NLE Neurosensory Nursing — Neurologic Assessment and DiagnosticsConcept Map

Concept

Neurophysiology Fundamentals

Sub Concepts

• Central Nervous System (CNS)
• Peripheral Nervous System (PNS)
• Brain Regions (Cerebrum, Cerebellum, Brainstem)
• Monro-Kellie Doctrine
• Intracranial Pressure (ICP)
• Cerebral Perfusion Pressure (CPP)

Relationship To Central

Foundation for understanding the anatomical and physiological basis of neurologic assessment

Concept

Clinical Assessment Components

Sub Concepts

• History Taking
• Level of Consciousness (LOC)
• Glasgow Coma Scale (GCS)
• Pupillary Assessment
• Cranial Nerve Testing
• Motor Function Assessment
• Sensory Testing
• Reflex Testing

Relationship To Central

Direct bedside evaluation methods used in neurologic assessment

Concept

Diagnostic Imaging and Procedures

Sub Concepts

• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Lumbar Puncture (LP)
• Intracranial Pressure (ICP) Monitoring
• Electroencephalography (EEG)
• Cerebral Angiography

Relationship To Central

Laboratory and radiologic investigations supporting clinical assessment

Concept

Monitoring and Vital Signs

Sub Concepts

• Serial Neuro Checks
• Cushing's Triad
• Vital Signs Changes
• Waveform Analysis

Relationship To Central

Continuous assessment parameters indicating neurologic status change

Concept

Clinical Application and Nursing Care

Sub Concepts

• Patient Safety and Positioning
• Infection Control
• Patient Education
• Emergency Recognition
• Documentation
• Nursing Diagnoses (NANDA)

Relationship To Central

Implementation of assessment findings into patient care planning per RA 9173 scope

To

Glasgow Coma Scale

From

Level of Consciousness

Strength

strong

Relationship

GCS is the standardized quantitative tool for objectively measuring level of consciousness across three parameters

To

Intracranial Pressure

From

Monro-Kellie Doctrine

Strength

strong

Relationship

Doctrine explains the fixed skull volume containing three components; any increase in ICP occurs when compensatory mechanisms fail

To

Cerebral Perfusion Pressure

From

Intracranial Pressure

Strength

strong

Relationship

CPP is directly calculated from ICP using the formula CPP = MAP - ICP; critical for maintaining brain viability

To

Cranial Nerve III Oculomotor

From

Pupillary Assessment

Strength

strong

Relationship

Pupils are controlled by CN III; a blown pupil indicates compression of CN III from herniation

To

Abnormal Posturing

From

Motor Response Assessment

Strength

strong

Relationship

Motor response assessment reveals abnormal posturing; decorticate indicates supratentorial damage while decerebrate indicates brainstem involvement

To

Intracranial Pressure Elevation

From

Cushing's Triad

Strength

strong

Relationship

Cushing's triad (rising BP, bradycardia, irregular respirations) is a late clinical manifestation of dangerously elevated ICP

To

Airway Protection and Intubation

From

Glasgow Coma Scale

Strength

strong

Relationship

A GCS of 8 or below is the threshold for airway protection because of inability to protect airway

To

Intracranial Pressure Increased

From

Lumbar Puncture

Strength

strong

Relationship

Lumbar puncture is contraindicated when ICP is elevated due to risk of herniation from pressure gradient change

To

Stroke Differentiation

From

Computed Tomography

Strength

strong

Relationship

CT is first-line imaging in acute stroke to distinguish hemorrhagic from ischemic stroke

To

Metal Screening

From

Magnetic Resonance Imaging

Strength

strong

Relationship

MRI uses powerful magnetic field; metal implants, pacemakers, and ferromagnetic objects must be screened and removed for safety

To

CSF Therapeutic Drainage

From

ICP Monitoring Intraventricular Catheter

Strength

strong

Relationship

Ventriculostomy is gold standard for ICP monitoring because it allows direct measurement AND therapeutic CSF drainage to reduce pressure

To

Serial Monitoring

From

Neurologic Assessment

Strength

strong

Relationship

Serial neuro checks track changes over time; trending is essential to identify deterioration early

To

Upper Motor Neuron Lesion

From

Babinski Reflex

Strength

strong

Relationship

A positive Babinski reflex in adults indicates an upper motor neuron lesion; normal in infants

To

Subtle Motor Weakness

From

Pronator Drift

Strength

moderate

Relationship

Pronator drift is a sensitive sign of mild or early motor weakness often detected before frank strength loss

To

Localization of Lesion

From

Cranial Nerve Assessment

Strength

moderate

Relationship

Cranial nerve deficits help localize the neurologic lesion to specific brainstem or peripheral sites

To

Prevention of Complications

From

Patient Education

Strength

moderate

Relationship

Educating patients about red flag symptoms and post-procedure care facilitates early detection of problems

To

Spinal Cord Level Determination

From

Sensory Testing

Strength

moderate

Relationship

Sensory loss in specific dermatomal patterns helps determine the spinal cord level of injury or lesion

To

Seizure Detection

From

Electroencephalography

Strength

strong

Relationship

EEG records brain electrical activity and is primary tool for seizure diagnosis and brain death confirmation

To

Vascular Lesion Identification

From

Cerebral Angiography

Strength

strong

Relationship

Angiography visualizes cerebral vessels and identifies aneurysms, vascular malformations, and arterial dissections

To

Scope of Neurologic Assessment

From

RA 9173 Philippine Nursing Practice Act

Strength

strong

Relationship

RA 9173 defines the legal scope of nursing assessment and the conditions under which nurses can perform neurologic evaluations and report findings

To

Assessment Findings

From

NANDA Nursing Diagnoses

Strength

strong

Relationship

Assessment findings such as LOC changes, motor deficits, and sensory loss guide formulation of NANDA diagnoses like Altered LOC, Risk for Injury

To

Assessment Prioritization

From

Maslow's Hierarchy

Strength

strong

Relationship

Airway protection (GCS ≤8), vital sign stability, and prevention of further deterioration are physiologic/safety priorities in neurologic assessment

To

Spasticity and Tone Assessment

From

Deep Tendon Reflexes

Strength

moderate

Relationship

Hyperreflexia and muscle tone changes indicate upper motor neuron involvement; hyporeflexia indicates lower motor neuron involvement

To

Hypothalamic Function

From

Temperature Monitoring

Strength

moderate

Relationship

Rising temperature in neurologic patient may indicate hypothalamic involvement or secondary infection requiring investigation