{"id":3697,"date":"2018-11-12T19:45:23","date_gmt":"2018-11-13T00:45:23","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&#038;p=3697"},"modified":"2022-06-08T11:37:20","modified_gmt":"2022-06-08T15:37:20","slug":"2-6-head-to-toe-assessment-head-and-neck-neurological-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-6-head-to-toe-assessment-head-and-neck-neurological-assessment\/","title":{"raw":"2.6 Head-to-Toe Assessment: head and neck \/ Neurological Assessment","rendered":"2.6 Head-to-Toe Assessment: head and neck \/ Neurological Assessment"},"content":{"raw":"The neurological system is responsible for all human function. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen, Skillen, Day, &amp; Jensen, 2012).\u00a0A neurological assessment begins when the nurse first interacts with the client and involves observations about appearance, communication patterns, and general behaviour. The first part of the checklist provides a general overview of performing a basic neurological assessment. In some situations a more focused neurological assessment is necessary. The last part of the checklist provides some guidelines for some elements of a focused neurological assessment.\r\n\r\nChecklist 16 provides a guide for subjective and objective data collection in a neurological assessment.\r\n<table style=\"width: 100%;\" border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"width: 49.9633%; text-align: center;\" colspan=\"2\"><strong>\r\n<\/strong>\r\n<h3 style=\"text-align: center;\"><a id=\"checklist16\"><\/a>Checklist 16:\u00a0Head and Neck \/ Neurological Assessment<\/h3>\r\n[caption id=\"attachment_4067\" align=\"aligncenter\" width=\"202\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"wp-image-4067 \" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg-255x300.jpg\" alt=\"\" width=\"202\" height=\"238\" \/><\/a> Figure 2.4 Nervous system[\/caption]\r\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Al<\/span><span style=\"color: #000000;\">ways review and follow your agency\u00a0<\/span><span style=\"color: #000000;\">policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"width: 49.9633%; text-align: center;\" colspan=\"2\">\r\n<h5><span style=\"color: #000000;\">Safety considerations:<\/span><\/h5>\r\n<ul>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Perform hand hygiene.<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Introduce yourself to patient.<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Explain process to patient.<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Be organized and systematic in your assessment.<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Use appropriate listening and questioning skills.<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Listen and attend to patient cues.<\/span><\/li>\r\n \t<li style=\"text-align: left;\"><span style=\"color: #333333;\">Ensure patient's privacy and dignity.<\/span><\/li>\r\n \t<li style=\"text-align: left;\">Document according to agency guidelines.<\/li>\r\n<\/ul>\r\n<strong>\u00a0<\/strong><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"width: 49.9633%; text-align: left;\" colspan=\"2\">\r\n<h3 style=\"text-align: center;\">Objective Data<\/h3>\r\n<h5 style=\"text-align: center;\"><span style=\"font-size: 16.8px; text-align: left;\">Consider the following observations.<\/span><strong>\r\n<\/strong><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%; text-align: center;\">\r\n<h4 style=\"text-align: center;\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%; text-align: center;\">\r\n<h4 style=\"text-align: center;\">Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">General appearance\r\n\r\n[caption id=\"attachment_3679\" align=\"aligncenter\" width=\"225\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"wp-image-3679 size-medium\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face-225x300.jpg\" alt=\"\" width=\"225\" height=\"300\" \/><\/a> Figure 2.5 Observe general appearance[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Observations about general appearance may provide insight into other physical or psychosocial issues affecting the patient.\r\n\r\nIf appearance is unkempt, it may suggest that the patient struggles with achieving activities of daily living. The nurse would further their questioning to elicit greater understanding, and potentially to refer to other healthcare professionals\u00a0<span style=\"font-family: inherit; font-size: inherit;\">subsequently.<\/span><span style=\"font-family: inherit; font-size: inherit;\">\u00a0<\/span>\r\n\r\n&nbsp;<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Level of consciousness (LOC)\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Altered LOC may indicate substance use, fatigue, brain injury, neurological disorder, mania, or depression.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Inspect eyes &amp; nose for drainage.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Drainage from eyes or nose may indicate infection, allergy, or injury.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Note nature of eye contact during interview.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">The extent of eye contact may reflect cultural norms, individual way of being, or possibly mental health issues.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Glasses, contacts, hearing aids\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">People who need these devices but don\u2019t have them, or if the devices are not in working order, may experience some level of isolation because of difficulty interacting with the world around them.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Inspect for facial asymmetry.\r\n\r\n[caption id=\"attachment_4150\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"wp-image-4150 size-full\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC.jpg\" alt=\"\" width=\"250\" height=\"250\" \/><\/a> Figure 2.6 Observe for facial asymmetry[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Evidence of nasal trauma. Ability to breathe through nose.