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INTRODUCTION

KNOWLEDGE COMPETENCIES

  1. Correlate neurologic assessments to patient problems and diagnostic findings.

  2. Identify indications, complications, and nursing management for commonly used neurodiagnostic tests.

  3. Identify causes of increased intracranial pressure and describe strategies for management.

  4. Compare and contrast the pathophysiology, clinical presentation, patient needs, and nursing management for:

    • Acute ischemic stroke

    • Hemorrhagic stroke

    • Seizure disorders

    • CNS infections

    • Selected neuromuscular diseases

SPECIAL ASSESSMENT TECHNIQUES AND DIAGNOSTIC TESTS

Although there is no single method of performing a neurological assessment, a systematic, orderly approach offers the best results. Knowledge of neurologic disease processes and neuroanatomy allows the progressive care nurse to tailor the assessment to individual patients. Obtaining a comprehensive past medical history that includes any preexisting neurologic conditions in addition to a thorough history of the present illness or injury is essential. The time from injury to symptom onset and identification of the mechanism of injury have important implications for diagnostic testing and treatment. The administration of any medications that may potentially alter the neurologic examination, especially sedatives and analgesics, should also be noted.

Serial assessments allow for detection of subtle changes in neurologic status. Detecting secondary brain injury (SBI) and early neurologic deterioration (END) permits rapid intervention and improves patient outcomes. The elements of a comprehensive neurologic assessment in the progressive care unit can be broken down into the following components: level of consciousness, mental status, motor examination, sensory examination, and cranial nerve examination. A baseline examination should be established and subsequent assessments are compared against that baseline.

Level of Consciousness

A change in the level of consciousness (LOC) is often the first sign of END. There are multiple components to LOC including: arousal, awareness, and responsiveness. Arousal refers to the state of wakefulness; awareness reflects the content and quality of interactions with the environment; and responsiveness refers to the ability to react to changes in the environment. Arousal reflects function of the reticular activating system (RAS) and brain stem; awareness indicates functioning of the cerebral cortex. Level of consciousness is assessed on all patients. A change in level of consciousness is the most important indicator of neurologic decline. Any change in the level of consciousness requires further assessment or action from the healthcare team.

Observation of the patient’s behavior, appearance, and ability to communicate is the first step in assessing level of consciousness. If the patient responds meaningfully to the examiner without the need for stimulation, then the patient is described as alert. If stimulation is required, auditory stimuli are used first. If the patient does not rouse to auditory stimuli, tactile stimuli such as a gentle touch or shake are used, followed by painful stimuli if necessary to elicit a response. Accepted methods of central painful stimulus include squeezing the trapezius or another large muscle group. Care is taken to avoid causing tissue trauma. Supraorbital pressure is also an acceptable ...

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