When a resident or patient falls, and hits their head, nursing staff have serious responsibility to monitor the possible effects. Brain injuries are life altering events and sometimes we can prevent this from happening. By intervening at critical times, we have a big impact on people.

Nursing Home Magazine’s October Issue has guild lines that are sound and should be followed. CNA’s often play an important role in helping the nurse perform neurological exams. It’s vitally important to be timely when you’re asked to help with these exams. The best scenario would be for the nurse and CNA to go together to do this.

Protecting Your Residents and Facility
A crisis of the neurological system can be the most challenging to monitor and evaluate for any healthcare professional. Whether it’s a brief check of neurological status or a comprehensive neuro exam, a nurse’s assessment may uncover nervous system dysfunction before it is too late. Therefore, it is essential that every nursing facility has policies and procedures, coordinated by the medical director, to guide and address when and how these exams should be done. Consider the following when developing your plans:

1. Have a licensed nurse perform neurological checks after all unwitnessed falls involving residents with a history of confusion or residents with a suspected head injury.

2. Check for signs and symptoms of head injury, which include one or more of the following:

* unusual drowsiness or can’t be awakened (easily or at all), mental confusion, slurred speech
* nausea and forceful or repeated vomiting, stiff neck and fever
* seizure activity
* unequal pupils, papillary response, or accommodation
* clumsy walking, stumbling, or other problems with use of extremities, areas of numbness, parasthesias
* headache (mild or severe), dizziness, double vision, or blind spots
* increased blood pressure or a marked drop in blood pressure
* decrease in pulse and/or increased and shallow respirations (these are associated with intracranial pressure)
* unequal grasp and/or nonexistent extremity movement (these are associated with cerebral damage)

Right here is where CNA’s are often called upon to assist with these exams. We’re the ones who will first encounter residents and patients who:
*Cannot be aroused as usual or who seem more tired than normal
*Have a fever
*Respirations that are different- slow and deep or fast and shallow
*Complain of a headache
*Vomit
*Experience dizzy spells or complain of double vision
*have a change in their normal B/P readings
*Cannot hold onto things they normally can- dropping a hairbrush or comb, for example
THESE observations should be reported the nurse immediately. Not in an hour. Not after care is given.

3. Conduct an initial thorough exam at the location where the resident was found, without moving him or her. Wear gloves when necessary and provide as much privacy as possible.

4. Evaluate the level of consciousness and mentation of the resident. A change is usually the first clue to a deteriorating condition. Since terms, such as lethargy, are frequently used imprecisely, it is wise to descriptively document how the resi-dent responds.

5. Check pupil reaction, blood pressure, temperature, pulse, respirations, grasp, and active range of motion of all extremities. If neck or spinal injury is suspected, keep the resident still and call for emergency help.

6. Obtain orthostatic blood pressures per facility protocol. Move the resident to his or her bed only after a full assessment of injuries or potential injuries is complete, and use a method that will protect the resident from any further injury.

7. Perform neurological checks according to the frequency indicated on the medical director’s or attending physician’s orders. In addition, subsequent assessments should be problem-focused, zeroing in on the parts of the nervous system affected by the resident’s condition. The resident’s diagnosis and the acuity of his or her condition will determine how extensive your problem-focused assessments will be and if you should conduct them more frequently.

8. Be sure to compare your findings with those of previous exams. Through comparison, you’ll be able to spot changes and trends and, when necessary, intervene quickly and appropriately.

9. Immediately notify the resident’s physician of any sign of deterioration in the resident’s status.

Initally after a fall, the resident/patient should not be moved by the CNA. Get the nurse. I have worked with nurses who will refuse to come right down to assess the situation- they’re in the middle of a med pass or something. This is not acceptable. If this happens go to the next person in the chain of command. If no such person is in house, inform the nurse that you will not move the resident/patient until an assessment is completed. And go stay with your resident/patient.

Learn what a full neuro exam is and what tools are needed, in case you’re asked to get them together. Every facility should have a kit with these items all ready for use and clearly labeled.

More about neuro checks:
Neurological assessment: A refresher
The Precise Neurological Exam (pictures included)