2-11. INTRODUCTION

A thorough neurological assessment is one that accurately and completely evaluates the patient’s vital signs, mental status, sensory function, motor function, and level of consciousness.

2-12. VITAL SIGNS

a. Vital signs should include:

(1) Blood pressure.

(2) Apical heart rate and rhythm.

(3) Radial pulses, bilaterally.

(4) Femoral pulses, bilaterally.

(5) Respiratory rate and rhythm.

(6) Temperature.

b. Vital signs should be evaluated as follows:

(1) Compare current vital signs with baseline and previous vital signs.

(2) Note any changes in pulse rate or rhythm.

(3) Note respiratory changes.

(4) Note temperature elevations.

(5) Note elevation of blood pressure, especially when it occurs with a widening pulse pressure.

2-13. MENTAL STATUS

a. Mental status assessment should evaluate the following areas:

(1) State of consciousness.

(2) Orientation.

(3) Affect. (Mood)

(4) Memory.

(5) Cognition.

 

b. The terms used to describe state of consciousness are often subjective and ambiguous. For this reason, such terms should not be used in nursing documentation unless they are qualified with an explanatory statement. When assessing a patient who is other than “awake and alert,” it is best to use a standardized assessment scale. One such scale is the Glasgow Coma Scale (GCS), described in paragraph 2-16. Terms used to describe state of consciousness include:

(1) Conscious (alert)–the patient responds immediately, fully, and appropriately to visual, auditory, and other stimuli.

(2) Somnolent–unnatural drowsiness. The patient can be aroused and will respond to commands, but will fall asleep again as soon as he is left alone.

(3) Stuporous–partial unconsciousness. The patient can be aroused with painful stimuli and will attempt to respond with purposeful withdrawal from the stimulus. The patient may be restless or combative as well.

(4) Comatose–complete unconsciousness, no purposeful response to any stimulus.

c. Orientation is determined by questioning the patient about person, place, and time.

(1) Ask the patient to spell his name, name his children, or recite his address. Does the patient know who he is? Does the patient know who others are?

(2) Ask the patient to tell you where he is. He may be asked to name the hospital, city, state, and so on.

(3) Ask the patient to tell you the year, month, and time-of-day (mid-morning, late afternoon, and so forth). Do not ask for the date. This is a poor indication of orientation. Most people cannot tell you the exact date when questioned.

d. Affect, or mood, is evaluated by observing the patient’s verbal and nonverbal behavioral responses for appropriateness. For example:

(1) Does the patient laugh when talking about serious or sad subjects?

(2) Is the patient easily startled by loud noises?

(3) Does the patient respond to stimuli in a normal manner?

(4) Does the patient display excessive anger, fear, confusion, and so forth?

e. Long and short term memory should be evaluated by asking questions.

(1) Discussing past events or questioning the patient about his medical history will test his ability for remote recall (long-term memory).

(2) Questions about daily events will test recent recall (short- term memory). For example, ask the patient what he ate for breakfast that morning.

f. Cognition is tested by asking the patient to perform calculations. For example, ask the patient to count backward from 100 by 7s.

2-14. SENSORY FUNCTION

a. Sensory function is evaluated by testing perception of pain, touch, and position.

(1) Pain–using a safety pin, touch the skin as lightly as possible to elicit a sharp sensation.

(2) Touch–ask the patient to close his eyes. Use a piece of cotton or gauze to gently brush the skin on the patient’s arms, legs, and feet. Ask the patient to tell you when and where he feels a touch.

(3) Position–ask the patient to close his eyes. Grasp one of the patient’s digits (thumb, great toe) and move it up or down. Ask the patient to tell you which direction the digit is pointing. Do not exert any pressure with your grasp that will indicate which direction you are moving the digit.

b. Pupillary response is another sensory function indicator. Evaluate:

(1) Size in millimeters (do not use subjective terms such as dilated or pinpoint.)

(2) Equality in size of the pupils.

(3) Response to light.

2-15. MOTOR FUNCTION

Evaluate motor function by testing muscle strength, mobility, and coordination.

a. Position the patient comfortably so that you can observe both upper and lower extremities.

b. Beginning with upper extremities, ask patient to put each joint (wrist, elbows, shoulders) through active range of motion.

(1) Observe smoothness of movement.

(2) Note inability to move any body part.

(3) Observe patient’s facial expression for signs of any pain/discomfort.

c. Extend your index and middle fingers of each hand and ask patient to grip firmly.

(1) Dominant hand will usually be slightly stronger.

(2) Note strength of both hands and compare strength of one to the other.

d. Instruct patient to put each lower extremity joint (ankles, knees, hips) through active range of motion.

(1) Observe smoothness of movement.

(2) Note inability to move any body part.

(3) Observe patient’s facial expression for signs of any pain/ discomfort.

e. Ask the patient to alternately flex and extend his feet while you provide resistance with your hands.

(1) Note the strength that the patient exerts against your resistance and compare right to left.

(2) If muscle group is weak, lessen your resistance or provide no resistance to permit more accurate observation.

f. Observe coordination.

(1) Ask the patient to run his left heel along his right shin (while standing) and vice versa.

(2) Ask the patient to close his eyes, extend his arms, and touch his index finger to his nose.

(3) Ask the patient to walk in a straight line, forward and backward. Observe posture and balance.

2-16. LEVEL OF CONSCIOUSNESS

a. The Glasgow Coma Scale (GCS) is a standardized, objective, reliable instrument for the assessment of level of consciousness.

b. The scale measures three areas of observable behavioral responses (verbal, motor, and eye). Patient responses are graded by the degree of dysfunction. The patient’s best response in each of the three areas is recorded. The combined score of the three areas is the “consciousness level” score.

c. Recording and/or graphing the scores on a flow sheet permits easy tracking of the patient’s status.

d. Response scale. (Explanation)

(1) Eye response.

(a) 4 points–eyes open spontaneously.

(b) 3 points–eyes open in response to sound.

(c) 2 points–eyes open in response to painful stimuli.

(d) 1 point–eyes do not open in response to any stimuli.

(2) Verbal response.

(a) 5 points–the patient is oriented to person, place, and time.

(b) 4 points–the patient is confused but is able to communicate.

(c) 3 points–the patient speaks in a disorganized manner. (Inappropriate speech.)

(d) 2 points–the patient’s response is moaning or groaning sounds. (Incomprehensible sounds.)

(e) 1 point–the patient does not respond.

(3) Motor response.

(a) 6 points–the patient obeys commands appropriately and moves all extremities equally and spontaneously.

(b) 5 points–the patient “localizes” to the stimulus (pain). Attempts to locate the source of the pain and move the limb away from the stimulus.

(c) 4 points–the patient attempts to withdraw from the source of the (painful) stimuli in a less than purposeful movement. (Flexor withdrawal.)

(d) 3 points–the patient flexes an extremity abnormally. (Decorticate response.)

(e) 2 points–the patient extends an extremity abnormally. (Decerebrate response.)

(f) 1 point–the patient has no motor response. (Flaccid.)

e. Abbreviated Response Scale.