Understanding neuro assessment is important for nursing students preparing for the NCLEX exam due to several reasons:
Common Neurological Issues: Neurological conditions and injuries are prevalent in various healthcare settings. Nurses need to be able to assess and monitor neurological status accurately to detect changes promptly.
Vital Sign Monitoring: Neurological changes often manifest as alterations in vital signs. Nurses need to understand the relationship between neurological function and parameters like blood pressure, heart rate, and respiratory rate.
Early Detection of Changes: Neurological deterioration can occur rapidly. Nurses trained in neuro assessment can detect subtle changes in consciousness, motor function, and sensory perception early, allowing for timely intervention.
Diverse Presentation: Neurological conditions present differently across age groups and populations. Nurses should be familiar with variations in presentation, such as altered consciousness in the elderly and seizures in children.
Diagnostic Tool Interpretation: Nurses need to understand the significance of diagnostic tests like CT scans, MRIs, and electroencephalograms (EEGs) to aid in assessing and diagnosing neurological conditions.
Intervention Planning: Accurate neuro assessment informs the development of appropriate care plans, including interventions to manage symptoms and prevent complications.
Medication Management: Nurses should be knowledgeable about medications used to manage neurological conditions, including dosages, administration routes, and potential side effects.
Functional Implications: Neurological changes can have profound implications on a patient's ability to perform activities of daily living. Nurses should assess for these limitations and plan care accordingly.
NCLEX Preparation: The NCLEX exam may include questions related to neuro assessment, the Glasgow Coma Scale, signs of increased intracranial pressure, and other neurological topics. A strong understanding of this area is crucial for answering questions accurately.
Overall, understanding neuro assessment equips nursing students to provide safe, patient-centered care to individuals with neurological conditions or injuries. It ensures that nursing students are prepared to address the unique challenges and needs of patients with neurological issues and contribute to positive patient outcomes.
1. Level of Consciousness
a. Assess alertness
b. Assess orientation, Person, place, time, situation
c. Assess response to stimuli
i. Start with verbal
ii. Then light touch
iii. Deep touch/shaking
iv. Painful (nail beds)
v. Deep pain (sternal rub)
2. Glasgow Coma Scale
a. Can never be zero (0)
b. Worst score is 3, with best being 15
c. In each category, give the highest score, and
then add all three scores up
i. Best Eye Opening
1. 4 – spontaneous
2. 3 – to voice
3. 2 – to pain
4. 1 – no response
ii. Best Verbal Response
1. 5 – oriented
2. 4 – disoriented, converses
3. 3 – inappropriate words
4. 2 – incomprehensible speech
5. 1 – no response / intubated
iii. Best Motor Response
1. 6 – follows commands
2. 5 – localizes to pain (when pain response initiated, client reaches toward pain)
3. 4 – withdraws from pain (when pain response initiated, client reaches toward
pain, but cannot cross the midline, or the middle, of the body)
4. 3 – abnormal flexion (“decorticate”)
5. 2 – abnormal extension (“decerebrate”)
6. 1 – no movement
d. Example:
i. A client who opens their eyes to voice (3), is disoriented (4) and follows commands (6) can be given a GCS of 13.
ii. A client who does not open their eyes (1), does not respond verbally (1) and who is
decorticate (3) receives a GCS of 5.
3. Pupil Assessment
a. Equal, Round, Size
b. Reactive to Light→ Should constrict briskly, and equally on both sides when the light shined in eyes
c. Accommodation→ Should constrict when focusing from far to near
4. Strength x 4 Extremities
a. 5 – full strength
b. 4 – overcomes some resistance
c. 3 – overcomes gravity, no resistance
d. 2 – cannot overcome gravity
e. 1 – no movement at all
1. Notify provider of any acute changes
2. May need STAT CT or MRI to rule out possible increased intracranial pressure or stroke
Patient Profile:
John Miller, a 65-year-old man, is admitted to the emergency department with sudden-onset right-sided weakness and difficulty speaking. His wife reports that John suddenly couldn't move his right arm and leg and was having trouble understanding her.
Assessment:
Upon assessment, John appears anxious and frustrated. He is able to respond verbally but struggles to form coherent sentences. His right arm and leg are weak, and his facial droop is more pronounced on the right side. He has difficulty following commands and appears disoriented.
Interventions:
1. Neurological Assessment:
Perform a thorough neurological assessment, including assessing John's level of consciousness, facial symmetry, strength, sensation, and coordination.
2. Airway and Breathing Management:
Ensure John's airway is clear and monitor his respiratory status, as some neurological conditions can affect swallowing and respiratory function.
3. Vital Sign Monitoring:
Monitor John's blood pressure, heart rate, and respiratory rate, as changes in vital signs can indicate changes in neurological status.
4. Glasgow Coma Scale (GCS):
Administer the Glasgow Coma Scale to assess John's level of consciousness, eye opening, verbal response, and motor response.
5. NIH Stroke Scale:
Utilize the National Institutes of Health Stroke Scale (NIHSS) to assess the severity of John's stroke and guide treatment decisions.
6. Brain Imaging:
Collaborate with the healthcare provider to order a CT scan or MRI to assess the type and location of the stroke.
7. Thrombolytic Therapy:
If appropriate and within the time frame, collaborate with the healthcare provider to administer thrombolytic therapy to dissolve the clot causing the stroke.
8. Positioning:
Position John in a semi-Fowler's position to promote venous drainage and reduce the risk of aspiration.
9. Dysphagia Assessment:
Assess John's ability to swallow safely to prevent aspiration and ensure proper nutrition and hydration.
Outcome:
John's CT scan confirms an ischemic stroke in the left middle cerebral artery territory. He is administered thrombolytic therapy within the appropriate time window. Over the next few days, John's speech gradually improves, and he gains partial strength in his right arm and leg. He is transferred to a stroke rehabilitation unit for further recovery and therapy.
Are you looking for more must-know NCLEX review topics? Download our free eBook "NCLEX Flash Notes" as a valuable resource for nursing students. Encourage readers to download their free copy of the "NCLEX Flash Notes."
You CAN Do This
Happy Nursing!