Open Resources for Nursing (Open RN)
Now that we have reviewed tests included in a neurological exam, let’s review components of a routine neurological assessment typically performed by registered nurses. The neurological assessment begins by collecting subjective data followed by a physical examination.
Subjective Assessment
Subjective data collection guides the focus of the physical examination. Collect data from the patient using effective communication and pay particular attention to what the patient is reporting, including current symptoms and any history of neurological illness. Ask follow-up questions related to symptoms such as confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (called dysphagia) or speaking (called dysphasia), or lack of coordination of body movements.[1]
See Table 6.10a for sample interview questions to use during the subjective assessment
Table 6.10a Interview Questions Related to Subjective Assessment of Neurological System
| Interview Questions | Follow-up |
|---|---|
| Are you experiencing any current neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, or decreased coordination?
Have you experienced any difficulty swallowing or speaking? Have you experienced any recent falls? |
If the patient is seeking care for an acute neurological problem, use the PQRSTU method to further evaluate their chief complaint. The PQRSTU method is described in the “Health History” chapter.
Note: If critical findings of an acute neurological event are actively occurring, such as signs of a stroke, obtain emergency assistance according to agency policy. |
| Have you ever experienced a neurological condition such as a stroke, transient ischemic attack, seizure, or head injury? | Describe the condition(s), date(s), and treatment(s). |
| Are you currently taking any medications, herbs, or supplements for a neurological condition? | Please describe. |
Life Span Considerations
Newborn
At birth, the neurologic system is not fully developed. The brain is still developing, and the newborn’s anterior fontanelle doesn’t close until approximately 18 months of age. The sensory and motor systems gradually develop in the first year of life. The newborn’s sensory system responds to stimuli by crying or moving body parts. Initial motor activity is primitive in the form of newborn reflexes. Additional information about newborn reflexes is provided in the “Assessing Reflexes” section. As the newborn develops, so do the motor and sensory integration. Specific questions to ask parents or caregivers of infants include the following:
- Have you noticed your infant sleeping excessively or having difficulty arousing?
- Has your infant had difficulty feeding, sucking, or swallowing?
Children
Depending on the child’s age and developmental level, they may answer questions independently or the child’s parent/guardian may provide information. Specific questions for children include the following:
- Have you ever had a head injury or a concussion?
- Do you experience headaches? If so, how often?
- Have you had a seizure or convulsion?
- Have you noticed if your child has any problems with walking or balance?
- Have you noticed if your child experiences episodes of not being aware of their environment?
Older Adults
The aging adult experiences a general slowing in nerve conduction, resulting in a slowed motor and sensory interaction. Fine coordination, balance, and reflex activity may be impaired. There may also be a gradual decrease in cerebral blood flow and oxygen use that can cause dizziness and loss of balance. Examples of specific subjective questions for the older adult include the following:
- Have you ever had a head injury or recent fall?
- Do you experience any shaking or tremors of your hands? If so, do they occur more with rest or activity?
- Have you had any weakness, numbness, or tingling in any of your extremities?
- Have you noticed a problem with balance or coordination?
- Do you ever feel lightheaded or dizzy? If so, does it occur with activity or change in position?
Educate older adults to change positions slowly, especially when standing up from a lying or sitting position. Light-headedness and loss of balance during these activities increase the risk for falls.Objective Assessment
The physical examination of the neurological system includes assessment of both the central and peripheral nervous systems. A routine neurological exam usually starts by assessing the patient’s mental status followed by evaluation of sensory function and motor function. Comprehensive neurological exams may further evaluate cranial nerve function and deep tendon reflexes. The nurse must be knowledgeable of what is normal or expected for the patient’s age, development, and condition to analyze the meaning of the data that are being collected.
Inspection
Nurses begin assessing a patient’s overall neurological status by observing their general appearance, posture, ability to walk, and personal hygiene in the first few minutes of nurse-patient interaction. For additional information about obtaining an overall impression of a patient’s status while performing an assessment, see the “General Survey” chapter.
Level of orientation is assessed and other standardized tools to evaluate a patient’s mental status may be used, such as the Glasgow Coma Scale (GCS), NIH Stroke Scale, or Mini-Mental State Exam (MMSE). Read more information about these tools under the “Assessing Mental Status” section earlier in this chapter.
The nurse also assesses a patient’s cerebellar function by observing their gait and balance. See the “Assessing Cerebellar Function” section earlier in chapter for more information.
Auscultation
Auscultation refers to the action of listening to sounds from the heart, lungs, or other organs with a stethoscope as a part of physical examination. Auscultation is not typically performed by registered nurses during a routine neurological assessment. However, advanced practice nurses and other health care providers may auscultate the carotid arteries for the presence of a swishing sound called a bruit. Bruits suggest interference with cerebral blood flow that can cause neurological deficits.
Palpation
Palpation during a physical examination typically refers to the use of touch to evaluate organs for size, location, or tenderness, but palpation during the neurologic physical exam involves using touch to assess sensory function and motor function. Refer to sections on “Assessing Sensory Function,” “Assessing Motor Strength,” “Assessing Cranial Nerves,” and “Assessing Reflexes” earlier in this chapter for additional information on how to perform these tests.
