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Neurologic Vital Sign

The document discusses neuro vital signs (NVS), which assess brain activity through a patient's level of consciousness, pupil reaction, motor skills, and other responses. It describes tools for evaluating NVS, including the Reaction Level Scale (RLS), Glasgow Coma Scale (GCS), and assessing pupils, hand grip, and leg movement. Proper assessment of a patient's NVS can help detect neurological issues, guide care, and monitor a patient's condition.

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Manuel Pormento Escurzon V
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© Attribution Non-Commercial (BY-NC)
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Topics covered

  • Stimulation Response,
  • Patient Condition,
  • Neuro Vital Signs,
  • Assessment Tools,
  • Nursing Procedures,
  • Glasgow Coma Scale,
  • Patient Care,
  • Clinical Evaluation,
  • Assessment Protocols,
  • Patient Response
1K views13 pages

Neurologic Vital Sign

The document discusses neuro vital signs (NVS), which assess brain activity through a patient's level of consciousness, pupil reaction, motor skills, and other responses. It describes tools for evaluating NVS, including the Reaction Level Scale (RLS), Glasgow Coma Scale (GCS), and assessing pupils, hand grip, and leg movement. Proper assessment of a patient's NVS can help detect neurological issues, guide care, and monitor a patient's condition.

Uploaded by

Manuel Pormento Escurzon V
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

Topics covered

  • Stimulation Response,
  • Patient Condition,
  • Neuro Vital Signs,
  • Assessment Tools,
  • Nursing Procedures,
  • Glasgow Coma Scale,
  • Patient Care,
  • Clinical Evaluation,
  • Assessment Protocols,
  • Patient Response

NEUROLOGIC VITAL SIGN

By: Manuel P. Escurzon V


Rezty Cariaga
Nemesio Carigaba III
What is NVS?
 The neuro assessment is a key component in the
care of the neurological patient.
 Neuro vital signs tell you if there are brain
activities going on - electrical impulses firing,
neuron activity. Or has the brain shut down.
 It can help you detect the presence of neurological
disease or injury and monitor its progression,
determine the type of care you'll provide, and
gauge the patient's response to your interventions.
HOW DO WE ASSESS NEURO
VITAL SIGNS?
RLS
Reaction Level Scale
RLS
 Evaluation of level of consciousness (LOC)
and mentation are the most important parts
of the neuro exam. A change in either is
usually the first clue to a deteriorating
condition.
 In assessing the neuro vital signs, you have
to assess for the level of consciousness.
assess whether the patient is :
 conscious, lethargic, obstunded, stuporous
or in coma.
 Full consciousness. The patient is alert, attentive,
and follows commands.
 If asleep, she responds promptly to external
stimulation
 and, once awake, remains attentive.1
 Lethargy. The patient is drowsy but awakens—
although not fully—to stimulation.
 She will answer questions and follow commands,
but will do so slowly and inattentively.1
 Obtundation. The patient is difficult to arouse and
needs constant stimulation in order to follow a
simple command.
 She may respond verbally with one or two words,
but will drift back to sleep between stimulation.
 Stupor. The patient arouses to vigorous and
continuous stimulation; typically, a painful
stimulus is required.1
 She may moan briefly but does not follow
commands.
 Her only response may be an attempt to
withdraw from or remove the painful stimulus.
 Coma. The patient does not respond to
continuous or painful stimulation.
 She does not move—except, possibly, reflexively
—and does not make any verbal sounds.
RLS SCALE

1 ALERT – no delay response

2 DROWSY – respond to light stimuli

3 VERY DROWSY - respond to pain/strong stimuli

4 UNCONSCIOUS LOCALIZING – localize pain

5 UNCONSCIOUS WITHDRAWING – withdrawing


movement to pain stimulation

6 UNCONSCIOUS DECORTICATE - stereotype flexion


movement to pain stimuli
7 UNCONSCIOUS DECEREBRATE - stereotype
extension movement to pain stimuli
8 NO RESPONSE - no response to pain stimuli
GCS
Glascow Coma Scale
Pupillary Assessment
When assessing pupils (eyes) it is important to assess the following:
 􀂃 size

 􀂃 shape

 􀂃 reactivity to light

 􀂃 comparison of one pupil to the other

Hand Grip- Strong, Moderate, Weak


Leg movement- Strong, Moderate, Weak
A bedside neuro assessment almost always includes an
evaluation of motor function. Since you'll be assessing
the ability to move on command,
-the patient must be awake,
-willing to cooperate, and
-able to understand what you are asking her.
EYE OPENING VERBAL RESPONSE

4 SPONTANEOUS 5 ORIENTED
3 TO SPEECH 4 CONFUSED
2 TO PAIN 3 INAPPROPRIATE WORD
1 NO OPENING 2 INCOMPREHENSIBLE
1 NO RESPONSE

MOTOR RESPONSE

6 OBEYING
5 LOCALIZED PAIN
4 FLEXION WITHDRAWING
3 DECORTICATE
2 DECERABRATE
1 NO RESPONSE
 References:

 PATTY NOAH, RN, MSN, CNRN .


(2004).Neurological Assessment: A refresher.
Retrieved August 11, 2010, from
http://www.modernmedicine.com/modernm
edicine/article/articleDetail.jsp?id=120796

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