Download Neuro Assessment

Neurological Assessment
At the end of this self study the
participant will:
1. Describe the neuro nursing
assessment
2. List 5 abnormal findings in a neuro
assessment
3. List 3 early signs which would
indicate the patient is worsening
4. List 3 late signs of neurological
depression.
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Neurological Assessment
Level of Consciousness
 Most sensitive indicator of neurological change
 Measurement of a person's arousability and
responsiveness to stimuli from the environment (not
accuracy of response to questions)
Impairments to Assessment
Trauma
Alcohol
Insulin
Epilepsy
Psych
Infection
Poison
Opiates
Shock/Stroke
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Level of Consciousness
 Patient’s level of awareness - don’t confuse with
orientation
 Awake - interactive
 Lethargic - sleepy, drowsy, rousable/responsive
 Stuporous - arousable with stimuli, resists arousal
 Obtunded - cannot maintain arousal without
repeated stimuli, moans/groans to stimuli
 Comatose - non interactive with surroundings
 Orientation (appropriateness)
 Person, place, time, situation
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Glascow Coma Scale
• Assesses level of
consciousness
• Look for patients’ best
responses
• Total the numbers for
documentation
• Restrictions:
– If eyes swollen closed, use
“C” instead of number
(maximum 11C)
– For artificial airway, use
“T” instead of number
(maximum 10T)
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Parameter
Score Response
Eye Opening
4
3
2
4
C
Spontaneous
To Voice
To Pain
No Response
Closed by swelling
Best Verbal
Response
5
4
3
2
1
T
Oriented
Confused
Inappropriate Words
Incomprehensible sounds*
No response or Intubated
Artificial Airway
Best Motor
Response
6
5
4
3
2
1
Follows commands
Purposeful, localizes
Withdraws
Abnormal Flexion **
Abnormal Extension**
No response
Total
3/15-15/15
Pupillary Response
 PERRLA: pupils equal, round and reactive to light
and accommodation
 Pupil size
 Response to light
 Brisk
 Sluggish
 Non-reactive/fixed
5
Pupillary Response
 Accommodation
 have patient focus on your finger and move finger
towards their nose
 Pupils should constrict and eyes should cross
 Alteration
 Changes seen on which side?
 Hippus: spasmodic, rhythmic but irregular dilating
and contracting pupillary movement
6
Reflexes
 Corneal Reflex
 Blink reflex
 To assess, touch cornea with tip of
cotton, instill eye drop, touch lashes
 Gag Reflex
 Airway protection mechanism
 Neck injury/surgery
 Aspiration risk
 Voice changes
 Volume changes
7
Extremity Assessment
 Strength
 Sensory
 Pinprick
Hand grasps
Arm drift
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 Touch
 Warm/cold
Foot flexion
 Compare right
to left
Assess with
resistance
Neurological Assessment
Motor Assessment
Response to stimuli - Normal vs Abnormal
Abnormal Posturing:
Decorticate posturing/flexor posturing
Decerebrate posturing/extensor posturing
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When is your patient in trouble?
• Behavior changes first
– If normally quiet, may get restless or vocal
– If normally boisterous, may get quiet
• Speech next
– Slurring, difficulty forming words
• Orientation next
– Oriented x4 on admission, starts forgetting what
you’ve said is going on – Oriented x3
• Arousability next
– Drowsiness but may respond to stimuli – Glascow
Coma Scale changes
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Early signs your patient is in trouble
Early signs:
1. Decreasing LOC: needs more stimulus to display
same responses
2. Motor: Subtle weakness on one side, pronator
drift.
3. Pupils: Sluggish reaction; unilateral hippus; an
ovoid shape; any irregularity that is unusual for the
patient.
4. VS: Not reliable at this point; may have cheynestokes respirations, but is dependent upon where the
lesion is located in the brain.
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Late signs your patient is in trouble
1. LOC: Unarousable.
2. Motor: Dense weakness on a side; worsening
responses to painful stimuli; posturing; then no
response.
3. Pupils: One “blown” pupil; then both fixed and
dilated.
4. VS: Cushing’s triad:
– widening pulse pressure (increased SBP)
– profoundly slow pulse rate,
– abnormal respirations.
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Tips for accurate neuro assessments
• Always use the same structure for your assessment
– Head to toe
• Always compare right to left
– Asymmetry is abnormal
• Take your time. Patients’ response times vary with
age, history, medications, and other factors
• If a family member tells you something is wrong,
investigate
– Level of consciousness is the most sensitive
indicator of neuro status
– Family may pick up on something staff
may
not
abcdefghi
see as abnormal
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