Reporting on Neurological Decline as Identified by Hourly Neuroassessments.

ABSTRACT: BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

Standardizing the Frequency of Neurologic Assessment After Acute Stroke.

The National Institutes of Health Stroke Scale (NIHSS) is considered the standard for assessing neurologic status after an acute stroke. Currently, there is no guideline for when this assessment should be completed, nor is there consensus on how frequently or for how long.We initiated a quality improvement project that sought first to determine when and how often nurses at a variety of institutions in our multisite health care system completed the NIHSS assessment and then to identify the minimum frequency at which nurses should complete the assessment. After reviewing the literature and current practices and observing internal and external benchmarks, we set a new standard for all institutions in the system to follow.The new assessment frequency was based on patient condition and level of care, although that frequency would change if a patient showed new or worsening neurologic changes. The new standard was successfully implemented at all the primary and comprehensive certified stroke centers in our network. Ongoing monitoring confirmed that the frequency of NIHSS assessment met the needs of our patients and ensured staff adherence to the new practice.

Routine Neurological Assessments by Nurses in the Pediatric Intensive Care Unit.

BACKGROUND: Brain injury with changes in clinical neurological signs and symptoms can develop while children are undergoing treatment in the intensive care unit. Critical care nurses routinely screen for neurological decline by using serial bedside neurological assessments. However, assessment components, frequency, and communication thresholds are not standardized. OBJECTIVES: To standardize neurological assessment procedures used by nurses, improve compliance with physicians' ordering and nurses' documentation of neurological assessments, and explore the frequency with which changes from preillness neurological status and previous assessments can be detected by using the assessment tool developed. METHODS: A quality improvement intervention was implemented during a 1-year period in a 55-bed pediatric intensive care unit with 274 nurses. Procedures for neurological assessment by nurses were standardized, a system for physicians to order neurological assessments by nurses at a frequency based on the patient's risk for brain injury was developed and implemented, and a system to compare patients' current neurological status with their preillness neurological status was developed and implemented. RESULTS: Process metrics that focused on compliance of ordering and documenting the standardized neurological assessments indicated improvement and sustained compliance greater than 80%. Exploratory analyses indicated that 29% of patients had an episode of neurological decline and that these episodes were more common in patients with developmental disabilities than in patients without such disabilities. CONCLUSIONS: Compliance with physicians' ordering and nurses' documentation of standardized neurological assessments significantly increased and had excellent sustainability. Further work is needed to determine the sensitivity of standardized nurses' neurological assessment tools for clinically meaningful neurological decline.

The Bedside Nurse: The Foundation of Multimodal Neuromonitoring.

Although technology over the past several decades has enabled improved neuroimaging and advanced noninvasive and invasive neuromonitoring, the role of the bedside nurse conducing ongoing neurologic examination is still a foundational element of neuromonitoring. Ongoing neurologic monitoring by the bedside nurse in the neuroscience intensive care unit is variable and guided by little evidence or data. When neurologic monitoring through clinical examination is possible, data obtained from multimodal monitoring should be interpreted in the context of the neurologic examination. The bedside nurse plays a crucial role in conducting ongoing neurologic examinations.

The Use of Automated Pupillometry in Critical Care.

The neurologic examination (neuroexamination) is one of the most powerful tools available to nurses and physicians caring for patients with neurologic or neurosurgical illness. Assessing cranial nerve function is one of the most vital components of the neuroexamination. The pupillary light reflex helps to evaluate the status of the second and third cranial nerves and is one of the most well-known elements of the cranial nerve examination. Automated pupillometers have been developed that provide objective measures of size of the pupil and the responsiveness of the pupil to light (neuropupillary index).

Description and Identification of the Peripheral Immune Response Trajectories Over Time in First-Time and Recurrent Stroke/Transient Ischemic Attack.

A unique extant database to explain heterogeneity in peripheral immune response (PIR) over time in response to stroke/transient ischemic attack (TIA) was used to compare changes in PIR between first-time and recurrent stroke/TIA and to identify distinct and common trajectories of change in the PIR in stroke/TIA. Associations between risk factors for stroke (hypertension, smoking, diabetes, hypercholesterolemia, infection) and PIR trajectory were quantified using multivariate random effects modeling. With comparable admission values, patients with recurrent stroke/TIA had a persistent elevation in lymphocyte percentage as opposed to the significant decline in lymphocyte percentages over time observed in those with first-time stroke/TIA. Two naturally occurring trajectories of the PIR to stroke/TIA were observed, one indicative of a primed PIR and one indicative of an unprimed PIR. A large proportion of the sample, 80%, was classified as having persistently higher lymphocyte percentages and lower neutrophil percentages over time compared with the remainder of the sample. When controlling for risk factors for stroke, adults admitted with recurrent stroke/TIA without infection were more than three times as likely to have a primed PIR (i.e., the high lymphocyte-low neutrophil trajectory) than those with first-time stroke with infection. Interventions for reduction of neurological deficits require tight implementation windows early after stroke occurs. The outlined classification of cases in these primed and unprimed trajectories of the PIR adds to the knowledge of optimal clinical timing for de novo immune-based interventions.

