5.17 Summary: Subjective Assessment and Pain Assessment Tools
Subjective assessment of pain is an integral step of pain management. Be aware of your own biases concerning pain: do not make assumptions. The main focus of subjective assessment is self-report, which can be elicited through a verbal account or having the client point or write it down.
The use of pain tools is also important in combination with subjective and objective forms of assessment. Many tools are available to assess pain; we have introduced you to a few, but you will come across others in your clinical practice and from reading the literature. Best practices in tool selection should focus on the reason for the assessment, developmental considerations, and the client situation and acuity. Another part of decision-making regarding tool selection is related to where you work, as units and areas of care will commonly identify specific tools and procedures for using those tools. They may also provide training related to tool implementation, with the goal of ensuring all health care practitioners use it consistently and as it was designed. See summary in Table 5.4.
| Tool | Description |
| Numerical Rating Scale | Most commonly used tool with older children and adults who are able to rate their pain on a scale of zero to 10. Recall: this tool focuses on rating of pain severity only. |
| PQRSTU mnemonic | Commonly used in many settings and populations when a more comprehensive understanding of pain is needed, beyond intensity. |
| Brief Pain Inventory | Used to elicit a more comprehensive understanding of pain and is often used in primary care settings, inpatient units, and to assess chronic pain. |
| Abbey Pain Scale and PAIC15 | Commonly used for older clients with cognitive impairments such as dementia. |
| FACES Pain Scale-Revised Version | Often used with young children who can point to the face that corresponds to their pain level. |
| FLACC Pain Tool | Used with pre-verbal or nonverbal children as young as 2 months of age, or any children who are too distressed or sedated to accurately self-report. It has also been used with other populations, including nonverbal adults with cognitive impairment and critically ill adults. |
| Behavioral Pain Scale and the Critical-Care Pain Observation Tool | Common tools used in critical care that have a focus on behavioral dimensions of pain. |
Clinical Tip
Pain intensity ratings are often categorized by health care providers as follows:
- 1–3: Mild pain.
- 4–6: Moderate pain.
- 7–10: Severe pain (and sometimes a 10 or above may be described as very severe).
These ratings and categories can be useful to provide a baseline for pre- and post-pain treatment so you know whether treatment has been effective for this specific client. However, the categories above are qualitative descriptors that have a subjective element to them and the potential for bias. For example, you might categorize a client’s pain as moderate if they have rated it a five, but if asked, the client might describe their pain as severe. Therefore, it is important to engage in comprehensive assessments that are client-centered and be careful about making judgments about the “number” the client provides.
Determining whether treatment is needed is dependent on the acuity of the situation and the specific client. Each situation is different in terms of an acceptable level of pain. For example:
- In an acute care situation when a client is having angina pain, treatment should result in no pain. With angina pain, think about the pathological processes leading to the pain (i.e., narrowing coronary arteries in which insufficient blood and oxygen is feeding the heart muscle). Treatment should resolve this pathological process and result in no pain.
- In a client who has chronic pain related to arthritis, typically treatment should result in no pain or to a level that is manageable for the client and does not significantly interfere with their functioning.
Depending on the situation, remember that treatment includes many possibilities such as medication, repositioning, activity, distraction, and other modalities.
Priorities of Care
Some of the main priorities of care related to pain assessment include:
- Angina pain: this is a critical finding that requires immediate action.
- A significant increase in pain, particularly when rated higher on intensity scales and the pain does not respond to treatment (e.g., medication). An increase in pain should prompt you to think critically about what is going on and what could be causing the increase. In this case, a full subjective and objective assessment of the pain is required and it should be promptly reported to the physician or nurse practitioner.
- Inadequately managed postoperative pain is of concern because of the physiological effects of pain on the body, such as tachycardia and hypoxia. Additionally, poorly controlled postoperative pain has been correlated with prolonged opioid use (Goesling et al., 2016). Thus, if the prescribed medications are not controlling the pain, you should do a full subjective and objective assessment of the pain and discuss with the health care team alternative medications and pain management approaches.
- Pain upon movement with a suspected fracture. Complications associated with fractures include hemorrhage and blood vessel damage, which can cause ischemia distal to the fracture due to a disruption in blood flow, nerve damage, and pulmonary embolism (usually associated with hip and pelvis fractures). Therefore, during the acute period you should immobilize the affected area/limb and continually assess peripheral blood flow (temperature, pulses), quality of breathing, breath sounds, respiration rate, and heart rate. When blood flow is disrupted distal to the periphery, this can cause cool skin temperature and decreased pulse force or absent pulse in the affected limb. Notify the physician or nurse practitioner of this pain and any associated critical findings immediately.
