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Neurological checks: level of consciousness, pupils and the Glasgow scale

  • Assessment

Neuro checks repeat the same assessment (consciousness, orientation, Glasgow, pupils) at set intervals to catch any deterioration early.

Updated

What it is

A nursing neuro check is not looking for a diagnosis: it is looking for a change. It is repeated with the same technique at the ordered times: level of consciousness and orientation, the Glasgow Coma Scale, pupil size and reaction, and vital signs. The first assessment, on admission, is the baseline; each check is compared with the one before. New confusion or any acute drop in the Glasgow score is a sign of potentially serious deterioration and is escalated at once.

Reference values

  • Glasgow: 4 eye responses, 5 verbal and 6 motor; total 3 to 15.
  • A Glasgow score below 8 is classed as coma.
  • Pupils: 2 to 5 mm, equal, with a brisk reaction to light.
  • Orientation is checked with name, place and day; normal is recorded as «alert and oriented ×3».

What you need

  • Penlight and a pupil gauge (paper pupillometer).
  • The previous assessment (baseline) and the ordered frequency of checks.
  • Knowing what can distort the assessment: sedation, intubation, eyelid swelling, deafness, language, or missing glasses or hearing aids.

How to measure it (and why)

  1. Check what may prevent assessing each component (sedation, intubation, deafness, language) — it is recorded as «not testable» instead of being scored wrongly.
  2. Observe without stimulating: do they open their eyes, move, speak on their own? — the spontaneous response is the best one.
  3. If there is no response, speak to them, then apply a physical stimulus per protocol — the aim is the best response with the least stimulus needed.
  4. Ask name, place and date; if the date is not known, ask the day of the week, month or season — orientation picks up subtle confusion.
  5. Dim the lights, shine the light into each pupil from the side and compare size, shape and speed — new asymmetry is a warning sign.
  6. Rate each response against the defined criteria of the scale — so different nurses score it the same way.
  7. Record each response, the total, pupils, vital signs and time — this shows the trend and communicates it clearly.

How to read it

  • NEWS2 adds new confusion to the level of consciousness: AVPU becomes ACVPU.
  • Delirium is acute, reversible confusion (from fever, infection or low oxygen); dementia is chronic, irreversible confusion and memory loss.
  • On NEWS2, new confusion scores 3 by itself and calls for urgent assessment.
  • Check glasses and hearing aids before testing orientation: poor sight or hearing can look like confusion.

Next step: when to call for help

  • Call at once for any drop in the Glasgow score, new confusion, agitation or drowsiness that was not there before.
  • Call at once if a pupil enlarges, becomes sluggish or the pupils become unequal.
  • If the patient becomes unresponsive, call for emergency help per protocol.
  • Record the name of the person told, the time and the measures taken.

Test yourself

Think of the answer, then tap the question to see it.

Which three responses does the Glasgow scale assess?

Eye opening, verbal response and motor response; their scores are added for a total of 3 to 15.

What pupil size is considered normal?

Between 2 and 5 mm, with both pupils equal, round and reactive to light and accommodation.

What steps does the structured Glasgow assessment follow?

Check what prevents assessment, observe the spontaneous response, stimulate if there is none and rate against defined criteria.

What do you do for new confusion in a patient who was oriented?

Call at once. It is a sign of possibly serious deterioration, and if in doubt whether it is new, assume it is.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Skills (Open RN), 6.4 Assessing Mental Status (Open RN, Wisconsin Technical College System (LibreTexts), 2021); Nursing Skills (Open RN), 6.5 Assessing Cranial Nerves (Open RN, Wisconsin Technical College System (LibreTexts), 2021); Glasgow Coma Scale: structured approach (Royal College of Physicians and Surgeons of Glasgow, 2014); National Early Warning Score (NEWS) 2: executive summary and recommendations (Royal College of Physicians, 2017).

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