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    Neurological Assessment: Paula Deibel, RN, BSN, MBA/HCM

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    Celeste Dias
    This document provides guidance on performing a neurological assessment. It discusses assessing a patient's mental status, including their level of consciousness, orientation, and Glasgow Coma Scale. It also reviews assessing the 12 cranial nerves and performing a motor and sensory exam. The motor exam assesses strength in major muscle groups. The sensory exam evaluates sensations like touch. The document emphasizes comparing sides and documenting any abnormalities found. It provides reminders for special situations like comatose patients or those with potential cervical injuries.

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    Neurological Assessment: Paula Deibel, RN, BSN, MBA/HCM

    Uploaded by

    Celeste Dias
    32 views25 pages
    This document provides guidance on performing a neurological assessment. It discusses assessing a patient's mental status, including their level of consciousness, orientation, and Glasgow Coma Scale. It also reviews assessing the 12 cranial nerves and performing a motor and sensory exam. The motor exam assesses strength in major muscle groups. The sensory exam evaluates sensations like touch. The document emphasizes comparing sides and documenting any abnormalities found. It provides reminders for special situations like comatose patients or those with potential cervical injuries.

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    This document provides guidance on performing a neurological assessment. It discusses assessing a patient's mental status, including their level of consciousness, orientation, and Glasgow Coma Scale. It also reviews assessing the 12 cranial nerves and performing a motor and sensory exam. The motor exam assesses strength in major muscle groups. The sensory exam evaluates sensations like touch. The document emphasizes comparing sides and documenting any abnormalities found. It provides reminders for special situations like comatose patients or those with potential cervical injuries.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views25 pages

    Neurological Assessment: Paula Deibel, RN, BSN, MBA/HCM

    Uploaded by

    Celeste Dias
    This document provides guidance on performing a neurological assessment. It discusses assessing a patient's mental status, including their level of consciousness, orientation, and Glasgow Coma Scale. It also reviews assessing the 12 cranial nerves and performing a motor and sensory exam. The motor exam assesses strength in major muscle groups. The sensory exam evaluates sensations like touch. The document emphasizes comparing sides and documenting any abnormalities found. It provides reminders for special situations like comatose patients or those with potential cervical injuries.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 25

    Neurological

    Assessment

    Paula Deibel, RN, BSN, MBA/HCM


    Clinical Nurse Educator for Neurosciences
    St. Anthony Hospital
    What are we doing?
    „ What are we assessing?

    „ What are we looking for?

    „ Is it too late to change


    careers?
    The Mistakes
    „ We don’t know HOW to
    assess
    „ We neglect to look at the
    H&P
    „ We do not dare to
    compare
    „ We do not recognize
    subtle clues
    „ We are not aggressive
    enough
    Mental Status:
    LOC
    „ Alert
    100
    90
    „ Lethargic 80
    70
    Alert
    60
    „ Obtunded 50
    Lethargic
    Obtunded
    40
    Stuperous
    „ Stuperous 30
    Comatose
    20
    10
    „ Comatose 0
    Good Hmm Uh Oh Yikes BAD
    Mental Status:
    Orientation
    Awake, Alert and Oriented
    to:

    ƒ Person

    ƒ Place

    ƒ Time

    ƒ Situation
    Mental Status:
    Glasgow Coma Scale
    Best Eye Opening Response Best Verbal Response
    ƒ Spontaneous (4) ƒ Oriented (5)
    ƒ To voice (3) ƒ Confused (4)
    ƒ To Pain (2) ƒ Inappropriate (3)
    ƒ None (1) ƒ Incomprehensible Sounds (2)
    ƒ None (1)
    Best Motor Response
    ƒ Obeys Commands (6) „ Maximum stimulus for
    ƒ Localizes / Purposeful (5) Maximum results
    ƒ Withdraw / Non purposeful (4)
    „ GCS score = 3-15
    ƒ Abnormal Flexion (3)
    „ “I” or “T” can be used in
    ƒ Abnormal Extension (2)
    ƒ None (1)
    some situations
    To Cranial Nerve or Not to Cranial
    Nerve…That is the question
    ƒ ON (Olfactory CN I) ƒ Fat (Facial CN VII)

