Neurological assessment

Rationale for “Do you know where you are? Who you are? What time it is?

Assesses consciousness and orientation

Rationale for “Have you noticed any weakness or difficulty moving any part of your body”

• Assesses motor function and muscle strength

• Changes indicates nerve damage, spinal cord injury or other conditions

Rationale for “Do you have any past medical conditions that may affect your nervous system?”

Identifies previous health conditions that may increase neurological issues

Rationale for “Have you experienced any headaches recently?”

Symptom of stroke and increase ICP

What are cues to note when talking to the pt?

• Alertness

• Facial features

• Speech

• Eye contact

• Coordinated movements

Why is Glasgow Coma Scale used?

Assesses how well the brain is functioning

What is the normal resting size of pupils?

3-4 mm

What could no pupillary response indicate?

• Increased ICP

• Impaired cranial nerve function

• Head injury

• Stroke

What is PERRLA?

Pupil is equal, round, reactive to light and accommodation

What does consensual light reflex test?

• Brainstem

• Cranial nerve function

Why do we check limb movement?

To see how well brain and motor pathways are working

Why do we check limb strength?

To compare both sides

What does it indicate if one side of a limb is weaker than the other?

• Stroke

• Nerve dysfunction

Nursing diagnoses for neurological assessment

• Impaired cerebral tissue perfusion

• Impaired verbal communication

• Risk of self care deficit

• Impaired sensation

• Impaired physical mobility

what position would you put the pt in?

Up right

What objective data are you assessing?

• General inspection

• Pupillary response

• Limb strength and symmetry

What is stroke and symptoms?

Bleeding that disrupts blood flow to brain

• One sided weakness

• Facial drooping

• Slurred speech

• Dizziness

What is Increased intracranial pressure and symptoms?

Increased pressure inside the skull which can compress brain tissue

• Headache

• Vomiting

• Decreased consciousness

• Pupil changes