Practice Recommendations: Neurological Assessment

Recommendation	Level of Evidence
3.0 Nurses in all practice settings should conduct a neurological assessment on admission, and when there is a change in client status. This neurological assessment, facilitated with a validated tool such as the Canadian Neurological Scale , National Institutes of Health Stroke Scale or Glasgow Coma Scale (See appendix C of the Stroke Assessment Nursing BPG), should include at minimum: Level of consciousness; Orientation; Motor (strength, pronator drift, balance and coordination); Pupils; Speech/Language; Vital signs (TPR, BP, SpO2); and Blood glucose.	IV
3.1 Nurses in all practice settings should recognize that signs of decline in neurological status may be related to neurological or secondary medical complications. Clients with identified signs and symptoms of these complications should be referred to a trained healthcare professional for further assessment and management.	IV

Recommendation

Level of Evidence

3.0 Nurses in all practice settings should conduct a neurological assessment on admission, and when there is a change in client status.

This neurological assessment, facilitated with a validated tool such as the Canadian Neurological Scale , National Institutes of Health Stroke Scale or Glasgow Coma Scale (See appendix C of the Stroke Assessment Nursing BPG), should include at minimum:

Level of consciousness;
Orientation;
Motor (strength, pronator drift, balance and coordination);
Pupils;
Speech/Language;
Vital signs (TPR, BP, SpO2); and
Blood glucose.

3.1 Nurses in all practice settings should recognize that signs of decline in neurological status may be related to neurological or secondary medical complications.

Clients with identified signs and symptoms of these complications should be referred to a trained healthcare professional for further assessment and management.

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Changes or decline in neurological status

Changes or decline in neurological status may be related to:

Neurological complications:

New stroke event
Increased intracranial pressure
Seizures
Hemorrhagic transformation
Vasospasm, hydrocephalus, and/or re-bleeding post subarachnoid hemorrhage.

Secondary medical complications:

Metabolic imbalance (hypoglycemia, electrolyte imbalance)
Aspiration pneumonia and respiratory compromise
Myocardial infarction
Medication side effects
Pulmonary embolism
Urinary tract infection
Sepsis

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