    ƒ Old (Optic CN II) ƒ Armed (Acoustic VIII)

    ƒ Olympus (Oculomotor CN III) ƒ German (Glossopharyngeal


    CN IX)
    ƒ Tippy (Trochlear CN IV)
    ƒ Viewed (Vagus CN X)
    ƒ Top (Trigeminal CN V)
    ƒ Some (Spinal Accessory CN
    ƒ A (Abducens CN VI) XI)

    ƒ Hawks (Hypoglossal CN XII)


    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN II –
    (Optic)

    ƒ Visual Acuity
    (Diplopia)

    ƒ Visual Fields
    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN III, IV, IV
    (Oculomotor,Trochlear &
    Abducens)

    ƒ PERRLA, Ptosis

    ƒ Four to the Floor

    ƒ Six to the Sticks


    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN V
    (Trigeminal)
    „ Facial Sensation (three
    branches)

    „ Corneal Sensation
    (reflex)

    „ Masseter muscle
    strength
    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN VII
    (Facial)

    ƒ Facial Symmetry

    ƒ Taste
    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN VIII
    (Acoustic)

    ƒ Hearing

    ƒ Vestibular function
    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN IX, X, XII
    (Glossopharyngeal, Vagus,
    Hypoglossal)

    ƒ Swallow
    ƒ Couch, Gag, Voice
    quality, Movement of soft
    palate and uvula
    ƒ Tongue Symmetry and
    Strength
    To Cranial Nerve or Not to Cranial
    Nerve…That is the Question
    CN XI
    (Spinal Accessory)

    ƒ Trapezius Strength

    ƒ Sternocleidomastoid
    Strength
    Motor Exam
    Motor Exam
    Motor Exam
    „ 5) Normal Strength
    „ 4) Cannot Overcome
    Resistance (or “moves”
    against resistance)
    „ 3) Overcomes gravity
    „ 2) Cannot overcome
    gravity
    „ 1) Flicker of muscle
    (movement)
    „ 0) None
    Motor Exam

    „ Deltoid
    „ Biceps
    „ Triceps
    „ Wrist Extensor
    „ Grip
    Motor Exam

    „ Leg Elevation
    „ Hip adduction
    „ Hip abduction
    „ Knee Extension
    „ Knee flexion
    „ Plantar Flexion
    „ Dorsi Flexion
    Sensory Exam
    Sensory Exam
    „ Tend to do a general
    exam vs. comprehensive
    „ Compare both sides
    „ Documented as:

    „ Intact
    „ Present but diminished
    „ Numbness/tingling
    „ Absent
    Cerebellar Exam
    Abnormal Reflexes

    „ Brudzinki’s sign

    „ Babinski’s Reflex

    „ Negative Oculocephalic

    „ Negative Oculovestibular
    Special Reminders
    „ Change in LOC / Behavior
    „ If you don’t know, grab a
    buddy
    „ For the comatose pt.,
    assess GCS, pupils,
    cough & gag, and corneal
    reflex
    „ If your patient has a
    cervical injury, doll’s eyes
    may not be assessed
    „ Is it CSF?
    „ Battle signs = Basilar Skull
    Fx
    References
    Bader, M.K., & Littlejohns, L.R. (2004). AANN core curriculum
    for neuroscience nursing (4th ed.). Philadelphia: Sanders.
    Boling, J.L. (2008). Neuroanatomy and Physiology [PowerPoint
    Slides]. Retrieved from the American Association of
    Neuroscience Nursing website:http://www.aann.org/
    Guin, P. (1991). Anatomy and Physiology of the Nervous
    System: Continuing educationModule. Florida: Shands
    Hospital at the University of Florida
    Hickey, J.V. (2003). The clinical practice of neurological and
    neurosurgical nursing (5th ed.). Philadelphia: Lippincott.
    McNair, N.D. (2008). Neurological Assessment [PowerPoint
    Slides]. Retrieved from the American Association of
    Neuroscience Nursing website: http://www.aann.org/

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