This article shows how through the application of a conceptual model the nurse uses tools in the neurological assessment of the individual, to identify, analyze and interpret, through the coping, cognitive and regulatory mechanisms, all those effective and ineffective responses, and the stimuli that trigger them. In this way, it identifies problems of adaptation and generates a nursing diagnosis, in order finally to be able to give timely and effective care, that allows the individual to achieve his/her adaptation, and the nurse to evaluate, in an objective and pertinent way.
Since its inception, the Faculty of Nursing of the University of La Sabana has implemented in its curriculum the Callista Roy model, through which, in each of the nursing subjects. And, it delves not only into the conceptual part of the model but into its application to provide nursing care.
Through physical evaluation, conditions of the person are discovered as being integral, which allows planning of nursing care and, therefore, to promote the adaptation of the individual, as stated by Callista Roy.
Roy’s model is based on the theory of systems, according to which stimuli (inputs) are the ones that provoke a response (outputs). It is done through some mechanisms of confrontation, which are the cognitive subsystem, which refers to the assessment of judgment, emotion, memory, and reasoning, and includes the role of the role, interdependence, and self-concept of the individual, and the regulatory subsystem, which involves the entire physiological part of being. And it does through the functions, which Roy will be the effectors: the oxygenation and circulation function, the neurological, the sense organs, the endocrine function and reproductive, protection, nutrition, activity and rest, the elimination of fluids and electrolytes.
The Coping mechanisms (cognitive and Regulatory) are based on processes of neurological function. (Intact neural channels affect regulatory processing). Similarly, perceptual processing, information, learning, judgment, and emotions are cognitive processes, with a neurological basis. Managing a good knowledge of the anatomy and physiology of neurological function gives sufficient elements to understand the thought, feeling, movement and interaction of the individual subject to adaptation in the changing environment.
The effectors, which are the psychosocial and physiological mode, contribute to the holistic functioning of the person. In neurological function, there are two basic vital processes: cognition and consciousness. The processes of cognition, which make it possible to relate past and present experiences, act as a regulator of vital events.
Let us remember that cognition encompasses human abilities to think, feel and act.
“Roy’s model shows that cognitive processes occur within the field of consciousness. Consciousness is characterized by awakening and being alert. The environment for cognitive processing includes Focal stimuli, such as immediate sensory experience, and contextual and residual stimuli are considered primarily in terms of education and experience.”
This confirms the importance of realizing a complete anamnesis of the individual subject to be valued, as it can give us fundamental elements for their care, among others, the direct influence of the surrounding environment. It can affect it effectively or ineffectively. We cannot forget to look into their family and personal history since most of the behaviors learned in the course of life are obtained from the family and their own experiences, and the individual can use them when they are in a process of illness.
Guidance For Assessing Neurological Function
To guide a good and complete assessment of Nursing in the neurological function, we must contemplate some steps that can guide us to find more clearly the answers in that function, as well as the stimuli that produce them.
The minimum elements that are used, are the phonendoscope, the tensiometer, the hammer of reflections, the equipment of the senses organs, the applicators, the essences of different smells, the substances for the perception of flavors, the ocular occluders, a tuning fork, Snell’s letter, a flashlight, a tongue shaper, cold, hot, sharp and soft elements.
You must also possess the skill in the interview technique to obtain the data that the patient or their family can provide.
The technique of permanent observation is used for the physical evaluation of neurological function from the time the individual enters the consultation or from the time they are identified in the unit. If the patient is hospitalized, the examiner should be highly observable. Another technique used is palpation, which provides information on shape, size, strength, sensitivity, displacement, and vibration. Finally, by means of the measurement technique, we obtain data quantity, such as visual acuity, strength, muscle tropism, and reflective activity.
Anamnesis should be performed once the assessment is initiated to determine the age, sex, occupation, origin, marital status, names of the respondents or the person responsible, EPS to whom they are affiliated ; personal history, such as illnesses that the individual has suffered or are suffering from; medicines that they usually consume, whether medicated or self-medicated, or if they consume any psychoactive substance; cigarette and alcohol consumption; history of previous traumas, surgeries or hospitalizations; important family history and etc.
As what is intended is to provide holistic care to the individual, we must take into account the effectors, that is to say, evaluate the psychosocial and physiological modes. Next, the evaluation of the role, interdependence and self-concept are carried out, since these can provide key elements to analyze the mechanisms of confrontation (cognitive and regulatory).
