Download NEUROLOGICAL OBSERVATIONS

DEFINITION
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NEUROLOGICAL OBSERVATIONS RELATE
TO THE EVALUATION OF THE INTEGRITY
OF AN INDIVIDUAL’S NERVOUS SYSTEM
INDICATIONS
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IN PAIRS DISCUSS ON WHAT TYPE OF
PATIENT’S WOULD WE PERFORM
NEUROLOGICAL OBSERVATIONS.
NEUROLOGICAL OBSERVATIONS ARE
REQUIRED TO MONITOR AND EVALUATE
CHANGES IN THE NERVOUS SYSTEM BY
INDICATION TRENDS, THUS AIDING
DIAGNOSIS AND TREATMENT. THE FREQUENCY
OF THESE OBSERVATIONS WILL DEPEND ON
THE PATIENT’S CONDITION
EXAMINATION OF THE
NEUROLOGICAL SYSTEM
INCLUDES AN ASSESSMENT OF:
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LEVEL OF CONSCIOUSNESS
PUPILLARY ACTIVITY
MOTOR FUNCTION
SENSORY FUNCTION
VITAL SIGNS
CONSCIOUSNESS DEPENDS ON:
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AROUSABILITY
AWARENESS
BOTH OF THESE REQUIRE AN INTACT
CEREBRAL CORTEX TO INTERPRET SENSORY
INPUT AND RESPOND ACCORDINGLY.
LEVELS OF CONSCIOUSNESS MAY VARY AND
ARE DEPENDENT ON THE LOCATION AND
EXTENT OF NEUROLOGICAL DAMAGE.
TRY TO THINK OF THREE WAYS IN
WHICH WE CAN ASSESS A
PATIENT’S CONSCIOUSNESS LEVEL
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EYE OPENING
VERBAL RESPONSE
MOTOR RESPONSE
LEVEL OF CONSCIOUSNESS
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IS THE SINGLE MOST IMPORTANT
INDICATOR OF A PATIENTS BRAIN
FUNCTION. IT RANGES, ON A
CONTINUUM, FROM ALERT
WAKEFULNESS TO DEEP COMA WITH NO
APPARENT RESPONSIVENESS
THE GLASGOW COMA SCALE
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IS A RELIABLE AND EASY TO USE
MEASURE OF CONSCIOUS LEVEL, SINCE
IT GIVES AN INSTANT GRAPHIC
REPRESENTATION OF THE CONSCIOUS
STATE
Glasgow Coma Scale
Eye Opening (E)
4=Spontaneous
3=To voice
2=To pain
1=None
Verbal Response (V)
5=Orientated
4=Confused
3=Inappropriate words
2=Incomprehensible
1=None
Motor Response (M)
6=Obeys commands
5=Localizes to pain
4=Withdraws to pain
3=Flexes to pain
2=Extends to pain
1=None
Total = E+V+M
Paediatric Glasgow Coma Scale
Eye Opening (E)
Verbal Response (V)
Motor Response (M)
4=Spontaneous
3=To speech/noise
2=To pain
1=None
5=Appropriate words/phrases,
smiles, coos, cries
4=Confused, monosyllables, cries,
irritable
3=Inappropriate words /
Inconsolable screams
2=Incomprehensible Sound
1=None
6=Obeys commands,
normal spontaneous
Movements
5=Localizes to pain
4=Withdraws to pain
3=Flexes to pain
2=Extends to pain
1=None
Total = E+V+M
GLASGOW COMA SCALE
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LOWEST SCORE COULD BE 3
HIGHEST SCORE 15 INDICATES FULL
CONSCIOUSNESS
PAIN STIMULI
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THE PAINFUL STIMULI APPROVED FOR USE
WHEN ASSESSING NEUROLOGICAL STATE IS:
SUPRAORBITAL PRESSURE (ONLY ONCE)
REPEATED ASSESSMENT THESE PAINFUL
STIMULI SHOULD BE USED:
SQUEEZING THE TRAPEZIUM
PRESSING ON THE ANGLE OF THE JAW
PAINFUL STIMULI NOT APPROVED INCLUDE:
EXERTING PRESSURE ON THE NAILBED
APPLYING PRESSURE TO THE SUPRAORBITAL RIDGE
PINCHING THE ACHILLES TENDON
RUBBING THE STERNUM
NOW CHECK YOUR
PARTNERS GLASGOW COMA
SCORE
RECORD ON YOUR CHART
 HOPEFULLY YOU HAVE ALL
SCORED 15 (4:5:6) UNLESS
YOU HAVE FALLEN
ASLEEP!!!!!
