Pediatric neurological assessment nursing

Pediatric neurological assessment nursing

Neurological Assessment Joanne V. Hickey The purposes of this chapter are 1 to provide an overview for establishing and updating a database for a hospitalized neuroscience patient, and 2 to provide a framework for understanding the organization and interpretation of data from the systematic bedside neurological assessment.

Some content that appears in Chapter 7 has also been included in this chapter for the convenience of the reader. Most nursing departments have adopted a specific format for this purpose as part of their documentation system.

The data may be entered in a written format or typed into a computerized documentation system.

Neurological Assessment

The database is the foundation for ongoing assessment, planning, implementation, and evaluation of care and outcomes. The database is the key to maintain continuity of care across levels of care through discharge and follow-up. One section of the database includes demographics, and circumstances of admission, vital signs, weight, and other general information e. Other section of the database includes assessment for risk of falls and pressure ulcers.

While fall risk assessment and the implementation of fall preventive measures are vital to all patients, they are very crucial to neurological patients to promote safety and reduce harm. Neurological patients usually are high fall risk due to their possibly depressed cognition e. In addition, the pressure ulcer risk assessment was also added to the admission database to comply with the NPSG 14 to prevent health care-associated pressure ulcers.

pediatric neurological assessment nursing

This goal is very crucial to the neurological patients who usually are at high risk of developing pressure ulcers due to their possibly depressed sensory pain, discomfort and musculoskeletal functions activity, mobility. Many hospitals adopted the Braden Scale as a tool for pressure ulcer risk assessment.

The largest section includes a comprehensive systematic assessment often based on body systems or functional patterns. The circumstances of admission affect the data collection.

Ideally, the nurse has an opportunity to interview the patient and family on admission. The interview is not only a mechanism for gathering data and dispensing information but also an opportunity to establish rapport with the patient and family. Throughout the interview, the nurse should be alert for any misconceptions or misunderstandings held by the patient or family.

Complete Head-to-Toe Physical Assessment Cheat Sheet

Information should be corrected and clarified as necessary and appropriate referrals made. Identify high-risk patients and families who have problems that will affect recovery negatively, such as drug abuse or family dysfunction. Early identification can result in timely interventions and referrals. This baseline information is useful for future comparison throughout the course of hospitalization.

pediatric neurological assessment nursing

In the event of an emergency admission, some data gathering will be postponed until the patient is stabilized or the family can be reached. As soon as possible, the nurse should interview the patient and family to develop a plan of care. If care maps are used, the appropriate care map should be reviewed and modified as necessary. The neurological assessment is the core nursing database for identifying nursing care needs, collaborative problems, and planning care.

While the taxonomy of nursing diagnoses may be a helpful framework to use when analyzing data from neurological assessment, the updated practice is identifying health care needs and working collaboratively with the interdisciplinary team to formulate an interdisciplinary care plan. There are many collaborative problems that require an interdisciplinary collaborative approach. For example, increased intracranial pressure ICP is a problem that requires collaboration of the entire health care team.

A patient with increased ICP will require supportive and restorative care, along with definitive treatment for the underlying cause. Nurses participate as collaborative team members with physicians, respiratory therapists, physical therapists, occupational therapists, speech therapists, physiatrists, nutritionists, and social workers to address the comprehensive patient needs. Care includes various supportive, preventive, maintenance, and restorative strategies.Nursing assessment is an important step of the whole nursing process.

With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet that you can print and use to guide you throughout the first step of the nursing process.

I appreciate the topics you are posting. It helps a lot and very informative. It enhances my nursing practice. Keep up the good work! It is a big helpful source of info which today im using it for our activity regarding to physical assestment. I really appreciate it. Thank you.

From 1st yr nursing student. Thank you for what you do. Since we started inNurseslabs has become one of the most trusted nursing sites helping thousands of aspiring nurses achieve their goals.

Our ultimate goal is to help address the nursing shortage by inspiring aspiring nurses that a career in nursing is an excellent choice, guiding students to become RNs, and for the working nurse — helping them achieve success in their careers. Sign in. Log into your account. Password recovery. Care Plans.

Notes Fundamentals of Nursing. I appreciate your hard work by putting everything together and sharing. Good site to refer for your care plans and physical assessments.

pediatric neurological assessment nursing

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Nursing Theories and Theorists. Normal Lab Values Reference Guide. About Nurseslabs Read more. This website uses cookies to give you an optimal browsing experience. By continued used of this site, you agree to our use of cookies. When skin is pinched it goes to previous state immediately 2 seconds. With fair complexion. With dry skin. Evenly distributed hair.

