Saturday, March 6, 2010

Selected Areas of Care - Neurological Assessment

Neurological Assessment
  1. Complies with established guidelines -
  2. Assesses the patient's level of consciousness by
    • Asking specific questions to determine orientation to all of the following:
      • Time
      • Place
      • Person OR
    • Determining the patient's ability to recognize familiar people or common objects in the environment OR
    • Presenting visual, auditory, and tactile stimuli to a child between 1 and 3 years of age or a non-communicating child or adult
  3. Palpates the anterior fontanel of a child under 1 year of age, with the child in an upright position, unless contraindicated
  4. Assessess pupillary response regarding
    • Equality of pupil size and
    • Reaction to light
  5. Assesses equality of the motor response in upper and lower extremities in a responsive patient by
    • Asking the patient to
      • use both hands to squeeze your hands simultaneously and
      • Dorsiflex or plantarflex both feet simultaneously agains resistance OR
    • Observing musculoskeletal response(s) in a child under 3 years or noncommunicating child or adult for
      • Symmetry and
      • Movement
  6. Assessess the patient's response to a noxious stimulus when the patient is nonresponsive to verbal stimuli by applying pressure to a nailbed
  7. Records data related to
    • level of consciousness
    • assessment of fontanel
    • assessment of fontanel
    • pupillary response
    • equality of motor response or observation of musculoskeletal response
    • response to noxious stimuli
Nursing Neuro Assessment Refresher
Nursing Care for Neuro patients
Neuro Assessment

Neuro Assessment -
Adults - COPS Make Nice CAMP for kids

Noxious Stimuli

Assess Fontenel

No comments:

Post a Comment