Neurology 2 Part 1

History Family member present Vaccination Major injuries Childhood illnesses Family Present illness

Complaints specific to neurology Pain – Location – Quality – Severity – Duration – Precipitating factors – Associated symptoms – Exasperation / diminished pain – Onset

Pain assessment

Headaches Multiple causes Not a good indicator of neuro trouble

Vertigo Sensation of moving around in space or objects moving around them Assoc symptoms

Paresthesia Definition – Unusual sensation Examples – Numbness – Tingling – Burning Assessment – ? Weak – ? Intermittent or constant

Vision Diplopia Clarity Nystagmus

Disturbances in… Thinking Memory Personality

Nausea and vomiting Projectile

Assessing Cerebral Function - PE Mental status Intellectual function Thought content Emotional status Perception Motor ability Language ability

Mental Status Level of consciousness – Rostral-claudal Progression Dullness  Confusion  Lethargy  Stupor  Coma

Alert – Alert Open eyes spontaneously Responds appropriately, briskly Oriented

Lethargic – Opens eyes to verbal stimuli – Slow to respond, but appropriate – Short attention span – Obtunded Sleepy

Stupor – Responds to stimuli (usually physical) with moans and groans – Never fully awake – Confused – Conversation unclear

Semi-comatose Semi Comatose – Responds to painful stimuli – Conversation: none – Protective reflexes present

Comatose Coma – Unresponsive except to severe pain – Protective reflexes absent – Pupils fixed – No voluntary movement

Unconscious Non-medical word Ranges from stupor to coma

Persistent Vegetative State No cognitive brain function Wake sleep cycles Very poor prognosis (if > 3-6 months)

Brain Dead No brain function Only reflexive movements

Types of Stimuli  response Voice Touch Shaking Voice + Shaking Noxious/painful stimuli

Nature of response Eye opens Remove stimuli Abnormal posturing No response

Glasgow Coma Scale Eye Opening – Spontaneous – 4 – To speech – 3 – To pain – 2 – Nil – 1

Glasgow Coma Scale Best Motor Response – Obeys -6 – Localizes – 5 – Withdraws – 4 – Abnormal flexion – 3 – Extension response – 2 – Nil - 1

Glasgow Coma Scale Verbal response – Oriented – 5 – Confused conversation – 4 – Inappropriate words – 3 – Incomprehensible sounds – 2 – Nil - 1

Glasgow Coma Scale A strong predictor of outcome  13: mild brain injury  9-12: Moderate brain injury  < 8: Severe brain injury (coma)

Sample Question The nurse is caring for an adult client who was admitted unconscious. The initial assessment utilized the Glasgow Coma Scale. The nurse knows that the Glasgow Coma Scale is a systemic neurological assessment tool that evaluates all of the following EXCEPT Eye opening Motor response Pupillary reaction Verbal performance

Sample Question The nurse is caring for an adult client who was admitted unconscious. The initial assessment utilized the Glasgow Coma Scale. The nurse knows that the Glasgow Coma Scale is a systemic neurological assessment tool that evaluates all of the following EXCEPT Eye opening Motor response Pupillary reaction Verbal performance

Small Group Questions A.Give 5 questions you might ask a neuro patient who is complaining about a headache during an intake assessment B.Identify the rostral-caudal progression of consciousness C.Identify the differences in patients in each of the stages of consciousness D.What is the lowest score a patient can get on a Glasgow coma scale? E.What is the highest score a patient can get on a Glasgow Come Scale? F.What is the most sensitive indicator on the Glasgow Coma Scale?

General Appearance How do they look? – Grooming – Dress – Aids – Eye deviation – Skin

Signs of trauma, wounds, scrapes, ecchymosis etc.

Battle’s sign Bruising over the Mastoid – Where’s the mastoid?

Battle’s sign Bruising over the Mastoid

Battle’s sign Bruising over the Mastoid

Battle’s sign Bruising over the Mastoid

Battle’s sign Bruising over the Mastoid

Battle’s Sign Bruising over the Mastoid area Suggests – Basal skull fracture

Raccoon’s eyes Periorbital edema and bruising

Raccoon’s eyes Periorbital edema and bruising Suggests: – Frontal-basal fracture

Rhinorrhea Drainage of CSF from the nose Suggests – Fracture of the cribiform with torn meninges

Otorrhea Drainage of CSF from the ear Suggests: – Fracture of the temporal bone with torn meninges

Decorticate Posturing Flexed Posturing – Flexed arm/elbow – Flexed wrists/fingers – Adducted arms – Legs with internal rotation – Foot: Plantar flexed

Decorticate Posturing Suggests – Damage to the cortico-spinal tract More favorable than decerebrate posture

Decerebrate Posturing - Extension posturing – Extended arm/elbow – Flexed wrist/fingers – Adducted arm – Pronation of arm – Foot: Plantar flexed

Decerebrate Posture Suggests – severe injury to the brain at the level of the brainstem Opisthotonos – severe muscle spasm of the neck and back More ominous posture

Orientation x 3 – Person – Place – Time