Assessment and Examination

Presented By: Melvin Mari, RN Jameelah Carama, RN Level III

Neurologic Vital Signs:

Learning Objectives
Define Level of Consciousness Acquire knowledge and skills using flow charts or neurologic assessment forms such as LOC, Glasgow Coma Scale, ACDU/AVPU scale, Pupils and Eye movement, Motor Function Describe how to assess a patient with a altered conscious levels Utilize different assessment and examination findings for evaluation of nursing care

Neurologic Assessment And Examination For nursing purposes, neurologic assessment and examination are used
to determine whether nervous system dysfunction is present; to determine the patients responses to actual or potential health problems precipitated by the dysfunction

Neurologic Assessment And Examination

It reviews of the patients mental state; cranial nerves, motor and sensory systems; and cerebellar function and reflexes. The first step is to assess neurologic vital signs, starting with the patients level of consciousness and orientation level. Tells a lot about a patients neurologic and physiologic status

Neurologic Assessment And Examination

3 PARAMETER
Eye opening Verbal response Motor response

Neurologic Assessment And Examination

Respiratory assessment constitutes an important part of an overall neurological assessment.

Thoroughly respiratory care goes hand in hand with neurologic care.

Neurologic Assessment And Examination

Neurologic assessment supplements the routine measurement of temperature, pulse rate, and respirations by evaluating the patients level of consciousness (LOC), GCS, papillary activity and orientation to person, place, and date.

Materials Needed:
Penlight Thermometer Sterile cotton ball or cotton tipped applicator Stethoscope Sphygmomanometer Pupil size chart Pencil or Pen

Level of Consciousness
LOC, a measure of environmental and self-awareness, reflects cortical function and usually provides the first sign of central nervous system deterioration. An altered level of consciousness is any measure of arousal other than normal.

Level of Consciousness
Such as An altered level alterations in the chemical environment of consciousness of the brain (e.g. can result from a exposure to poisons) variety of factors insufficient oxygen or blood flow in the brain due to inadequate excessive pressure perfusion. within the skull. medications, drugs, alcohol, or poisoning

Level of Consciousness
Medical Condition Hypoxaemia Cerebral infarction Hypotension Intracranial infection Hypercapnia Hypothermia Hypoglycaemia Hyperthermia Seizures Hypothyroidism Intracranial Hepatic haemorrhage encephalopathy Head injury

Level of Consciousness
Thus, it is a valuable measure of a patient's medical and neurological status. In fact, some sources consider level of consciousness to be one of the vital signs. Orientation tests mental status. Evaluates a persons ability to remember:
Person Place Time Event

Level of Consciousness
Scales and terms to classify the levels of consciousness differ, but in general, reduction in response to stimuli indicates an altered level of consciousness:

Level of Consciousness
Level Summary (Krause) Description
checking orientation: people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented

Conscious

Normal

Level

Summary (Krause) Disoriented; impaired thinking and response Disoriented; restlessness, hallucinations, sometimes delusions

Description
People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or "confused". Some scales have "delirious" below this level, in which a person may be restless or agitated and exhibit a marked deficit in attention

Confused

Delirious

Level

Summary (Krause)

Description
A somnolent person shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements.
In obtundation, a person has a decreased interest in their surroundings, slowed responses, and sleepiness.

Somnolent

Sleepy

Obtunded

Decreased alertness; slowed psychomotor responses

Level

Summary (Krause)

Description

Stuporous

Sleep-like state People with an even lower level of (not consciousness, stupor, unconscious); only respond little/no by grimacing or spontaneous drawing away from painful stimuli. activity
Comatose people do not even make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light.

Comatose

Cannot be aroused; no response to stimuli

 The most commonly used tool for measuring LOC objectively is the Glasgow Coma Scale (GCS). It has come into almost universal use for assessing people with brain injury, or an altered level of consciousness. Verbal, motor, and eye-opening responses to stimuli are measured, scored, and added into a final score

The Glasgow Coma Scale

Assesses patients neurological condition Value range 3 to 15 3 totally comatose patient 15 fully alert patient

The Glasgow Coma Scale

Evaluates long-term memory, intermediate-term memory, and short-term memory The Glasgow Coma Scale (GCS) score can be helpful in providing additional information on mental status changes.

Classification of Brain Injury According to Glasgow Coma Scale (GCS)

(HICKEY 2003)

SEVERE

MODERATE GCS 9-12

MILD GCS 13-15

The Glasgow Coma Scale

The GCS evaluates consciousness by scoring a response in three areas: eye opening verbal performance motor response

The application of the GCS requires skill to achieve consistency in scoring.