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Nasal flaring or use of accessory muscles when breathing may indicate altered breathing patterns. Unusual findings should be followed-up with a focused respiratory assessment.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Inspect mouth, tongue, and teeth for moisture, colour, dentures, hygiene.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Dry mucous membranes may indicated altered hydration. Dental disease can influence one\u2019s general health.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Ability to swallow\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Difficulty swallowing may suggest neurological impairment. Frequent coughing or choking associated with eating or drinking may suggest risk of aspiration. Unusual finding should be followed-up with a swallow assessment and a referral to an occupational therapist.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Neck range of motion (ROM)\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">This includes flexion, extension (front and back, and side to side) and ability to rotate the neck side to side.\r\n\r\nImpaired neck ROM may indicate an old injury. Neck pain and stiffness (nuchal rigidity) may be related to old injury or signs and symptoms of a serious neurological illness.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Ability to communicate\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Difficulty communicating may be the result of a language barrier or neurological impairment. Communication barriers related to language differences between the patient and healthcare givers might be alleviated through interpreters making information available in the patient\u2019s language.\r\n\r\nCommunication barriers related to neurological impairment require further investigation and a creative approach during patient care.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000; width: 30%;\">\r\n<td style=\"border: 1px solid #000000; width: 50%;\">General arm and leg strength.\r\n\r\n[caption id=\"attachment_4112\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"wp-image-4112\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips-300x225.jpg\" alt=\"\" width=\"250\" \/><\/a> Figure 2.7 Assessing hand strength[\/caption]\r\n\r\n[caption id=\"attachment_326\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"wp-image-326 size-medium\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-300x199.jpg\" alt=\"\" width=\"250\" \/><\/a> Assess dorsiflexion[\/caption]\r\n\r\n[caption id=\"attachment_327\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"wp-image-327\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-300x199.jpg\" alt=\"\" width=\"250\" \/><\/a> Assess plantar flexion[\/caption]<\/td>\r\n<td style=\"width: 50%;\">&nbsp;\r\n\r\nGeneral arm and hand strength can be assessed by asking the patient to extend their arms and grip the nurse\u2019s hands simultaneously.\r\n\r\nGeneral leg strength can be assessed by asking the patient to dorsiflex, plantar flex, and bend each knee.\r\n\r\nDorsiflexion strength can be assessed by asking the\u00a0patient to pull up on their feet while the nurse applies some resistance to the top of the feet.\r\n\r\nPlantar flexion strength is assessed while the nurse applies some resistance to the bottom of the feet while asking the patient to push (i.e., step on the gas).\r\n\r\nAlways compare extremities.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div>\r\n<table style=\"border: 1px solid #000000;\" border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td colspan=\"2\">\r\n<h3 style=\"text-align: center;\">Subjective Data<\/h3>\r\n<h5 style=\"text-align: center;\">Ask about vision, hearing, headaches, neck stiffness, history of head injury, neurological disease, history of seizures, stroke, memory loss, mental health history.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td colspan=\"2\">\r\n<h4 style=\"text-align: left;\">Focused neuro assessment may also include:<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Pain Assessment<\/strong><\/td>\r\n<td style=\"border: 1px solid #000000;\">\u00a0See\u00a0<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&amp;p=105&amp;preview=true\">Chapter 2.42 Pain Assessment<\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Mental Status Exam (MSE)<\/strong>: Is used in psychiatry to guide the examiner to collect data and form impressions about an individual\u2019s mental health.<\/td>\r\n<td style=\"border: 1px solid #000000;\">MSE involves the following components:\r\n<ul>\r\n \t<li>Appearance,\u00a0Motor,\u00a0Speech,\u00a0Thought Content,\u00a0Thought Process,\u00a0Perception,\u00a0Intellect,\u00a0Insight<\/li>\r\n<\/ul>\r\nFor more resources about MSE, go to RNAO's\u00a0<a href=\"https:\/\/bpgmobile.rnao.ca\/content\/components-mental-status-assessment\">Nursing Best Practice Guidelines: Outline of a Mental Status Examination<\/a>.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Mini-Mental State Exam (MMSE)<\/strong>: Used to measure cognitive impairment and often performed in the context of persons with dementia.<\/td>\r\n<td style=\"border: 1px solid #000000;\">For more information about the MMSE see BCGuidelines.ca (2014)\u00a0<a href=\"https:\/\/www2.gov.bc.ca\/assets\/gov\/health\/practitioner-pro\/bc-guidelines\/cogimp-smmse.pdf\">Standardized Mini-Mental State Exam (SMMSE)<\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Glasgow Coma Scale (GCS<\/strong>): Used to guide assessment in patients with head injury, suspected brain bleeds, stroke, and cranial surgery, and in persons with altered level of consciousness. In general, the GSC measures assess:\r\n<ul>\r\n \t<li>Best eye-opening response<\/li>\r\n \t<li>Best motor response<\/li>\r\n \t<li>Best verbal response<\/li>\r\n<\/ul>\r\nThe lower the score, the more serious the neurological impairment. This assessment tool allows for objective assessment and greater reliability in terms of being able to observe patterns and trends in the patient's health status.<\/td>\r\n<td style=\"border: 1px solid #000000;\"><strong>Glasgow Coma Scale\u00a0<\/strong>(adapted from Jarvis et al., 2014, p. 699)<strong>\r\n<\/strong>\r\n<table style=\"border-collapse: collapse;\" border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Best eye-opening response<\/strong>\r\n\r\nRecord \"C\" if eyes closed due to swelling.