Neurological Examination of an Unconscious or Comatose Patient

Neurological examination of an unconsious or comatose identifies lesion location, monitors progression, and guides urgent interventions in patients who cannot cooperate. Early baseline assessment informs comparisons and may detect changes before they appear on imaging or lab tests

Purpose of Neurological Examination

• Localize lesions: Pinpoint the anatomical location of a problem (e.g., brain, spinal cord, cranial nerves).
• Guide further testing: Help determine which diagnostic tests (MRI, CT, EEG, etc.) are needed.
• Track progression: Monitor changes over time in chronic conditions like Parkinson’s or multiple sclerosis.
• Evaluate treatment response: Assess how well a patient is responding to therapy or rehabilitation.

Components

1. Past medical history
2. Review of general parameters (e.g., skin, scalp, mouth odor, ears)
3. Vital signs including respiratory patterns
4. Level of consciousness
5. Pupillary size and response to light
6. Eyelids, gaze, and extraocular movement
7. Facial symmetry
8. Other reflexes (corneal, gag, swallowing reflexes)
9. Motor tone and response to pain

Medical History

Any history provided by a family member, if present, may be helpful in suggesting the underlying cause of coma in a nontrauma patient. For example, a history of diabetes mellitus or drug or alcohol use could be related to the current problem. It is essential to know the factors related to the onset of coma and the length of coma also.

Review of General Parameters

• General appearance: Predominant position of the extremities, position of the head and the neck, presence of spontaneous movement, and the position of the eye when the lids are open.
• Skin: Color, evidence of bleeding disorder, needle marks, or bruises.
• Scalp: Checking for fracture or signs of injury.
• Mouth and nose: Odor and any drainage from mouth or nose.
• Ears: Otoscopic examination for evidence of trauma. infection, or drainage.

Vital Signs

• Respiration

Note the rate, rhythm, and characteristics of the inspiratory and expiratory phases of respiration. Look for abnormal respiratory patterns such as Cheyne-Stokes respiration, central neurogenic hyperventilation, apneustic breathing, cluster breathing, and ataxic breathing.

• Pulse and Heart Rate

Note the rate, rhythm, and quality of the pulse and the heart rate, and compare with previous data.
Abnormal findings:

• Tachycardia: May indicate hypoxia, terminal stages of increased intracranial pressure (ICP), and internal bleeding in the abdominal, thoracic, or pelvic cavity.
• Bradycardia: Late stage of increased ICP.
• Bradycardia with hypertension: May be secondary to cervical spinal cord injury with interruption of descending sympathetic pathways.
• Cardiac arrhythmias: Seen in patients with subarachnoid hemorrhage, severe head injury, have undergone posterior fossa surgery, or have increased ICP.
• Blood Pressure

Abnormal findings:

• Hypertension: Massive hypothalamic discharge or a rising ICP.
• Cushing’s reflex: Elevated systolic blood pressure, widening pulse pressure, and bradycardia seen in the advanced stages of increased ICP.
• Hypotension with tachycardia: Is a terminal event seen with severe neurological injury.
• Hypotension with bradycardia: Seen in patients with cervical spinal injury.

• Temperature

Abnormal findings:

• Hypothermia: Seen in spinal shock, metabolic or toxic coma, drug overdose, and destructive brainstem or hypothalamic lesions.
• Hyperthermia: Is more common and may be of infectious origin, or noninfectious origin such as systemic inflammatory conditions, drug induced (e.g., phenytoin). posterior fossa syndrome, neuroleptic malignant syndrome, and malignant hyperthermia.
• Central fever: Caused by a central neurogenic etiology, for example, space-occupying lesions, and trauma or lesions involving the hypothalamus.
• Level of Consciousness
  Assess depth of coma; give a verbal stimulus (call out patient’s name or clap hands loudly over the patient’s head). If there is no response, provide a noxious stimulus by putting pressure on the nail bed of the hand or pinching the muscles of the shoulder.

