New & Improved Physical Assessment: Neurological

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

Technical contact: If you have technical questions please contact the Service Desk 414-647-3520 in Milwaukee or 1-800-889-9677 Content contact: System Nursing Research 414-219-5394

Objectives After 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

Defining Normal (WDL) for Neurological Status

Parameter
Pupils/Vision

Defined Limits (WDL)

Equal, normal size (2-6 mm), round shape, and reactive with vision per patients baseline, and no extra-ocular muscle movements. Moves all extremities with equal strength*. Absence of involuntary movements. Reports normal sensations throughout body, no paresthesias. Verbalization is clear and understandable

Neurological Movement Sensation: Speech: 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

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 26mm. 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.

Pupils and Vision 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.

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 Parkinsons 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.

ICU Scenario
Pt. admitted to ICU following a motor vehicle collision. He has suffered severe head trauma. The patients 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: Mental Status Assessment

Parameter
Level of Consciousness Attention, Thought Process, Orientation, Memory, Perceptions, Motor Behavior, Sleep/Wake, Affect/Behavior

WDL except
Obtunded

Unable to assess: Reason: Obtunded.

ICU Scenario: Neurological Assessment

Parameter Pupils/ Vision WDL except Pupils: Left (6mm) , Right (3mm), Reactivity: sluggish, Extraocular Eye Movement: Nystagmus Posturing to Pain/ Noxious Stimuli: decorticate posturing. Comment: positive plantar reflex Unable to assess: Reason: Obtunded. No Speech Abnormal (absent/weak) Gag reflex.

Neurological Movement

Sensation Speech Swallow

ICU Scenario: Intubated Patient

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: Subsequent Neurological Assessment

Parameter
Pupils/ Vision Neurological Movement

WDL except
Reactivity: sluggish Posturing to Pain/ Noxious Stimuli: decorticate posturing. Comment: positive plantar reflex Unable to assess: Reason: Obtunded/ ETT Unable to assess: Reason: Obtunded/ ETT. Only select No Speech if you are able to confirm that the patient is not able to speak. Abnormal Gag reflex.

Sensation Speech

Swallow

ICU Scenario: Neurologic Injury

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: Mental Status Assessment

Parameter LOC Attention Thought Process Orientation, Memory, Perceptions Motor Behavior WDL except Hyperalert Reduced ability to maintain attention (chronic) Rambling, Irrelevant or Incoherent Conversation Unable to assess: Reason: Cognitive impairment with garbled speech

Agitation: Restless, repeated or constant shifting of position Sleep/ Wake Cycle Insomnia Affect/ Behavior Impulsive

ICU Scenario: Neurological Assessment

Parameter
Pupils/ Vision

WDL except
WDL

Neurological Movement
Sensation Speech Swallow

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

Parameter Pupils/Vision* Neurological Movement* Sensation* Speech* Swallow WDL except Left visual field cut Facial Droop-Left LUE, Numbness and Tingling Slurred Speech Unable to Assess (deferred)

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).
Parameter LOC Orientation Pupils/Vision Neurological Movement Sensation Speech Finding WDL WDL WDL WDL WDL WDL

Post Test
1. 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

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

Post Test
3. Where would you document a change in level of

consciousness (LOC)? a) On the Mental Status Assessment form b) On the Neurological Assessment form c) Write a comment on the Neurological Assessment form d) LOC is no longer assessed Answer: a

Post Test
4. Which of the following statements about the Neuro Check, Frequent form is true? a) The form is designed as a screening tool after a stroke, head trauma, or neurosurgery. b) The form contains both mental status & neurological assessment parameters. c) 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. d) The form screens for changes in LOC, pupils/vision, movement, and speech; Charting a Glasgow Coma Scale with the same parameters would be duplication. e) All of the above Answer: e

Next Steps:
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.

Selected References
American 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.