neurological assessment Flashcards
• What and why do we need neurological assessments?
-Neurological observation is the collection of information about a patient’s central nervous system. Despite advances in neurological monitoring, clinical observations remain fundamental for measuring neurological function (Adam, Osborne and Welsch, 2017)
• The neurological system is highly complex, a sit is continuously detecting, processing and acting on data that it receives. The three principles of the neurological system are:
- Sensory input
- Integration
- Motor input
• Trauma to brain/neurological system from injury can cause sustained, raised intracranial pressure
- In these patients, NA are needed as they provide the structures process that monitors a patient’s neurological status (i.e deterioration).
- Annually, 200,000 people are admitted to hospital with a head injury (NICE,2014)
- The ability to take and record such observations is therefore an essential nursing skill (Derbyshire and Hill, 2018:2019).
whats included in the nurse’s neurological assessment?
what section f the ABCDE approach is this in?
how often do you take NA?
- When nurses complete a neurological assessment, this entails collecting info on the function and integrity of a patient’s central nervous system (CNS) (Derbyshire and Hill, 2018;2019).
- Neurological assessments are under the D in the ABCDE algorithm; neurological function can disable an individual to some degree (Greenshields, 2019).
- Frequency of NA depends on the patient’s condition. Carried out regularly by a registered practitioner.
• Neurological observations carried out in 3 key areas:
- Glasgow Coma scale (GCS) and AVPU
- Focal signs: pupillary response and limb power
- Vital signs
what is a Battle sign?
A Battle sign, or Battle’s sign, is a bruise that indicates a fracture at the bottom of the skull. At first, it can look just like a typical bruise that could heal on its own. However, Battle’s sign is a much more serious condition. The type of fracture that causes Battle’s sign is considered a medical emergency.
what symptoms may prompt the need for a NA?
-Headache Dizziness Seizure pain Confusion/ orientation Altered consciousness Pins and needles Visual disturbance Numbness Weakness Unsteady on feet/ loss of balance Slurred speech/ no speech Blurred vision Swallow difficulties Bruising/bleeding/swelling
• Examples of conditions that can cause neurological deficit:
stroke, epilepsy, traumatic
What are the signs and symptoms of amini stroke?
numbness of the face, difficulties with speech, limb weakness and visual disturbances
What are the signs and symptoms of amini stroke?
what is the tretament?
numbness of the face, difficulties with speech, limb weakness and visual disturbances
TIA treatment:
- Aspirin 300 mg daily or Clopidogrel as a substitute
- Lifestyle advice : blood pressure, diet
- Carotid scanning: stenosis or occulusion
- possible carotid endarterectomy and acrotid stenting
what are the signs and symptoms of a stroke>
treatment?
-depressed LOC/collapse, facial weakness or numbness, difficulty speaking, difficulty walking, paralysis or numbness on one side, visual disturbances, Papiloedema, neck stiffness, severe ehadache, difficulty swallowing
TREATMENT:
- Ischaemic stroke: urgent CT scan within 24 hr but if designated “immediate”- within 1 hr
- Treatment: thrombolysis with intravenous altolase within 3-5 hr or antiplatelet treatment
- Main risk: hemorrhage
- Haemorrhagic stroke: urgent CT scan within 24 hr or if “immediate” then within 1 hr.
- Treatment: reversal of anticoaggulation: blood products
- surgical evacuation or if too severe then palliation
what is AVPU/ACVPU?
- AVPU is a simplified neurological assessment tool used by first aiders, accident and emergency staff and ambulance crews to assess a patient’s conscious level in an emergency situation.
- Quick and objective, incorporated into NEWS2 chart (Derbyshire and Hill, 2010)
- AVPU in some areas might include a “C”= ACPU
- Acronym for:
-Alert: eyes open spontaneously.
The patient is orientated to the time and place and recalls their own name.
-Voice: So eyes don’t open spontaneously but open to verbal stimuli
Eyes may or may not be open, but the patient does not always give correct answers to questions like “Do you know where you are?”
-Pain: eyes don’t open spontaneously or from verbal stimuli but do open from painful stimuli.
Patient may respond to being gently shaken. May localise, flex or extend to trapezius pinch.
-Unresponsive: the patients doesn’t respond to any stimuli.
No response to voice, gently shaken, trapezius pinch or supraorbital ridge pressure.
-Confusion.
what is the GCS, what is it used for and what is it assessed out of?
- The Glasgow Coma Scale is a tool used to assess and calculate a patient’s level of consciousness.
- Initially used to assess level of consciousness in had injury patients. But, now used to assess acutely unwell patients across multiple healthcare settings, as there is no other comprehensive assessment tool that offers the same accuracy or credibility for the escalation of treatment/care (Mehta and Chinthapalli, 2019; Waterhouse, 2020).
- The GCS measures arousal and awareness by assessing the 3 areas of patients behaviour (Carvalho et al, 2020).
- The GCS scale assesses the conscious level from the patients verbal, motor and eye opening responses.
- GCS scored out of 15
- 3 is the lowest score
how many people are needed to carry out a GCS?
• Assessment of a GCS score can be deemed subjective , so need 2 independent clinicians to calculate the GCS score to mitigate subject bias.
• What scores what?
-Eye opening
-Eye opening indicates that the arousal mechanism in the brain is active.
SCORE #4 best response. Spontaneous blinking, unprompted
SCORE#3 Eye opening in response to speech such as calling the patient by their name or asking patients to open their eyes would score a 3.
SCORE #2 Eye opening in response to a painful stimuli, which involves applying an unpleasant stimulus i.e. trapezium squeeze.
SCORE #1 The minimum score of 1 indicates no eye opening in response to pain. However, if there is no response due to primary ocular cause , such as swelling, then “C” (confusion) should be documented alongside the score.
-Different factors that can influence the eye-opening score may include if a patient has their eyes closed due to swelling/injury or if the patient has hearing impairment. To indicate this on the GCS chart, the letter C is given.
