12.1 Neurological Assessment, Glasgow Coma Scale (GCS) & Stroke Care

12.1 Neurological Assessment, Glasgow Coma Scale (GCS) & Stroke Care

Neurological nursing requires precise clinical assessment skills, rapid pattern recognition, and immediate evidence-based interventions. In Singapore acute hospitals, such as the National Neuroscience Institute (NNI), Singapore General Hospital (SGH), Tan Tock Seng Hospital (TTSH), and National University Hospital (NUH), standardized assessment protocols ensure early detection of deteriorating central nervous system (CNS) function.

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1. Baseline Neurological Assessment & AVPU Scale

A structured neurological assessment evaluates level of consciousness (LOC), pupillary light reflex, motor function, sensory perception, and cranial nerve integrity. For rapid baseline triage, nurses utilize the AVPU Scale:

• Alert: Fully awake, spontaneously conscious, aware of person, place, and time.
• Voice: Responds to auditory stimuli or verbal commands.
• Pain: Responds only to painful/noxious tactile stimuli (e.g., trapezius squeeze or supraorbital pressure; sternal rubs should be avoided to prevent tissue trauma).
• Unresponsive: No motor or verbal response to any external stimuli.

For ongoing detailed assessment, the Glasgow Coma Scale (GCS) remains the international gold standard in neuro-trauma and medical wards.

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2. Glasgow Coma Scale (GCS) Scoring & Clinical Application

Developed by Teasdale and Jennett, the GCS evaluates three discrete categories of responses: Eye Opening (E), Verbal Response (V), and Motor Response (M). Scores range from a minimum of 3 (deep coma or brain death) to a maximum of 15 (fully alert and oriented).

Clinical Nuances & Escalation Protocols

• Score Interpretation: GCS 13–15 indicates mild injury; GCS 9–12 indicates moderate injury; GCS ≤8 defines severe brain injury/coma and typically mandates endotracheal intubation for airway protection.
• Critical Drop: Under Singapore Nursing Board (SNB) clinical governance, a drop of ≥2 points in total GCS (or a drop of 1 point in the motor score) represents a clinical emergency. The registered nurse must immediately initiate an emergency bedside review, elevate the head of bed, notify the primary medical team or Rapid Response Team (RRT), and communicate via ISBAR (Identify, Situation, Background, Assessment, Recommendation).
• Pupillary Assessment: Pupillary reactivity (brisk, sluggish, fixed) and size (measured in millimeters, normal 2–6 mm) must be assessed alongside GCS. A unilaterally dilated, unreactive pupil ("blown pupil") indicates third cranial nerve (oculomotor) compression from uncal herniation.

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3. Acute Ischemic Stroke & Hyperacute Pathways in Singapore

Stroke is a leading cause of long-term disability and death in Singapore. The Singapore Ministry of Health (MOH) Clinical Practice Guidelines (CPG) on Stroke Care emphasize early recognition and immediate activation of the Hyperacute Code Stroke Pathway.

Screening Tools: BE-FAST

Public health education and clinical triage rely on the BE-FAST mnemonic:

• B (Balance): Sudden loss of balance or coordination (ataxia).
• E (Eyes): Sudden visual disturbance, diplopia, or loss of vision in one or both eyes.
• F (Face): Facial drooping or asymmetric smile.
• A (Arms): Arm weakness or drift on one side.
• S (Speech): Slurred speech, dysarthria, or expressive/receptive aphasia.
• T (Time): Time of onset is critical; immediate activation of emergency medical services (995 ambulance call in Singapore).

Hyperacute Hospital Protocol & Door-to-Needle (DTN) Targets

When a Code Stroke is activated in Singapore public acute hospitals:

1. Emergency Department Triage: Immediate triage as Priority 1 (P1). Urgent non-contrast Computed Tomography (CT) brain scan is ordered to differentiate ischemic stroke from intracranial hemorrhage.
2. Target Timelines:
   • Door-to-CT completion: ≤20 minutes.
   • Door-to-CT interpretation: ≤45 minutes.
   • Door-to-Needle (DTN) time: ≤60 minutes (with leading institutions aiming for <45 minutes) for intravenous thrombolysis administration.

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4. Intravenous Thrombolytic Therapy (r-tPA / Alteplase & Tenecteplase)

Recombinant tissue plasminogen activator (r-tPA / Alteplase) or Tenecteplase dissolves blood clots to restore cerebral perfusion in acute ischemic stroke.

Therapeutic Window & Indications

• Administered within 4.5 hours of witnessed symptom onset.
• Patient must be ≥18 years old with a measurable neurological deficit on the National Institutes of Health Stroke Scale (NIHSS).

Absolute Contraindications for Thrombolysis

• Non-contrast CT showing intracranial hemorrhage or multi-lobar infarction (>1/3 hemisphere).
• Active internal bleeding or bleeding diathesis (platelets <100,000/mcL, INR >1.7).
• Severe uncontrolled blood pressure: Systolic BP >185 mmHg or Diastolic BP >110 mmHg resistant to IV antihypertensives (e.g., IV Labetalol or Nicardipine).
• History of intracranial hemorrhage, recent major head trauma or intracranial surgery within 3 months.
• Suspected aortic dissection or infective endocarditis.

Post-Thrombolysis Nursing Protocol

• Blood Pressure Parameters: Maintain BP <180/105 mmHg for at least 24 hours post-thrombolysis to prevent reperfusion injury and hemorrhagic transformation.
• Neurological & Vital Sign Frequency: Monitor GCS, NIHSS, pupils, and blood pressure every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every 1 hour for 16 hours.
• Bleeding Precautions: Avoid invasive procedures (NG tube insertion, indwelling urinary catheter, arterial punctures) for 24 hours post-infusion. Withhold antiplatelets (Aspirin, Clopidogrel) and anticoagulants (Heparin, Warfarin) for 24 hours until a repeat CT brain confirms no bleeding.

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5. Post-Stroke Nursing Interventions & Safety Protocols

Mandatory Dysphagia Screening

Post-stroke dysphagia occurs in up to 50% of patients, presenting a severe risk of aspiration pneumonia. Under MOH Nursing Guidelines:

• NPO Status: The patient must remain strict Nil By Mouth (NPO)—including oral medications, water, and ice chips—until a validated Bedside Water Swallow Test (BWST) is conducted by a trained nurse or Speech Therapist.
• Screening Procedure: If the patient fails the screening (coughing, wet/gurgly voice, choking, or delayed swallow), they remain NPO, and a Speech Therapist is consulted for formal videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES).

Positioning & Secondary Prevention

• Head Elevation: Maintain Head of Bed (HOB) at 30 degrees to optimize cerebral venous drainage and lower intracranial pressure while preventing aspiration.
• Venous Thromboembolism (VTE) Prophylaxis: Apply intermittent pneumatic compression (IPC) devices within 24 hours for immobile stroke patients. Subcutaneous low-molecular-weight heparin (LMWH) is initiated 24 hours post-thrombolysis if follow-up CT is negative for hemorrhage.
• Patient Data & Dignity: Adhere to the Personal Data Protection Act (PDPA) and SNB Code for Nurses and Midwives (2023) when handing over sensitive neurological status and clinical updates to designated family members.