PUPILLARY ACTIVITY
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CAREFUL EXAMINATION OF THE REACTION OF THE
PUPILS TO LIGHT IS AN IMPORTANT NEUROLOGICAL
ASSESSMENT
NOTE THE SIZE, SHAPE, EQUALITY AND REACTION OF
BOTH EYES TO LIGHT
P.E.A.R.L
CHECK THE POSITION OF THE EYES. ARE THEY
DEVIATING UPWARDS OR DOWNWARDS? ARE THEY
LOOKING IN THE SAME DIRECTION OR ARE THEY
DISCONJUATED
WHAT CRANIAL NERVE CONTROLS PUPILLARY
ACTIVITY?????
III - OCULOMOTOR
EXAMINATION OF THE PUPILS
2
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3
4
5
6
7
8
Normal diameter: 1.5 – 6 mm
Shape: round and midposition
Equality of pupils: equal
Reaction to light: constricts swiftly
Consensual light reflex: both pupils constrict
LOOK AT YOUR PARTNER PUPILS AND CHART
WHAT SIZE THEIR PUPILS ARE
9
Checking consensual
light reflex
Checking pupillary
reaction to light
NORMAL VISUAL FUNCTION
DEPENDS ON:
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CRANIAL NERVES III,IV,VI
INTACT VISUAL CENTRE IN THE
OCCIPITAL CORTEX
NOW CHECK YOUR
PARTNERS PUPIL
REACTION TO LIGHT TRY
BOTH TESTS
 HOPEFULLY YOUR PUPILS
WILL HAVE CONSTRICTED
SWIFTLY AND WILL BE
CONSENSUAL
LIST 5 REASONS FOR POOR
PUPILLARY REACTIONS
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OPIATES
SOME CARDIAC DRUGS E.G. ADRENALINE
TRAUMATIC HEAD INJURY
BRAIN HAEMORRHAGE
ENCEPHALITUS/MENINGITIS
BRAIN LESION
NERVE PALSY
SYNDROMES SUCH AS HORNERS SYNDROME
MOTOR FUNCTION
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DAMAGE TO ANY PART OF THE MOTOR
NERVOUS SYSTEM CAN AFFECT THE
ABILITY TO MOVE
MOTOR FUNCTION ASSESSMENT
INVOLVES:
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MUSCLE STRENGTH
MUSCLE TONE
MUSCLE CO-ORDINATION
REFLEXES
ABNORMAL MOVEMENTS
REFLEXES
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BLINK
GAG
OCULOPHALIC
PLANTAR
BLINK REFLEX
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If the conjunctiva or
cornea are touched,
this results in blinking
of the eyelids due to
the blink reflex.
GAG REFLEX
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IS A NORMAL REFLEX CONSISTING OF
RETCHING
IT MAY BE PRODUCED BY TOUCHING THE
SOFT PALATE AT THE BACK OF THE
MOUTH
OCULOCEPHALIC REFLEX
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OTHERWISE KNOWN AS
DOLL’S EYES
Contraindications
Possible Cervical Spine
Injury
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Technique
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Eyes open
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Head is rotated briskly
from side to side
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Interpretation
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If Brainstem intact:
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Eyes deviate
contralaterally
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Look away from rotation
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If Brainstem injury:
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Eyes follow direction of
head rotation
PLANTAR REFLEX
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With the patient supine,
support the weight of the
foot at the ankle.
With a pointed object,
stroke the lateral
aspect of the sole of
the foot, from the heel
up and across the ball of
the foot.
