the findings and
subsequent actions that need to be
taken.
Lower Limbs
Assess the ability of the patients’ lower
limbs by completing the following tasks.
Page 14 of 33
11ci
11cii
Observe
the
patient
for To establish strength of limb.
spontaneous/involuntary movements.
If evident, the assessor should apply an
opposing force to the direction that the
limb is moving.
If no spontaneous movements, apply
central painful stimulus to elicit a motor
response.
Before any stimulus is applied, it is
fundamental that the child and family are
informed of the need for a deep stimulus
and an apology for the need to hurt the
child (even if the child is, or seems,
unconscious) (Waterhouse, 2005).
Pain is applied by using the Trapezius
muscle squeeze manoeuvre (refer to
3iii).
11ciii If no response to painful stimulus,
position the patient on their back and flex
the knees so that both feet are flat on the
bed. Release the knees simultaneously.
NB. The patients’ environment must be
safe to ensure they will not injure
themselves by allowing their legs to fall
independently.
Grade each lower limb appropriately
11d
using the following categories:


Central stimulation produces an overall
body response and is more reliable than
peripheral stimulation for this purpose. In
an unconscious patient, peripheral
stimulation, such as nail bed pressure,
can elicit a reflex response, which is not
a true indicator of motor activity.
If the leg falls to an extended position
with the hip externally rotated, paralysis
is present. The normal leg should stay
in the flexed position for a few seconds
and then gradually assume its previous
position.
To establish ability of limb and detail the
geographical
distribution
of
any
dysfunction.
Limb strength;
o Normal power
Full movement against both gravity and
resistance.
o Mild weakness
Limb moves against gravity but not
against resistance.
o Severe weakness
Limb is unable to move against gravity
and resistance.
Level of stimulation;
o Spontaneous
o Painful stimulus
o No response
Any brain injury may lead to weakness to
one side of the body or to certain limbs
and therefore requires close observation
for any worsening or improvement of
condition.
NB. It is important to consider any
previous disability that the patient had
Page 15 of 33
12
prior to the neurological impairment as
this may impact upon the findings and
subsequent actions that need to be
taken.
Document
Assessment
of
Limb Allows for any trends or patterns to be
Movement findings clearly on the illustrated in line with previous findings,
Modified Paediatric Glasgow Coma and to enable findings to be
Scale (Appendix 2).
communicated to other members the
Multi disciplinary team (Nursing &
Midwifery Council, 2002).
Part C: Pupil Assessment
13
Undertake a pupil assessment
completing the following:
by Pupillary changes may be a sign of
pressure on the optic or occulomotor
nerves (Cranial nerves II and III
respectively) and increased intracranial
pressure (Waterhouse, 2005).
14
Reduce any external bright light and Pupils are photosensitive and by reducing
position the patient so their eyes can be lighting this allows for pupillary reaction to
seen.
be monitored more easily.
15
Observe pupils simultaneously using a To determine size and equality of the
unstimulated pupils to create a baseline.
millimetre scale (Appendix 8) to assess
Normal size of a pupil is between 1.5 - 6.0
pupil size and shape.
mm.
Normal pupils are round in shape (Shah,
1999).
NB. An ovoid or irregularly shaped pupil
may indicate intracranial hypertension or
brain damage (Shah, 1999).
16
Shine the pen torch into each eye To stimulate the pupil into reacting.
moving from the outer corner of each
eye towards the pupil (Appendix 9).
NB. This requires both eyes to be open
and observed simultaneously and may
need them to be held open (Appendix
10).
In normal neurological functioning when a
light is shone into the eye, the pupil should
constrict immediately. Likewise, the other
pupil should also constrict. Withdrawal of
the light causes pupil dilation in both eyes
(Direct light reflex) (Shah, 1999).
If one pupil dilates larger than the other
pupil (unilateral dilated pupil) this may
indicate constriction of the occulomotor
Page 16 of 33
nerve (III cranial nerve) (Shah, 1999).
This could be caused by; a rapidly
expanding ipsilateral lesion, tentorial
herniation, III cranial nerve nucleus lesion,
or epileptic seizures (Advanced Life
Support Group, 2004).
NB. Causes of small reactive pupils
include;
metabolic
disorders,
and
medullary lesions (Advanced Life Support
Group, 2004). Causes of pinpoint fixed
pupils include; Metabolic disorders,
narcotic/barbiturate/organophosphate
ingestion, pontine haemorrhage, and
ischemia (Shah, 1999, Waterhouse, 2005,
Advanced Life Support Group, 2004).
Causes of fixed dilated pupils include;
anticholinergic drugs such as atropine
(Shah,
1999,
Waterhouse,
2005,
Advanced Life Support Group, 2004),
hypothermia, severe hypoxia, severe
anoxia-ischemia, barbiturates(Advanced
Life Support Group, 2004), or at death.
17
Document findings on pupil section of This is to ensure consistency in
neurological assessment chart using the documentation of findings and allows for
following symbols or letters:
any trends or patterns to be illustrated in
line with previous findings, and to enable
 Brisk reaction = ‘+’
findings to be communicated to other
members of the multi disciplinary team
 No reaction = ‘-‘
(Nursing & Midwifery Council, 2002).

