Long-Term Care

Neurological checks for head injuries

LTC Clinical Pearls: Powered by HCPro's Long-Term Care Nursing Library, January 8, 2013

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  1. Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours.
  2. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion; memory loss; difficulty speaking; gait or balance problems; pupils of unequal size or reactions; headache; vomiting; visual disturbances; or periods of coherence alternating with periods of confusion or lethargy. Monitoring must continue for a minimum of 72 hours (or until the resident is asymptomatic for a specified period of time).
  3. Perform frequent neurologic assessments every:
    • 15 minutes for two hours
    • 30 minutes for two hours
    • 60 minutes for four hours
    • Eight hours for 16 hours
    • Eight hours until at least 72 hours have elapsed and resident is stable
  4. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. Completing the Glasgow Coma Scale immediately, then once each shift following a head injury, helps keep findings objective.



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