1 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.

2 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 TraumaAlcoholInsulin EpilepsyPsychInfection PoisonOpiatesShock/Stroke

3 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

4 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) ParameterScoreResponse Eye Opening4324C4324C Spontaneous To Voice To Pain No Response Closed by swelling Best Verbal Response 54321T54321T Oriented Confused Inappropriate Words Incomprehensible sounds* No response or Intubated Artificial Airway Best Motor Response Follows commands Purposeful, localizes Withdraws Abnormal Flexion ** Abnormal Extension** No response Total3/15-15/15

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

7  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 Reflexes

8 Extremity Assessment Hand grasps  Strength  Sensory  Pinprick  Touch  Warm/cold  Compare right to left Arm drift Foot flexion Assess with resistance

9 Neurological Assessment Motor Assessment Response to stimuli - Normal vs Abnormal Abnormal Posturing: Decorticate posturing/flexor posturing Decerebrate posturing/extensor posturing

10 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

11 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.

12 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.

13 abcdefghi 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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