- Back pain associated with potential spinal cord compression: this is a serious issue that may require urgent intervention. The client should remain at rest while you report findings to the physician or nurse practitioner. Compression may be suspected with new onset and severe back pain associated with loss of bladder and/or bowel function and numbness and tingling in the arms and/or legs.
Activity: Check Your Understanding
References
Goesling, J., Moser, S., Zaidi, B., Hassett, A., Hilliard, P., Hallstrom, B., Clauw, D., & Brummett, C. (2016). Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain, 157(6), 1259-1265. https://doi.org/10.1097/j.pain.0000000000000516
Subjective assessment of the neurological system involves asking questions about the health of the client and symptoms that might be caused by pathologies affecting the central and peripheral nervous system. A full exploration of these pathologies is beyond the scope of this chapter, but common problems associated with the neurological system include cerebrovascular accidents (stroke), cerebral aneurysms, traumatic brain injury, neurodegenerative disorders (dementias, Parkinson’s disease), movement disorders, seizures, diabetes-related neuropathy, spinal cord injuries, brain tumours, delirium, migraines, and neurodiverse conditions.
Common symptoms that may be related to the neurological system include headache, paresis, paralysis, paraesthesia, dysphagia, dysarthria, visual changes/impairment, dizziness, balance issues, incoordination, seizures, tremors, confusion, fatigue, and nausea and vomiting. See Table 1 for guidance on subjective health assessment: many of the questions in the table align with the PQRSTU mnemonic (or variations of it). Try to ask questions in order of importance – you will not necessarily follow the sequential order of PQRSTU.
Always ask about any medications (prescribed or over the counter) or supplements the client is taking: name, dose, frequency, reason it was prescribed, and how long they have been taking it.
To help determine the validity of your findings, ask about other factors that may affect the neurological assessment such as alcohol or substance use. Try to evaluate the condition of the client in relation to their ability to comprehend questions and provide subjective data. On initial contact you will assess neurological status based on client responses: Are they awake? Are they paying attention to you?
Remember to ask questions related to health promotion. Depending on the context of the assessment, you may ask these questions and engage in a discussion during a subjective assessment or after an objective assessment. A section on “Health Promotion Considerations and Interventions” is included later in this chapter after the discussion of objective assessment.
Knowledge Bites
One common neurological condition is stroke, which is caused by a blocked or leaking cerebral artery (hemorrhage) causing damage in the brain. Its pathology is related to atherosclerosis and blood clots. If it is a temporary disruption of blood flow, it can result in a transient ischemic attack (TIA), commonly known as a mini-stroke. See Figure 4, which presents one type of stroke.
Figure 4: Ischemic stroke.
(from National Heart Lung and Blood Institute (NIH), Public domain, via Wikimedia Commons
https://commons.wikimedia.org/wiki/File:Stroke_ischemic.jpg)
Another common condition is traumatic brain injury (TBI). Always monitor clients closely when they have experienced an injury to the head and brain, which might be caused by a fall or a physical bump or jolt to the body/head. Concussion is one possible serious consequence of this kind of injury, and it can disrupt normal brain function and lead to an altered level of consciousness. Symptoms of concussion include confusion, headaches, problems with memory and judgment, sensitivity to light, disruptions in sleep, and nausea and vomiting. Another serious risk associated with traumatic brain injury is increased intracranial pressure (pressure inside the skull), which can be related to swelling and bleeding in the brain. Symptoms of increased intracranial pressure include headaches, vision impairment, vomiting, and weakness.
Table 1: Common symptoms, questions, and clinical tips.
