Neuro assessment in awake and alert patient

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    Profile photo of Sz721213b

    I’d like to get feedback from seasoned neuro nurses on this: When you have an alert and awake patient who has a stable, not fresh, smaller intracranial bleed, when you have every 2 hour neuro checks, after establishing you baseline with a through check, do you, in your practice go through the whole head to toe neuro assessment BY THE BOOK every 2 hours? The patient is alert, talking, looking right at you, joking, using a urinal, turns self, watches TV, etc., able to tell you if he is feeling any numbness, headache, etc… Or, do you use your experience and nursing judgement to deduce most of your assessment just from observing, interacting, helping, talking to, taking care of the patient?
    Your input is appreciated.

    Profile photo of Kimo

    At minimum, you should be doing pupil checks. By the end of the shift, most alert and awake pts will just repeat the orientation answers without you having to ask. I once had an alert and awake pt who’s first sign of a neuro change was a nonreactive, dilated pupil. I called the provider. Shortly thereafter, he started getting obtunded and had to go for a stat CT and immediately for a crani after.

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