With short, black and shiny hair. With presence of pediculosis Capitis. Convex and with good capillary refill time of 2 seconds.Speech Affect and facial expression appropriate to situation. Patient not observed OOB. Speech clear. Skin Color, texture, hygiene, moisture. Intactness, lesions, breakdown Skin mostly warm and dry.

Braden score- Catheter insertion site found with dried sanguineous urine around meatus. Area cleaned thoroughly. R midline dressing covered with Telfa cloth adhesive dressing soaked with dried blood inferior to incision, gauze covering changed, JP drain intact.

Midline and 2 groin incisions at top of each leg clean, dry and well approximated with derma bond. R wrist PIV medlocked. Foley catheter. JP drain from R midline incision drained 19 ml sanguineous fluid, drain reactivated. Drain later removed by MD, incision left clean, dry and intact. Neuro LOC, pupils. Feet — flexion, extension Oriented x4. Grips, flexion, extension strong bilaterally.

Pulse rate No accessory muscles used. Breath sounds clear in all areas. Bowel sounds x 4. Tenderness only in compromised areas. No pain or bladder tenderness reported. No distention. Pain interventions and effectiveness Pain noted at 6 on the number scale. Pain medication administered and pain noted at 3 on same scale 30 minutes later. Speech Flat affect. Posture stupped. Gait unsteady and weak. Affect and facial expression appropriate to situation.Maturational ability of the child to cooperate with the examiner is of major importance to adequate physical assessment.

Accomplish as much of the examination as possible while the infant is sleeping or resting undisturbed. Blood pressure measurement, preferably with appropriate size manual cuff by age 3, or sooner if cardiac or renal disease is suspected.

Anticipatory guidance: seat belts, bicycle helmets, skateboarding gear helmets and pads, water safety, sports participation protective gear; diet, nutrition; dental hygiene need for orthodontics, cavity prevention. Hold a prehospitalization nursing interview with the parents and give a tour of the pediatric unit when possible. Correct any misconceptions, and if appropriate, reassure them that they are not the cause of the illness.

Displays excessive irritability. Appears lethargic, withdrawn. Changes eating pattern. Verbalizes discomfort or becomes stoic. Use pain assessment tool Wong-Baker Faces or Oucher. This procedure assures the child that the parent will return. During developmental history, elicit exact routines and rituals that the child uses; attempt to modify hospital routine to continue these rituals.

Keep consistency among nursing staff in guidelines for behavior that is acceptable; set firm limits. Maintain a schedule that is consistent and as closely resembling the usual routine as possible. Is regressive and completely withdrawn. Shows excessive dependency. Has insomnia. Teach the child about his or her illness; take the opportunity to explain the functioning of the body.

Explain all procedures completely; allow the child to see special rooms e. Whenever possible, provide honest and direct explanations in age-appropriate language. Your email address will not be published. This site uses Akismet to reduce spam. Learn how your comment data is processed. Remember me Log in. Lost your password? Elizabeth Perez.

Leave a Reply Cancel reply Your email address will not be published. Search for:. Test Prep.It is primarily conducted for two reasons:. It is important to explain the reason for doing the observations and their frequency.

pediatric neurological assessment nursing

Always collect all the required equipment prior to approaching the child and always observe the child from afar before coming close to him or her. Children post head injury will often refuse to open their eyes. Lights can be dimmed to reduce the glare distressing the child. Tempting a child to open their eyes to look at a TV screen or a toy is very effective.

Depending on the age of the child, obtaining a best verbal response is important. In a child who is talking, a verbal response should be appropriate and coherent. This can be done by asking three age-appropriate questions.

Children can be talking but may be confused or disorientated and this is scored accordingly. In children who are not yet talking and babies, verbal sounds such as babbling can be reassuring. A high-pitched cry is a warning sign and can indicate raised intracranial pressure. Again, this assessment is age-specific. Ask the child to obey simple commands such as asking them stick out their tongue. Pupil reaction is controlled by the third cranial nerve. The assessment looks at the following responses:.

Turn down the lights. Look into the eyes, are the pupils of equal size and shape? Shine a torch from the outer aspect of the eye towards the nose and observe the reaction of the pupil. Repeat on the other side. It is important to look at all four limbs and to try to detect any weakness. See if the child can stand and walk, ask them to do this. If they cannot stand or they are too tired to stand, ask them to push your hands away with the soles of their feet.

Squeezing your fingers and pushing your hands away can let you assess the strength of the upper limbs. There are advantages to having the same nurse carry out the observations over a period of time as then a rapport can be built up with both the child and carer.Definition of Terms. Shift Assessment. Focused Assessment. The aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments. The guideline specifically seeks to provide nurses with:.

Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs. Focused assessment: Detailed nursing assessment of specific body system s relating to the presenting problem or current concern s of the patient. This may involve one or more body system. An admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission.

Privacy of the patient needs to be considered all times. Recent overseas travel should be discussed and documented. For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, Apgar score, resuscitation required at delivery and Newborn Screening Tests see Child Health Record for documentation. This should occur on admission and then continue to be observed throughout the patients stay in hospital.

Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement. Ongoing assessment of vital signs are completed as indicated for your patient. It is mandatory to review the ViCTOR graph at least every 2 hours or as patient condition dictates to observe trending of vital signs and to support your clinical decision making process.

A structured physical examination allows the nurse to obtain a complete assessment of the patient. Clinical judgment should be used to decide on the extent of assessment required.

Assessment information includes, but is not limited to:. At the commencement of every shift an assessment is completed on every patient and this information is used to develop a plan of care. Initial shift assessment is documented on the patient care plan and further assessments or changes to be documented in the progress notes.

Patient assessment commences with assessing the general appearance of the patient. Use observation to identify the general appearance of the patient which includes level of interaction, looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement. A detailed nursing assessment of specific body system s relating to the presenting problem or other current concern s required. Nursing staff should utilise their clinical judgement to determine which elements of a focussed assessment are pertinent for their patient.

A comprehensive neurological nursing assessment includes neurological observations, growth and development including fine and gross motor skills, sensory function, seizures and any other concerns.

Respiratory illness in children is common and many other conditions may also cause respiratory distress. Assessment of severity of respiratory conditions Respiratory assessment includes:.Colleague's E-mail is Invalid.

Your message has been successfully sent to your colleague. Save my selection. Neurologic assessment doesn't just take place in neuro units and the ED. A patient who doesn't have a neurologic diagnosis may also require a neuro assessment; for example, a patient with pneumonia can develop neurologic changes due to hypoxia or a post-op patient may have a neurologic deficit due to blood loss.

No matter what setting you work in, you'll have to perform a neurologic assessment at some point. The value of a solid neurologic assessment can't be overstated—a small change in the assessment is indicative of a neurologic injury, and early intervention can prevent permanent damage.

Performing a neurologic assessment sends many of us into a panic. Fortunately, it doesn't have to be that way.

Neurological assessment in children

In this article, I'll review not only how to perform a solid neurologic assessment, but also how you can tailor your assessment to the situation. I'll also give you some helpful tips to make your assessment as smooth as possible. A thorough neurologic assessment will include assessing mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs.

However, unless you work in a neuro unit, you won't typically need to perform a sensory and cerebellar assessment. Also, most vital sign changes are a sign of end-stage neurologic injury. Therefore, we'll look at assessment of mental status, cranial nerves, motor function, and pupillary response.

Although this isn't a comprehensive neurologic exam, it will yield valuable clinical information. Let's get started with mental status. Evaluating a patient's mental status includes level of consciousness LOCorientation, and memory. LOC is crucial to test because it's the first assessment to change when there's neurologic injury. You should always elicit your patient's best level of response for an accurate assessment of LOC. Begin with speaking your patient's name in a normal tone.

If he doesn't respond, say his name again in a louder tone. If your patient is hearing-impaired, you'll need to document this; it shouldn't change his score. If there's still no response, gently shake your patient. If you still can't get a reaction, you'll need to use painful stimulation. To do this, you can use one the following techniques:. If these techniques elicit a reaction, it comes from the brain.

But there's one more technique you'll need in your repertoire. The patient who requires painful stimuli isn't following commands; therefore, if he reacts to the painful stimuli with only one side of his body, you'll need to assess the nonreactive side. This can be done by pressing a pencil into the cuticle of one of your patient's fingers. The response you'll see will be purposeful, occurring when your patient pulls away from the pain; nonpurposeful, occurring when he moves in response to the pain but not in any meaningful way including flexion posturing [arms bent up toward the trunk with legs extended] and extension posturing [arms extend down and legs extended], formerly called decorticate and decerebrate posturing ; or no response at all.

All painful stimuli should be applied for 15 to 30 seconds. To determine orientationask detailed questions about your patient's name, where he is, and the date.

Obtain as much information as you can from the question; for example, when asking the date, also ask for the month and year. Keep in mind that hospitalized patients often know the month but not the date or day of the week. Evaluate your patient's knowledge of date and time carefully; patients who are confused may still answer correctly enough that a disorder goes unnoticed.

I once had a patient who was clearly confused in conversation but confidently stated the name of the hospital each time I asked where we were. Halfway through my shift, I realized he was reading the hospital's name off his roommate's sheets, which were emblazoned with our logo. For the same reason, alternate your questions with each assessment.


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