Neurological Assessment includes
-client's current condition
-Glasgow Coma Scale
-pupillary changes
-hand grips/leg lifts/pushing strength of
... [Show More] feet
-Babinski reflex
Neurological Assessment of Client's Current Condition - Onset: It's important to know
when the symptoms started
Neurological Assessment of Client's Current Condition - Onset: Ask them _______________________________ and what ____________________________
when was the onset; symptoms did the client have intially
Neurological Assessment of Client's Current Condition - Description of Symptoms: Have them
describe
Neurological Assessment of Client's Current Condition - Description of Symptoms: Know the ________________, how __________________________, and how _______________
location; long the symptoms have persisted; severe
Neurological Assessment of Client's Current Condition - Associated Factors: Determine if there were any __________________________________ associated with the symptoms
triggers or aggravating factors
Neurological Assessment of Client's Current Condition - Associated Factors: Ask them "did anything ________________________ the symptoms?"
help relieve
Neurological Assessment of Client's Current Condition - Overall Appearance: Note the client's general
appearance and behavior
Neurological Assessment of Client's Current Condition - Overall Appearance: Observe if there are any ______________________________ of a ____________________________ deficit?
obvious signs; neurological (speech slur? drooping side of face?)
Neurological Assessment of Client's Current Condition - Degree of Consciousness: What is the MOST important aspect of the neuro exam?
assessment of the client's mental status, including LOC
Neurological Assessment of Client's Current Condition - Degree of Consciousness: Mental status includes
-awareness of surroundings and alertness
-orientation to person, place, and time
-memory: both short-term and long-term
Neurological Assessment of Client's Current Condition - Degree of Consciousness: The most sensitive indicator of neuro status is
LOC
Neurological Assessment of Client's Current Condition - Degree of Consciousness: A change in LOC may be
the first sign that there is a problem
Neurological Assessment - Glasgow Coma Scale: This scale is used to
assess the LOC in a client who already has altered consciousness or has the potential of altered consciousness
Neurological Assessment - Glasgow Coma Scale: This scale is used primarily in the
ED or ICU
Neurological Assessment - Glasgow Coma Scale: The definition of this scale is
a scale that measures the degree of LOC
Neurological Assessment - Glasgow Coma Scale: 3 responses of this scale
1. eye opening
2. motor response
3. verbal response
Neurological Assessment - Glasgow Coma Scale: RULE - we like a
high number ranging from 13 to 15
Neurological Assessment - Glasgow Coma Scale: What is always #1 with neurological assessment?
LOC
Neurological Assessment - Glasgow Coma Scale: Eye Opening (E) scores
4 - spontaneous
3 - to verbal command
2 - to pain
1 - no response
Neurological Assessment - Glasgow Coma Scale: Motor Response (M) scores
6 - to verbal command
5 - to localized pain
4 - flexed/withdraws
3 - flexes abnormally
2 - extends abnormally
1 - no response
Neurological Assessment - Glasgow Coma Scale: Verbal Response (V) scores
5 - oriented/talks
4 - disoriented/talks
3 - inappropriate words
2 - incomprehensible sounds
1 - no response
Neurological Assessment - Glasgow Coma Scale: The total score is determined using what formula?
E + M + V
Neurological Assessment - Pupillary changes: Determined using
PERRLA
Neurological Assessment - Pupillary changes: Normal pupil size
2-6 mm
Neurological Assessment - Hand Grips/Leg Lifts/Pushing Strength of Feet: This is assessed for
strength and equality and if client will follow a command
Neurological Assessment - Babinski Reflex: Normal in an infant up to
1 year
Neurological Assessment - Babinski Reflex: Though it is normal in an infant up to 1 year, it may be seen up to
2 years (should disappear when walking starts)
Neurological Assessment - Babinski Reflex: Abnormal in
an adult
Neurological Assessment - Babinski Reflex: The adult or child greater than 1 year should have a normal reflex or ____________________________ when the bottom of the foot is stroked
curling of the toes (Plantar Reflex)
Neurological Assessment - Babinski Reflex: What does it mean if the adult has a Babinski reflex or fanning of the toes when you stroke the bottom of the foot?