[The nurse and the clinical examination of the nervous system]. / L'infirmière et l'examen clinique du système nerveux.

The clinical examination of the neurological system provides valuable information regarding a person's health status. The nurse, in her daily practice, must be able to identify certain signs which may reveal situations requiring urgent treatment. Others are regularly assessed to monitor the evolution of the patient's condition.

Standardizing neurological assessments.

Evaluation of neurological status is imperative to patient assessment. Multiple assessment tools are readily available for clinicians to diagnose and report changes in neurological condition. Some of these tools include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale, the Canadian Neurological Scale, and the Four Score. Although assessment tools are beneficial to help standardize the assessment and communication of findings, they are at times cumbersome, leaving bedside clinicians with questions concerning which tool is appropriate for a given patient population. This initiative began as a means to standardize assessments and communication for neuroscience patients. As success was met, the project was moved forward locally at our hospital campus and later extended to the entire health system. With the support of the chief of neurology, the neuroscience patient care services director, the stroke coordinator, and the neuroscience clinical educator, three different neurological examinations were developed. They were defined as the Basic Neurological Check, the Coma Neurological Check, and the National Institutes of Health Stroke Scale/Stroke Neurological Check. The neurological examinations would address the assessment needs of patients with acute stroke, general neurosurgery/neurology patients, and patients in coma.

Refining Neurobehavioral Assessment of the High-Risk Infant Using the NICU Network Neurobehavioral Scale.

Nurses caring for high-risk infants use advanced assessment skills to identify the nature of infant instability and to assure timely intervention. The NICU Network Neurobehavioral Scale (NNNS) is a comprehensive assessment of neurological integrity and behavioral function of infants at risk. Research evidence supports its validity and reliability for clinical and research use. The NNNS offers nurses a neurobehavioral assessment especially suited to high-risk and premature infants.

Pediatric neurologic exam.

Although emergency nurses receive education and training in performing comprehensive and rapid assessment, pediatric patients may prove to be challenging due to dynamic growth, development and maturation. If the emergency department (ED) has limited exposure to pediatric patients, performing assessments and prompt interventions may be daunting. Neonates, infants and young children with illness or trauma have unique and often times subtle signs and symptoms that can change rapidly. Although the neurological exam for older children may be similar to that of an adult, there are significant differences based on maturation. The neurologic exam for neonates and infants provides the nurse with even more opportunity to be familiar with developmental differences. Therefore, it is important for ED nurses to become familiar with typical development and early recognition of neurologic insult.

The reliability and validity of a modified total neuropathy score-reduced and neuropathic pain severity items when used to measure chemotherapy-induced peripheral neuropathy in patients receiving taxanes and platinums.

BACKGROUND: Assessment of chemotherapy-induced peripheral neuropathy signs and symptoms has been hampered because of the lack of simple, reliable, and valid measures. OBJECTIVE: The study objective was to examine the internal consistency and interrater reliability as well as the structural validity of a 5-component total neuropathy score-reduced (TNSr) variant and a chemotherapy-induced neuropathy-specific Neuropathic Pain Scale. METHODS: One hundred seventeen outpatients receiving taxanes or platinums were assessed by a consistent nurse practitioner using the 2 instruments. Ten subjects participated in interrater reliability testing. RESULTS: Mean scores and SDs for individual items were low. The strength item was deleted because of low interitem correlations and a floor effect. The reflex item was deleted because of low interitem correlations and its negative influence on Cronbach alpha. Pin sensibility was deleted because of low factor loadings. The TNSr-short form and the chemotherapy-induced neuropathy-specific Neuropathic Pain Scale formed 2 distinct factors, providing evidence of structural validity. Cronbach alpha's for the 2 instruments were .80 and .96, respectively. The TNSr interrater reliability results suggested acceptable rater concordance, but minor revisions could further improve scoring precision. CONCLUSION: Clinimetric evidence supports the use of 2 new instruments when monitoring taxane- and platinum-related neuropathy and pain. Further instrument modifications are recommended, followed by additional testing in diverse populations. IMPLICATIONS FOR PRACTICE: With these new instruments, nurses can more easily incorporate prospective neuropathy assessment into daily clinical practice. The outcome will be improved symptom awareness by oncology clinicians and patients, leading to fewer chemotherapy-induced peripheral neuropathy-related devastating effects on functionality and quality of life.

Assessing the neurological status of patients with head injuries.

The aim of this article is to inform staff who are new to emergency care settings how to use the Glasgow Coma Scale (GCS) when managing patients with head injuries. It may also be useful as a refresher for experienced staff and a helpful teaching tool. It emphasises the need for continual, standardised assessment of neurological status and emphasises how the GCS is seen as best practice nationally and internationally.