Pupillary Response

• Pupil Size
• Millimeter scale: It is normally equal and 3-4 mm in diameter (smaller in elderly). It may range between 2 and 6 mm with an average diameter of 3.5 mm.

• Pupillary Reaction to Light

Normal response:

• Direct light reflex: Pupillary constriction when light is shone into the eyes, and immediate and brisk dilation on withdrawal of the light.
• Consensual light reflex: Constriction of both pupils, simultaneously on exposure of any one pupil to light, and dilatation of both pupils on withdrawal of light.

Abnormal Pupillary Responses to Light

• Eyelashes, Eyelids, Gaze, and Ocular Movements

Signs of deepening coma:

• Loss of spontaneous blinking and finally loss of corneal reflex.
• Eyelids close slowly once they are released.
• Roving-eye movement – Spontaneous, slow, and random deviation of the eyes in patients with intact brainstem oculomotor function.
• Gaze disorders
• Downward deviation of one eye (CN III palsy).
• Medial deviation of one eye (CN VI palsy).
• Deviation of both eyes toward the side of the lesion and away from the hemiparesis (acute hemispheric lesion).
• Deviation of both eyes away from the discharging focus (seizures).
• Deviation of both eyes away from the side of the lesion and toward the hemiplegia (pontine gaze palsies due to infarcts, hemorrhage, gliomas, abscesses, Wernicke’s encephalopathy, and multiple sclerosis).
• Impaired upward gaze (dorsal midbrain lesion).
• Parinaud’s syndrome: Upward gaze paralysis, nystagmus on downward gaze, paralysis of accommodation, midposition pupils, and light near dissociation.
• Oculocephalic reflex (Doll’s eye movement): Brisk turning of the head from side to side (test of CN III and VI), or vertically up and down (CN III) while holding the eyelids open. If reflex is intact, eyes move conjugately in the direction opposite to the head movement. Absence of the reflex indicates severe brainstem dysfunction from the pons to the midbrain level (this test is usually performed by the physician).
• Oculovestibular or cold caloric testing is done if the oculocephalic response is inconclusive. Raise patient’s head 30°. Unilateral irrigation with 30-50 mL of cold water (33°C) over 30 seconds results in slow deviation of eyes toward the irrigated ear followed by rapid corrective movement of the eye, if the brainstem is intact. Wait at least 5 minutes before testing the other side.

Other methods of assessing vestibular function:

• Unilateral irrigation with warm water (44°C): Eyes deviate away from the side of the irrigation.
• Bilateral irrigation with cold water (33°C): Eyes deviate downward.
• Bilateral irrigation with warm water (44°C): Eyes deviate upward.

(Mnemonic for the responses-COWS: cold, opposite, warm, same)

Facial Symmetry

Observe facial symmetry at rest and when stimulated.

• Other Reflexes

Corneal (CNs V and VII) and gag (CNs IX and X) reflex if absent indicates brainstem dysfunction. In an intubated patient, the gag and swallowing reflex can be tested by tugging gently on the endotracheal tube. If the reflex is intact, the patient will gag or cough. Also test the deep tendon and plantar reflexes and check for the presence of pathological reflexes.

Motor Tone and Response to Pain

• Assess predominant posture for abnormalities (decerebrate or decorticate).
• Assess muscle tone for flaccidity (limb drops rapidly onto the bed and flails, on release from a 12-to 18-inch elevated position).
• Apply a central painful stimulus (pinching the trapezius or pectoralis major muscles of the neck or by applying firm pressure to the supraorbital area). Possible responses are the following:
• Purposeful: Localization or pushing the painful stimuli away (coma of moderate severity).
• Non purposeful: Movement of the stimulated area, but no attempt to push the stimuli away.
• No response: No reaction to painful stimuli.

Documentation & Monitoring

Chart level of Consciousness, pupillary diameters, reflex responses, vital signs, and examination timing in a coma chart. Reassess at least every 1–2 hours or more frequently if deterioration is suspected. Early detection of subtle changes is critical to prevent irreversible brain injury

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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