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to close the eyes. Hold the tip of one of the patient’s fingers between your thumb and index finger. Move it up and down and ask the patient to say in which direction it is moving. Repeat with the other hand. For the legs, hold the big toe. To test proprioception. (Bickley and Szilagyi 2009, E). Proprioception is the receipt of information from muscles and tendons in the labyrinth that enables the brain to determine movements and the position of the body (Tortora and Derrickson 2009, E).

Postprocedure

32 Document the observation recordings on the patient’s observation chart, record only what you see and do not be influenced by previous observations. To ensure adequate records and enable continued care of the patient (NMC 2009, C).

33 Report any abnormal findings to medical staff. To prevent further deterioration. E

34 Clean the equipment after use. To prevent crossinfection (Fraise and Bradley 2009, E).

Problem-solving Table 12.8 Prevention and resolution (Procedure guideline 12.9)

Postprocedural considerations

Documentation

A validated observation chart is the most common method of monitoring and recording neurological observations. Although the layout may differ from chart to chart, in essence all neurological observation charts measure and record the same clinical information, including the level of consciousness, pupil size and response, motor and sensory response and vital signs (Dawes and Durham 2007).

Observation charts ensure a systematic approach to collecting and analysing essential information regarding a patient’s condition. Such charts also act as a means of communication between nurses and other healthcare professionals (Dawes and Durham 2007).

References

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Aucken, S. and Crawford, B. (1998) Neurological observations, in NeuroOncology for Nurses (ed. D. Guerrero). Whurr, London, pp. 29–65.

Bateman, D. (2001) Neurological assessment of coma. Journal of Neurology Neurosurgery and Psychiatry, 71 (Suppl 1), i13–i17.

Bayer Diagnostics (1997) Urinary Tract Infection. Technical Information Bulletin No. 8. Bayer Diagnostics, Newbury.

Bayer Diagnostics (2006) Your Practical Guide to Urine Analysis. Bayer Diagnostics, Newbury.

Bayham, E., Fucile, F., McKenzie, N. and O’Hara, O (1996) Clinical Considerations for Use of First Temp R and First Temp Tympanic Thermometers, Sherwood Davis and Geck, St Louis, MO.

BCSH (1999) The administration of blood and blood components and the management of transfused patients. Transfusion Medicine, 9, 227–238.

Beachy, W. (2009) Acidbase balance, in Egan’s Fundamentals of Respiratory Care, 9th edn (eds R.L. Wilkins, J.K. Stoller and R.M. Kacmarek). Mosby Elsevier, St Louis, MO.

Belford, K. (2005) Central nervous system cancers, in Cancer Nursing: Principles and Practice, 6th edn (eds C. HenkeYarbro, M. Frogge and M. Goodman). Jones and Bartlett, Sudbury, MA, pp. 1089–1136.

Bern, L., Brandt, M., Mbelu, N. et al. (2007) Differences in blood pressure values obtained with automated and manual methods in medical inpatients. MEDSURG Nursing, 16 (6), 356–361.

BHS (2006) Factfile 01/2006 – Blood pressure measurement. www.bhsoc.org/bhf_factfiles/bhf_factfile_jan_2006.doc.

Bickley, L.S., and Szilagyi, P.G. (2009) Bates’ Guide to Physical Examination and History Taking, 10th edn. Lippincott Williams and Wilkins, London.

Bishop, T. (2008) Urine testing. Practice Nurse, 35 (12), 18–20.

Blake D.R. and Nathan D.M. (2004) Pointofcare testing for diabetes. Critical Care Nurse, 27 (2), 150–161.

Booker, R. (2008) Pulse oximetry. Nursing Standard, 22 (30), 39–41.

Booker, R. (2009) Interpretation and evaluation of pulmonary function tests. Nursing Standard, 23