| Symptoms | Questions | Clinical tips |
|
Headache is a specific type of pain that can be felt in one certain location or all over the head. It can be described in many ways including sharp, achy, throbbing, full, or squeezing with a viselike quality (a tight, strong, constricting feeling). Headaches occur when nociceptors react to certain triggers. There are many causes. Although some headaches are related to musculoskeletal injuries, most are neurologically-related and can be related to inflamed or damaged nerves and triggers such as stress, alcohol, lack of sleep, and certain food and medications. Other influences can include muscular tension, dental or jaw problems, infections, and eye problems. |
Do you currently have a headache? Have you recently experienced any headaches that you are concerned about? Do you have frequent, severe, and/or recurring headaches that disrupt your day-to-day functioning? |
A severe headache with a quick onset is a cue for concern. This kind of headache can be related to conditions such as stroke. Patients may describe these types of severe headaches as the worst headache they have ever had or say they have never experienced pain like this before. |
|
Paresis, paralysis, and paraesthesia are common symptoms associated with neurological conditions such as stroke or nerve damage. Paresis is decreased muscle strength of the voluntary muscle groups (often referred to as muscle weakness) whereas paralysis is the inability to move a muscle such as a limb. Paraesthesia is abnormal sensory sensations such as numbness (loss of feeling), tingling (sometimes described as pins and needles), or other characteristics such as burning and prickling. |
Have you experienced any decrease in muscle strength? (Or inability to move a muscle/limb or abnormal sensations such as numbness or tingling in your face, arm or leg?) Remember to incorporate the language that the client uses into your probing questions (below, “XX” is used to represent the client’s language). Additional probes if the client’s responses are affirmative may include: Timing: Are you currently experiencing XX now? When did it begin? Did it come on suddenly or gradually? Is it constant or intermittent? What were you doing when it began? How often do you get it? Quality/quantity: What does it feel like? How bad is it? |
Falls are a safety concern with paresis, paralysis, and paraesthesia. Fall risk assessment and prevention strategies are essential for client safety. If the client is mobile, strategies may include non-skid shoes or socks, use of prescribed mobility and assistive devices, and removal of hazards in the room. Nurses should consult with occupational therapists and physiotherapists to decrease the client’s risk of falls. Skin ulcers are another risk factor. Areas of the body that have lost or limited sensation or strength/movement should be assessed daily to decrease further damage to the area. Therefore, it may be important to assess clients using the Braden Scale for risk of pressure sores (see: Skin inspection via Braden Scale). Paresis, paralysis, and paraesthesia decrease client mobility and therefore increase the risk of blood clots, urinary stasis, decreased peristalsis, and pneumonia. Passive range of motion (ROM) exercises should be performed to encourage continuous movement of the joints and muscles. |
|
Dysphagia and dysarthria are common symptoms associated with various neurological conditions such as stroke, brain tumour, and neurodegenerative diseases (e.g., Alzheimer’s, multiple sclerosis, Parkinson). Dysphagia is impairment in swallowing. Clients often refer to it as difficulty or trouble swallowing and it is sometimes associated with pain. Dysarthria is a neuromotor impairment in speaking: clients may have difficulty saying or forming a word and may have reduced strength and speed when speaking. This can result in slow or slurred speech. |
Have you experienced any difficulty swallowing? Have you experienced any difficulty speaking? Remember to incorporate the language that the client uses into your probing questions (remember that below, “XX” refers to the client’s language). Additional probes if the client’s responses are affirmative may include: |
New onset of dysphagia requires immediate action because it can be associated with conditions such as stroke and can lead to clinical deterioration as well as other complications such as choking or aspiration pneumonia. Always notify the physician or nurse practitioner. Additionally, if the client is experiencing new onset dysphagia, it is important to restrict food or fluids until this has been fully assessed. If possible, have the client sit upright (e.g., High Fowler's position) or raise the head of the bed. After any acute symptoms have been managed, consult with a speech language pathologist and dietician to discuss safety measures required during meal assistance to decrease risk of choking and aspiration pneumonia. Dysphagia management tips may include a special dysphagia diet, having the client sit upright, placing food on the noneffective side of the mouth, use of thickening fluids, and taking small bites. Dysarthria can cause slowed, slurred speech, which may be misdiagnosed as intoxication. A thorough assessment is required to determine the cause of dysarthria to ensure proper interventions are performed. Evaluating a client’s speech, including changes in speech, is part of the primary survey assessment. Consult with a speech-language therapist on exercises to strengthen speech-related muscles and use of other communication aids. |
|
Visual impairment is a disturbance in the client’s ability to see. Symptoms may include blurred vision, double vision, or partial or complete vision loss (central or peripheral) in one eye or both, dark area in the visual field, shadowed vision, and/or light sensitivity. |
