Neurological assessment in children

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Neurological assessment in children

Neurological assessment in  children overview

Neurological assessment of children is a common nursing observation. It is primarily conducted for two reasons:

to monitor a child with an altered level of consciousness after an event, e.g. after a convulsion;
to monitor a child at risk of raised intracranial pressure following an event such as a head injury.

Neurological observations need to be performed when taking into account the child’s developmental stage or any existing conditions that already impair a child’s neurological function.

Family involvement

As with any observation in children, a full explanation should be given to both the child, in an age-appropriate manner, and the parents/carers. It is important to explain the reason for doing the observations and their frequency.

If English is not the child’s first language, arrangements will need to be made to obtain a translator to help assess the child’s neurological status.

Equipment

Always collect all the required equipment prior to approaching the child and always observe the child from afar before coming close to him or her.

Primary assessment of neurological status

The quickest assessment of a child’s level of consciousness is using the AVPU score:

A – Alert. Responsive, alert and orientated which means the child can identify people and is behaving normally.
V – Responds to voice. This is often because a child is tired or in pain.
P – Responds only to pain. Be careful when inflicting pain on children. Be sure to explain to the parents that this is necessary and use as little force as possible to obtain a response. Squeezing the trapezius or gently pulling a child’s hair are among the kindest ways of inflicting pain.
U – Unresponsive. A child who is unresponsive or only responds to painful stimulus requires emergency treatment to protect his or her airway.

Secondary neurological assessment

It is recommended that the Glasgow Coma Scale (GCS) is used for the assessment of all children post head injury. GCS evaluates the child’s ability to participate in three key activities: eye opening, verbal response and motor response.

Eye opening

Children post head injury will often refuse to open their eyes. Lights can be dimmed to reduce the glare distressing the child. Tempting a child to open their eyes to look at a TV screen or a toy is very effective.

Verbal response

Depending on the age of the child, obtaining a best verbal response is important. In a child who is talking, a verbal response should be appropriate and coherent. This can be done by asking three age-appropriate questions. Children can be talking but may be confused or disorientated and this is scored accordingly. In children who are not yet talking and babies, verbal sounds such as babbling can be reassuring. A high-pitched cry is a warning sign and can indicate raised intracranial pressure.

Motor response

Again, this assessment is age-specific. Ask the child to obey simple commands such as asking them stick out their tongue.

Pupil response

Pupil reaction is controlled by the third cranial nerve. The assessment looks at the following responses:

brisk reaction: +
no reaction: –
sluggish reaction: S
are the pupils equal and reacting to light (PEARL)?
are the pupils dilated or pinpoint? This may indicate toxins.
if one eye is closed, this is recorded as C.

Turn down the lights. Look into the eyes, are the pupils of equal size and shape? Shine a torch from the outer aspect of the eye towards the nose and observe the reaction of the pupil. Repeat on the other side.

Limb movement

It is important to look at all four limbs and to try to detect any weakness. See if the child can stand and walk, ask them to do this. If they cannot stand or they are too tired to stand, ask them to push your hands away with the soles of their feet. Squeezing your fingers and pushing your hands away can let you assess the strength of the upper limbs.

Posturing

Any abnormal posture can indicate severe neurological deficit

opisthotonus – arching of the neck and back
decorticate – arms are flexed/legs extended
decerebrate – arms and legs are extended.

Physiological assessment

Temperature, pulse, respirations, blood pressure and oxygen saturations are all recorded. Altered temperatures may indicate damage to the hypothalamus which regulates temperature. A slow bounding pulse, coupled with a rise in blood pressure, can indicate raised intracranial pressure.
In children under 3, the unfused skull sutures can allow swelling to occur. In children under 18 months, always check for a bulging fontanelle.
Always perform a blood glucose test on any unconscious child.
Subtle changes in the assessment should be reported.
Vomiting can be a sign of raised intracranial pressure and should be monitored and reported.

Who does the assessment and for how long?

There are advantages to having the same nurse carry out the observations over a period of time as then a rapport can be built up with both the child and carer.

The frequency of observation will depend on the situation of the child. Any abnormal observation should increase the frequency to every 15 minutes. In a well child, this can range from 30 minutes to hourly.

Carrying out neurological observations at night can be very challenging with both child and parent/carer becoming irritable but it is necessary. It is important to explain this to the family before they go to sleep.

Documentation

All neurological observations should be recorded on a neurological observation chart. Any changes should be discussed with the nurse in charge and a doctor.

Tags: Children and Young Peoples Nursing Skills at a Glance

Oct 25, 2018 | Posted by admin in NURSING | Comments Off

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Neurological assessment in children