Page 232 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 217

Neurological Needs: Assessment

It is far too easy for the health care provider to miss the most minor change in
a patient’s neurological status. The slightest change can be an initial sign that
the patient’s condition is deteriorating and can rapidly worsen. Therefore, it is
paramount that a thorough clinical assessment be completed especially in
patients with a neurological problem.

History

In obtaining a comprehensive neurologic history, it is necessary to identify the
patient’s associated signs and symptoms, statements of concern, onset, sever-
ity, and duration of clinical manifestations that describe a neurological distur-
bance, such as confusion and other behavioral changes, slurred speech,
seizures, loss of consciousness, abnormal balance and loss of motor coordina-
tion, weakened musculature, pupillary abnormalities, localized or generalized
paralysis, visual changes such as blurred vision, diplopia or double vision, or
even partial visual field blindness. Determine if the patient has sustained any
recent falls or injuries that would contribute to his or her onset of illness.
A drug history is also essential to determine if neurological deficits can be Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
attributed to particular medication combinations, over the counter or street
drugs. The patient’s past medical history should also be well known and
documented by the health team.

Inspection

This is the major component of a thorough neurological assessment. The nurse
spends most of her or his time in baseline observation, trending of data, and
communicating this information to other nurses and members in the health
care team.
It consists of evaluating major components such as the level of consciousness
(LOC). The AVPU scale, general terms for LOC description, and the Glasgow
Coma Scale are ways the critical care nurse can evaluate and track the patient
with neurological issues. A quick and easy way to perform LOC without the
use of charts or graphs is the AVPU scale:
A – Alert
V – Verbal response

P – Pain
U – Unconsciousness