The psychosocial model is determined by means of the family assessment tools: familiogram, and ecomap, which generally show the functionality of the valued individual’s family, as well as the relationships of the valued individual as a family member and the way it interacts with the surrounding environment.
We have to delve into self-concept, how their physical, ethical, moral and spiritual self feels; inquire about the roles they play and how they feel performing each of these. To complement this, the information should be obtained on how to relate to others and the need for others to live together.
Do not forget that this information provides important data on neurological function, such as memory, judgment, emotion, reasoning, affection, aspects that are valued to establish the intellectual capacity of the individual.
To organize the information and to continue the assessment of the neurological function, one must follow the mental examination, in which the levels of alert of the individual and his / her way of reacting to the medium are identified.
- These levels are : consciousnes;
- The patient responds coherently to the call and the surrounding environment; drowsiness:
- The patient awakens to various stimuli, his/her motor and verbal responses are adequate, mentally appears clear, but, when the stimulus is withdrawn, returns to drowsiness; confusion:
- The patient has altered his / her responses to external stimuli, is unable to recognize and understand the world around him/her, nor is there clarity in thought or memory; stupor:
- The patient responds to painful and tactile stimuli, as well as strong auditory stimuli, and can answer some questions or execute simple orders; by withdrawing the stimulus, he/she enters again in lethargy and often presents spontaneous movements; coma:
The next step is the assessment of intellectual capacity, considered “as the ability to make an abstraction, to use symbols and to value new experiences in the light of past experiences”. This assessment necessarily leads to an analysis of the coping mechanism, the cognitive subsystem, for which they are valued:
- Guidance. It depends on memory and attention. It should be investigated whether the patient knows who he/she is, what the date or day he/she is and he/she is.
- Attention. The patient’s ability to concentrate on an activity or task, or the fact of answering the interviewer’s questions, is observed.
- Memory. It evaluates the recent or remote mental record; it must describe recent historical facts as well as past historical or relevant facts.
- Thought. The logical, coherent and relevant sequence of the individual is evaluated when addressing a selected object; for example, with the question “What do you see in the picture?”
- Affection. It is a feeling that can be observed immediately in the patient, as an episode of crying or laughing.
- Estimate. The ability to do mathematical calculations, such as sums or failing by identifying banknotes, is assessed.
- Judgment. The capacity for abstraction or interpretation is measured by asking it to interpret, for example, a saying.
- And finally,the language. This must be understandable and coherent; it also assesses how words are spoken.
This concludes the first part of the neurological assessment.
The second step is the assessment of cranial nerves, where the organs of the senses are also involved. Some of these cranial nerves are sensitive. Therefore, the identification of both effective and ineffective responses of the individual depends on the correct assessment of each individual.
In the third step they are valued:
- Motor function, which is defined as the neurological organization of motion and involves physical mobility, gait, coordination of all individual movements and synchronism.
- Muscle strength, which goes from complete absence of force to normal force (0-5).
- Muscular tone, which can be seen by observing the patient’s attitude in the bed or in the way of manipulating elements, in the position of the extremities, in the relief of the muscle masses, in the consistency of the muscles when they touch them and in the resistance they present to the movements; the responses can be hypotonia.
- Muscle tropism, observable in muscle development. The best way to discover its decrease or increase is to measure symmetrically the muscles of the extremities, without forgetting that there is greater development of the muscles of the dominant hemisphere, depending on whether the individual is right-handed or left-handed; the difference should not be greater than one centimeter.
- The coordination or proper use of motor and sensory pathways, which depends on the proper functioning of the cerebellum and vestibular apparatus. The assessment of coordination, according to Callista Roy, becomes more thorough in the functions of activity and rest.
- Reflexes, which are the involuntary motor response triggered by a specific sensory stimulus. Among these we have the tendinomuscular, consisting of the sudden stretching of a muscle, which is obtained by hitting the tendon of the muscle near its insertion; the answer is the rapid movement of the body part.
Finally, sensitivity is assessed, which is of two types: superficial and deep. The superficial is evaluated by means of the temperature, pain, and touch, and the second, in the experienced deep pain, through pressure, vibration and proprioception.
The neurological assessment allows us to easily identify stimuli and responses and therefore to analyze completely the coping mechanisms, which are more framed in cognition, since, thanks to the knowledge and the fact that the individual becomes aware of his or her own problems of adaptation, this can contribute to improving them and getting involved through self-care.