Neurological Assessment Flashcards
List 14 areas and questions you should ask in subjective data?
- Headaches-when did this start? Duration? Have you suffered it before? What type of pain? Characterise it (throbbing, pounding,shooting) Anything make it better or worse?
- Neck pain, limitation of motion- How did it start? Location. Associated symptoms? Does stress bring it on.
- Pain-What part of the body? Intensity? Onset/duration? Relief from the pain? Quality? Effects from having it?
- Head injury- Have you ever had one? How did it occur? Did you lose consciousness and for how long? Any side effects?
- Dizziness/vertigo- Do you ever feel light headed or feel faint? When have you noticed it? Frequency?
- Seizures/Convulsions- Ever had one? When did it start? How often does it occur?
- Tremors- Do you experience any shakes or tremors in the hands or face? When did it start? Do they effect your daily activities? Anything relieve it?
- Weakness-Any weakness or problem moving any part of your body? Generalised or local? Does it occur with particular movement?
- Incoordination- Any coordination problem? Do you lean to one side? Any falling? DO your legs seem to give way? How is your balance when you walk?
- Numbness or tingling- Any in your body? Does it feel like pins and needles? When did it start? Where do you feel it? Does it occur with activity?
- Difficulty swallowing-Ever experienced a problem with swallowing? Does it occur with solids or liquids? Have you experienced excessive drooling or saliva?
- Difficulty speaking- any problems forming words or saying the words you intend to say? When did you first notice this? How long did it last?
- Significant past history? Any stroke, head injury, spinal cord injury, meningitis, degenerative neurological disease, drugs or alcohol abuse?
- Environmental/occupational hazards- Are you exposed to any environmental or occupational hazards?
List the indications for doing a neurological observation assessment.
To establish a baseline for subsequent comparison.
For early detection and intervention of CNS functioning, particularly for:
-acute patients
-cerebrovascular accident
-pre and post neuro surgery
-brain tumours and cerebral infections
-patients with diminished LOC
What is the Glasgow Coma Scale (GSC)?
What is it scored out of and made up of?
When should you be worried?
The GCS is to assess the level of consciousness.
Is scored out of 15 points and is made up of 3 parts, eye opening, verbal response and motor response.
Life threatening under 8 points. Remember under 8 intubate (no gag reflex)
What is the GCS eye opening score and list the them.
Made up of 4 points.
4- spontaneous- the patient eyes open when you come to their side.
3- to voice - the patients eyes open to command
2- to pain - the patient’s eyes open to triapeze muscle pinch
1- none- the patient’s eyes don’t open
What is the GSC verbal response scored out of and list them.
Maximum score for verbal response is out of 5.
5- Orientated - the patient can give name, address and day of the week
4- Confused - the patient gives name but are less likely to know their address or day of the week. Names seem to be retained better than numbers.
3- Inappropriate words - Inconsistent answers: patient can give their name but only occasionally. Profanity is often retained and frequently the patient repeats the same word over and over.
2- Incomprehensible sounds- the patient may have deteriorated to the point that intubation has to be done. Sounds like grunting.
1- none- no verbal response
What is the GCS point score for motor response and list them.
Maximum score for the motor response is 6.
6- obeys commands- commands maybe complex, as in cranial assessment e.g.:”squeeze my hand”. A positive response from the patient is only meaningful if the second part of the command “now let go” is also performed.
5- localizes pain - the patient is able to localize the source of the pain. (triapezius muscle pinch)
4- withdraw (pain) - the patient knows there is pain, but can not localize it. The whole body withdraws from the pain.
3- abnormal flexion- the patient flexes their arms tightly on their chest and extends the lower extremities. (remember- flex in-Decorticate)
2- abnormal extension- the upper extremities extend on stimulation or as the situation worsens spontaneously. (remember- flex out-Decerebrate)
1- none- no response: the patient is flaccid.
What would you say for your therapeutic interaction?
Hello, my name is (insert your name here) and I’m a student nurse looking after you today. Is it ok if I call you by your first name? Great, thank you, (insert person’s name). I need yo conduct a neurological assessment on you. What that involves is asking you a bunch of questions, looking in your eyes, and asking you to do a few movements with your arms and legs. Then I will take your temperature, pulse, blood pressure and oxygen saturation. All up it should take a maximum of 20 minutes, is that ok? Great, I will just collect the equipment I need and I’ll be right back.
What equipment would you gather?
Pen light Pupil gauge neurological observation chart pen stethoscope thermometer pulse oximeter disposable covers alcohol wipes
How would you demonstrate your problem solving abilities?
Ensuring the bed brakes are on.
Ensure that the tv or radio is switched off.
Curtain closed or door shut for privacy
Sufficient lighting in the room.
List the 5 moments of hand hygiene
- Before touching a patient
- After touching a patient
- Before a procedure
- After a procedure or exposure to bodily fluids
- After touching a patients surroundings
What position should the patient be in for a neurological assessment?
Fowlers or semi-fowlers. If the patient is not sitting up, adjust the height of the bed.
List how you would collect objective data for the patients pupil response and how you would document this?
- Check face for any droop.
- Check pupil response with penlight. (looking for size, shape, length of time for response. equality)
- use index finger hold it in front of patients face, ask patient to follow your index finger to each quadrant.
- Document in ISOBAR as PERRLA (Pupils Equal Round Responsive to Light Accommodating) score out of 4
List how you would collect objective data for the patients verbal response.
You would orientate the patient by asking:
Can you tell me your name?
Can you tell me what day it is?
Can you tell me where you are?
The GCS score for this is out of 5.
(Do not ask same questions every time. Ask further questions if patient cannot answer first question as they may not simply know.)
List how you would collect objective data for the patients motor response and what GCS score it is out of.
- Visually assess the patient at the end of the bed, in line with the patient, assessing for symmetry between both sides of the body, particularly the face.
- ask patient to raise both arms together. (looking for shakes, strength and equality)
- Ask the patient to squeeze index fingers with their hand and then asking them to release.
- Asking them to raise the left leg up and then down and then same for right leg. (looking for strength, equality)
- Ask the patient to push on your hand with their feet (abduction then adduction) (looking for strength, equality)
The GCS is scored out of 6 for the motor response.
Why would you perform a vitals sign check on the patient?
To ensure that all vital signs are within normal limits.