See Table 6.10b for a summary of expected and unexpected findings when performing an adult neurological assessment.
Table 6.10b Expected Versus Unexpected Findings on Adult Neurological Assessment
| Assessment | Expected Findings | Unexpected Findings (Document and notify provider if new finding*) |
|---|---|---|
| Inspection | Alert and oriented to person, place, and time
Symmetrical facial expressions Clear and appropriate speech Ability to follow instructions PERRLA (Pupils are equal, round, and reactive to light and accommodation) Cranial nerves all intact Negative Romberg test Sensory function present Cortical functioning (indicated by stereognosis) intact Good balance Coordinated gait with equal arm swing Finger-to-nose, rapid alternating arm movements, and heel-to-shin performance intact Negative pronator drift test Motor strength in upper and lower extremities equal bilaterally Deep tendon reflexes intact |
Not alert and oriented to person, place, and/or time
Asymmetrical facial expressions Garbled speech Inability to follow directions Pupils unequal in size or reactivity Deficits in one or more cranial nerve assessments Positive Romberg test Sensory function impaired in one or more areas Stereognosis not intact Poor balance Shuffled or asymmetrical gait with unequal arm swing Unable to complete finger-to-nose, alternating arm movement, or heel-to-shin tests Positive pronator drift test Unequal strength of upper and/or lower extremities One or more deep tendon reflexes are not reactive
|
| Critical findings to report immediately and/or obtain emergency assistance: | Change in mental status, pupil responsiveness, facial drooping, slurred words or inability to speak, or sudden unilateral loss of motor strength |
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear.
Wound cultures are obtained from wounds suspected to be infected. Results are used to determine treatment options. Wound culture results indicate the type and number of bacteria present, as well as the antibiotics to which bacteria are susceptible. When performing a wound culture, it is vital for the nurse to avoid contamination and to use evidence-based techniques to obtain a good specimen that the patient’s treatment plan will be based upon.[1]
Use the checklist to review the steps to “Perform a Wound Culture.”
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: sterile wound swab, sterile normal saline, sterile irrigation kit with 30-60 mL syringe, and sterile 2" x 2" gauze.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Prepare the environment, position the patient, adjust the height of the bed, and turn on the lights. Ensure proper body mechanics for yourself and create a comfortable position for the patient. Ensuring proper lighting allows for good visibility to assess the wound. Premedicate if indicated and ensure patient’s comfort prior to and during the procedure.
- Place a clean, dry barrier on the bedside table or create a sterile field per agency policy. Pour sterile saline into the irrigation tray.
- Perform hand hygiene and apply nonsterile gloves.
- Remove the dressing and expose the patient's wound. Dispose of the soiled dressing according to agency policy.
- Remove gloves and perform hand hygiene.
- Put on a new pair of nonsterile or sterile gloves, depending on the patient's condition and the type, location, and depth of the wound.
- Irrigate the wound with sterile normal saline solution to remove surface debris or exudate and to prevent specimen contamination. Alternatively, cleanse the wound with a commercial wound irrigation device.
- Wipe the surface of the wound with a sterile gauze pad moistened with normal saline solution to remove surface contaminants.
- Gently blot excess normal saline solution from the wound bed with a dry sterile gauze pad.
- Remove gloves and perform hand hygiene.
- Put on new nonsterile gloves.
- Open the swab specimen collection and transport system. Prepare the contents as needed following the manufacturer's instructions.
- Use the culture swab(s) to collect the specimen according to agency policy.
- Note that some agencies use swab collection and transport systems that contain specific swabs designed for anaerobic and aerobic specimen collection.
- If the wound bed appears dry, moisten the swab with normal saline solution.
- Identify a 1-cm2 area of viable wound tissue at or near the center of the wound.
- Note: The culture must be obtained from the cleanest tissue possible and not from pus, slough, eschar, or necrotic tissue.
- Rotate the tip of the swab over the identified 1-cm2 area of the wound for 5 seconds, applying sufficient pressure to express fluid from the wound.
- Remove the swab from the wound.
- Immediately insert the swab into the appropriate transport system following the manufacturer's instructions for use.
- Remove gloves and perform hand hygiene.
- Put on a new pair of nonsterile or sterile gloves depending on the patient's condition and the type, location, and depth of the wound.
- Apply a new sterile dressing to the patient's wound using a sterile, no-touch technique.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Label the specimen in the presence of the patient (such as name, date, time, location of the wound, and site and source of the specimen) to prevent mislabeling:
- Note the patient's recent or current antibiotic therapy on the laboratory request form because it might affect test results. If possible, obtain a culture specimen before starting antimicrobial therapy.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Immediately send the specimen to the laboratory in a laboratory biohazard transport bag with a completed laboratory request form.
- Document the procedure and related assessments in the patient's chart. Report any concerns according to agency policy.