Have you experienced any difficulty seeing or new changes to your sight? (You may choose to provide some examples.) Remember to incorporate the language that the client uses into your probing questions (remember that below, “XX” refers to the client’s language). Additional probes if the client’s responses are affirmative may include: Timing: Are you currently experiencing XX now? When did it begin? Did it come on sudden or gradual? Is it constant or intermittent? How often do you get it? Quality/quantity: What does it feel like? How bad is it? Severity: Can you rate it on a scale of 0 to 10 with 0 being no XX and 10 being the most XX you have ever had? Region/radiation: Where in your eye do you experience it? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Treatment: Have you taken anything to treat it? Have you taken any medications? Understanding: Do you know what is causing it? Other: How does it affect your daily life? |
A sudden change in vision is a priority in care. This cue is considered an emergency and needs immediate action. Sudden vision change could indicate a stroke and blood clot in the retinal artery. Immediate care is required to decrease the risk of permanent vision loss (blindness). |
|
Dizziness, balance issues, and incoordination are neurological symptoms that are sometimes, but not always, associated with each other. Dizziness refers to impaired spatial orientation in which clients describe feeling light-headed, woozy, or that they might faint. It may be associated with nausea and syncope. (Vertigo is often described as dizziness, but vertigo is actually a different neurological symptom in which the client feels like they are spinning or the environment around them is spinning.) Balance issues are associated with feeling unsteady: the client feels like they may lose their balance or fall down. It can sometimes be associated with dizziness. Incoordination refers to loss of muscle control and lack of coordination such as the impaired ability to use parts of the body together (e.g., hands, arms, legs). It may result in impaired ability to walk smoothly or to use arms/hands together. |
Have you experienced any dizziness or a feeling of light-headedness? Remember to incorporate the language that the client uses into your probing questions (remember that below, “XX” refers to the client’s language). Additional probes if the client’s responses are affirmative may include: Quality/quantity: What does XX feel like? Have you ever passed out or lost consciousness? How bad is it? Timing: Are you currently experiencing it now? When did it begin? Is it constant or intermittent? What were you doing when it began? Is it associated with position changes such as standing up? How often do you get it? Severity: Can you rate it on a scale of 0 to 10 with 0 being no XX and 10 being the most XX you have ever had? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Treatment: Have you taken anything to treat it? Have you taken any medications? Understanding: Do you know what is causing it? Other: How does it affect your daily life? |
Fall risk assessment is essential to help the client take precautions against falling. As per the Canadian Institute of Patient Safety (2015), think about the SAFE mnemonic: Safe environment (e.g., well-lit environment, remove tripping hazards). Assist with mobility, including balance and transfers (e.g., if relevant, ensure mobility aids [cane, walkers], assistive devices [bars, eyeglasses, hearing aid], and assist client as needed). Fall risk reduction (e.g., non-slip footwear, bed in lowered position, call bell in reach). Engage the client and family (e.g., having conversations about risk factors and prevention). Various fall assessment tools are available to help you systematically assess risk factors related to falls. These factors may include a history of falls/near falls, acute condition, ability to move around, mobility aids, or hearing, vision, or cognitive impairment. If the client has already been assessed, you should follow all recommendations, as well as all institutional policies to prevent falls. |
|
Seizures are sudden changes in the brain’s electrical function that affect consciousness, muscle tone, movement, and sensations. For example, a client may be unable to move or walk, or may blink repeatedly, stare with no movement of eyes, experience stiffening and spasms of the muscles, loss of muscle tone, or exhibit sudden repetitive movements often described as twitching or jerking. Tonic-clonic seizures refer to seizures in which a client’s muscles stiffen and twitch. In contrast, a client experiencing an absence seizure often stares off into space and/or repeatedly blinks. After the active (ictal) phase, many clients experience a recovery (postictal) phase that typically last minutes to 30 minutes (but for some this period may last for days), with symptoms including sore muscles, fatigue, confusion, and headache. The cause of a seizure may be unknown, or a result of a head injury, infection, high fever, certain medications, electrolyte imbalance, or other diagnosis/illness. A client who has two or more seizures is often diagnosed with epilepsy. |
Have you experienced a seizure? Remember to incorporate the language that the client uses into your probing questions. Additional probes if the client’s responses are affirmative may include: Quality/quantity: What does it feel like or look like? Have you ever lost consciousness? How bad is it? Timing: When did you experience one last? How often do you experience them? At what age did you experience your first one? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Treatment: Have you ever sought treatment for it? Have you taken anything to treat it? Have you taken any medications? Understanding: Do you know what is causing it? Other: How does it affect your daily life? Has anyone ever told you that you have short episodes where you stare off into space or repeatedly blink? |
