Nurse Neurological Assessment

What goes on in a Nurse Neurological Assessment?

Since a Nurse Neurological Assessment is a comprehensive examination, a lot goes into it, including other tests. For this section, we will list down what is normally included in the Nurse Neurological Assessment. Here is what they need to do (based on the checklist of Ernstmeyer and Christman):

1. The nurse should prepare certain supplies for this exam. These include:

• A penlight
• Snellen chart
• Tongue depressor
• Cotton wisp or applicator
• Percussion hammer
• Coins and paper clips for patients to touch
• Vanilla, mint, or coffee for patients to smell
• Pinches of sugar and salt, and lemon for patients to taste

2. Perform safety and clerical nurse work, which includes the following:

• Perform hand hygiene and ensure their hands are totally clean
• Inspect the room for any transmission-based precautions
• Introduce themself to the patient, what their role is, what they’re about to do, and how long it’ll take to conduct the assessment
• Confirm the patient’s ID using their full name and date of birth
• Explain the process of the assessment to the patient
• Ask the patient for any questions they might have regarding the assessment

The nurse must also ensure that they keep in mind and do the following throughout the assessment:

• They must be organized and systematic as they conduct the assessment
• Use appropriate listening and questioning skills, especially during the subjective part of the assessment
• Listen and attend to patient cues
• Ensure the patient’s privacy and dignity
• Assess the patient’s ABCs (Airway, Breathing, and Circulation)

3. They will start with the subjective part of the assessment. They must ask the patient the following questions:

• Are you experiencing any current neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, or decreased coordination?

• Have you experienced any difficulty swallowing (dysphagia) or speaking (dysphasia)?

• Have you experienced any recent falls?

• Have you ever experienced a neurological condition such as a stroke, transient ischemic attack, seizures, or head injury?

• Are you currently taking any medications, herbs, or supplements for a neurological condition?

They should also ask follow-up questions depending on the patient’s answers, especially regarding symptoms.

During this part of the assessment, the nurse should note down the patient’s behavior, language, mood, hygiene, and choice of dress while asking the questions listed above. They should also note down if the patient has any hearing or visual deficits. If the patient has glasses or hearing aids, the nurse must ensure they are in place, if needed.

4. They must assess their level of alertness. Are they awake and alert, lethargic, obtunded, stuporous, or unresponsive. If they are unresponsive, perform the steps of the AVPU Scale or the Glasgow Coma Scale.

5. After assessing their level of alertness, the nurse will assess the patient’s orientation through the following questions:

• What is your name?
• Where are you right now?
• Why did you come to the hospital?
• What is the month and/or year?
• What day of the week is it?

6. They must conduct the Mini-Mental State Exam (MMSE) to check on their cognition.

7. Next, they will assess the eyes by conducting the PERRLA Eye Exam, which requires a penlight. This will assess if the pupils are equal in size, if they are perfectly round, if they react to light, and if the eyes can change focus normally. They must also check if the eyes can move in all directions.

8. After checking the eyes, they must assess the motor strength and sensations of the patients by specifically looking at their hand grasps, the strength and resistance of the upper and lower body, and sensations in their extremities.

9. Once they’re done checking their motor strength and sensations, the nurse must assess the patient’s balance and coordination. They can have the patient walk with an assistive device, and while they’re walking, the nurse will note down observations related to their gait, arm swings, coordination, ability to tandem walk, tiptoe, and walk on heels.

They must also assess their cerebellar function via tests like the Romburg, Pronator Drift, Rapid Alternating Hand Movement, Fingertip-to-Nose, and Heel-to-Shin tests.

10. After assessing their balance and coordination, the nurse will assess the patient’s twelve cranial nerves using various assessments and items.

11. After assessing their cranial nerves, the assessment is done and the nurse should help the patient get back to a comfortable permission, ask them if they have any questions, answer those questions accordingly, and thank them for their time.

12. Before the nurse leaves the room, they must ensure the following:

• The call light is within the reach of the patient
• The patient’s bed is low and locked and the side rails are secured
• The table is within the patient’s reach
• The room is risk-free from falls by scanning the room and clearing any obstacles

13. Perform hand hygiene.

14. Document all their findings. They can also do this after each part of the assessment. It’s important to document them to pass information to other nurses or doctors handling the patient.

When is it best to conduct a Nurse Neurological Assessment?

There are two appropriate times when it is best to conduct a Nurse Neurological Assessment.

Conducting a Nurse Neurological Assessment during the initial encounter is crucial. It allows you to gather vital preliminary information about the patient, serving as a baseline for neurologists. This information helps frame the neurologists' approach, guiding the testing process and highlighting specific symptoms to focus on. Moreover, it informs the development of a personalized treatment and care plan for the patient once all the testing is complete. By performing this assessment, healthcare professionals ensure comprehensive and tailored care for their patients.

Another suitable time is during the shift handover between nurses when one nurse is finishing their shift and handing over to another nurse who is about to start. The Nurse Neurological Assessment, as previously mentioned, plays a crucial role in this transition. It provides the incoming nurse with valuable information about the patient's current condition and the observations made by the previous nurse. This assessment should be conducted before the outgoing nurse clocks out of their shift.

In addition to serving as a means of communication, it also serves as a tool for tracking any changes in the patient's condition. If there are any changes, it is the responsibility of the nurse to promptly notify other healthcare professionals, including doctors, so that appropriate actions can be taken, such as conducting additional tests or adjusting the treatment plan.

What are the benefits of the Nurse Neurological Assessment?

It will give healthcare professionals a comprehensive look at a patient.

Since the Nurse Neurological Assessment is a comprehensive examination, you can trust that it can give a clear picture of the patient’s current health status. This examination covers many factors such as your patient’s balance, if their eyes are in optimal condition, their motor functions, etc. The results of this assessment will serve as a baseline for what professionals will do and decide for the patient moving forward.

It can help professionals determine what to do for the patient.

The Nurse Neurological Assessment offers valuable insights that can guide subsequent nurses and other professionals in determining the necessary course of action. By identifying factors contributing to less-than-stellar results, the next nurse and neurologists can conduct appropriate tests and develop effective strategies for managing or curing those factors. This collaborative approach ensures optimal care and treatment for patients.

It can be used to monitor the patient efficiently.

The Nurse Neurological Assessment is routinely conducted to ensure seamless communication between nurses. It serves as an opportunity to update the incoming nurse on the patient's condition. If significant changes are observed, it is crucial for the nurses to notify other professionals, such as neurologists. This collaborative approach allows for timely adjustments in treatment, additional tests, or simply providing rest to the patient if there is an improvement.