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center;\">1<\/td>\r\n<td style=\"border: 1px solid #000000;\">No response<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center;\">2<\/td>\r\n<td style=\"border: 1px solid #000000;\">To pain<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center;\">3<\/td>\r\n<td style=\"border: 1px solid #000000;\">To speech<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center;\">4<\/td>\r\n<td style=\"border: 1px solid #000000;\">Spontaneously<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border-collapse: collapse;\" border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"2\"><strong style=\"font-size: 15.12px;\">Best motor response (to painful stimuli)<\/strong>\r\n\r\n<span style=\"font-size: 15.12px;\">Press fingernail bed, and record best upper-limb response.<\/span><\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">1<\/td>\r\n<td style=\"border: 1px solid #000000;\">No response<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center;\">2<\/td>\r\n<td style=\"border: 1px solid #000000;\">Extension \u2013 abnormal<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">3<\/td>\r\n<td style=\"border: 1px solid #000000; height: 14px;\">Flexion \u2013 abnormal<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">4<\/td>\r\n<td style=\"border: 1px solid #000000;\">Flexion - withdrawal<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">5<\/td>\r\n<td style=\"border: 1px solid #000000; height: 14px;\">Localizes pain<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">6<\/td>\r\n<td style=\"border: 1px solid #000000; height: 14px;\">Obeys verbal command<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border-collapse: collapse;\" border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td colspan=\"2\"><strong>Best verbal response<\/strong>\r\n<ul>\r\n \t<li>Record \"E\" if endotracheal tube is in place.<\/li>\r\n \t<li>Record\u00a0\"T\" if tracheostomy is in place.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">1<\/td>\r\n<td style=\"border: 1px solid #000000;\">No response<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">2<\/td>\r\n<td style=\"border: 1px solid #000000;\">Sounds \u2013 incomprehensible<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">3<\/td>\r\n<td style=\"border: 1px solid #000000;\">Speech \u2013 inappropriate<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">4<\/td>\r\n<td style=\"border: 1px solid #000000;\">Conversation \u2013 confused<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">5<\/td>\r\n<td style=\"border: 1px solid #000000;\">Oriented \u00d7 3 (to person, place, and time)<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nFor more information about neuro assessment go to Critical Care Services Ontario's\u00a0<a href=\"https:\/\/www.criticalcareontario.ca\/EN\/Neurosurgical%20Care\/Guidelines%20for%20Basic%20Adult%20Neurological%20Observation%20(2014).pdf\">Guidelines for Basic Adult Neurological Observation<\/a>.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">Assess <strong>arm drift<\/strong> by asking the patient to extend their arms in front of them and close their eyes.<\/td>\r\n<td style=\"border: 1px solid #000000;\">Drift of one arm may suggest neurological dysfunction. Report concerns immediately.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Pupil Assessment:<\/strong> Assess pupils for size, equality, reaction to light, and consensual reaction to light.\r\n\r\n<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1.jpg\" target=\"_blank\" rel=\"noopener\"><img class=\"size-medium wp-image-321 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-300x199.jpg\" alt=\"\" width=\"150\" \/><\/a><\/td>\r\n<td style=\"border: 1px solid #000000;\">In a darkened room ask the patient to look at your nose. With a lit flashlight, shine the light moving from the lateral across the open eye to the space between the eyes. Note the pupil\u2019s reaction to light.\r\n\r\nRepeat on the other side.\r\n\r\nTo test <strong>consensual reaction<\/strong>, have the patient look at your nose. Shine a flashlight from the hairline at the mid-forehead to the space between the eyes. Observe for the pupils to react equally at the same time.\r\n\r\nPupils that are equal and reactive to light are described as PERL.\r\n\r\nAlterations may be a part of the patient\u2019s norm or they may indicate severe neurological dysfunction, and should be reported immediately.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Dermatome Assessment<\/strong>: Dermatomes are areas of skin supplied by a single spinal nerve.\r\n\r\nTo perform a dermatome assessment use ice. Begin at the neck area. Move the ice downward along the side of the patient\u2019s body asking them to indicate if and when sensation changes. Continue to the lateral side of the foot. Repeat on the other side.\r\n\r\n[caption id=\"attachment_3692\" align=\"aligncenter\" width=\"150\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg.png\" target=\"_blank\" rel=\"noopener\"><img class=\"size-medium wp-image-3692\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg-159x300.png\" alt=\"\" width=\"150\" \/><\/a> Figure 2.8 Dermatomes[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000;\">Dermatome assessment may be indicated in persons with spinal cord injury or when patients receive spinal or epidural analgesics (local anesthetics).\r\n\r\nDepending on the context, changes in dermatome levels may indicate local anesthetic is moving up or down in the epidural space.\r\n\r\nIn spinal cord injury, alterations in dermatomes may indicate improving or worsening changes in patient status.\r\n\r\nDocument blocked dermatomes according to agency guidelines. E.g., Right side: T12-L1; Left side: L1-L4.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>Sedation Score Assessment<\/strong>: Nursing assessment of opioid induced sedation is quick and easy. Having a guide provides some level of consistency between assessors and provides important information to the healthcare team about trends in the patient\u2019s level of sedation.