Overview:

1. New & Improved Physical Assessment: Neurological

2. ObjectivesAfter completion of this self paced course you will be able to: Describe how the neurological assessment process has changed: The mental status aspects of central nervous system function was relocated to a separate form. The neurological screen was redesigned to focus on systematically assessing central and peripheral nerve function. Demonstrate how to appropriately conduct a neurological assessment using the following defined parameters: Pupils/Vision Neuromuscular Movement Sensation Speech Swallow Verbalize when to use additional assessment parameters and the “Neuro Check-Frequent” screening process.

3. Why Change the Neurological Assessment?

4. Current Neurological Assessment Mental status parameters are currently assessed in two screens – Mental Status and Neurological. All of the mental status parameters are being moved to the Mental Status section to support nursing evaluation. Physical exam references were used to update the neurological assessment with comprehensive parameters. OLDOLD

5. Assessing Neurological Status Monitor for subtle indications of neurological changes during conversation. Evaluate pupils in ambient room light. Muscles with intact nerve function move and relax voluntarily with a slight residual tension known as muscle tone and no abnormal movements.

6. Write out the Defined NormalsWrite out the Defined Normals

7. The revised neurological assessment parameters provide a framework for evaluating changes in central (cranial) and peripheral nerve function. Pupils/ Vision Sensation Neurological movement Speech Swallow New Neuro screenshotNew Neuro screenshot

8. Pupils and Vision Pupil evaluation is a necessary neurological assessment parameter. Normal pupil sizes ranges from 2-6mm. It is easy to see if abnormal size: <1 or >6 mm. Pupil size and reactivity can be evaluated in ambient room lighting.

9. Reference Text Reference Text is provided to tell you how to evaluate and define vision and extraocular muscle movement abnormalities (and most of the other parameters). Right click on the column header of the grid (green row) and view the reference text.

10. Ref. text for pupilsRef. text for pupils

11. Neurologic Assessment: Movement The presence of abnormal neurologically-based movement and muscle tone is assessed in this section. It also captures the presence of any neurologically-based involuntary movements including posturing.

13. Neurological Assessment: Sensation Abnormal Sensation is evaluated by location & type:

14. Neurological Assessment: Speech & Swallow New assessment descriptors have been added. The ability to consult nutrition services and speech therapy will remain.

15. Additional Parameters Include: Intermittent Loss of Normal Neurological Function Dizziness Fainting/Loss of Consciousness Blackout Seizure Assessment Neurological Standardization Measurement Scales Dysphagia Screen for Stroke Symptoms Glasgow Coma Scale Hunt and Hess Subarachnoid Stroke Scale Modified Parkinson’s Assessment Form National Institutes of Health Stroke Scale (NIHSS)

16. Dysphagia Screen for Stroke Symptoms The System Stroke Committee recommended the use of this tool to screen for dysphagia related to stroke. Use of this tool by nurses varies across the system and is dependant upon resources available to do a dysphagia screen.

17. Neurological Assessment: Seizure The Seizure section was revised to allow for more specific documentation of seizure activity. Seizures are classified based on symptoms and test findings about the location in the brain. Reference text about what the classification means is available. Document as Unknown, unless you work in an area that classifies.

18. Frequent Neuro Checks The Neuro Check – Frequent form is designed for patients who need frequent neurological assessments after a stroke, head trauma, or neurosurgery. The Neuro Check – Frequent form briefly screens for altered mental and neurological status. Complete a comprehensive system assessment if changes occur that are not reflected on this form.

19. Reviewing Findings in the GenViews The most recent values for each assessment parameter appear in the GenViews. Note: Findings post with the date and time that it was recorded. Data may come from different forms.

20. Remember: The Nursing Flowsheet is the Best Method to Trend Parameters over Time

21. Summary of the Improvements Mental status parameters were moved to their own section to support comprehensive patient assessment. The Neurological Assessment process was updated to provide nurses with a framework for evaluating changes in central and peripheral nerve function: Pupils/Vision were added to the defined normal section along with other neurological parameters including movement, sensation, speech, & swallow. The additional parameters section was updated to improve patient assessment (e.g. dysphagia, seizures, etc.)

22. Case Studies: ICU & Non-ICU Lori . . . Do what ever you need to do to make these two sections accessible based on staff unit.

23. Pt. admitted to ICU following a motor vehicle collision. He has suffered severe head trauma. The patient’s eyes open briefly to pain, but he is unaware of his surroundings. There is no verbal response. His pupils are 6mm on the left and 3mm on the right. Both pupils have sluggish reactivity to light with nystagmus. He decorticate postures with a positive plantar (Babinski) reflex. ICU Scenario

24. ICU Scenario: Mental Status Assessment

26. The patient is quickly intubated and sedated. Mental Status Assessment LOC is the only parameter of Mental Status that can be assessed given his obtunded status. Remember: The LOC of sedated patients can vary between lethargic and comatose. Sedation scales are used to monitor and document response to sedation.

28. A week has passed. The patient is improving. He is extubated, but has some neurologic deficits including: Being overly sensitive to environmental stimuli. Not being able to rest/ sleep for more than a couple minutes at a time. His speech is unintelligible sounds He coughs with liquids.

31. Non-ICU Scenario A 78-year-old female patient is admitted to your area. Her initial mental status and neurological assessments are WDL. Hours later, the patient exhibits a change in neurological status (suggestive of a Transient Ischemic Attack – TIA): Mental Status: WDL Loss of vision in left field of vision Left sided facial droop Numbness and tingling in the left hand Slurred speech

32. Non-ICU Scenario: Neurological Findings

33. Non-ICU Scenario: Neurological Assessment Back to Baseline Within 30 minutes, the patient assessment returns to baseline (documented on the Neuro Check – Frequent Form).

34. Post Test What parameters must be assessed for a neurological assessment? a. Pupils/vision b. Neurological movement c. Sensation d. Swallow e. Speech f. All of the above Answer: F

35. Post Test 2. Which of these statements is true about documenting an abnormal plantar (positive Babinski) reflex? a. Deep tendon reflexes (DTRs) are not routinely assessed by nurses b. Reflex assessments may be charted as a comment in the Neurological Movement Assessment Section c. The reference text in the Movement Section tells nurses where to document reflexes d. All of the above Answer: d

36. 3. Where would you document a change in level of consciousness (LOC)? On the Mental Status Assessment form On the Neurological Assessment form Write a comment on the Neurological Assessment form LOC is no longer assessed Answer: a

38. You have completed the second session of this two part series on physical assessment. Practice using these new patient assessment forms in the Cerner Training Environment: Log in: ID=Train, Password=Train Familiarize yourself with these new assessments in the Physical Assessment form (complete) or as a separate section in Ad Hoc Charting. Next Steps:

39. Selected References