How do you assess the neuro status of a patient?

Comprehensive Neurological Status Assessment

A comprehensive neurological assessment should include evaluation of level of consciousness using the Glasgow Coma Scale (GCS) or FOUR score, assessment of pupillary responses, brainstem reflexes, motor function, and sensory function to accurately determine a patient's neurological status. 1

Level of Consciousness Assessment

• The Glasgow Coma Scale (GCS) is the most widely used tool for assessing level of consciousness, evaluating eye opening, verbal response, and motor response 1, 2
• The FOUR (Full Outline of UnResponsiveness) score may provide a more complete assessment of brainstem function in unresponsive patients by measuring ocular responses to command and pain, pupillary responses, and respiratory pattern 1
• The FOUR score shows good inter-rater reliability and may show better discrimination in the most unresponsive patients 1
• For intubated patients, the FOUR score has an advantage as it does not rely on verbal responses, which are impossible to assess in these patients 1, 2

Pupillary Assessment

• Evaluate pupillary size, symmetry, and reactivity to light 1, 3
• Absent pupillary light reflex at 72 hours post-cardiac arrest has a false positive rate of 0-8% for predicting poor outcomes 1
• Newer devices provide objective measurement of pupillary diameter and the speed of pupillary response, though additional research is needed to confirm their role 1

Brainstem Reflexes

• Assess corneal reflexes by gently touching the cornea with a cotton swab and observing for blink response 1, 3
• Evaluate oculocephalic (doll's eyes) and oculovestibular reflexes in comatose patients 1
• The combined absence of corneal reflex, pupillary light reflex, and motor response at 72 hours post-cardiac arrest has a very low false positive rate for predicting poor outcomes 1

Motor Function Assessment

• Evaluate motor response to verbal commands and painful stimuli 1, 3
• Assess muscle tone, bulk, and strength in all extremities 3
• Document any abnormal posturing (decorticate or decerebrate) or myoclonus 1
• Note that myoclonus within 72 hours of cardiac arrest has been associated with poor outcomes, though some patients with early-onset myoclonus have had good recovery 1

Sensory Function Assessment

• Test various sensory modalities including temperature sensation, pinprick sensation, vibration perception, and pressure sensation 3
• Document any sensory deficits or abnormalities 3

Standardized Assessment Tools

• For cognitive assessment in non-critical patients, validated tools like the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Examination (MMSE) can be used 1
• For delirium assessment, the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) are recommended 1
• Note that delirium in neurocritical care patients may represent progression of underlying disease and should prompt evaluation for new neurologic deficits 1

Frequency of Assessment

• In critical care settings, neurological assessments should be performed at least hourly, or more frequently based on the patient's condition 1
• For patients with neurological concerns, daily assessment by a neurologist or neurointensivist is recommended 3
• Document baseline status and any changes over time using standardized evaluation forms 3

Special Considerations

• Sedation, opioids, and neuromuscular blockade can confound neurological assessment 1
• "Wake-up tests" in patients with unstable intracranial hypertension pose significant risks and should be performed only when the benefit of neurological assessment outweighs the risk of physiological decompensation 1
• For patients with atypical findings or rapidly progressive conditions, expedited referral to a specialist is recommended 1

Documentation

• Document all findings systematically, noting any changes from previous assessments 3, 4
• Use standardized documentation forms when available to ensure consistency 3
• Record the time of assessment and any interventions that may affect neurological status 4

Remember that neurological assessment is not just about collecting data but interpreting findings in the context of the patient's overall clinical picture to guide appropriate management and determine prognosis.