The purposes of this chapter are (1) to provide an overview for establishing and updating a database for a hospitalized neuroscience patient, and (2) to provide a framework for understanding the organization and interpretation of data from the systematic bedside neurological assessment. Some content that appears in Chapter 7 has also been included in this chapter for the convenience of the reader.
Once a patient is admitted, the nurse begins to collect a comprehensive database by completing a nursing admission history and general admission assessment before conducting a neurological assessment. Most nursing departments have adopted a specific
Format for this purpose as part of their documentation system. The data may be entered in a written format or typed into a computerized documentation system. The database is the foundation for ongoing assessment, planning, implementation, and evaluation of care and outcomes. The database is the key to maintain continuity of care across levels of care through discharge and follow-up.
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One section of the database includes demographics, and circumstances of admission, vital signs, weight, and other general information (e.g., eyeglasses, hearing aid). Other section of the database includes assessment for risk of falls and pressure ulcers. The fall risk assessment was added to the admission database to comply with the National Patient Safety Goals (NPSG) set by The Joint Commission (TJC) to reduce the risk of harm resulting from falls. As of September 2009, this goal was moved to a TJC Standard. While fall risk assessment and the implementation of fall preventive measures are vital to all patients, they are very crucial to neurological patients to promote safety and reduce harm. Neurological patients usually are high fall risk due to their possibly depressed cognition (e.g., poor judgment, unable to follow safety instruction) and musculoskeletal functional compromise. In addition, the pressure ulcer risk assessment was also added to the admission database to comply with the NPSG #14 to prevent health care-associated pressure ulcers. This goal is very crucial to the neurological patients who usually are at high risk of developing pressure ulcers due to their possibly depressed sensory (pain, discomfort) and musculoskeletal functions (activity, mobility). Many hospitals adopted the Braden Scale as a tool for pressure ulcer risk assessment. Sensory, activity, and mobility are three of six components (50%) of the Braden Scale. The largest section includes a comprehensive systematic assessment often based on body systems or functional patterns. The circumstances of admission affect the data collection. Ideally, the nurse has an opportunity to interview the patient and family on admission. The interview is not only a mechanism for gathering data and dispensing information but also an opportunity to establish rapport with the patient and family.
Throughout the interview, the nurse should be alert for any misconceptions or misunderstandings held by the patient or family. Information should be corrected and clarified as necessary and appropriate referrals made. Identify high-risk patients and families who have problems that will affect recovery negatively, such as drug abuse or family dysfunction. Early identification can result in timely interventions and referrals.
For a patient with altered consciousness or cognitive deficits, enlist a family member to help you learn about the patient’s personality and behavior before the current illness. This baseline information is useful for future comparison throughout the course of hospitalization. In the event of an emergency admission, some data gathering will be postponed until the patient is stabilized or the family can be reached. As soon as possible, the nurse should interview the patient and family to develop a plan of care. If care maps are used, the appropriate care map should be reviewed and modified as necessary. The neurological assessment is the core nursing database for identifying nursing care needs, collaborative problems, and planning care. The accuracy of these assessment data and the nurse’s critical thinking skills form the foundation of neuroscience nursing practice.
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While the taxonomy of nursing diagnoses may be a helpful framework to use when analyzing data from neurological assessment, the updated practice is identifying health care needs and working collaboratively with the interdisciplinary team to formulate an interdisciplinary care plan. There are many collaborative problems that require an interdisciplinary collaborative approach. For example, increased intracranial pressure (ICP) is a problem that requires collaboration of the entire health care team. A patient with increased ICP will require supportive and restorative care, along with definitive treatment for the underlying cause. Nurses participate as collaborative team members with physicians, respiratory therapists, physical therapists, occupational therapists, speech therapists, physiatrists, nutritionists, and social workers to address the comprehensive patient needs. Care includes various supportive, preventive, maintenance, and restorative strategies. Examples of collaborative problems include safety measures to prevent falls and injury, prevention of the complications of immobility, adaptation of activities of daily living (ADLs), maintenance of a patent airway, maintenance of adequate blood pressure, and nutritional-hydration support.
The purposes of the care nurse’s neurological assessment are different, in some respects, from those conducted by the physician, the advanced practice nurse, and other health care professionals. The care nurse’s purposes are to
A baseline assessment of neurological signs is made to determine deviations and trends in clinical status. A comparison is made between current assessment data and previously collected data to determine whether neurological signs are stable, deteriorating, or improving. Changes in neurological signs may develop rapidly in a few minutes, or subtly over a period of hours, days, weeks, or even months. There are various sources from which information about the neurological status can be derived, including the nursing admission history and comprehensive assessment, nurses’ notes, neurological assessment sheets, and intershift nurses’ reports. Other parts of the medical record are also a rich source of data (e.g., comprehensive neurological examination) and should be reviewed.
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Nursing management of the neurological patient is based on highly developed nursing assessment and clinical reasoning skills. The nurse must know which parameters to be assessed, the proper technique for assessment, the appropriate method of documentation, and how to interpret the data to decide what action, if any, should be taken.
