General assessment in SICU

allnurses Guide · Aug 3, 2008

http://www.kathywhite.com/images/pdfs/07neuro.pdf

sicushells, RN · Aug 8, 2008

Does the ICU you're asking about have neurosurg patients as well? I wasn't really sure what the connection was. my hospital has a Neuro ICU which handles neurosurg pts.

Where I work we do standard head to toe ass'ts. Pupil checks, A&O checks, lung and heart sounds, bowel sounds, Feeding tube placements, pulses, push/pulls in all four extremeties. The only thing really specific to surgical vs. another ICU is pain assessment, and incision sites (where they are what they look like, any drainage/swelling/redness) also checking for s/sx of bleeding.

-Hope that answers your question.

love-d-OR · Aug 8, 2008

Neuro assessment on a SICU patient is done q4hr unless the patient is unstable and requires more frequent checks. Some of the things that we assess are :

- PERRLA

-Upper and lower extremity muscle strength

-Level of consciousness to person, place, time (year is sufficient), purpose of admission

-Sensation

-Arousable (easily or only to pain)

A neuro check can be done by walking into the patient's room and talking to them (if applicable). You can assess their speech (aphasic? slurred speech?), do they open their eyes when you walk in and start talking to them, or do you have to elicit pain to arouse them (obviously use common sense, if they are sedated they will not be battering their eyes at you).

If you are going to be working in the neuro ICU, you will most likely have more frequent and more thorough neuro assessments to perform. In my unit (second day tomorrow :smokin: ) and in most ICU's, neuro assessments are part of the general ICU assessments and are also done to catch any decline in stability i.e blown out pupils=cranial bleed?=CT scan!

BTW SICU is awesome! I know that I sound like a crushing high schooler right now but :bow: to all the ICU nurses! I guess that includes me too, haha!!

joeyzstj, LPN · Aug 8, 2008

In the CVICU we use the NIH stroke scale a lot in addition to our routine neuro assessment due to the fact that we deal with a lot of carotids and/or procedures that could cause a stroke. My daily assessment starts with:

"Can you tell me what hospital you are at"

"Tell me your birth month"

What year is it?

Hold up your thumbs

Wiggle the toes on your left foot, now on the right foot.

Smile, frown and stick out your tongue

Pupil assessment for PERRLA

Grips, Dorsiflextion and plantar flexion

Grips should not be used as a "follows commands" type of prompt. If you think about it, you dont want to ask the person to do something that a newborn baby could perform. A newborn will grip your hands when your fingers are placed in their hands, however it is a reflex of sorts and not a purposefull movement performed on command.

sicushells, RN · Aug 12, 2008

Grips should not be used as a "follows commands" type of prompt. If you think about it, you dont want to ask the person to do something that a newborn baby could perform. A newborn will grip your hands when your fingers are placed in their hands, however it is a reflex of sorts and not a purposefull movement performed on command.

Correct me if I'm wrong, but newborn reflexes normally disappear within the first 18 months of life, so in a neurologically intact adult, grips should not be a reflex, but rather purposeful. In the patients I've taken care of that had neurologic injuries, I've not had someone grasp my hand consistently to command. Have you had other experiences?

nursecass · Aug 14, 2008

Correct me if I'm wrong, but newborn reflexes normally disappear within the first 18 months of life, so in a neurologically intact adult, grips should not be a reflex, but rather purposeful. In the patients I've taken care of that had neurologic injuries, I've not had someone grasp my hand consistently to command. Have you had other experiences?

I've had people when sedated that reflexively grip hands when something is placed in them. Not at all purposeful, but just as soon as you touch their palms they close their hand (so if your fingers are there it feels like a grip). Usually I ask for toe wiggle or will leave my fingers in their hand for about 30 seconds before asking for a squeeze to see if it is actually to command. It's a bummer though too for family because they usually don't understand-they put their hand in patients and the patient squeezes and family sees that as a good sign no matter what. Not sure if that's different for neuro patients as we don't get many of those.

cardiacRN2006, ADN, RN · Aug 15, 2008

The trick is for them to let go of your hand after the grip. Then we know that they are following commands. Just squeezing the hands isn't enough.

If they aren't strong enough for that, then ask them to move a toe or finger. Or squint their eyes.

joeyzstj, LPN · Aug 15, 2008

Correct me if I'm wrong, but newborn reflexes normally disappear within the first 18 months of life, so in a neurologically intact adult, grips should not be a reflex, but rather purposeful. In the patients I've taken care of that had neurologic injuries, I've not had someone grasp my hand consistently to command. Have you had other experiences?

OK...........The point that Im trying to make is that placing your hand in a confused patients hand and having them grip really isnt a correct response to a neuro assessment. When you place you hand in that of a newboard baby the same is ovserved, however it is not a purposefull movement. If you just cant live without doing this movement, have them let go of your hands on command. That holds greater weight in assessing neuro status then of that which I previously mentioned.