Tips to teach nurses to do neuro assessments

You should perform a neurological assessment for any patient whose history or mechanism of injury indicates a possible neurological problem, says Cynthia Bautista, PhD, RN, CNRN, neuroscience clinical nurse specialist at Yale-New Haven (CT) Hospital.

These patients include any who reports a loss of consciousness or change in level of consciousness; patients with head injuries; patients who are not oriented to time or place; patients whose pupils appear sluggish to light; patients whose pupils are more than 2 mm different in size; and any patient in whom a decrease in motor strength, facial droop, and slurred speech are present, says Bautista.

To improve your neurological assessment of patients, consider the following:

  • Trend in level of consciousness. Reassessing the level of consciousness helps you to determine if the patient is getting better or worse, says Bautista. "The GCS [Glasgow Coma Scale] helps you determine when you need to call the physician," she says. "When there is a change in the GCS score, it is the earliest sign that further neurological problems may occur."

Score the patient’s best possible response for eye opening, verbal, and motor response, and be sure to stimulate the patient sufficiently to get the best possible response, notes Bautista. "Only score a 1 in each category when the patient has been stimulated for 30 seconds and there is still no eye opening, verbal, or motor response," she says.

When assessing eye opening and the eyes are swollen shut, the letter "C" may be used to indicate eyes closed by swelling, says Bautista. Orientation to time and place will be lost before orientation to person, says Bautista. "When assessing motor response, use the command Show me two fingers.’"

  • Pupillary response. Note the size of the pupils, and shine a penlight into the eyes to assess whether the patient’s reaction is brisk, sluggish, or fixed, says Bautista. Dilated pupils may indicate brain herniation or hypoxia, constricted pupils may be due to narcotics or a pontine infarct, and fixed pupils may indicate brain herniation, she adds.
  • Motor strength. Motor strength is assessed by how well the extremity can move against gravity and resistance, says Bautista. "Ask the patients to lift their arm or leg up into the air and then push against resistance," she advises.

Source

For more information on use of the Glasgow Coma Scale, contact:

  • Cynthia Bautista, PhD, RN, CNRN, Neuroscience Clinical Nurse Specialist, Yale New Haven Hospital, 20 York St., New Haven, CT 06504. Telephone: (203) 688-3352. E-mail: cindy.bautista@ynhh.org.