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Chapter 20
Chapter 20
Please note: this presentation is also suitable for use with Foundation Studies for Caring Chapter 30: Emergency Care and Interventions
Introduction
This presentation examines the notion of consciousness and walks you through a neurological assessment. Part 1 Level of Consciousness and Neurological Status Part 2 Neurological Assessment and the GCS Part 3 Pain & Noxious Stimuli Part 4 Pupil Documentation & Assessment Part 5 Limb Power & Sensation
Consciousness
Consciousness is the most sensitive indicator of neurological change and is usually the first to be noted in neurological signs A state of general awareness of oneself & the environment, including the ability to orientate towards new stimuli (Hickey, 2003) Dynamic state, subject to change (Hickey, 2003) Results from integrated activities of numerous neural structures, including the reticular formation and interaction with the cerebral cortex (Marieb & Hoehn
Level of Consciousness
There are three properties of consciousness which can be individually affected by the disease process (Jennett 1992). These are: Arousal or wakefulness (i.e. eyes open to command) Alertness and awareness (i.e. orientation and communication) Appropriate voluntary motor activity (i.e. obeying commands)
Emergency Care
A = Airway B = Breathing and ventilation C = Circulation D = Disability: Neurological status E = Exposure
(American College of Surgeons Committee 2004)
AVPU
A Alert Responds spontaneously
V Verbal
Responds to voice
P Pain
This is an example of a neurological assessment chart When documenting observations on the neurological assessment chart, it is important to: 1. Complete all sections. 2. Use dots not ticks! The chart demonstrates the patients graphical trends over time.
The GCS tool provides a common language for communication between multi-disciplinary groups. (Hickey 2003) It is an important assessment tool. Care should be taken when delegating this assessment to ensure individual competency to perform the procedure GCS is applicable for paediatrics as well as adults, and has been adapted for use in in this area
Glasgow Coma setting may Patients in any clinicalScale (G.C.S.) require assessment of conscious level for a number of reasons:
Hypoxia Metabolic imbalance such as hypoglycaemia Falls and trauma to the head Unresponsiveness Neurological disease processes e.g. stroke, brain tumours, epilepsy Post-anaesthesia New admissions to form a baseline assessment
Pain/Noxious Stimuli
Central stimuli: Trapezium squeeze - advocated best practice Supraorbital pressure Jaw margin pressure Sternal rub - not advocated Peripheral Stimuli: Finger pressure
Correct
Incorrec
Extension (decerebrate)
In extension the body can become rigid, with the arms externally rotated and toes pointing down
In abnormal flexion the arms are flexed at the elbow and wrists rotate outwards.
Vital Signs
Centres for vital signs are located in the brain stem. Complex networks of neurones, the brainstem and reticular formation participate in regulation of cardiovascular, respiratory and other visceral functions.
Pupils
Pupils should generally be equal in size, and in the majority of people they are round in shape. Pupils should react briskly to direct light. Oculomotor nerve (III) - the motor nerve that controls pupillary motor response.
Pupil Documentation
Pupil size should be recorded before proceeding to test pupil response to direct light. + 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.
Pupil Assessment
Torch position for testing light reflex Approach from the side. Do not move in from directly in front.
Limb Power
In this section you are assessing all limbs as opposed to the best response in a limb, as in the GCS section. It is a combination of active and active resisted movements (Hickey 2003).
Sensation (dermatones))
Sensation is not routinely checked unless patient diagnosis, signs and symptoms or interventions (e.g. epidural), indicate a potential for sensory loss or disturbance. There are various sensation charts based upon dermatone body maps.
C2
C4 C5 T1
C7
C5
C6 C7 C8 C6 C8 C7 T12 S5 S2 L2 S3 L1 L2
S2
S1 L5
L3 L5 L4 S1 L5 S1