Comprehensive Neurological and Neurovascular Observations for Mrs. Mary Windsor

QUESTION

I – Mrs Mary Windsor is a 70 year old Aboriginal woman of the Gadigal people of the Eora Nation. MRN 1020304, Nil known allergies.

S – Mary has been in hospital for 2 days and has been showing signs of confusion, this morning Mary was found on the bathroom floor with a head laceration and a haematoma on her left (L) upper thigh.

B – Mary was admitted 2 days ago, with pneumonia in her right lung. She has been showing signs of confusion, since her admission.
Mary has a history of small cell carcinoma of the (R) upper lobe of the lung. She experiences breathless after activities of daily living.

Mary has episodes of confusion and incontinence due to her vascular dementia. She suffered an Ischemic Stroke 5 years ago, maintaining most functions of daily living.
Mary wears prescription glasses when awake and bilateral hearing aids but needs reminding to do so.

A – Pain 9/10, temperature 38.C, pulse 120 bpm, BP 90/50, RR 22, Sp02 90%. A 3cm laceration above left eye brow and 10cm x 4 cm haematoma on left thigh.

R – X-ray confirms a fracture to the (L) neck of the femur requiring traction and pain management. A laceration to left eyebrow is dressed with Sterestrips. Orders to complete neurovascular observations every 2 hours and neurological observations every 15min for the first hour, then 1 hourly for 4 hours

How to done step by step neurological and neurovascular observations for Mary and documented it.

Explain neurological and neurovascular chart as well .

explain everything like to do assessment

ANSWER

Comprehensive Neurological and Neurovascular Observations for Mrs. Mary Windsor

Introduction

Performing thorough neurological and neurovascular observations is crucial in assessing a patient’s neurological status and circulation. In the case of Mrs. Mary Windsor, a 70-year-old Aboriginal woman with multiple medical conditions, including pneumonia, small cell carcinoma, vascular dementia, and a recent fracture, these observations are essential to ensure her well-being and monitor any changes in her condition. This essay outlines step-by-step instructions for conducting neurological and neurovascular observations and explains the significance of the neurological and neurovascular chart.

Neurological Observations

Step 1: Initial Assessment
1. Introduce yourself to Mrs. Mary and explain the purpose of the assessment.
2. Check Mary’s identification details, including name, age, and medical record number (MRN).
3. Ensure a calm and quiet environment to minimize distractions.

Step 2: Level of Consciousness (LOC)
1. Assess Mary’s orientation to person, place, and time.
2. Use the Glasgow Coma Scale (GCS) to evaluate her eye, verbal, and motor responses.

Step 3: Pupillary Response
1. Dim the lights and ask Mary to focus on a distant point.
2. Use a penlight to observe the size, shape, and reactivity of her pupils. Document findings.

Step 4: Motor Function
1. Ask Mary to squeeze your hands, lift her legs, and move her fingers and toes.
2. Assess for any weakness, asymmetry, or abnormal movements.

Step 5: Sensory Function
1. Test Mary’s ability to sense touch, temperature, and pain on both sides of her body.
2. Document any sensory deficits or abnormalities.

Neurovascular Observations

Step 1: Initial Assessment
1. Ensure Mary is comfortable and in a suitable position for assessment.
2. Ensure proper lighting and privacy during the examination.

Step 2: Temperature
1. Gently touch both Mary’s limbs (including the affected left thigh) to assess for temperature differences.
2. Document any temperature discrepancies.

Step 3: Capillary Refill
1. Press down on Mary’s nailbed and observe the time it takes for color to return.
2. A normal capillary refill time is less than 3 seconds.

Step 4: Pulses
1. Palpate radial and dorsalis pedis pulses on both sides.
2. Compare the strength, rate, and rhythm of pulses bilaterally.

Step 5: Color
1. Observe the color of Mary’s skin and nailbeds, noting any pallor, cyanosis, or mottling.

Neurological and Neurovascular Chart

The neurological and neurovascular chart is a structured documentation tool that records the findings of the assessments. It typically includes columns for each assessment parameter (e.g., LOC, pupil size, temperature, pulses) and allows healthcare professionals to track changes over time. Accurate and timely documentation is essential for communicating Mary’s condition to other members of the healthcare team.

Conclusion

Performing comprehensive neurological and neurovascular observations for Mrs. Mary Windsor requires systematic assessment techniques to evaluate her cognitive status and circulatory function. Regular and accurate observations enable healthcare professionals to detect any deterioration in her condition promptly and intervene appropriately. The neurological and neurovascular chart serves as a vital tool for documentation, facilitating communication and continuity of care among the healthcare team.