<\/td>\r\n<td style=\"border: 1px solid #000000;\"><strong>Sample Sedation Score Assessment <\/strong>(adapted from Pasero, 2009)\r\n<table style=\"border: 1px solid #000000;\" border=\"1\">\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">1<\/td>\r\n<td style=\"border: 1px solid #000000;\">Awake &amp; alert<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">2<\/td>\r\n<td style=\"border: 1px solid #000000;\">Slightly drowsy, easily aroused<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">3<\/td>\r\n<td style=\"border: 1px solid #000000;\">Slightly drowsy, easily aroused<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">4<\/td>\r\n<td style=\"border: 1px solid #000000;\">Somnolent, minimal or no response to verbal or physical stimulation<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\">5 \/ S<\/td>\r\n<td style=\"border: 1px solid #000000;\">Sleeping<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nSedation scores may form a part of an agency\u2019s assessment protocol(s). Some agencies provide direction for opioid use based on the sedation score.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\"><strong>The National Institute of Health Stroke Scale<\/strong> (NIHSS): Used specifically when stroke is suspected. It is often a part of an institution's stroke protocol.<\/td>\r\n<td style=\"border: 1px solid #000000;\">For reference see:\r\n\r\nHeart and Stroke Foundation. (2019). <em>Canadian partnership for stroke recovery<\/em>. Retrieved from\u00a0<a href=\"https:\/\/www.stroke.nih.gov\/documents\/NIH_Stroke_Scale_508C.pdf\">https:\/\/www.stroke.nih.gov\/documents\/NIH_Stroke_Scale_508C.pdf<\/a>.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Potential neurological related nursing diagnoses:\r\n<ul>\r\n \t<li>Pain related to injury<\/li>\r\n \t<li>Risk of falls due to altered level of consciousness<\/li>\r\n \t<li>Risk for injury related to disturbed sensory perception<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Data sources: Alberta Health Services, 2009; Assessment Skill Checklists, 2014; Critical Care Services Ontario, 2014; Heart and Stroke Foundation, 2019; Jarvis, Browne, MacDonald-Jenkins, &amp; Luctkar-Flude, 2014; Pasero, 2009; Perry, Potter, &amp; Ostendorf, 2018; RCH, 2015; RNAO, n.d.; Stephen et al., 2012; Wilson &amp; Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/neurological_assessment.html\"><em>Neurological Assessment - Basic<\/em><\/a> by Ren\u00e9e Anderson and Wendy McKenzie, Thompson Rivers University, 2019<\/div>\r\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/assessing_ROM.html\"><em>Assessing Range of Motion and Strength<\/em><\/a> by Candace Walker and Wendy McKenzie, Thompson Rivers University<\/div>\r\n<div>\r\n\r\n&nbsp;\r\n\r\n<\/div>\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center;\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>What patient situations would require a dermatome assessment?<\/li>\r\n \t<li>When caring for a client post CVA, consider the difference between completing a Glasgow Coma Scale (GCS) assessment and a National Institutes of Health Stroke Scale (NIHSS).<\/li>\r\n \t<li>Besides opioid induced sedation, identify one other situation where sedation score might be appropriate part of an assessment.<\/li>\r\n<\/ol>\r\n<\/div>\r\n<h2>Attributions:<\/h2>\r\nFigure 2.4\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:TE-Nervous_system_diagram.svg\">Neurological System<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:The_Emirr\">the Emirr<\/a>\u00a0 is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/deed.en\">CC BY 3.0 license<\/a>.\r\n\r\nFigure 2.5\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/Face#\/media\/File:Sabaa_Nissan_Militiaman.jpg\">A Man\u2019s Face<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Christiaan\">Christiaan Brigs<\/a> is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">CC BY-SA 3.0 license<\/a>.\r\n\r\nFigure 2.6\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Bells_Palsy_CDC.jpg\">B<span style=\"font-size: 18.6667px; text-indent: 18.6667px;\">ells Palsy<\/span><\/a><span style=\"text-indent: 1em; font-size: 14pt;\">\u00a0by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/Category:PD_US_HHS_CDC\">CDC and <\/a><\/span>United States Department of Health and Human Services<span style=\"text-indent: 1em; font-size: 14pt;\"> is in the public domain.<\/span>\r\n\r\nFigure 2.8\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/File:Dermatoms_alt.svg\">A Diagram Showing Human Dermatomes<\/a> by <a href=\"http:\/\/Ralf Stephan\">Ralf Stephan<\/a>is in the public domain.\r\n\r\n<\/div>","rendered":"<p>The neurological system is responsible for all human function. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen, Skillen, Day, &amp; Jensen, 2012).\u00a0A neurological assessment begins when the nurse first interacts with the client and involves observations about appearance, communication patterns, and general behaviour. The first part of the checklist provides a general overview of performing a basic neurological assessment. In some situations a more focused neurological assessment is necessary. The last part of the checklist provides some guidelines for some elements of a focused neurological assessment.<\/p>\n<p>Checklist 16 provides a guide for subjective and objective data collection in a neurological assessment.<\/p>\n<table style=\"width: 100%;\">\n<tbody>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"width: 49.9633%; text-align: center;\" colspan=\"2\"><strong><br \/>\n<\/strong><\/p>\n<h3 style=\"text-align: center;\"><a id=\"checklist16\"><\/a>Checklist 16:\u00a0Head and Neck \/ Neurological Assessment<\/h3>\n<figure id=\"attachment_4067\" aria-describedby=\"caption-attachment-4067\" style=\"width: 202px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4067\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg-255x300.jpg\" alt=\"\" width=\"202\" height=\"238\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg-255x300.jpg 255w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg-65x76.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg-225x265.