Chapter 2: Patient Assessment
2.6 Head-to-Toe Assessment: Neurological Assessment
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- What patient situations would require a dermatome assessment?
Some possible situations requiring dermatome assessment include:
- Spinal cord injury: Dermatome assessment would help to determine level of sensation that corresponds to trauma at specific nerve roots.
- Numbness in certain regions of the body can correspond to issues at particular vertebra. For example sciatica corresponds to nerves emerging in the lumbar region; numbness down the arm and specific fingers correspond to nerves emerging in the cervical region.
- Intrathecal (spinal) / epidural medications: Dermatome assessment would hep to determine effectiveness of the medication.
Source:
Sawhney, M. (2012). Epidural analgesia: What nurses need to know. Nursing, 42(8), 36-41. https://www.researchgate.net/publication/228102596_Epidural_analgesia_What_nurses_need_to_know
2. When caring for a client post-CVA, discuss the difference between completing a Glasgow Coma Scale (GCS) assessment and a National Institutes of Health Stroke Scale (NIHSS).
GCS |
NIHSS |
| GCS scoring system is used to describe the level of consciousness in someone following a brain injury https://www.glasgowcomascale.org/ | NIHSS is an assessment tool that quantifies stroke severity
https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf
|
Requires observation in relation to:
|
|
| Appropriate to complete in persons who have had a brain injury (trauma, stroke, surgery). | Appropriate to complete in persons who have had a stroke. NIHSS includes everything the CGS has, plus more detailed neurological observations. |
Sources:
Lynden, P. (2017). Using the National Institutes of Health Stroke Scale: A Cautionary Tale. Stroke, 48(2), 513-519. https://doi.org/10.1161/STROKEAHA.116.015434
National Institute of Health Stroke Scale. (2003). National Institute of Health Stroke Scale. https://www.stroke.nih.gov/documents/NIH_Stroke_Scale.pdf
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
3. Besides opioid induced sedation, identify one other situation where sedation score might be appropriate part of an assessment.
When the patient has a head injury or stroke. Sedation score provides an objective measure of alertness and level of consciousness. Increasing sedation or an altered level of consciousness (in the absence of pharmaceuticals i.e. benzodiazepines or opioids) can suggest brain injury and/or worsening of brain trauma. Deteriorating level of consciousness in someone with brain trauma is a serious concern requiring immediate action.
Source:
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
Sample Learning Activity
- With the following resource, ask students to begin creating a general plan of care for any one patient with a brain injury by identifying what is important to assess and why.
Ryan, D. (2009, September 11). Caring for patients with traumatic brain injuries: Are you up to the challenges? American Nurse Today, 4(8). https://www.americannursetoday.com/caring-for-patients-with-traumatic-brain-injuries-are-you-up-to-the-challenges/