Seizures can last a few seconds to many minutes or longer. In some institutions, seizures are treated when they last longer than 3 minutes or the client has 3 within 30 minutes. Seizures can place the client in danger and safety precautions need to be considered. The client could be at risk of falling, accidents in the workplace (e.g., machinery), and pregnancy complications due to medications. Encourage clients to wear a medical alert bracelet. As per the Canadian Epilepsy Alliance (n.d.), when a client has a seizure:
Consider the client’s own unique plan to manage their seizures. |
|
Other neurological symptoms can include fatigue, tremors, fasciculations, confusion, hearing impairment, difficulty breathing, and nausea and vomiting. For example, tremors can be related to neurological diseases (e.g., Parkinson’s disease) or other factors such as caffeine, certain medications, or overactive thyroid. |
Always ask one question at a time. Questions might include: Have you experienced tremors or twitching like movements? (Or confusion, fatigue, hearing impairment, difficulty breathing, or nausea and vomiting?) Use variations of the PQRSTU mnemonic to assess these symptoms further if the client’s response is affirmative. |
These symptoms can be related to the neurological system as well as other body systems. It is important to explore these symptoms specifically if the client answers affirmatively. |
|
Personal and family history of neurological conditions and diseases. As noted earlier, common issues associated with the neurological system include stroke, migraines, seizures, dementia, Parkinson's disease, multiple sclerosis, or other movement disorders. |
Do you have any chronic neurological conditions or diseases? Do you have a familial history of neurological conditions or diseases? (Give examples). If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disease? Remember to incorporate the language that the client uses into your probing questions. If the client has a personal history, probing questions might include: Timing: When were you diagnosed? Quality/quantity: How does it affect you? What symptoms do you have? Treatment: How is it treated? Do you take medication? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? |
Risk factors may be influenced by genetics and/or culture, so you should ask about the biological and non-biological nature of family. Some neurological-associated diseases (e.g., Parkinson’s) are related to genetics, but it is more likely that environmental and cultural factors (such as family traditions and practices) play a larger role. Examples might include diet, sedentary lifestyle, and smoking. |
Priorities of Care
Respiratory distress is a first-level priority of care. Signs of respiratory distress and respiratory failure can be related to various neuromuscular disorders (Racca et al., 2019). Always screen for and recognize signs of respiratory distress (e.g., shortness of breath, stridor, desaturation, intercostal tugging, nasal flaring, difficulty talking). If any of these signs are present, notify the physician or nurse practitioner while supporting the client’s airway.
- If an airway is not patent, try to open the airway with a head-tilt-chin-lift and inspect the mouth and nose for obstructions.
- If oxygen saturations are low, try to wake the client if they are sleeping, sit them upright, and ask them to take a few deep breaths. Supplemental oxygen can be applied if there are standing orders on your unit.
- You may need to keep the client in a supine position if you suspect that they are deteriorating quickly and may go into respiratory or cardiac arrest. Notify the critical care response team (CCRT) or call a code in this case. Bag-mask-ventilation may be needed if the client is in respiratory arrest.
- If you suspect the client is choking, stay with the client and call for help while you place them in a High Fowler's position. If they are able to, encourage them to cough and clear their airway. You may need to suction the oral cavity and airway, if possible. If you suspect a complete obstruction, use a combination of “back blows, abdominal thrusts, and chest thrusts” (Canadian Red Cross – What to do if an adult is choking)
Stroke is one of the most acute neurological pathological conditions. As per the Canadian Stroke Best Practice Recommendations, acute stroke is a medical emergency. You should respond immediately by reporting your findings to a physician or nurse practitioner or call 911 in the community (or the emergency telephone number in your area, if not in Canada) (Heart & Stroke Foundation of Canada, 2022).
FAST – or more recently, BE-FAST – are common mnemonics used when assessing stroke (Aroor et al., 2017; Heart & Stroke of Canada, n.d.).
Balance: Are they having difficulty with balance, walking, coordination, or lower extremity weakness?
Eyes: Are they having difficulty with vision? (e.g., sudden trouble seeing out of one or both eyes or double vision).
Face: Is their face drooping, does it look asymmetrical, or do they have numbness on one side?
Arms: Do they have difficulty raising both arms or have numbness or weakness on one side?
Speech: Are they having trouble speaking, have slurred speech, or seem confused?
Time: Time is of utmost importance, so assess when the symptoms/signs began.
If you suspect a stroke, complete a brief scan (detailed later) and notify the physician or nurse practitioner. Depending on the hospital, you may notify the Critical Care Response Team or the Stroke Response Team. Assess and monitor vital signs, specifically blood pressure. Monitor for neurological deficits (e.g., decreased consciousness, confusion, dysphagia, dysphasia, ataxia, respiratory dysfunction such as Cheyne–Stokes respiration pattern). If you suspect a stroke, stay with the client and ensure their safety: restrict food/fluid intake and keep bed railings raised.
