Neurological observations

Neurological observations are essential in the assessment and monitoring of patients with neurological conditions, such as head injuries or strokes, and chronic conditions, such as multiple sclerosis. These observations help nurses to identify early signs of deterioration, enabling timely interventions to prevent complications (Park et al, 2020). By systematically evaluating key neurological functions, such as consciousness, motor skills and pupillary response, nurses can assess the patient’s condition and provide tailored, patient-centred care. Neurological observations are central to ensuring patient safety, promoting recovery and improving outcomes for patients with neurological conditions (Derbyshire and Hill, 2018).

Performing accurate neurological observations involves a structured and comprehensive approach, focusing on key areas of assessment:

1. Consciousness: the Glasgow Coma Scale is used to assess consciousness levels by evaluating eye opening, verbal response and motor response. This scale provides a score that reflects the patient’s cerebral function (Table 1). Painful stimuli should be applied appropriately to assess motor response, including the use of the Medical Research Council scale for grading muscle strength (Strauss et al, 2021)
2. Pupillary response: examination of the size, shape and reaction of the pupils to light is essential in detecting raised intracranial pressure or damage to cranial nerves, particularly the third cranial nerve, which controls pupil constriction (Smith and Czyz, 2022). Abnormal pupil reactions can indicate serious conditions, such as brain herniation because of increased intracranial pressure (Figure 1)
3. Motor function: assessment of limb strength, coordination and movement should be carried out in all four limbs.

1. Preparation: ensure the patient is comfortable and understands the procedure. Gather necessary tools, such as a pen torch for pupil examination and a reflex hammer
2. Consciousness assessment: conduct the Glasgow Coma Scale assessment to gauge the patient’s level of consciousness, ensuring accurate documentation of eye, verbal and motor responses. For the motor assessment, apply painful stimuli if required to test the patient’s reaction and document using the Medical Research Council scale (Peate and Hill, 2022)
3. Pupillary response: assess pupil size, symmetry and reaction to light in both eyes. Changes in pupillary response could signal increased intracranial pressure or cranial nerve damage (Figure 1) (Derbyshire and Hill, 2018)
4. Motor function: test the patient’s ability to move all four limbs, noting any signs of weakness, paralysis or asymmetry
5. Sensory and reflex testing: assess the patient’s ability to detect touch, pain and temperature. Test reflexes such as the biceps, patellar and Achilles reflexes

Raised intracranial pressure is a critical concern in patients who are undergoing a neurological examination. It occurs when there is an increase in the pressure inside the skull, which can compress brain tissue and reduce blood flow. This can lead to herniation, which is a life-threatening condition (Peate and Hill, 2022). Common signs of raised intracranial pressure include altered consciousness, abnormal posturing and changes in vital signs, such as bradycardia and hypertension (Cushing reflex). Immediate intervention is crucial to prevent permanent damage or death (Munakomi and Das, 2024).

Neurological observations are fundamental to nursing care, ensuring early detection of neurological deterioration and supporting timely, life-saving interventions. Nurses must continue to develop their knowledge and skills in performing these assessments, supported by evidence-based guidelines and ongoing education. Enhanced understanding of neurological observations, including the recognition of raised intracranial pressure and appropriate pain stimulation techniques, will improve patient outcomes and safety.

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

2. Use evidence-based, best practice approaches to undertake the following procedures:

2.7 undertake a whole body systems assessment including respiratory, circulatory, neurological, musculoskeletal, cardiovascular and skin status

2.12 undertake, respond to and interpret neurological observations and assessments

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Munakomi S, Das JM. Intracranial pressure monitoring. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.

Park TH, Lee JK, Park MS et al. Neurologic deterioration in patients with acute ischemic stroke or transient ischemic attack [published correction appears in Neurology. 2024;103(1):e209550. https://doi.org/ 10.1212/WNL.0000000000209550]. Neurology. 2020;95(16):e2178–e2191. https://doi.org/10.1212/WNL.0000000000010603 

Peate I, Hill B. Fundamentals of critical care: a textbook for nursing and healthcare students. Chichester: Wiley-Blackwell; 2022

Peate I. Alexader’s nursing practice: hospital and home. 9th edn. London: Elsevier; 2024

Smith AM, Czyz CN. Neuroanatomy, Cranial Nerve 2 (Optic). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022

Strauss S, Barby S, Härtner J et al. Graded motor imagery modifies movement pain, cortical excitability and sensorimotor function in complex regional pain syndrome. Brain Commun. 2021;3(4):fcab216.