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
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.
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 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.
ICU Scenario
• 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: 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
Pupils/ Vision
Neurological
Movement
Sensation
Speech
Swallow
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.
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
WDL except
Pupils/ Vision
Neurological Movement
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
WDL except
Pupils/ Vision
WDL
Neurological Movement
WDL
Sensation
Unable to assess: Reason: Cognitive
Impairment with Garbled Speech
Speech
Swallow
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
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.
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
Finding
WDL
Orientation
WDL
Pupils/Vision
WDL
Neurological Movement
WDL
Sensation
WDL
Speech
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.