Do not delay repeat assessments
Don't overlook neurological patients
A woman reported a sudden loss of consciousness at home, but she came to the ED alert, oriented, and looking completely fine. Stephanie Topscher, RN, a clinical partner in the ED at Greater Baltimore (MD) Medical Center, performed a thorough neurological assessment and repeated it 30 minutes later.
At that point, the woman's speech was slurred, and she had become confused. After a CT scan showed an intracranial bleed, an immediate craniotomy was done and the hematoma was evacuated.
"Had I not done a really good neuro assessment the first time, I would not have seen the change," says Topscher. "She may have had a really bad outcome."
Topscher says that in a crowded ED, neurological patients can be overlooked easily. Repeat neuro assessments, she says, can "tell you a multitude of things. If the Glasgow Coma Score decreases in a trauma patient, that indicates an increase in intracranial pressure. If a stroke patient's scores improve, it means they will have less disability."
Topscher says that any patient with weakness, visual problems, possible stroke, head trauma, or altered mental status should receive a Glasgow Coma Score.
"Facial droop could be Bell's palsy, but it could also be stroke. Syncopal episodes could be related to the heart but could be a stroke," says Topscher. The most important thing to remember is that any delays in treatment can be detrimental to the patient, she says.
"Do assessments frequently. Changes can happen so rapidly, and that's really going to determine the outcome of the patient," Topscher says.
A good baseline neurological assessment can be performed simply by obtaining a Glasgow Coma Score intertwined with the mini-mental status exam (MMSE), says Carol Howat, RN, BSN, CEN, clinical educator for the ED at Northwest Community Hospital in Arlington Heights, IL. "Taking a patient history is the most important part of the neurological exam," says Howat. "Even the elderly with a mild cognitive deficit is a more accurate historian than a caregiver or family member."
If the patient has an abnormal Glasgow Coma Score or Mini Mental Status exam result, it might signal that the patient is experiencing an underlying illness, such as meningitis with altered mental status, or experiencing a mood disorder, says Howat. "The elderly patient that is confused, disoriented, or depressed may require close observation or restraints," says Howat. (See story, below, on pupillary assessment.)
Sources
For more information on neurological assessments of ED patients, contact:
- Carol Howat, RN, BSN, CEN, Clinical Educator, Emergency Department, Northwest Community Hospital, Arlington Heights, IL. Phone: (847) 618-4020. E-mail: [email protected].
- Shelley L. Sides, RN, MSN, Trauma Coordinator, Eastern Maine Medical Center, Bangor. E-mail: [email protected].
- Stephanie Topscher, RN, Clinical Partner, Emergency Department, Greater Baltimore (MD) Medical Center. Phone: (443) 849-3938. E-mail: [email protected].
Dim lights when assessing pupils When assessing your patient's pupillary responses, dim the lights when possible, says Shelley L. Sides, RN, MSN, EMT-I, trauma coordinator at Eastern Maine Medical Center, Bangor, ME. "This will help facilitate a better view of the reaction of the pupils," says Sides. Assess for equality, size, shape, and reaction to light on all patients presenting with trauma, she adds. "This is especially important for those with any alteration in mental status and or head trauma," Sides says. [The neurological assessment form used by Eastern Maine's ED nurses is included.] |
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