Be creative teaching nurses to do neuro assessments

Your head trauma patient bounces back and seems fine after an epidural bleed and temporary loss of consciousness, but lapses into a profound coma — all in a matter of minutes.

Your elderly Alzheimer’s patient has gone from confused to aphasic, and suddenly can’t move her left side.

Both these scenarios illustrate the importance of performing a quick neurological assessment in the ED, says Teri Howick, RN, nurse educator for the ED at McKay Dee Hospital in Ogden, UT.

"We see so many patients that are neurologically altered, whether from injury, drugs, hypoxia from pneumonia, delirium from fever, or acute insulin reactions," says Howick. "Neuro baselines are a noninvasive way to cue you in to changes."

To ensure that all ED nurses know how to perform a neurological assessment, take these steps:

  • Give nurses a test on the GCS.

At McKay Dee’s ED, nurses take a self-administered test on the GCS using a CD-ROM tool developed internally, with results kept in nurses’ education files. "Joint Commission surveyors loved it," she says. "They were very impressed with our education documentation." (See below to order a copy of the tool.)

Although the GCS was developed primarily for head trauma patients, it can be used for all patients with decreased neurological status, says Howick. "This includes drug-impaired patients, senile or Alzheimer’s patients, intoxicated patients, and head injuries," she says.

The scale provides a baseline assessment, which is important in determining if your patient is improving or getting worse, says Howick. This is especially critical for head injuries, but it also is helpful for overdose or chemically impaired patients, she adds.

"It is very easy to learn and is a quick assessment to let you know where the patient is at this time," she says. "The patient’s condition may change within minutes, and those changes are what’s important, as well as any changes from their normal status."

  • Have nurses practice by scoring patients.

Nurses review case studies and score patients, and charts are reviewed for accuracy by the ED’s trauma coordinator, says Howick. Results are kept in education files, and she follows up with individual nurses as needed.

  • Start a "neuro education" series.

At St. Joseph’s Hospital and Medical Center in Phoenix, a series of neurological inservices will be given to ED nurses, says Keri J. Hohm, RN, BSN, clinical supervisor for emergency services. "I am going to do the educating myself by providing a short 10- to 15-minute presentation to the staff," she says. "This gives them opportunities to ask questions and practice on each other."

The informal sessions will be held in the ED during slow periods, with three to four nurses at a time, says Hohm. "After the presentation, staff will practice by performing a complete neuro assessment on each other or observing one if there is a patient with neuro deficits present at the time," she says.

The first part of the series will cover the use of the GCS and how to check pupils and cranial nerves, says Hohm. To prepare the presentations, Hohm will draw on her experience in a neurological intensive care unit and include material from neurological text books and web sites.

"Also, since we have the Barrow Neurological Institute here in-house, I use the nurses and physicians as references when I have questions I cannot find an answer to," she says.

Topics will include different types of brain injuries such as subarachnoid hemorrhages, epidural and subdural hematomas, acute cerebrovascular accidents, herniation, and the placement of ventriculostomies. "We will also cover how each of these injuries should be managed in the acute onset stage, including management of blood pressure, intercranial pressure, and cerebral perfusion pressure," says Hohm.

  • Have nurses act out patient scenarios with neurological symptoms.

Howick says she’s a fan of fun education. "It improves retention and makes it memorable," she says. "It’s a riot to see nurses portray patients."

Nurses are given a diagnoses and signs and symptoms, such as "You are a transient who frequently comes in intoxicated and combative. A car struck you earlier in the evening. Now you have a headache, vomiting, blurred vision, and can’t walk a straight line. There is an abrasion on your temple. You can answer questions regarding yourself, until you become confused and unresponsive."

Other nurses then are asked to name the patient’s possible diagnosis, which in this case is an intracranial bleed. You also can have nurses complete self-learning packets listing scenarios and options for diagnosis, suggests Howick.

  • Create an "education cart."

At St. Joseph’s, a cart contains educational information that ED staff members have created, including a handout on neurological assessment.

"It is kept in a closet and brought out only when it’s going to be used, so that things don’t disappear," says Hohm. n

Sources/Resource

For more information on neurological assessment in the ED, contact:

  • Keri J. Hohm, RN, BSN, Clinical Supervisor, Emergency Services, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. Telephone: (602) 406-3600. E-mail: Keri.Hohm@chw.edu.
  • Teri Howick, RN, Nurse Educator, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-2286. Fax: (801) 387-2244. E-mail: mkthowic@ihc.com.

A 32-minute video demonstrates how to use Glasgow Coma Scale scores to evaluate patients with traumatic head injury, including how to properly score eye, verbal, and motor responses in adults and children. The cost, including instructor guidelines, pre- and post-tests and answer sheet, is $50 including shipping. The tool also is available in a CD-ROM format that costs $10 including shipping. To order, send a check made out to "GCS Video" to: