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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