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Nervous_system_diagram_svg.jpg 306w\" sizes=\"auto, (max-width: 202px) 100vw, 202px\" \/><\/a><figcaption id=\"caption-attachment-4067\" class=\"wp-caption-text\">Figure 2.4 Nervous system<\/figcaption><\/figure>\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Al<\/span><span style=\"color: #000000;\">ways review and follow your agency\u00a0<\/span><span style=\"color: #000000;\">policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"width: 49.9633%; text-align: center;\" colspan=\"2\">\n<h5><span style=\"color: #000000;\">Safety considerations:<\/span><\/h5>\n<ul>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Perform hand hygiene.<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Introduce yourself to patient.<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Explain process to patient.<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Be organized and systematic in your assessment.<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Use appropriate listening and questioning skills.<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Listen and attend to patient cues.<\/span><\/li>\n<li style=\"text-align: left;\"><span style=\"color: #333333;\">Ensure patient&#8217;s privacy and dignity.<\/span><\/li>\n<li style=\"text-align: left;\">Document according to agency guidelines.<\/li>\n<\/ul>\n<p><strong>\u00a0<\/strong><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table>\n<tbody>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"width: 49.9633%; text-align: left;\" colspan=\"2\">\n<h3 style=\"text-align: center;\">Objective Data<\/h3>\n<h5 style=\"text-align: center;\"><span style=\"font-size: 16.8px; text-align: left;\">Consider the following observations.<\/span><strong><br \/>\n<\/strong><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%; text-align: center;\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%; text-align: center;\">\n<h4 style=\"text-align: center;\">Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">General appearance<\/p>\n<figure id=\"attachment_3679\" aria-describedby=\"caption-attachment-3679\" style=\"width: 225px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3679 size-medium\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face-225x300.jpg\" alt=\"\" width=\"225\" height=\"300\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face-225x300.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face-65x87.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/A-mans-face.jpg 250w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-3679\" class=\"wp-caption-text\">Figure 2.5 Observe general appearance<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Observations about general appearance may provide insight into other physical or psychosocial issues affecting the patient.<\/p>\n<p>If appearance is unkempt, it may suggest that the patient struggles with achieving activities of daily living. The nurse would further their questioning to elicit greater understanding, and potentially to refer to other healthcare professionals\u00a0<span style=\"font-family: inherit; font-size: inherit;\">subsequently.<\/span><span style=\"font-family: inherit; font-size: inherit;\">\u00a0<\/span><\/p>\n<p>&nbsp;<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Level of consciousness (LOC)<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Altered LOC may indicate substance use, fatigue, brain injury, neurological disorder, mania, or depression.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Inspect eyes &amp; nose for drainage.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Drainage from eyes or nose may indicate infection, allergy, or injury.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Note nature of eye contact during interview.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">The extent of eye contact may reflect cultural norms, individual way of being, or possibly mental health issues.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Glasses, contacts, hearing aids<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">People who need these devices but don\u2019t have them, or if the devices are not in working order, may experience some level of isolation because of difficulty interacting with the world around them.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Inspect for facial asymmetry.<\/p>\n<figure id=\"attachment_4150\" aria-describedby=\"caption-attachment-4150\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4150 size-full\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC.jpg\" alt=\"\" width=\"250\" height=\"250\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC.jpg 250w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC-150x150.jpg 150w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC-65x65.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Bells_Palsy_CDC-225x225.jpg 225w\" sizes=\"auto, (max-width: 250px) 100vw, 250px\" \/><\/a><figcaption id=\"caption-attachment-4150\" class=\"wp-caption-text\">Figure 2.6 Observe for facial asymmetry<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Evidence of nasal trauma. Ability to breathe through nose.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Nasal flaring or use of accessory muscles when breathing may indicate altered breathing patterns. Unusual findings should be followed-up with a focused respiratory assessment.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Inspect mouth, tongue, and teeth for moisture, colour, dentures, hygiene.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Dry mucous membranes may indicated altered hydration. Dental disease can influence one\u2019s general health.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Ability to swallow<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Difficulty swallowing may suggest neurological impairment. Frequent coughing or choking associated with eating or drinking may suggest risk of aspiration. Unusual finding should be followed-up with a swallow assessment and a referral to an occupational therapist.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Neck range of motion (ROM)<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">This includes flexion, extension (front and back, and side to side) and ability to rotate the neck side to side.<\/p>\n<p>Impaired neck ROM may indicate an old injury. Neck pain and stiffness (nuchal rigidity) may be related to old injury or signs and symptoms of a serious neurological illness.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Ability to communicate<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 49.9633%;\">Difficulty communicating may be the result of a language barrier or neurological impairment. Communication barriers related to language differences between the patient and healthcare givers might be alleviated through interpreters making information available in the patient\u2019s language.<\/p>\n<p>Communication barriers related to neurological impairment require further investigation and a creative approach during patient care.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000; width: 30%;\">\n<td style=\"border: 1px solid #000000; width: 50%;\">General arm and leg strength.<\/p>\n<figure id=\"attachment_4112\" aria-describedby=\"caption-attachment-4112\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips.jpg\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"wp-image-4112\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips-300x225.jpg\" alt=\"\" width=\"250\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips-300x225.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips-225x168.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/02\/handgrips.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-4112\" class=\"wp-caption-text\">Figure 2.7 Assessing hand strength<\/figcaption><\/figure>\n<figure id=\"attachment_326\" aria-describedby=\"caption-attachment-326\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1.jpg\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"wp-image-326 size-medium\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-300x199.jpg\" alt=\"\" width=\"250\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2278-1-350x232.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-326\" class=\"wp-caption-text\">Assess dorsiflexion<\/figcaption><\/figure>\n<figure id=\"attachment_327\" aria-describedby=\"caption-attachment-327\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1.jpg\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"wp-image-327\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-300x199.jpg\" alt=\"\" width=\"250\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2277-1-350x232.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-327\" class=\"wp-caption-text\">Assess plantar flexion<\/figcaption><\/figure>\n<\/td>\n<td style=\"width: 50%;\">&nbsp;<\/p>\n<p>General arm and hand strength can be assessed by asking the patient to extend their arms and grip the nurse\u2019s hands simultaneously.<\/p>\n<p>General leg strength can be assessed by asking the patient to dorsiflex, plantar flex, and bend each knee.<\/p>\n<p>Dorsiflexion strength can be assessed by asking the\u00a0patient to pull up on their feet while the nurse applies some resistance to the top of the feet.<\/p>\n<p>Plantar flexion strength is assessed while the nurse applies some resistance to the bottom of the feet while asking the patient to push (i.e., step on the gas).<\/p>\n<p>Always compare extremities.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div>\n<table style=\"border: 1px solid #000000;\">\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td colspan=\"2\">\n<h3 style=\"text-align: center;\">Subjective Data<\/h3>\n<h5 style=\"text-align: center;\">Ask about vision, hearing, headaches, neck stiffness, history of head injury, neurological disease, history of seizures, stroke, memory loss, mental health history.<\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td colspan=\"2\">\n<h4 style=\"text-align: left;\">Focused neuro assessment may also include:<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Pain Assessment<\/strong><\/td>\n<td style=\"border: 1px solid #000000;\">\u00a0See\u00a0<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&amp;p=105&amp;preview=true\">Chapter 2.42 Pain Assessment<\/a><\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Mental Status Exam (MSE)<\/strong>: Is used in psychiatry to guide the examiner to collect data and form impressions about an individual\u2019s mental health.<\/td>\n<td style=\"border: 1px solid #000000;\">MSE involves the following components:<\/p>\n<ul>\n<li>Appearance,\u00a0Motor,\u00a0Speech,\u00a0Thought Content,\u00a0Thought Process,\u00a0Perception,\u00a0Intellect,\u00a0Insight<\/li>\n<\/ul>\n<p>For more resources about MSE, go to RNAO&#8217;s\u00a0<a href=\"https:\/\/bpgmobile.rnao.ca\/content\/components-mental-status-assessment\">Nursing Best Practice Guidelines: Outline of a Mental Status Examination<\/a>.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Mini-Mental State Exam (MMSE)<\/strong>: Used to measure cognitive impairment and often performed in the context of persons with dementia.<\/td>\n<td style=\"border: 1px solid #000000;\">For more information about the MMSE see BCGuidelines.ca (2014)\u00a0<a href=\"https:\/\/www2.gov.bc.ca\/assets\/gov\/health\/practitioner-pro\/bc-guidelines\/cogimp-smmse.pdf\">Standardized Mini-Mental State Exam (SMMSE)<\/a><\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Glasgow Coma Scale (GCS<\/strong>): Used to guide assessment in patients with head injury, suspected brain bleeds, stroke, and cranial surgery, and in persons with altered level of consciousness. In general, the GSC measures assess:<\/p>\n<ul>\n<li>Best eye-opening response<\/li>\n<li>Best motor response<\/li>\n<li>Best verbal response<\/li>\n<\/ul>\n<p>The lower the score, the more serious the neurological impairment. This assessment tool allows for objective assessment and greater reliability in terms of being able to observe patterns and trends in the patient&#8217;s health status.