New

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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.
Technical contact
If you have technical questions please contact
the Service Desk 414-647-3520 in Milwaukee or
1-800-889-9677
Features
Content contact
Instructions on how to navigate this course. This
course does not have sound.
System Nursing Research 414-219-5394
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ObjectivesAfter completion of this self
paced course you will be able to

• 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.

• 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.

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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

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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.

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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

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Defining Normal (WDL) for Neurological Status
Parameter Defined Limits (WDL)
Pupils/Vision Equal, normal size (2-6 mm), round shape, and reactive with vision per patients 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
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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

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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 lt1 or gt6 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.

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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.

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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.
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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.
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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

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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

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Neurological Assessment Speech Swallow

• New assessment descriptors have been added.
• The ability to consult nutrition services and
  speech therapy will remain.

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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)

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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.

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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.

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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.

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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.

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

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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.)

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Case Studies ICU Non-ICU

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

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• 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.

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• 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.
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ICU Scenario Neurological Assessment
Parameter WDL except
Pupils/ 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 Speech
Swallow Abnormal (absent/weak) Gag reflex.
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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.

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ICU Scenario Subsequent Neurological Assessment
Parameter WDL except
Pupils/ Vision Reactivity sluggish
Neurological 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.
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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.

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ICU Scenario Mental Status Assessment
Parameter WDL except
LOC Hyperalert
Attention Reduced ability to maintain attention (chronic)
Thought Process Rambling, Irrelevant or Incoherent Conversation
Orientation, 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
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ICU Scenario Neurological Assessment
Parameter WDL except
Pupils/ 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.
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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

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Non-ICU Scenario Neurological Findings
Parameter WDL except
Pupils/Vision Left visual field cut
Neurological Movement Facial Droop-Left
Sensation LUE, Numbness and Tingling
Speech Slurred Speech
Swallow 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.

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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 Finding
LOC WDL
Orientation WDL
Pupils/Vision WDL
Neurological Movement WDL
Sensation WDL
Speech WDL
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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

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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

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Post Test

• 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

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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

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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 IDTrain, PasswordTrain
• Familiarize yourself with these new assessments
  in the Physical Assessment form (complete) or as
  a separate section in Ad Hoc Charting.

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Selected References
American Speech-Language-Hearing Association
(1997-2008). Dysarthria. Accessed at
http//www.asha.org/public/speech/disorders/dysart
hria/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.