NEUROLPA | Coma | Consciousness

SUBJECT: LP Focus A -- Assessment of Neurological Function I. List the purpose for assessing neurological status. A.

There are actually several reasons for assessing the neurological status of your patient. 1. 2. 3. To determine the presence or absence of neurological dysfunction. To establish a baseline. To assess the effects of the neurological deficits in regards to the patients: a. b. c. d. stress (ALL of 3 above is referring to the idea that rehabilitation begins on admission) 4. 5. II. To establish a nursing diagnosis so that the remaining steps of the nursing process can be carried out (Individualized Care Plan) Aides the physician in establishing a diagnosis Lifestyle Independence in ADL Ability to take responsibility for his life (decision making, cognitive function, etc.) Ability to cope psychologically & emotionally with

Describe the components of a neurological assessment in terms of: Level of consciousness (Glasgow's Coma Scale); Pupils & Eye movement; Sensory function; Motor function; Vital Signs A. Components of Neurological Assessment - Neuro assessments are conducted every 15 mins to 4 hrs, depending on condition of pt. 1. Level of consciousness a. controlled by reticular activating system (RAS) (1) a diffuse system of neurons extending from the lower brain stem to the cerebral cortex (2) the earliest indicator of neurological change, probably because the RAS is most sensitive to changes in blood supply (Oxygen & glucose) No uniformly accepted terminology to describe levels of consciousness - The nurse should describe the behavior noted: 1

b.

month. confused words spoken but conversation in not content 3 sustained 2 1 (3) groans evoked by pain no response best motor response 6 5 4 3 2 obeys a command localizes a painful stimulus normal flexion either arm abnormal flexion of arm extends arm to painful stimulus 2 . then: Assess painful stimuli (a) (b) press dull end of pencil against fingernail bed press knuckle into sternum page 1476 c.(1) Assess orientation to: (a) (b) (c) Person (his identity) Place (present location) Time (general time of day. Based on the pt's response in three areas: (1) eye opening 4 3 2 1 (2) spontaneously on request to pain stimuli no opening best verbal response 5 4 Oriented to time. Glasgow's coma scale An objective measure to describe LOC. place. person engages in conversation. year) by his (2) (3) (4) Assess ability to follow directions response to simple commands No response to verbal.

do they protrude. and the lowest possible score is 3.5 mm in diameter normal range (2 mm . sluggish.(Known as direct light reflex) normally this reaction should also occur in the other pupil although not as pronounced (Known as consensual light reflex) brisk. or nonreactive (fixed). The highest GCS score is 15 for a fully alert person. Sensory Function . Pupils & Eye Movement a. Eye Movement (1) (2) Observe the eyes within their sockets as the pt. size of pupils (1) (2) (3) b. follow object with eyes as you move it 3. direct light response in both eyes should be equal abnormal response of the pupil is related to interruption of the oculomotor nerve (cranial nerve III) tested (4) (5) (6) (7) c.) 2. A GCS score of 8 or less is generally indicative of coma. light touch 3 .1 no response (The total GCS score is a sum of the numeric values assigned to each of the three areas evaluated. or are they sunken? Hold finger or object 12 inches from nose and have pt.usually assess once a day Can assess while administering care a.6 mm) Reaction to light (1) (2) (3) need dimly lit room pupils checked one at a time direct beam of light toward pupil of eye to be normally pupil contracts briskly & dilates as quickly on removing light . looks straight ahead . should be round & equal in size pupil normally 3.

Test by having patient close eyes while standing. muscle size (1) (2) observe & measure same muscle on opposite sides of body for symmetry abnormal findings: (a) (b) b. reflexes (1) gag 4 . weight. and resistance of objects in relation to the body.b. deep pressure c. muscle tone (1) (2) guide muscle thru passive range of motion abnormal findings (a) (b) (c) c. temperature *ask to close eyes. movement and changes in equilibrium and the knowledge of position.The awareness of posture. pain d. to differentiate between cold & warm water during bath 4. flaccidity spasticity rigidity atrophy asymmetry 5. Motor Function a. Proprioception . muscle strength (1) (2) observe muscle movement against gravity & against active resistance abnormal findings (a) (b) (c) weakness (paresis) paralysis involuntary movements d. compare for both sides *ask pt.

however. in intoxicated adults and following a generalized seizure. thready.extension of the great toe and fanning of the other toes usually indicative of injury to the corticospinal (pyramidal) tract. this is not an infallible sign since it can be elicited in the newborn infant. 6.frequency depends on the pt's condition a. rhythm & quality (full.brisk flexion of the toes abnormal . bounding) (2) 5 . Vital Signs . chart apical or radial b. temperature (1) controlled by the hypothalamus (2) could be subnormal or elevated (3) take rectally in unconscious pt (4) stay with the pt while the thermometer is in place (5) always record the route used (6) assess every 30 minutes until normal pulse (1) record rate.(a) (b) (2) stroke one side of the mucous membrane of the post pharynx at a time should gag swallow (a) (b) stroke one side of the uvula at a time uvula should rise & deviate to stimulated side the (3) corneal reflex (a) (b) lightly touch cornea with cotton immediate blink (4) Babinski reflex (a) (b) (c) (d) use blunt object (key) to stroke lateral side of sole of the foot normal .

clusters of breaths follow each other with irregular pauses between Ataxic -. bradycardia (60 or below) bradypnea (often irregular) hypertension (140/90 or above) with a widening pulse pressure above findings are related to pressure on the medulla (a late clinical finding) 6 .prolonged inspiratory phase or pauses alternating with expiratory pauses Cluster -. Random. pg 1478 respirations (1) record rate & pattern (a) (b) (c) (d) (e) Cheyne-Stokes -cycles of hyperventilation and apnea Central neurogenic hyperventilation -sustained. regular rapid and deep breathing Apneustic -. slow rate.completely irregular with some breaths deep and some shallow. blood pressure (1) onset of cerebral pressure on blood pressure and pulse is variable (2) with continued increase of pressure on the brainstem.with even further pressure (a) (b) (c) (d) d.c. irregular pauses. there will be an increase in systolic pressure (3) Cushings triad .

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