nerological, neurovascular, cardiac, resp assessment Flashcards
Neurological Assessment
History Assess consciousness- has there been Loss of consiousness Appearance and behaviour Motor function Sensory function Coordination and gait Reflexes
Diseases of the Neurological System
The following diseases may show symptoms Stroke/TIA Head injury Tumours Altered conscious state Spinal cord injury Inflammatory or infective conditions Degenerative neurological conditions
method of assessing level of consciousness : AVPU scale.
A- Alert V- Responds to voice P- Responds to pain U- Unconscious Any concerns following this assessment should be followed up by performing a GCS (Glasco Coma Scale)
Glasco Coma Scale
A total GCS score of 15 indicates patient is normal.
GCS score of 12 to 14 indicates mild neurological deficit.
GCS score of 9 to 12 indicates moderate neurological deficit.
GCS score of 8 and below indicates severe neurological deficit and requires emergency care i.e. intubation and surgery.
there is a saying amongst nurses
“less than 8 - INTUBATE!”
open eye response 1-4 score (4 best)
verbal response 1-5 (5 best)
motor response (1-6) 6 best
what is PEARL
Pupils Equal And Reactive to Light
PQRST pain assesment
P - provoking or precipitating factors Q- Quality of pain R - Region S - Severity T - time
abbey pain scale
It is designed for patients who cannot verbalise their pain (such as in dementia)
capillary refill time
Estimates the time of peripheral blood flow
Should be <3 seconds
Compress nail bed so that it blanches. Release the pressure.
Slow capillary refill indicates sluggish perfusion to the tissues
CWMS-neurovascular observations
- Colour: pink, pale, yellow, mottled
- Warmth: cold, cool, warm, hot
- Movement: strong, weak, limited, full
- Sensation: normal, pins and needles, numbness
Peripheral Oedema
Accumulation of fluid in the tissuesof dependent areas of the body, e.g legs, hands.