The Glasgow Coma Scale

Eye Opening Verbal Response Motor Response
Obeys commands = 6 Localises pain = 5 Withdrawal to pain = 4 To pain = 2 None = 1 Monosyllabic = 3

Spontaneous = 4 Orientated = 5 To speech = 3 Disorientated = 4

Flexion to pain = 3

Incomprehensive = Extension to pain = 2 2 None = 1 None = 1

To Assess For Responsiveness AVPU / ACDU: AVPU

Awake and alert

ACDU
Alert

Responsive to Verbal stimuli

Responsive to Pain Unresponsive

Confused
Drowsy Unresponsive

Test Responsiveness To Painful Stimuli

Pinch Earlobe

Press Down On Bone Above Eye

Pinch Neck Muscles

Assessing LOC and Orientation

Assess the patients LOC by evaluating his responses. Use standard methods such as the Glasgow Coma Scale Begin by measuring the patients response to verbal, light tactile (touch), and painful (nail bed pressure) stimuli.

 Assess the patients ability to understand and follow one step commands that require a motor response.
If the patient doesnt response to commands, apply a painful stimulus. A patients response to painful stimuli should be described as one of the following:
localization the patient withdraws from the pain, and can localize where the pain originates; withdrawalthe patient moves slightly, but makes no attempt to push the painful stimulus away; unresponsivethe patient doesnt react to the application of painful stimulus (commonly seen in patients in a deep coma).

Pupils And Eye Movement

The pupil is a circular opening in the center of the pigmented iris of the eye.
The pupils are normally round and of approximately equal size. In the absence of any light, the pupils will become fully relaxed and dilated.

Pupils And Eye Movement

Diameter and reactivity to light reflect the status of the brains:
Perfusion Oxygenation Condition

Pupils And Eye Movement

CONSTRICTED

Pupils And Eye Movement

D I L AT E D

Pupils And Eye Movement

UNEQUAL
ANISOCORIA

ANISOCORIA
A small number of the population exhibit unequal pupils (anisocoria). Causes of depressed brain function:
Injury of the brain or brain stem Trauma or stroke Brain tumor

Inadequate oxygenation or perfusion

Drugs or toxins

Pupils And Eye Movement

Changes in papillary activity (pupil size, shape, equality and response to light) may signal increase intracranial pressure (ICP) associated with a space-occupying lesion caused by an increase of the id or tissue in the associated area.

PUPIL SIZE CHART

 PERRLA is a useful assessment guide:

Pupils Equal

PERRL - Pupils Equal, - Round, - Reactive to - Light EOMI - ExtraOcular - Movements - Intact

Round
Regular in size React to Light and Accommodation

Examining Pupils And Eye Movement

Ask the patient to close his eyes. Test the patients direct light response. Now test consensual light response. Brighten the room and have the conscious patient open his eyes. Check the patients accommodation-convergency reflex. If the patient is comatose, test the corneal reflex by touching a wisp of cotton ball to the cornea. If the patient is unconscious, test the oculocephalic (dolls eye) reflex.

Evaluating Motor Function

Evaluating muscle strength and tone, reflexes and posture also may help identify nervous system damage.

Evaluating Motor Function

P O S T U R I N G

Evaluating Motor Function

Identify the patients strength on a scale of 0 to 5, with 0 being no muscle strength and 5 being full muscle strength. If the patient is conscious, test his grip strength in both hands, extend your hands, ask him to squeeze your fingers as hard as he can, and compare the strength of each hand. Test arm strength by having the patient close his eyes and hold his arms straight out in front of him with the palms up for 20 to 30 seconds.

Evaluating Motor Function

Test leg strength by having patient raise his legs, one at a time, against gentle downward pressure from your hand.

Flex and extend the extremities on both sides to evaluate muscle tone. Test the plantar reflex in all patients.

Completing The Neurologic Examination

Take the patients temperature, pulse rate, respiratory rate, and blood pressure. His pulse pressure is especially important because widening pulse pressure can indicate increasing ICP. A change in the LOC is one of the earliest changes that may occur with increasing ICP. Changes in pulse and blood pressure also occur, but are generally seen late in the course of increasing ICP.

What To Document?
Baseline data require detailed documentation subsequent notes can be brief unless the patients condition changes Record the patients LOC and orientation, papillary activity, motor function, and routine vital signs as your facilitys policy directs.

REMEMBER!
Changes in vital signs alone dont indicate possible neurologic compromise. Alterations in LOC or papillary changes are the early signs that indicate neurologic problems.

 LOC - should be performed with any patient who has:

Changes in mental status A possible head injury Stupor Dizziness/drowsiness Syncope

Evaluate the level of consciousness and orientation. Assess the patients thought process. Inspect the head for trauma. Check for bilateral muscle strength and weaknesses.

REMEMBER!
Therefore, any change in vital signs should be evaluated in light of a complete neurologic assessment. Because vital signs are controlled at the medullary level, changes noted after the deterioration of neurologic status are too late, and irreversible neurologic damage should be suspected

Thank you... And good luck!