Contextualizing Inclusivity
The symptoms of neurological conditions (e.g., confusion, ataxia) and diseases or conditions that affect the neurological system can sometimes resemble intoxication from alcohol or substance use. It is important to reflect on your own biases and consider how they influence your perception of neurological symptoms and (in)actions and how this can lead to racist approaches to care. Prime examples of this are the real-life cases of Brian Sinclair and Joyce Echaquan, two Indigenous people who died from neglect as a result of factors associated with racism and being stereotyped.
Taking part in cultural safety and anti-racism training is one effective way to develop competence in working with diverse communities. This kind of training can help you understand the historical and institutional trauma experienced by marginalized communities including Indigenous and Black people, and how and why hospitals and emergency rooms can be considered unsafe places for them. Reflective practice is an important way to explore and understand one’s potential biases: education is a key element to help uncover one’s unconscious biases and disrupt deeply rooted problematic beliefs.
It is also vital to listen, validate, and act on what clients say. This is particularly important with racialized people because of the racism they have experienced and the serious effects it has on their lives and the healthcare they receive. Racism is consistently recognized as a social determinant of health and as a factor in the high rates of cardiovascular disease among Indigenous and Black communities in Canada (Olanlesi-Aliu et al., 2023; Vervoort et al., 2022). For example, these populations may have inequitable access to healthy food and inequity, which can be linked with cardiovascular diseases including stroke, which has a significant neurological impact.
With regard to sex and gender differences, increased mortality and disability rates have been observed among women (Rexrode, 2022). More research is needed to explore symptom presentation, as well as biases among healthcare providers that may influence how symptoms are interpreted and responded to (Rexrode, 2022).
Knowledge Bites
Choosing Wisely Canada recommends that opioids should not be the first line of treatment for neuropathic pain and should not be used to treat migraines (Canadian Neurological Society, 2022). Other analgesics have demonstrated better results in treating neuropathic pain (Moulin et al., 2014), and opioids are also associated with increased risk of harm (Canadian Neurological Society, 2022).
Aroor, S., Singh, R., & Goldstein, L. (2017). BE-FAST (Balance, eyes, face, arm, speech, time). Reducing the proportion of strokes missed using the FAST mnemonic. Stroke, 48(2), 479-481.
Canadian Epilepsy Alliance (n.d.). Seizure First Aid. https://www.canadianepilepsyalliance.org/about-epilepsy/epilepsy-safety/seizure-first-aid/
Canadian Neurological Society (2022). Neurology: Five tests and treatments to questions. https://choosingwiselycanada.org/recommendation/neurology/
Canadian Patient Safety Institute (2015). Reducing falls and injuries from falls. https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Epilepsy Canada (n.d.), https://www.epilepsy.ca/seizures
Heart & Stroke of Canada (2022). Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7th edition. https://www.strokebestpractices.ca/-/media/1-stroke-best-practices/acute-stroke-management/csbpr7-acute-stroke-management-module-final-eng-2022.pdf?rev=44cca46747ed4f4c8870b8a135184f5a
Heart & Stroke of Canada (n.d.). Signs of stroke. https://www.heartandstroke.ca/stroke/signs-of-stroke
Olanlesi-Aliu, A., Alaazi, D., & Salami, B. (2023). Black health in Canada: Protocol for a scoping review. JMIR Research Protocols, 12, e42212.
Racca, F., Vianello, A., Mongini, T., Ruggeri, P., Versace, A., Vita, G. L, & Via G. (2019). Practical approach to respiratory emergencies in neurological diseases. Neurological Sciences, 41, 497-508.
Rexrode, K., Madsen, T., Yu, A., Carcel, C., Lichtman, J., & Miller, E. (2022). The impact of sex and gender on stroke. Circulation Research, 130(4), 512-528. https://doi.org/10.1161/CIRCRESAHA.121.319915
Vervoort, D., Kimmaliardjuk, D., Ross, H., Frames, S., Ouzounian, M., & Mashford-Pringle, A. (2022). Access to cardiovascular care for Indigenous Peoples in Canada: A rapid review. Canadian Journal of Cardiology Open, 4(9), 782-791.
An objective assessment of the neurological system includes:
- Brief scan of the neurological system.
- Glasgow Coma Scale.
- Cranial nerve testing.
- Motor function and cerebellar testing.
- Sensory function testing.
- Reflex testing.