<\/td>\n<td style=\"border: 1px solid #000000;\"><strong>Glasgow Coma Scale\u00a0<\/strong>(adapted from Jarvis et al., 2014, p. 699)<strong><br \/>\n<\/strong><\/p>\n<table style=\"border-collapse: collapse;\">\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Best eye-opening response<\/strong><\/p>\n<p>Record &#8220;C&#8221; if eyes closed due to swelling.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center;\">1<\/td>\n<td style=\"border: 1px solid #000000;\">No response<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center;\">2<\/td>\n<td style=\"border: 1px solid #000000;\">To pain<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center;\">3<\/td>\n<td style=\"border: 1px solid #000000;\">To speech<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center;\">4<\/td>\n<td style=\"border: 1px solid #000000;\">Spontaneously<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-collapse: collapse;\">\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"2\"><strong style=\"font-size: 15.12px;\">Best motor response (to painful stimuli)<\/strong><\/p>\n<p><span style=\"font-size: 15.12px;\">Press fingernail bed, and record best upper-limb response.<\/span><\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">1<\/td>\n<td style=\"border: 1px solid #000000;\">No response<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center;\">2<\/td>\n<td style=\"border: 1px solid #000000;\">Extension \u2013 abnormal<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">3<\/td>\n<td style=\"border: 1px solid #000000; height: 14px;\">Flexion \u2013 abnormal<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">4<\/td>\n<td style=\"border: 1px solid #000000;\">Flexion &#8211; withdrawal<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">5<\/td>\n<td style=\"border: 1px solid #000000; height: 14px;\">Localizes pain<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; height: 14px;\">6<\/td>\n<td style=\"border: 1px solid #000000; height: 14px;\">Obeys verbal command<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-collapse: collapse;\">\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td colspan=\"2\"><strong>Best verbal response<\/strong><\/p>\n<ul>\n<li>Record &#8220;E&#8221; if endotracheal tube is in place.<\/li>\n<li>Record\u00a0&#8220;T&#8221; if tracheostomy is in place.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">1<\/td>\n<td style=\"border: 1px solid #000000;\">No response<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">2<\/td>\n<td style=\"border: 1px solid #000000;\">Sounds \u2013 incomprehensible<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">3<\/td>\n<td style=\"border: 1px solid #000000;\">Speech \u2013 inappropriate<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">4<\/td>\n<td style=\"border: 1px solid #000000;\">Conversation \u2013 confused<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">5<\/td>\n<td style=\"border: 1px solid #000000;\">Oriented \u00d7 3 (to person, place, and time)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>For more information about neuro assessment go to Critical Care Services Ontario&#8217;s\u00a0<a href=\"https:\/\/www.criticalcareontario.ca\/EN\/Neurosurgical%20Care\/Guidelines%20for%20Basic%20Adult%20Neurological%20Observation%20(2014).pdf\">Guidelines for Basic Adult Neurological Observation<\/a>.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">Assess <strong>arm drift<\/strong> by asking the patient to extend their arms in front of them and close their eyes.<\/td>\n<td style=\"border: 1px solid #000000;\">Drift of one arm may suggest neurological dysfunction. Report concerns immediately.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Pupil Assessment:<\/strong> Assess pupils for size, equality, reaction to light, and consensual reaction to light.<\/p>\n<p><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1.jpg\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"size-medium wp-image-321 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-300x199.jpg\" alt=\"\" width=\"150\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2331-1-350x232.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/td>\n<td style=\"border: 1px solid #000000;\">In a darkened room ask the patient to look at your nose. With a lit flashlight, shine the light moving from the lateral across the open eye to the space between the eyes. Note the pupil\u2019s reaction to light.<\/p>\n<p>Repeat on the other side.<\/p>\n<p>To test <strong>consensual reaction<\/strong>, have the patient look at your nose. Shine a flashlight from the hairline at the mid-forehead to the space between the eyes. Observe for the pupils to react equally at the same time.<\/p>\n<p>Pupils that are equal and reactive to light are described as PERL.<\/p>\n<p>Alterations may be a part of the patient\u2019s norm or they may indicate severe neurological dysfunction, and should be reported immediately.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Dermatome Assessment<\/strong>: Dermatomes are areas of skin supplied by a single spinal nerve.<\/p>\n<p>To perform a dermatome assessment use ice. Begin at the neck area. Move the ice downward along the side of the patient\u2019s body asking them to indicate if and when sensation changes. Continue to the lateral side of the foot. Repeat on the other side.<\/p>\n<figure id=\"attachment_3692\" aria-describedby=\"caption-attachment-3692\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg.png\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"size-medium wp-image-3692\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg-159x300.png\" alt=\"\" width=\"150\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg-159x300.png 159w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg-65x123.png 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg-225x426.png 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg-350x662.png 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Dermatoms_alt_svg.png 518w\" sizes=\"(max-width: 159px) 100vw, 159px\" \/><\/a><figcaption id=\"caption-attachment-3692\" class=\"wp-caption-text\">Figure 2.8 Dermatomes<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000;\">Dermatome assessment may be indicated in persons with spinal cord injury or when patients receive spinal or epidural analgesics (local anesthetics).