Head-to-toe assessments are going to look different for each patient. Especially for a patient with neurological concerns. So, how do we complete a full neurological assessment? Let’s go over what neurological assessments are, who requires one, and what the nurses’ role is.
What is a Neurological Assessment?
Neurological assessments are assessments that can be done to determine the patients’ neurological status. They need to be completed routinely by nurses and providers to make sure patients are remaining at their known baseline and not getting worse. If patients are declining in their neurological status in any way, this is a medical emergency. And the provider needs to be notified right away. In the emergency department, there will likely by an initial neuro assessment done by the provider if indicated. The rest of the stay, bedside nurses will be performing the main chunk of neuro assessments in between provider assessments.
Who Needs a Neurological Assessment?
All patients with any current or history of neurological concern needs a neurological assessment. How often they will need one is a different story. It depends on how acute the patient is, what floor of the hospital they’re on (ED vs Neuro vs ICU), and what their reason is for their current hospitalization. If it’s an old neurological issue and the patient is here for something completely unrelated, then the patient may only require an initial assessment. Whereas a patient who is here for an altered level of consciousness or acute increased intracranial pressure will need these assessments done much more frequently. Check your hospital policy for more information on the required frequency of assessments.
The Nurses Role
The nurses role in assessing neurological patient status is to compare their current findings to that of the previous assessment and document if there is any change. Some change can be good, for example the patient is now responding to verbal stimuli when they were only responding to painful stimuli, like a sternal rub, before. However, some change can also be bad. For example, if the patient came in alert and oriented and is now falling in and out of consciousness. Because it is the nurses job to see this change in patient status, it is vital to give a good report to the oncoming nurse. This report should include previous neurological assessment findings, your assessment findings throughout your shift, and the patients baseline neurological status.
Components of a Neurological Assessment
According to NurseKey, “a neurological assessment is focused on selected critical components that are sensitive to change and that provide an overview of the patient’s overall condition.” These critical components are the patients:
- Level of consciousness
- Their behavior and stream of mental activity
- Pupillary responses, visual fields, and eye movement
- Motor functions
- All the cranial nerves
For a full breakdown of all the cranial nerves and their individual assessments, visit Nursing Fundamentals: A Guide to the Cranial Nerves.
Glasgow Coma Scale
When assessing a patients’ level of consciousness, it is important that we talk about the Glasgow Coma Scale, aka GCS. The Glasgow Coma Scale is a commonly used assessment tool that measures patients motor response, their verbal response, and their eye opening response. It is measured on a scale of 3, being the worst, to 15, being the best. See the image below provided by NurseKey for the scoring of the GCS.
By using the Glasgow Coma Scale, it is easy to see a change in the patients’ level of consciousness. It’s also an easy tool to help nurses document neurological status, and more specifically, level of consciousness. Check with your facility but this is one of the most common ways to assess a patients neurological status.
Neurological Assessment Decline
If you notice a change for the worse in your patient, either noted from your previous assessment or the last nurses assessment, this is a medical emergency. The patient may be suffering from a stroke, a serious electrolyte imbalance, or a seizure just to name a few. Depending on the severity, a rapid response team or a code may need to be called and the doctor needs to be informed. They may order stat labs, a new medication, or they may want to come in and assess the patient for themselves. Regardless, you’re going to need a full team to help treat this patient.
Do you perform neurological assessments? Comment below what unit you work on!
And don’t forget to check out the following posts:
- Common New Grad Nursing Interview Questions
- How to Cope with the Death of a Patient
- Nursing Fundamentals: A Guide to the Cranial Nerves