there is a severe problem in the CNS that is affecting an upper motor neuron
Neurological Assessment - Babinski Reflex: Possible causes of a Babinski reflex in an adult
-tumor or lesion on the brain or spinal cord
-meningitis
-multiple sclerosis
-Lou Gehrig's disease
Neurological Assessment - Deep Tendon Reflex Scale: 0 is
no response (absent)
Neurological Assessment - Deep Tendon Reflex Scale: 1+ is
present, but sluggish or diminished (hypoactive)
Neurological Assessment - Deep Tendon Reflex Scale: 2+ is
active or expected response (normal)
Neurological Assessment - Deep Tendon Reflex Scale: 3+ is
more brisk than expected. slightly hyperactive, but not necessarily pathological
Neurological Assessment - Deep Tendon Reflex Scale: 4+ is
brisk, hyperactive, with intermittent or transient clonus
Neurological Assessment - Deep Tendon Reflex Scale: An ankle clonus is
a series of abnormal reflex movements of the foot, induced by sudden dorsiflexion
Neurological Assessment - Deep Tendon Reflex Scale: A normal reflex response would be documented as
2+/4+ (you put the score you got over the highest number on the scale)
(documented this way because different nurses use different scales)
General Diagnostic Tests - Lumbar Puncture: Where is the puncture site?
lumbar subarachnoid space
General Diagnostic Tests - Lumbar Puncture: 3 Purposes
1. obtain CSF
2. measure pressure readings with a manometer &
reduce CSF pressure
3. administer drugs intrathecally (into the spinal
canal)
General Diagnostic Tests - Lumbar Puncture: Why would we want to obtain CSF?
to analyze for blood, infection, and even tumor cells
General Diagnostic Tests - Lumbar Puncture: How is the client positioned and why?
propped up over the bedside table with head down or on side in fetal position (chin to chest and knees flexed) to add a lot of arch to the back (opens up space between the vertebrae)
General Diagnostic Tests - Lumbar Puncture: If the patient is tense during the LP,
the results will be falsely elevated
General Diagnostic Tests - Lumbar Puncture: Inspect the surrounding skin at the puncture site for
any infection
General Diagnostic Tests - Lumbar Puncture: CSF should be
clear and colorless (looks like water)
General Diagnostic Tests - Lumbar Puncture: Post-procedure the client should lie _________________ for ________________ because _____________________
flat or prone; 4-8 hours; want a seal to form
General Diagnostic Tests - Lumbar Puncture: Post-procedure we want to increase fluids to
replace lost CSF and reduce the risk of complications
General Diagnostic Tests - Lumbar Puncture: What is the most post-procedure complication?
headache
General Diagnostic Tests - Lumbar Puncture: The pain of a post-procedure H/A ________________________ when the client sits up or stands up and ________________________ when they lie down
increases; decreases
General Diagnostic Tests - Lumbar Puncture: How is a post-procedure H/A treated?
-bed rest
-fluids
-pain meds
-blood patch
General Diagnostic Tests - Lumbar Puncture: Big complications are
-brain herniation
-infection
General Diagnostic Tests - Lumbar Puncture: With known increased ICP,
a LP is contraindicated
General Diagnostic Tests - Lumbar Puncture: The brain is pulled down with a LP so if you suspect brain herniation or IICP
NOTIFY MD
General Diagnostic Tests - Lumbar Puncture: Bacteria can get into the _____________________ and ________________ and would cause ____________________
puncture site; spinal fluid; meningitis
Intracranial Pressure: Earliest sign of IICP
change in LOC
Intracranial Pressure: A change in LOC may be as pronounced as _________________ or as subtle as ________________________
going into a coma; a change in attention span
Intracranial Pressure: Early signs/symptoms of IICP
-change in LOC (earliest sign)
-slurred or slowed speech
-delay in response to verbal suggestion
-increase in drowsiness
-restlessness for no apparent reason
-confusion
Intracranial Pressure: Late signs/symptoms of IICP
-marked change in LOC progressing to stupor, then coma
-VS changes (Cushing's triad)
-decerebrate and decorticate posturing
Intracranial Pressure: Cushing's Triad requires
immediate intervention to prevent further brain ischemia and restore perfusion
Intracranial Pressure: Cushing's Triad consists of
-systolic hypertension w/widening pulse pressure
-slow, full, and bounding pulse
-irregular respirations (look for change in pattern,
like Cheyne-Stokes or ataxic respirations)
Intracranial Pressure: Decerebrate and decorticate posturing indicate
that the motor response centers of the brain, mid-brain, and the brain stem are compromised
Intracranial Pressure: Decorticate posturing is present with
arms flexed inward and bent in toward the body and the legs extended
Intracranial Pressure: Decerebrate posturing is present with
all 4 extremities in rigid extension
Intracranial Pressure: With decerebrate and decorticate posturing, the client will be
rigid, tight, and burning more calories
Intracranial Pressure: Which posturing is the worst?
decerebrate posturing
Intracranial Pressure: Miscellaneous Signs of IICP
-H/As
-change in pupils and pupil response
-projectile vomiting
Intracranial Pressure: RULE-anytime you have a client with a head injury, if they start complaining of a H/A, assume
their ICP is going up [Show Less]