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

Consciousness
Orientation
Pupils
Sensation
Movement
Noxious Stimuli

Consciousness
Assess Fontenel
Movement
Pupils