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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

assessment3. List 3 early signs which would indicate

the patient is worsening4. List 3 late signs of neurological

depression.

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Neurological AssessmentLevel 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

Trauma Alcohol Insulin

Epilepsy Psych Infection

Poison Opiates Shock/Stroke

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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

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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)

Parameter Score Response

Eye Opening 4

3

2

4

C

Spontaneous

To Voice

To Pain

No Response

Closed by swelling

Best Verbal Response

5

4

3

2

1

T

Oriented

Confused

Inappropriate Words

Incomprehensible sounds*

No response or Intubated

Artificial Airway

Best Motor Response

6

5

4

3

2

1

Follows commands

Purposeful, localizes

Withdraws

Abnormal Flexion **

Abnormal Extension**

No response

Total 3/15-15/15

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Pupillary Response PERRLA: pupils equal, round and reactive to light

and accommodation Pupil size Response to light

Brisk Sluggish Non-reactive/fixed

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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

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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

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Extremity Assessment

Hand grasps

Strength

Sensory

Pinprick

Touch

Warm/cold

Compare right to left

Arm drift

Foot flexion

Assess with resistance

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Neurological Assessment

Motor AssessmentResponse to stimuli - Normal vs Abnormal

Abnormal Posturing:Decorticate posturing/flexor posturing

Decerebrate posturing/extensor posturing

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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

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Early signs your patient is in troubleEarly signs:

1. Decreasing LOC: needs more stimulus to display same responses2. 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.

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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.

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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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