Sluggish reaction = ‘S’

Eye closed = ‘C’
Part D: Vital Signs
18
Recording the child’s respiration rate
Obtain a respiration rate from the child
accurately and safely.
Specific changes in rate and pattern of
breathing can give an indication as to the
function of the brain stem (Shah, 1999)
specifically relating to the pons and upper
medulla (Waterhouse, 2005).
Page 17 of 33
Brain
damage/
raised
intracranial
pressure may impact on respiration and
manifest in the following ways:

Cheyne stoke breathing (breathing
that is erratic in rate and pattern) is
caused by a massive and sudden rise
in intracranial pressure (Shah, 1999,
Waterhouse, 2005) and is indicative of
Cushing’s triad which is a pre-terminal
sign (Waterhouse, 2005).

Hyperventilation (elevated respiratory
rate) blows off Carbon dioxide and
subsequently causes the cerebral
vessels to vasoconstrict, reducing
blood flow to the brain, in an attempt
to
reduce intracranial pressure
(Waterhouse, 2005).

19
20
Cluster breathing (periods of rapid
irregular
and
noisy
breathing
separated by apnoeic episodes) is
indicative of a rise in intracranial
pressure (Shah, 1999, Waterhouse,
2005).
Document patients’ respiration rate on Allows for any trends or patterns to be
the Modified Paediatric Glasgow Coma illustrated in line with previous findings,
Scale (Appendix 2).
and
to
enable
findings
to
be
communicated to other members of the
multi disciplinary team (Nursing &
Midwifery Council, 2002).
Recording the child’s pulse rate
Obtain a pulse rate from the child Specific changes in rate, rhythm, and
accurately and safely and document on quality of a patients pulse can give an
observation chart appropriately.
indication as to the function of their brain;
specifically relating to the medulla,
hypothalamus, thalamus and cerebral
hemispheres (Hinchliff et al., 2000,
Tortora and Anagnostakos, 1990).

If a patient has tachycardia related
to neurological impairment this might
indicate the patient is reaching a
terminal phase in their disease
process. This can be attributed to
either a reduction in parasympathetic
tone or increase in sympathetic tone.
NB. It should be remembered that
Page 18 of 33
tachycardia could also indicate,
particularly in a trauma patient,
additional haemorrhage (e.g. intraabdominal).

Bradycardia is seen in the later stages
of increased intracranial pressure.
Blood pressure rises in an attempt to
overcome the increased intracranial
pressure, reflex inhibition causes a
slowing of the heart rate. This
bradycardic response is indicative of
Cushing’s triad, which is a preterminal sign (Waterhouse, 2005).
Bradycardia can also be seen with
spinal cord injury and interruption of
the
descending
sympathetic
pathways.

