Neurological Assessment

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Neurological Assessment

• At the end of this self study the participant
  will
• Describe the neuro nursing assessment
• List 5 abnormal findings in a neuro assessment
• List 3 early signs which would indicate the
  patient is worsening
• 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

• Patients level of awareness - dont 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)

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

5
Pupillary Response

• PERRLA pupils equal, round and reactive to
  light and accommodation
• Pupil size
• Response to light
• Brisk
• Sluggish
• Non-reactive/fixed

6
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

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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

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Extremity Assessment

• Strength
• Sensory
• Pinprick
• Touch
• Warm/cold
• Compare right to left

Hand grasps
Foot flexion Assess with resistance
Arm drift
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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
  youve 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
  cheyne-stokes 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 Cushings 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
  see as abnormal

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