An objective assessment is usually completed after the subjective assessment, but if the client shows signs of clinical deterioration, you may proceed directly to the objective assessment and associated interventions. In this case, it is important to prioritize care after a brief scan that involves components of the primary survey.
The order of the neurological assessment, and choices about whether a complete neurological assessment is needed, will depend on the context (primary care setting, hospital setting, long-term care, rehabilitation) and the presence of neurological symptoms and signs or history. A complete neurological assessment includes all components listed above. You should conduct a complete neurological assessment if:
- The client reports neurological symptoms or you observe signs.
- The brief scan reveals abnormal findings.
- You need to track symptoms and signs when following the progression of a neurological disease.
Screening of the neurological system also depends on the context. At a minimum, you should conduct a brief scan of the neurological system and the Glasgow Coma Scale, as detailed in the next section. Always do a screening if you are aware of changes in behaviour and communication. Table 2 presents medical terminology related to neurological findings.
Contextualizing Inclusivity
Always use a trauma-informed approach when conducting an objective assessment, because you may need to expose the body.
- Maintain privacy by closing the door and/or curtains.
- Ask the client if they would like a family member, friend, or another healthcare provider present.
- Provide a drape to the client and only expose areas of the body as needed.
- Always ask permission to touch.
- Explain what you are doing throughout the assessment. Sometimes it is helpful to demonstrate it on yourself so the client knows what to expect.
- Collaborate “with” the client versus “doing to” the client.
- Use a culturally-informed approach and provide choice whenever possible to empower the client.
- Ensure the clients know that they can take a break at any point.
Consider how a trauma-informed approach can be used when a client is unable to speak or advocate for themselves due to their neurological condition or sedation. Sometimes healthcare professionals neglect this approach when the client is unresponsive, but in fact, it is even more important in these situations.
Table 2: Medical terminology related to neurological findings.
|
Term |
Definition |
|
Hyposmia |
Partial loss of the sense of smell. |
|
Anosmia |
Complete loss of the sense of smell. |
|
Esthesia |
Perception of touch sensation. |
|
Hypoesthesia |
Decreased sensitivity to touch sensation. |
|
Anesthesia |
Loss of sensitivity to touch sensation or inability to feel touch sensation. |
|
Hyperesthesia |
Increased sensitivity to touch sensation. |
|
Algesia |
Sensation of pain. |
|
Hypoalgesia |
Decreased sensitivity to pain sensation. |
|
Analgesia |
Loss of pain sensations or inability to feel pain sensation. |
|
Hyperalgesia |
Increased sensitivity to pain sensation. |
|
Paresis |
Decreased muscle strength of the voluntary muscle groups (often referred to as muscle weakness). |
|
Paralysis |
Inability to move a muscle such as a limb. |
|
Paraesthesia |
Abnormal sensory sensations such as numbness (loss of feeling) or tingling (sometimes described as pins and needles) or other characteristics such as burning and prickling. |
|
Dysphagia |
Impairment in swallowing such as difficulty swallowing or pain while swallowing. |
|
Dysphasia |
Impairment in use or comprehension of language. |
|
Dysarthria |
Neuromotor impairment in speaking in which clients have difficulty saying or forming a word, or difficulty with the strength and speed of speaking, which can result in slow or slurred speech. |
|
Flaccid |
Muscles that have no resistance and no tone (atonic). |
|
Rigid |
Increased muscle resistance that is consistent at rest and with movement. |
|
Spasticity |
Increased muscle resistance that decreases with continuous movement and worsens at extreme ROM. |
References
Arthur, E., Seymour, A., Dartnall, M., Beltgens, P., Poole, N., Smylie, D.,…Schmidt, R. (2013). Trauma informed practice guide. Vancouver, B.C: BC Provincial Mental Health and Substance Use Planning Council. Retrieved from https://bccewh.bc.ca/2014/02/trauma-informed-practice-guide/
A brief scan of the neurological system involves an assessment that allows you to quickly recognize neurological signs, changes in clinical status, and cues of clinical deterioration. This brief scan will influence your decision on whether immediate action is required and whether a focused assessment is needed.
Steps of a brief scan include:
- Assess airway patency. Are they having any difficulties breathing, talking, swallowing?
- Level of consciousness and level of orientation. Are they confused or disoriented about person, place, time, self? Are they unable to respond appropriately to questions such as: Can you tell me who I am? Can you tell me where you are? What year is it? Who are you?
- Assess vital signs. Are the vital signs within the normal ranges or have there been any changes?
- Speech. Is their speech unclear, slurred, delayed, not making sense?
