Neurological Assessment
Neuro - anything is about my favorite area of nursing. I will have to be careful not to OVER assess these pt. A typical neuro assessment pt may be post CVA or perhaps a CHI , suspected or otherwise.This is pretty simple and should not cause stress.
Mnuemonic is: AM LPN FR.: AM LPN Forever Records. It reminds me of this neurotic day shift LPN at our facility.
A- Alert?
M- Movement Capable of?Assess the strength equality of contralateral limbs. This is done by asking the pt to grasp and squeeze simultaneously two fingers on each of your hands AND with your hands against the palm of the pt feet ask them to press down. This is the plantar reflex.Observe for equality of movement in children under 3.
L- Level of Conciousness- The pt is asked if they are aware of who,where, and the time of day.This is commonly charted as Alert and oriented X3 or person, place and time. A young child is not able to be assessed in this manner. In this case, age appropriate awareness is substituted,such as recognition of a parent,tracking of lights and interaction with toys.Avoid opinions, look for objective data.A child who is of primary school age may be asked how old they are or where they go to school.
P- Pupils. Using a penlight flash briefly from the outer edge of each eye inward several times while the pt looks upward. Assess for reaction (accomodation),equality.Findings may include sluggishness, a fixed pupil,and inequality of pupil size.
N- Noxious stimulus needed? Noxious stimulus used on an unresponsive pt and the mode should be indicated by the primary nurse. Examples of noxious stimuli are pinching of finger nail beds bilaterally or a sternal rub.
F- Fontenel . This is done on an infant under a year old, with an infant in an UPRIGHT position. A normal anterior fontenel is flat or slightly depressessed. Any other findings are abnormal.
R-Record all data regarding LOC,Fontanel assessment,pupillary response,musculoskeletal observation/equality of motor movemet, noxious stimuli response.
Mnuemonic is: AM LPN FR.: AM LPN Forever Records. It reminds me of this neurotic day shift LPN at our facility.
A- Alert?
M- Movement Capable of?Assess the strength equality of contralateral limbs. This is done by asking the pt to grasp and squeeze simultaneously two fingers on each of your hands AND with your hands against the palm of the pt feet ask them to press down. This is the plantar reflex.Observe for equality of movement in children under 3.
L- Level of Conciousness- The pt is asked if they are aware of who,where, and the time of day.This is commonly charted as Alert and oriented X3 or person, place and time. A young child is not able to be assessed in this manner. In this case, age appropriate awareness is substituted,such as recognition of a parent,tracking of lights and interaction with toys.Avoid opinions, look for objective data.A child who is of primary school age may be asked how old they are or where they go to school.
P- Pupils. Using a penlight flash briefly from the outer edge of each eye inward several times while the pt looks upward. Assess for reaction (accomodation),equality.Findings may include sluggishness, a fixed pupil,and inequality of pupil size.
N- Noxious stimulus needed? Noxious stimulus used on an unresponsive pt and the mode should be indicated by the primary nurse. Examples of noxious stimuli are pinching of finger nail beds bilaterally or a sternal rub.
F- Fontenel . This is done on an infant under a year old, with an infant in an UPRIGHT position. A normal anterior fontenel is flat or slightly depressessed. Any other findings are abnormal.
R-Record all data regarding LOC,Fontanel assessment,pupillary response,musculoskeletal observation/equality of motor movemet, noxious stimuli response.
posted by taming the beast at 8:47 PM
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