Neuro assessment

  1. Hi!
    I work in a long-term facility caring for special-needs kids. My ADON has enlisted my help in devising a new neuro assessment for use in our day-to-day charting. This is difficult because of our population--infants through age 21, many with severe/profound retardation, CP, head injuries, microcephaly, and on and on...
    We have always in the past used the Glasgow coma scale, but we want to try to get away from it as it is only appropriate for acute neuro problems, and our kids are really chronic.
    Does anyone know of any other type of assessment tool, or have a really useful form that you use in your facility?
    Thanks a lot,
    Kristie
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  2. 1 Comments

  3. by   nurs4kids
    Kristie,
    Hi! We use glascow in ICU. On the floors, we use the following guidelines.


    We do head circ's on any child less than 2 years.
    Assess fontanels.
    Assess LOC (eyes open/closed, alert, lethargic, etc)
    Pupil size and reaction.
    Grasps for strength and equality.
    Extremity movement.
    Respiratory Rate and Heart Rate.
    Assess shunt tract for redness/edema.
    Color and saturation (if ^ICP is suspected).

    We don't have just a neuro sheet, this stuff is just on our nursing flowsheet. We did use a neuro flowsheet a few years ago, and I could probably dig one up for you if you want it, but it's designed more for post op neuro kids. The only other thing you may want to add to the above list, if you decide to make your own, would be something to indicate nausea or vomiting, since this will be your first sign of a problem on many of your kids.

    Hope this helps!
    Tracy

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