The third question, “How does it relate to previous assessments?” is critical because data are compared with the previous baseline assessments as well as the trends of multiple data points over time to denote change. The assessment can reveal no change, subtle change, or dramatic change from previous findings. Generally, a change of any kind is important to note because it usually reflects an intracranial change.
A change in any of the data included in the neurological assessment must be considered in conjunction with changes in other areas evaluated in the assessment. For instance, a rapidly developing hematoma or cerebral edema will affect multiple assessment data, such as the LOC and motor function. If, however, the pupil appears to be dilated and fixed (a new finding from the previous assessment) and the patient continues to be well oriented and maintains motor function, then the pupillary signs should be rechecked and other possible explanations explored.
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Critical thinking skills are inherent in the assessment process, both to detect subtle and substantive changes in the neurological assessment data and overall clinical condition, and to incorporate this information within the context of the overall patient profile. Well-developed critical thinking skills are the foundation for all patient management decision making.
Clinical Pearl: The 1-2-3 of patient safety. One, rescue; Two, investigate (assessment and data collection); and Three, communicate (to physician or interdisciplinary team). These are the three steps that the nurse needs to incorporate into his/her daily practice when findings are abnormal, thus promoting safety and improving patient outcomes.
The components included in a neurological assessment depend on the patient’s state of consciousness and cooperativeness as well as clinical stability. A comprehensive baseline must be established. A neurological assessment is focused on selected critical components that are sensitive to change and that provide an overview of the patient’s overall condition. The nurse must decide what other components, if any, should be added to best monitor the patient’s condition. An assessment in the intensive care unit for an unconscious patient is quite different from the assessment in an intermediate care unit for a patient who is recovering from a stroke. This neurological assessment at a minimum includes the following.
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The frequency and extent of the neurological assessment will depend on the stability of the patient and the underlying condition. For a stable patient who is doing well, an assessment may be ordered by the physician every 4 to 8 hours, or every shift. However, a patient who is very unstable may warrant assessment every 5 to 15 minutes to monitor changes and the need for or response to an intervention. The nurse should use independent clinical judgment to determine the need to assess the patient more frequently or to expand the assessment to include more parameters. A physician order, defines only the minimum required frequency of assessment, is not required to assess the patient more frequently than what might be included on the physician order sheet or unit standard because assessment is within the nurse’s scope of practice.
Most facilities use a standardized neurological assessment form or computerized assessment template to document neurological data. It
Nursing management of the neurological patient is based on highly developed nursing assessment and clinical reasoning skills. The nurse must know which parameters to be assessed, the proper technique for assessment, the appropriate method of documentation, and how to interpret the data to decide what action, if any, should be taken.
The third question, “How does it relate to previous assessments?” is critical because data are compared with the previous baseline assessments as well as the trends of multiple data points over time to denote change. The assessment can reveal no change, subtle change, or dramatic change from previous findings. Generally, a change of any kind is important to note because it usually reflects an intracranial change.
A change in any of the data included in the neurological assessment must be considered in conjunction with changes in other areas evaluated in the assessment. For instance, a rapidly developing hematoma or cerebral edema will affect multiple assessment data, such as the LOC and motor function. If, however, the pupil appears to be dilated and fixed (a new finding from the previous assessment) and the patient continues to be well oriented and maintains motor function, then the pupillary signs should be rechecked and other possible explanations explored.
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Critical thinking skills are inherent in the assessment process, both to detect subtle and substantive changes in the neurological assessment data and overall clinical condition, and to incorporate this information within the context of the overall patient profile. Well-developed critical thinking skills are the foundation for all patient management decision making.
Clinical Pearl: The 1-2-3 of patient safety. One, rescue; Two, investigate (assessment and data collection); and Three, communicate (to physician or interdisciplinary team). These are the three steps that the nurse needs to incorporate into his/her daily practice when findings are abnormal, thus promoting safety and improving patient outcomes.
The components included in a neurological assessment depend on the patient’s state of consciousness and cooperativeness as well as clinical stability. A comprehensive baseline must be established. A neurological assessment is focused on selected critical components that are sensitive to change and that provide an overview of the patient’s overall condition. The nurse must decide what other components, if any, should be added to best monitor the patient’s condition. An assessment in the intensive care unit for an unconscious patient is quite different from the assessment in an intermediate care unit for a patient who is recovering from a stroke. This neurological assessment at a minimum includes the following.
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The frequency and extent of the neurological assessment will depend on the stability of the patient and the underlying condition. For a stable patient who is doing well, an assessment may be ordered by the physician every 4 to 8 hours, or every shift. However, a patient who is very unstable may warrant assessment every 5 to 15 minutes to monitor changes and the need for or response to an intervention. The nurse should use independent clinical judgment to determine the need to assess the patient more frequently or to expand the assessment to include more parameters. A physician order, defines only the minimum required frequency of assessment, is not required to assess the patient more frequently than what might be included on the physician order sheet or unit standard because assessment is within the nurse’s scope of practice.
Most facilities use a standardized neurological assessment form or computerized assessment template to document neurological data. It
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