<\/p>\n<p>Depending on the context, changes in dermatome levels may indicate local anesthetic is moving up or down in the epidural space.<\/p>\n<p>In spinal cord injury, alterations in dermatomes may indicate improving or worsening changes in patient status.<\/p>\n<p>Document blocked dermatomes according to agency guidelines. E.g., Right side: T12-L1; Left side: L1-L4.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>Sedation Score Assessment<\/strong>: Nursing assessment of opioid induced sedation is quick and easy. Having a guide provides some level of consistency between assessors and provides important information to the healthcare team about trends in the patient\u2019s level of sedation.<\/td>\n<td style=\"border: 1px solid #000000;\"><strong>Sample Sedation Score Assessment <\/strong>(adapted from Pasero, 2009)<\/p>\n<table style=\"border: 1px solid #000000;\">\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">1<\/td>\n<td style=\"border: 1px solid #000000;\">Awake &amp; alert<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">2<\/td>\n<td style=\"border: 1px solid #000000;\">Slightly drowsy, easily aroused<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">3<\/td>\n<td style=\"border: 1px solid #000000;\">Slightly drowsy, easily aroused<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">4<\/td>\n<td style=\"border: 1px solid #000000;\">Somnolent, minimal or no response to verbal or physical stimulation<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\">5 \/ S<\/td>\n<td style=\"border: 1px solid #000000;\">Sleeping<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Sedation scores may form a part of an agency\u2019s assessment protocol(s). Some agencies provide direction for opioid use based on the sedation score.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\"><strong>The National Institute of Health Stroke Scale<\/strong> (NIHSS): Used specifically when stroke is suspected. It is often a part of an institution&#8217;s stroke protocol.<\/td>\n<td style=\"border: 1px solid #000000;\">For reference see:<\/p>\n<p>Heart and Stroke Foundation. (2019). <em>Canadian partnership for stroke recovery<\/em>. Retrieved from\u00a0<a href=\"https:\/\/www.stroke.nih.gov\/documents\/NIH_Stroke_Scale_508C.pdf\">https:\/\/www.stroke.nih.gov\/documents\/NIH_Stroke_Scale_508C.pdf<\/a>.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Potential neurological related nursing diagnoses:<\/p>\n<ul>\n<li>Pain related to injury<\/li>\n<li>Risk of falls due to altered level of consciousness<\/li>\n<li>Risk for injury related to disturbed sensory perception<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Data sources: Alberta Health Services, 2009; Assessment Skill Checklists, 2014; Critical Care Services Ontario, 2014; Heart and Stroke Foundation, 2019; Jarvis, Browne, MacDonald-Jenkins, &amp; Luctkar-Flude, 2014; Pasero, 2009; Perry, Potter, &amp; Ostendorf, 2018; RCH, 2015; RNAO, n.d.; Stephen et al., 2012; Wilson &amp; Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/neurological_assessment.html\"><em>Neurological Assessment &#8211; Basic<\/em><\/a> by Ren\u00e9e Anderson and Wendy McKenzie, Thompson Rivers University, 2019<\/div>\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/assessing_ROM.html\"><em>Assessing Range of Motion and Strength<\/em><\/a> by Candace Walker and Wendy McKenzie, Thompson Rivers University<\/div>\n<div>\n<p>&nbsp;<\/p>\n<\/div>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center;\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>What patient situations would require a dermatome assessment?<\/li>\n<li>When caring for a client post CVA, consider the difference between completing a Glasgow Coma Scale (GCS) assessment and a National Institutes of Health Stroke Scale (NIHSS).<\/li>\n<li>Besides opioid induced sedation, identify one other situation where sedation score might be appropriate part of an assessment.<\/li>\n<\/ol>\n<\/div>\n<h2>Attributions:<\/h2>\n<p>Figure 2.4\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:TE-Nervous_system_diagram.svg\">Neurological System<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:The_Emirr\">the Emirr<\/a>\u00a0 is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/deed.en\">CC BY 3.0 license<\/a>.<\/p>\n<p>Figure 2.5\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/Face#\/media\/File:Sabaa_Nissan_Militiaman.jpg\">A Man\u2019s Face<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Christiaan\">Christiaan Brigs<\/a> is used under a <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">CC BY-SA 3.0 license<\/a>.<\/p>\n<p>Figure 2.6\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Bells_Palsy_CDC.jpg\">B<span style=\"font-size: 18.6667px; text-indent: 18.6667px;\">ells Palsy<\/span><\/a><span style=\"text-indent: 1em; font-size: 14pt;\">\u00a0by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/Category:PD_US_HHS_CDC\">CDC and <\/a><\/span>United States Department of Health and Human Services<span style=\"text-indent: 1em; font-size: 14pt;\"> is in the public domain.<\/span><\/p>\n<p>Figure 2.8\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/File:Dermatoms_alt.svg\">A Diagram Showing Human Dermatomes<\/a> by <a href=\"http:\/\/Ralf Stephan\">Ralf Stephan<\/a>is in the public domain.<\/p>\n<\/div>\n","protected":false},"author":397,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-3697","chapter","type-chapter","status-publish","hentry"],"part":102,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3697","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":27,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3697\/revisions"}],"predecessor-version":[{"id":5214,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3697\/revisions\/5214"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/102"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3697\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=3697"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=3697"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=3697"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=3697"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}