Neurological assessment

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  • Created by: Kat:)11
  • Created on: 19-04-16 10:26

Cerebral lobes and their functions

Frontal lobe voluntary motor activity speech thought Temporal lobe processes sound / speech Occipital lobe processes visual input Parietal lobe processes sensations ( touch, pressure, heat, cold) proprioception; awareness of body position.        

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Why is neurological assessment important?

To determine if someone’s level of consciousness and general neurological condition is: static improving deteriorating

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Common causes of altered consciousness have reduce

Examples may include……...

          Direct causes: head / spinal injury, brain damage (hypoxia, CVA, etc), neuromedical conditions, trauma, metabolic changes

          Secondary causes: drugs (sedatives / opiates / anaesthetics), environmental factors, homeostatic changes

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What is the Glasgow Coma Scale?

  A standardised and practical method of assessing impaired consciousness

 Allows a baseline of neurological function to be established

 Determines any changes in the patients neurological condition over a period of time

 Detects life threatening situations & those which need medical intervention

 Establishes the impact a condition has on the patients independence.

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The Glasgow Coma Score (GCS)

Determining the degree of stimulation required to elicit a response. 

Three components Eye opening (max. 4 points) Best verbal responses (max. 5 points) Best motor response (max 6 points)

The maximum score is 15

Fully alert, orientated  and responsive

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Best eye opening response

Closely linked to being awake, and that arousal mechanisms are functioning Relates to function of brain stem, hypothalamus and thalamus (RAS) Eye opening does not always indicate intact neurological function

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Best eye opening response

4  Patient opens eyes spontaneously when nurse approaches bedside

3  Patient opens eyes in response to speech (normal, then increase volume if necessary)

2  Patient opens eyes in response to pressure (painful stimuli) (touch normally before using painful stimuli)

1  There is no response from the patient at all following sufficient stimuli

NT  To be recorded if patients eyes are closed due to peri-orbital swelling

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Best verbal response

       Examines comprehension (understanding) of sensory input & verbal stimuli

       Reflects patients ability to articulate and express a reply

       Involves cognition of stimuli

       May be affected if there has been damage to speech centres i.e. dysphagia

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Best verbal response

5             Patient is orientated to time (month), place (where they are & why) + person (their name).  Allowances are made for minor inconsistencies.

4              Patient is confused (able to converse but gives wrong answers)

3              Patient speaks only (inappropriate) words (minimal verbal response, no structure or sentence)

2              Patient makes only (incomprehensible) sounds (grunts or moans to verbal or painful stimuli)

1              Patient makes no response

NT          Factor interfering with communication i.e. endo- or tracheal tube in situ

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Best motor response

Testing ability to identify sensory input & translate into motor response

Focuses on performance of limbs

Scores from highest level of brain involvement to lowest

Purposeful response excludes automatic or reflex reaction. 

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Best motor response

6   Patient can obey commands which have 2 parts of instruction, such as ‘raise and lower your arm’.

5   Localises to pain (moves hand to remove a source of irritation). Needs to be specific response to source of sensory stimulation, usually to head or neck.

4   Attempts to withdraw (normal flexion) from the source of pain; flexion of arm towards pain but not localising.

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Best motor response

3(Abnormal) flexion to pain (decorticate posturing). Pt will flex arm & rotate wrist. Legs may extend

2  Extension to pain (decerebrate posturing).    Arms extend – elbow straight, arm rotates inwards. Legs may extend

.

1    No response, even to painful stimuli, in any limb

NT  Factor ie. Patient paralysed 

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Abnormal Flexion (decorticate

In abnormal flexion the arms are flexed at the elbow and wrists rotate outwards.  Legs are extended.

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Extension (decerebrate)

In extension the body can become rigid, with the arms externally rotated and toes pointing down, legs extended.

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Pain/Noxious Stimuli

Central stimuli: Trapezium squeeze

  -  advocated best   practice

Supraorbital pressure

But not…….

Jaw margin pressure Sternal rub     

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Pain/Noxious Stimuli

Peripheral Stimuli: Finger pressure

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Pupillary reflex assessment

Clinical test for brain stem function

The light reflex tests two cranial nerves.

  1. Optic Nerve (II) - the sensory nerve of visual acuity
  2. Oculomotor nerve (III) - the motor nerve that controls pupillary response

Light shone into eyes causes

      direct reflex response to light falling on retina

      Consensual constriction of both pupils.

      Involves the autonomic nervous system

      sympathetic- pupil dilation

      parasympathetic- pupil constriction

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Pupil assessment

Size – look before shining light in. 

Pupils size can be affected by certain drugs for eg….

Atropine

Opioids

Be aware of any pre-existing eye problems. 

Check each pupil reacts equally, or are unequal?

Are they mishapen?

Notice how sluggish, or briskly each pupil reacts to this light.

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Pupil Documentation

Pupil size should be noted before proceeding to test pupil response to direct light.

Score pupil size 1-6mm

+ is used to indicate a brisk response

- is used to indicate no response

SL is used to indicate a ‘sluggish’ response

C is used to indicate closed eyes due to perirobital oedema.

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Altered pupil responses

      Pupils should remain round throughout.

      If pupils are sluggish, oval or unequal may be a sign of raised ICP, haemorrhage or compression of cranial nerves

      However some people do have unequal pupils and are healthy

      Raised ICP constricts oculomotor (parasympathetic) nerve so eye remains dilated in response to light

      Abnormalities can include either constriction or dilation of pupils

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Timings of neurological Observations

      Neuro obs should be carried out thoroughly and frequently until GCS =15

      half hourly for 2 hours

      Then 1-hourly for 4 hours

      2 hourly thereafter

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What factors may affect the patient’s neurological

Time of day Is the patient usually asleep? Pain individual response to pain Pain induced increased BP, HR, RR Medication Sedatives, anticonvulsants, opiates. Individual interpretation

-    Assessment is subjective, seek second opinion when unsure.

Other factors

- Glucose

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Changes to GCS

Consistency important; do GCS at handover New or evolving neurological signs need to be reported immediately GCS of 8 or below indicates coma; immediate help is required. A, B, C. Helpful to note scores for each component as well as total i.e. GCS 10/15 (E=4, V=T, M=6) Pupil changes are often a late sign of deterioration 

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Emergency management of altered level of conscious

Ensure the patient airway is patent –adjuncts as necessary

Place patient horizontally in the lateral recovery position

Oxygen therapy

If patients breathing is inadequate, provide assisted ventilation using a manual resuscitator / bag-valve-mask

Administer intravenous fluids to maintain adequate systolic BP

Measure blood glucose & treat hypoglycaemia

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Glasgow Coma Scale

Advantages: Universal scale Relatively simple to use Aims to ensure changes in patients condition are detected and acted upon at the earliest opportunity 

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Glasgow Coma Scale

Disadvantages:

Can be misused / misunderstood

GCS score not always helpful

Some patients could score lower i.e. if intubated/ tracheostomy, or if on sedation etc

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