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

• Lethargic– Opens eyes to verbal

stimuli– Slow to respond, but

appropriate– Short attention span– Obtunded

• Sleepy

Stupor

• 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 outcome13: mild brain injury9-12: 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 QuestionsA. 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 consciousnessC. Identify the differences in patients in each of the stages of

consciousnessD. 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