What is a nursing neurological check for an inpatient?

Nursing Neurological Check for Inpatients

A nursing neurological check is a systematic bedside assessment performed by nurses to detect early signs of neurological deterioration in hospitalized patients, consisting of serial evaluations of level of consciousness, pupillary responses, motor function, and vital signs at frequencies determined by the patient's risk for brain injury.

Core Components of the Assessment

The neurological check includes specific elements that must be evaluated and documented 1:

• Level of arousal/consciousness – Assess mental status using standardized tools like the Glasgow Coma Scale 1, 2
• Pupillary responses – Evaluate size, symmetry, and light reactivity; fixed dilated pupils or new pupil changes indicate potential herniation or hemorrhagic transformation 1
• Motor responses – Examine extremity movement and strength bilaterally 1
• Cranial nerve function – Test brainstem reflexes including corneal, gag/cough, and oculocephalic reflexes 1
• Vital signs – Blood pressure, heart rate, respiratory rate, and oxygen saturation 1, 3

Assessment Frequency Based on Risk

The frequency of neurological checks should be guided by the patient's risk for complications, not a one-size-fits-all approach 1:

High-Risk Patients (Post-Stroke, Post-Procedure)

• Every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours after mechanical thrombectomy 3
• Every 30-60 minutes before and during high-risk procedures 1
• Every 1-4 hours for patients at elevated risk of acute brain injury 1

Standard Monitoring

• At least twice daily for general hospitalized patients with neurological conditions 1
• More frequent assessments if any change from baseline occurs or caregivers express concerns 1

Standardized Scoring Tools

Nurses should incorporate validated assessment scales rather than subjective descriptions 1, 2:

• National Institutes of Health Stroke Scale (NIHSS) – Examines global neurological status, stroke severity, and prognosis; should be obtained before procedures, immediately post-procedure, and serially thereafter 1, 3
• Glasgow Coma Scale – Standard tool for consciousness assessment 1, 2
• Confusion Assessment Method – For delirium screening 1

Critical Warning Signs Requiring Immediate Physician Notification

Any change in neurological assessment justifies notification of the physician 1. Specific red flags include:

• Decreased level of consciousness 1
• Worsening neurological deficits 1
• New or changing pupil abnormalities 1
• Changes in respiratory status 1
• Signs of increased intracranial pressure (ICP) – headache, vomiting, altered mental status 1

Documentation Requirements

The American Heart Association emphasizes that nurses must 1:

• Document baseline neurological status before any intervention
• Record serial assessments at prescribed intervals
• Document the patient's presenting symptoms
• Use standardized scoring tools for consistency and communication 2
• Compare current status to previous assessments to identify trends 1

Integration with Multimodal Monitoring

Serial bedside examination remains the mainstay of neurological assessment, but is frequently confounded by sedation and paralytic medications 1. In such cases:

• Noninvasive multimodal monitoring may be necessary for patients with impaired consciousness 1
• Daily assessment by a neurologist/neurointensivist improves neurological care when available 1
• More frequent nursing assessments (every 1-4 hours) are reasonable based on acute brain injury risk 1

Common Pitfalls to Avoid

The trend in assessment scores within an individual patient is more important than isolated values 1. Nurses should:

• Avoid relying solely on subjective descriptions; use standardized scales 2
• Not delay assessments due to sedation – document what can be assessed (pupillary responses, vital signs) 1
• Recognize that the absence of brainstem reflexes may be reversible, especially after epinephrine administration during resuscitation 1
• Implement conservative measures to minimize ICP increases: avoid patient straining, reduce environmental stimuli, cluster nursing activities 1

Purpose and Clinical Impact

Early recognition of neurological deterioration by nurses through systematic assessment can minimize complications and improve patient outcomes 1. The nurse is often the first healthcare team member to detect changes in patient status, making this assessment a critical line of defense in preventing secondary brain injury 1, 4.