1 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 assessment 3. List 3 early signs which would indicate the patient is worsening 4. List 3 late signs of neurological depression.
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1 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.
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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
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