Neurological Observations MUST include the following:
- A full set of NEWS2 observations
- ACVPU assessment (alert, new confusion, voice, pain, unresponsive)
- GCS (Glasgow coma scale)
- Pupillary responses
- Assessment of Limb power
Head injury is witnessed, reported, suspected, or cannot be excluded.
- There is any new onset of neurological symptoms or deterioration.
- The patient complains of pain / tenderness to the head
- Extra consideration should be given to patients currently prescribed anticoagulant medication at the time of the fall.
Post fall Neurological Observations must be completed for at least 12 hours and at the above intervals as a minimum:
During this time If there is any deterioration in the patient’s condition including level of consciousness, pupil reaction, limb power, cardiovascular observation you must revert to ½ hourly neurological observation and seek URGENT medical review.
Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.
Under no circumstances should Neurological observations be omitted because the patient is asleep
Admitted with Head Injury
- With a sudden deterioration in their level of consciousness
- Who are unconscious on arrival to hospital
- Post first seizure
During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must revert to ½ hourly neurological observations and seek URGENT medical review. Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.
Under no circumstances should Neurological observations be omitted because the patient is asleep.
- Acute Primary Intracerebral/Subarachnoid haemorrhage
- Any other Ischaemic stroke
- Post Thrombolysis /Thrombectomy for Stroke patients only
During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must seek URGENT medical review and revert to ½ hourly neurological observations as a minimum, or ¼ hourly, if still within the first 2 hours post thrombolysis.
Under no circumstances should Neurological observations be omitted because the patient is asleep.
