Professional Documents
Culture Documents
Clinical Assessment
Imperative for the early identification and treatment of a neuro
disorder and
serves as a source for comparison for ongoing assessments
The most important finding is changereport promptly
Early identification of neuro deterioration is vital to preventing
secondary brain
injury
History-of events preceding hospitalization
Common to all neuro assessments
Includes information about clinical manifestations, associated
complaints,
precipitating factors, progression, and familial occurrences.
If patient is unable to providefamily/significant others who have daily
contact
with the patient should be contacted ASAP.
Allows nurse to focus on certain aspects of the patients clinical
assessment
Include:
o Common neuro symptoms (e.g., fainting, dizziness, seizures,
pain, numbness
etc)
o Events preceding onset of symptoms (e.g., travel, falls, infection,
etc).
o Progression of symptoms (initial onset, evolution, frequency,
severity,
duration, associated activities/aggravating factors)
o Family history
o Medical history
o Surgical history
o Traumatic history
o Allergies
o Patient profile (personal habits, recent life changes,
living/working
conditions, exposure to toxins/chemicals, temperament)
o Current medication use
Physical Examination-5 Components
1) Level of consciousness
Most important aspect of the neuro exam
LOC deteriorates before any other neuro changes are noted
4) Respiratory Function
Respiration is a highly integrated function that receives input from the
cerebrum,
brainstem and metabolic mechanisms.
Correlations exist between altered LOC, the level of brain/brainstem injury,
and the
patients respiratory pattern
3 brainstem centers control respirations
-The lowest centerMedullary Respiratory Center sends impulses
through the
vagus nerve to innervate muscles of inspiration/expiration
--The apneustic and pneumotaxic centers of the pons are
responsible for the
length of inspiration/expiration and the underlying respiratory
rate
a) Observation of Respiratory Pattern
Changes in pattern assist in identifying the level of brainstem
dysfunction/injury
5) Vital Signs
As a result of brain/brainstem influences on cardiac, respiratory, and body
temp functions, changes in vital signs could be signs of deterioration in
neuro status
a) Evaluation of Blood Pressure
A common sx of intracranial injury is systemic hypertension
When controlling systemic hypertension, the mean arterial
pressure must be maintained at a level sufficient to
produce adequate CBF in the presence of elevated ICP.
Also pay attention to the pulse pressure because
widening of this may occur in the late stages of
intracranial hypertension.
b) Observation of Heart Rate and Rhythm
The medulla/vagus nerve provide parasympathetic control to
the heart. When stimulated, it produces bradycardia
Sympathetic stimulation increases the rate and contractility.
Cushing Reflex/Triad/Phenomena (systolic hypertension,
bradycardia, abnormal respirations) related to pressure
on the medullary area of the brainstem. This may occur
in response to intracranial hypertension or a herniation
syndrome.