- Mobility and balance. Are they having any difficulty with balance (standing, walking, sitting upright), movement of limbs, or exhibiting drooping of the face/eyelids/mouth?
- Mental health status. Are there any concerning cues, e.g., inattentive, flat affect, or labile affect? Has the client verbalized that they are not feeling quite themselves or provided a vague statement about their mental health?
Pupillary light reflex is often assessed as well. More to come on how to do so later in the chapter.
Knowledge Bites: Cognitive Impairment
Various tools are available to support assessment when cognitive impairment is observed during the brief scan or if the client or family member indicates the client is having some problems with memory. These include:
- The Mini-Mental State Exam (MMSE) and the Standardized Mini-Mental State Exam (SMMSE), which are used to evaluate cognitive function and detect cognitive impairment (Vertesi et al., 2001). Some nurses prefer the SMMSE because it is timed, meaning that clients are given a limited amount of time to answer a question (e.g., What year is it?).
- Montreal Cognitive Assessment Test (MoCA), which is particularly useful for detecting “mild” cognitive impairment (MoCA Cognition, 2023). For example, if the client/family has indicated problems with memory but the MMSE/SMMSE results are normal, you might decide to use the MoCA. Training and certification is encouraged for healthcare professionals to maintain the validity of the test.
Another tool is The Canadian Neurological Scale, which was developed to monitor and evaluate neurological functioning during the acute phase of a client with a stroke (Cote et al., 1986). The main components include mentation and motor response. Check it out: The Canadian Neurological Scale
Clinical Tips – Common Tests as Part of the Brief Scan
The following common tests are often used to evaluate mobility and innervation of muscles in hospitalized clients:
- Hand grip: Stick out the index and middle finger of both of your hands, and ask the client to grasp them and squeeze.
- Manual muscle testing - arms: Ask the client to extend their arms out in front of them and then bend their arms toward them (elbow flexion) and resist your force when you apply pressure both in the movement of flexion, and then extension.
- Pronator drift: Ask the client to close their eyes and extend their arms out in front of them with palms facing up for 30 seconds.
- Movement: Ask the client to wiggle their toes.
- Manual muscle testing - feet: While the client is lying supine, place your hands on the balls of the feet and ask the client to resist your pressure when you push.
Note: Clients should have equal muscle strength bilaterally in hands and feet, able to wiggle their toes, and maintain their arms out in front of them (see Video 1 for a demonstration).
Video 1: Common tests to evaluate mobility and innervation of muscles in hospitalized clients
Priorities of Care
Any issues with airway patency and respiratory distress (e.g., stridor, difficulty breathing, difficulty/inability to speak) are significant cues of concern.
- Stay with the client and call for help (an experienced nurse, physician, or nurse practitioner).
- If an airway is not patent, try to open the airway with a head-tilt-chin-lift and inspect the mouth and nose for obstructions.
- If oxygen saturations are low, try to wake the client if they are sleeping, sit them upright, and ask them to take a few deep breaths. Supplemental oxygen can be applied if there are standing orders on your unit.
- You may need to keep the client in a supine position if you suspect that they are deteriorating quickly and may go into respiratory or cardiac arrest. Notify the critical care response team (CCRT) or call a code in this case. Bag-mask-ventilation may be needed if the client is in respiratory arrest.
- If you suspect the client is choking, stay with the client and call for help while you place them in a High Fowler’s position. If they are able to, encourage them to cough and clear their airway. You may need to suction the oral cavity and airway, if possible. If you suspect a complete obstruction, use a combination of back blows, abdominal thrusts, and chest thrusts (Canadian Red Cross – What to do if an adult is choking).
All other abnormal cues of the brief scan (particularly if they are new onset) require immediate attention and a focused assessment. Abnormal cues can be associated with many conditions, stroke being of the most concern. For example, a sudden change and decrease in consciousness or aphasia or limb weakness are potential signs of a stroke and are critical findings that require immediate action and must be reported to a physician or nurse practitioner. Complete a primary survey and perform a focused assessment. Be aware that time from first symptom to treatment is a factor in permanent disability and/or death.
References
Cote, R. et al. (1986). The Canadian Neurological Scale: A preliminary study in acute stroke. Stroke, 17(4), 731-737.
MoCA Cognition (2023). About us. https://mocacognition.com/about/
Vertesi, A., Lever, J., Molloy, W., Sanderson, B., Tuttle, I. Pokoradi, L., & Principi, E. (2001). Standardized Mini-Mental State Examination. Canadian Family Physician, 47(10, 2018-2023.
