Overview:

Technical contact:

Content contact:

If you have technical questions please contact the Service Desk414-647-3520 in Milwaukee or 1-800-889-9677

System Nursing Research 414-219-5394

Instructions on how to navigate this course.This course does not have sound.

Features:

This course is the second of a two part series to update the physical assessment screens at Aurora. Participants will learn how to systematically assess central and peripheral nervous system function in ICU and non-ICU patients and document findings in the electronic health record to detect and monitor changes over time.

New & Improved Physical Assessment: Neurological

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.

Why Change the Neurological Assessment?

• Patients benefit when caregivers use a comprehensive, evidence-based framework to evaluate and detect subtle changes. The new screens focus on assessing central and peripheral nervous system function to detect abnormalities in sensation and movement.

• By using this approach, caregivers will:- Communicate more effectively - Collaborate to diagnose and treat problems early- Improve patient outcomes

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.

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.

• Prepare patients who have actual or potential neurological changes that the nurses may test their sensation and ability to move, talk, and swallow more often and not to worry

Parameter Defined Limits (WDL)

Pupils/Vision Equal, normal size (2-6 mm), round shape, and reactive with vision per patient’s baseline, and no extra-ocular muscle movements.

Neurological Movement

Moves all extremities with equal strength*. Absence of involuntary movements.

Sensation: Reports normal sensations throughout body, no paresthesias.

Speech: Verbalization is clear and understandable

Swallow: Swallowing without coughing, choking, tearing on liquids and / or solids.

Purple text indicates new content

*Note actual strength is evaluated in the musculoskeletal section

Defining “Normal” (WDL) for Neurological Status

Neurological Assessment

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

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.

• Use a flashlight for more brisk response if vision or neurological abnormality is suspected.

• Note: Abnormal pupil function seldom occurs alone in patients who appear to be interacting normally.

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.

Double vision may occur because of problems with the optic nerve (vision) or as a problem in the muscles of the eye that focus vision.

Refer to Reference Text for directions about how to assess to determine the difference.

Pupils and Vision Reference Text

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.

The Reference Text provides assessment directions and term definitions.

Neurological Assessment: Movement

• Loss of symmetrical movement or tone is documented by selecting the appropriate descriptor for each extremity

• The evaluation of muscle strength continues to be documented in the Musculoskeletal Section of Physical Assessment

Neurological Assessment: Sensation

Abnormal Sensation is evaluated by location & type:

• Numbness (loss of sensation)

• Tingling/Burning/Crawling (hyper-sensation)

• Unable to Distinguish meaning a loss of certain types of sensation

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

therapy will remain.

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)

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.

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.

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.

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.

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

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.)

Case Studies: ICU & Non-ICU

Lori . . . Do what ever you need to do to make these two sections accessible based on staff unit.

• 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

ICU Scenario: Mental Status Assessment

Parameter WDL except

Level of Consciousness Obtunded

Attention, Thought Process, Orientation, Memory, Perceptions, Motor Behavior, Sleep/Wake, Affect/Behavior

Unable to assess: Reason: Obtunded.

ICU Scenario: Neurological Assessment

Parameter WDL exceptPupils/ Vision Pupils: Left (6mm) , Right (3mm),

Reactivity: sluggish, Extraocular Eye Movement: Nystagmus

Neurological Movement

Posturing to Pain/ Noxious Stimuli: decorticate posturing. Comment: positive plantar reflex

Sensation Unable to assess: Reason: Obtunded.

Speech No SpeechSwallow Abnormal (absent/weak) Gag reflex.

• 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.

ICU Scenario: Intubated Patient

Parameter WDL exceptPupils/ Vision Reactivity: sluggishNeurological Movement Posturing to Pain/ Noxious Stimuli:

decorticate posturing. Comment: positive plantar reflex

Sensation Unable to assess: Reason: Obtunded/ ETT

Speech Unable to assess: Reason: Obtunded/ ETT. Only select “No Speech” if you are able to confirm that the patient is not able to speak.