21
22
Cardiac arrhythmias may occur in
patients; who have sustained a
subarachnoid haemorrhage and have
blood in the CSF, who have
undergone posterior fossa surgery.
Document patients’ pulse rate on the Allows for any trends or patterns to be
Modified Paediatric Glasgow Coma illustrated in line with previous findings,
Scale (Appendix 2).
and
to
enable
findings
to
be
communicated to other members of the
multi disciplinary team (Nursing &
Midwifery Council, 2002).
Recording the child’s blood pressure
Obtain a blood pressure from the child
accurately and safely and document on An
adequate
blood
pressure
is
observation chart appropriately.
fundamental for cerebral perfusion. A
‘normal’ brain has an autoregulation
response to fluctuations in blood pressure
by vasoconstricting and vasodilating
blood vessels in order to protect brain
tissue.
When the brain has suffered an insult,
autoregulation of hypotensive episodes
may be impaired.
In severe cases of raised intracranial
pressure, cerebral perfusion pressure
falls below a critical point. This results in
blood not being able to enter the brain. In
an attempt to increase cerebral perfusion,
Page 19 of 33
23
24
the systolic blood pressure is elevated;
however, the diastolic blood pressure
remains
relatively
stable,
causing
widening pulse pressure.
This is
indicative of Cushing’s triad which is a
pre-terminal sign (Waterhouse, 2005)
Document patients’ blood pressure on Allows for any trends or patterns to be
the Modified Paediatric Glasgow Coma illustrated in line with previous findings,
Scale (Appendix 2).
and
to
enable
findings
to
be
communicated to other members of the
multi disciplinary team (Nursing &
Midwifery Council, 2002).
Recording the child’s temperature
Obtain a temperature from the child A severe head injury can cause damage
accurately and safely and document on to the temperature regulating centre in the
observation chart appropriately.
brain located in the hypothalamus and
therefore impact upon a patient’s
temperature (Shah, 1999, Waterhouse,
2005).

A rise in temperature (hyperthermia)
has many detrimental effects to the
patient.
Each degree rise in
temperature results in an increase of
up to 10% in the patient’s rate of
metabolism.
This increases the
patient’s requirement of oxygen and
glucose, and results in increasing byproducts of metabolism, namely
carbon dioxide. Carbon dioxide is a
potent cerebral vasodilator and can
result in an increase in raised
intracranial pressure.

A fall in temperature (hypothermia)
can also result from damage to the
brainstem and hypothalamus as well
as spinal shock, metabolic or toxic
coma. This can result in the patient
assuming the room temperature. This
can cause;
o Peripheral
vasoconstriction,
which increases blood flow to
vital organs (including the
brain) and thus increase
intracranial pressure.
o Bradycardia, which can have
Page 20 of 33
25
detrimental effects particularly if
the patient already has a low
heart rate due to pre-existing
raised intracranial pressure and
systemic hypertension.
Document patients’ temperature on the Allows for any trends or patterns to be
Modified Paediatric Glasgow Coma illustrated in line with previous findings,
Scale (Appendix 2).
and
to
enable
findings
to
be
communicated to other members the
Multi disciplinary team (Nursing &
Midwifery Council, 2002).
Page 21 of 33
Appendix 1
A diagram showing the position of the Trapezius muscle.
Page 22 of 33
Appendix 2
Modified Paediatric Glasgow Coma Scale (BCH Model).
Page 23 of 33
Appendix 3
Localising response to painful stimulus.
PAIN
© Manning 2007
Page 24 of 33
Appendix 4
Neutral positioning.
© Manning 2007
Page 25 of 33
Appendix 5
Withdraw response to painful stimulus.
PAIN
© Manning 2007
Page 26 of 33
Appendix 6
Abnormal flexion (Decorticate Posturing) response to painful stimulus.
PAIN
© Manning 2007
Page 27 of 33
Appendix 7
Extension (Decerebrate Posture) response to painful stimulus
PAIN
© Manning 2007
Page 28 of 33
Appendix 8
Simultaneous observation of pupils using a millimetre scale
1
2
3
4
5
6
© Manning 2007
(Not to scale)
Page 29 of 33
Appendix 9
Shining of the pen torch into each eye moving from the outer corner of the eye
towards the pupil.
© Manning 2007
Page 30 of 33
Appendix 10
Holding both eyes open with your thumb and index finger, or index and middle
fingers by pulling the lower eyelid in a downward motion.
© Manning 2007
Page 31 of 33
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Author: Joseph Manning
Written: 2007 Updated: August 2014 by Jennifer Davidson Review Due: August 2019
Consultation Process: Janet Hagan Beverley King
Ratified by: Nottingham Children’s Hospital Clinical Educators
Signed off by: Jamie Crew, Kerry Webb and Rachel Keay
Page 33 of 33