Self-Directed Learning Module for Pediatric Neuro Vital Sign Assessment

Self-Directed Learning Module for Pediatric Neuro Vital Sign Assessment Developed by: Katrina Verschoor, Clinical Nurse Educator, 3A Neurosciences Edited by: Dr. Angela Price and Dr. Kati Wambara September 2002 Last Up-dated: March 2004 Table of Contents Module Objectives ............................................................................................................2 Introduction to Pediatric Neuro Vital Sign Assessment .........................................5 Patients At Risk .................................................................................................................6 Section One: Obtaining a History for the NVS Assessment...........................................................8 The Purpose of the Neuro Assessment..................................................................8 Obtaining a History.....................................................................................................9 Tools Required for a Standard NVS Assessment................................................11 Section Two: Assessing Mental Status using the Modified Glasgow Coma Scale .......................12 Level of Consciousness ...............................................................................................13 Eye opening/Arousal....................................................................................................14 Best Verbal Response/Awareness ...........................................................................15 Best Motor Response..................................................................................................19 Localization ...................................................................................................................20 Decorticate Posturing (abnormal flexion)..............................................................21 Decerebrate Posturing (abnormal extension).......................................................22 Infant Reflexes ...........................................................................................................25 Total GCS Score ..........................................................................................................27 Section Three: Assessing Extraocular Eye Movement and the Pupils..............................................26 Denver Developmental Test ......................................................................................32 Assessment of Cranial Nerves .................................................................................34 Section Four: Assessing Strength and the Ability to Move..............................................................36 Pronator Drift ..............................................................................................................35 Section Five: Assessing Color, Sensation and Warmth of Extremities and Bladder Function ........................................................................................................39 Summary of Physical Effects of Immobilization .................................................41 Section Six: Vital Sign Assessment ......................................................................................................47 Blood Pressure..............................................................................................................47 Cerebral Edema............................................................................................................49 Autoregulation..............................................................................................................52 Metabolic Regulation...................................................................................................52 CSF Regulation .............................................................................................................52 When the Regulatory System Fails.........................................................................53 Respirations ..................................................................................................................53 Oxygen Saturation ......................................................................................................55 Pulse ................................................................................................................................55 Temperature .................................................................................................................56 Nursing Interventions for Increased ICP.............................................................58 Mannitol Quick Reference Guide .............................................................................60 Section Seven: Assessing Pain.....................................................................................................................61 Standard Pain Scales Used at C&W ........................................................................64 Section Eight: Assessing Affect...............................................................................................................67 Section Nine: Monitoring Weight and Head Circumference .............................................................71 Summary: The Patient with a Head Injury .....................................................................................73 Appendices: Study Guide Answer Key (Provided by unit CNE on request) References 2 Module Objectives 1.0 The nurse will be able to define each area of a neuro vital sign assessment for the pediatric patient. 1.1 The nurse will be familiar with all components of the neurological assessment and have a clear understanding of the relevance of each area in a complete clinical assessment. 1.2 The nurse will know how to grade responses on the modified Glasgow Coma Scale appropriately. 1.3 The nurse will know how to determine the appropriate NVS record sheet based on the actual and/or the developmental age of the child. 2.0 The nurse will be able to identify the differences between a spinal neuro vital sign assessment and a standard neuro vital sign assessment. 2.1 The nurse will be able to identify the four main components of a spinal neurological assessment. 2.2 The nurse will be able to identify and use supporting clinical knowledge and Nursing Policy and Procedure to carry out a spinal neuro vital sign assessment. 3.0 The nurse will be familiar with basic neuro-anatomy in order to complete an accurate neuro vital sign assessment. 3.1 The nurse will understand the basic functions of the cranial nerves (CNs), how to test nerve integrity, and specify how alterations in function may present in clinical situations. 3.2 The nurse will understand the basic functions of the spinal nerves and how alterations in function may present in clinical situations. 4.0 The nurse will be able to identify trends in assessments and be able to intervene appropriately in the clinical setting. 4.1 The nurse will understand the importance of and demonstrate the practice of visual hand-over according to the guidelines provided. 4.2 The nurse will be familiar with the location and administration guidelines for Mannitol. 3 4.3 The nurse will be able to calculate and administer Mannitol according to C&W protocol. 4.4 The nurse will have a basic understanding of how and why Mannitol is used and which patient’s are at risk for increased intracranial pressure. 4.5 The nurse will be able to determine the need for increased vigilance based on assessment findings and carry this practice out as needed. 4.6 The nurse will understand why practice guidelines do not support decreasing the frequency of neuro vital sign assessments, or omitting any component of the NVS assessment, without a written physician’s order. 4.7 The nurse will support the principles of Family Centered Care by including the primary caregiver, when appropriate, to assist in the neuro vital sign assessment and in interpreting highly subjective data obtained from the assessment. 5.0 The nurse will be familiar with the three main pain scales used in the pediatric population. 5.1 The nurse will understand the rationale for routine pain assessments in determining the neurological status of the patient. 5.2 The nurse will be able to determine the appropriate pain scale for each patient based on the actual and/or developmental age of the child. 5.3 The nurse will understand the implications of intractable/worsening pain and know when to communicate assessment findings to the physician. 6.0 The nurse will understand the relevance of assessing the patient’s general behaviour and affect and record scores appropriately. 6.1 The nurse will support the principles of Family Centered Care by including the primary caregiver in assessing the child’s affect throughout a shift. 6.2 The nurse will understand the potential relevance associated with changes in behaviour and affect when determining the neurological status of the patient. 7.0 The nurse will follow C&W’s standards for documentation when recording all assessment findings, including information provided from the family and/or primary caregiver, and any contextual data that may provide information relevant to the patient’s condition. 4 7.1 The nurse will be competent in accurately recording any additional assessment information in the Nurse’s Notes section of the chart, providing context, when appropriate. 7.2 The nurse will be familiar with documentation guidelines for C&W and will review as needed. 8.0 The Pediatric Neuroscience Nurse at C&W will review the Self-Directed Learning Module for Pediatric Neuro

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