Swallow Abnormal Gag reflex.

ICU Scenario: Subsequent Neurological Assessment

• 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.

ICU Scenario: Neurologic Injury

ICU Scenario: Mental Status AssessmentParameter WDL exceptLOC HyperalertAttention Reduced ability to maintain attention

(chronic)Thought Process Rambling, Irrelevant or Incoherent

ConversationOrientation, Memory, Perceptions

Unable to assess: Reason: Cognitive impairment with garbled speech

Motor Behavior Agitation: Restless, repeated or constant shifting of position

Sleep/ Wake Cycle Insomnia

Affect/ Behavior Impulsive

ICU Scenario: Neurological Assessment

Parameter WDL exceptPupils/ Vision WDL

Neurological Movement WDL

Sensation Unable to assess: Reason: Cognitive Impairment with Garbled Speech

Speech Garbled Speech

Swallow Coughs with liquids - Speech and Nutrition consults have been initiated.

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

Non-ICU Scenario: Neurological Findings

Slurred SpeechSpeech*

Unable to Assess (deferred)Swallow

LUE, Numbness and TinglingSensation*

Facial Droop-LeftNeurological Movement*

Left visual field cutPupils/Vision*

WDL exceptParameter

• The doctor is notified and tests are completed.• The doctor orders frequent Neuro Checks

• The (*) indicates the parameters that are included on the Neuro Checks – Frequent form with LOC & Orientation.

Non-ICU Scenario: Neurological Assessment Back to Baseline

• Within 30 minutes, the patient assessment returns to baseline (documented on the Neuro Check – Frequent Form).

WDLOrientation

WDLLOC

FindingParameter

WDLSpeech

WDLSensation

WDLNeurological Movement

WDLPupils/Vision

Post Test

• What parameters must be assessed for a neurological assessment?a. Pupils/visionb. Neurological movementc. Sensationd. Swallowe. Speechf. All of the above

Answer: F

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 nursesb. Reflex assessments may be charted as a comment

in the Neurological Movement Assessment Sectionc. The reference text in the Movement Section tells

nurses where to document reflexesd. All of the above

Answer: d

3. Where would you document a change in level of consciousness (LOC)?

a) On the Mental Status Assessment formb) On the Neurological Assessment form c) Write a comment on the Neurological Assessment

formd) LOC is no longer assessed

Answer: a

Post Test

Post Test

4. Which of the following statements about the Neuro Check, Frequent form is true?

– The form is designed as a screening tool after a stroke, head trauma, or neurosurgery.

– The form contains both mental status & neurological assessment parameters.

– If the patient becomes disoriented, the nurse documents it on the Neuro Check-Frequent form and completes a Mental Status Assessment before calling the physician.

– The form screens for changes in LOC, pupils/vision, movement, and speech; Charting a Glasgow Coma Scale with the same parameters would be duplication.

– All of the above Answer: e

• 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:

Selected ReferencesAmerican Speech-Language-Hearing Association (1997-2008). Dysarthria. Accessed at http://www.asha.org/public/speech/disorders/dysarthria/htm

Bickley LS & Szilagyi PG. (2007). Bates' Guide to Physical Examination and History (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Cummings, C.W. et al. (2005) Otolaryngology: Head &Neck Surgery (4th ed.). St. Louis: Mosby.

Epilepsy Foundation, Seizure Types, Accessed from http://www.epilesyfoundation.org

Hickey, J.V. (2003). Clinical Practice of Neurological and Neurosurgical Nursing, 5th Ed. Philadelphia, PA: Lippincott Williams & Wilkins.

Kammerman S., & Wasserman, L. (2001). Seizure disorders: Classification and diagnosis. Western Journal of Medicine, 175, 99-103.

Medline Plus Dictionary (on-line); Service of the U.S. National Library of Medicine and National Institutes of Health.