Normal reaction is to curl
the toes downwards
ABNORMAL MOVEMENTS
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SEIZURES
TICS
TREMORS
SENSORY FUNCTIONS
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ASSESSMENT OF THE SENSORY FUNCTION
SHOULD INCLUDE:CENTRAL AND PERIPHERAL VISION
HEARING AND THE ABILITY TO UNDERSTAND
VERBAL COMMUNICATION
SUPERFICIAL SENSATIONS (LIGHT TOUCH
PAIN) AND DEEP SENSATIONS (MUSCLE AND
JOINT PAIN AND JOINT POSITION)
VITAL SIGNS
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RESPIRATION
TEMPERATURE
BLOOD PRESSURE
PULSE
RESPIRATION
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GIVES THE CLEAREST INDICATION OF
HOW THE BRAIN IS FUNCTIONING
THE RATE, CHARACTER AND PATTERN OF
A PATIENT’S RESPIRATION MUST BE
NOTED.
WITH A GCS OF 8 OR LESS IT IS
IMPORTANT TO ENSURE THE PATIENT IS
ABLE TO MAINTAIN AND PROTECT THEIR
AIRWAY
TEMPERATURE
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SEVERE HEAD INJURY OFTEN CAUSES DERANGED
TEMPERATURE DUE TO DAMAGE TO
HYPOTHALAMUS
FOR EVERY DEGREE RISE IN BODY TEMPERATURE
THE METABOLIC RATE INCREASES BY 10%. HOW
CAN THIS BE HAZARDOUS FOR THE PATIENT????
THEY ALREADY HAVE A COMPROMISED OXYGEN
AND GLUCOSE SUPPLY TO THAT PART OF THE
HEAD AND CARBON DIOXIDE IS A CEREBRAL
VASODILATOR THEREFORE CAN INCREASE
INTRACRANIAL PRESSURE.
BRAIN INJURY CAN CAUSE HYPERTHERMIA AND
HYPOTHERMIA
BLOOD PRESSURE
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EVIDENT IN THE LATER STAGES OF
RAISED INTRACRANIAL PRESSURE
HYPOTENSION CAN HAVE DRASTIC
EFFECT ON THE PATIENT WITH A HEAD
INJURY
PULSE
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CEREBRAL INSULT CAN HAVE ONE OF THE
FOLLOWING EFFECTS ON THE PULSE:BRADYCARDIA – CERVICAL INJURY AND IN THE
LATER STAGES OF RAISED INTRACRANIAL
PRESSURE
TACHYCARDIA – INJURY TO HYPOTHALAMUS
AND PRESENT IN TERMINAL STAGE OF RAISED
INTRACRANIAL PRESSURE
ARRYTHMIAS – BLOOD IN THE CEREBROSPINAL
FLUID
Apical pulse
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Detected in the fifth intercostal space midclavicular line left side of chest
Detected with the aid of a stethoscope
Routinely used to record pulse rate in infants
and children up to the age of 3 years
Can be used to detect discrepancies with radial
pulse
Recorded in conjunction with the administration
of some medicines
Equipment for assessing apical
pulse
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Watch with a second hand
Stethoscope
Antiseptic wipes
Stethoscope Traditional
Combination-style Chest piece
 Traditional
chest pieces have a
bell side to hear low frequencies
and a diaphragm side to hear
high frequency sounds. The chest
piece must be turned over to
listen to the different sounds.
Bell Mode (low-frequency)
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Use light contact
on the bell side to
hear low-frequency
sounds.
Diaphragm Mode
(high-frequency)
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Turn the chest
piece over, index to
the opposite side
and use firm
pressure to listen
to high-frequency
sounds.
Procedure
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Explain to the patient what you are going
to do
Perform hand washing to minimise cross
infection
Provide privacy for patient as chest will
need to be exposed
Position patient in a comfortable supine or
sitting position
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Locate the apical impulse – this is the
point over the apex of the heart where the
apical pulse can be most clearly heard
This is also referred to as the Point of
Maximal Impulse – PMI
The apical impulse is usually located in the
fifth intercostal space mid-clavicular line
Auscultate and count the heart beats with
the diaphragm of the stethoscope
Points to consider
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Count the heart rate for one minute to
accurately record
Assess the rhythm of the heart beat by
noting the pattern of intervals between
the beats
Assess the strength/volume of the heart
beat and describe as strong or weak
Record the pulse site, rate, rhythm and
volume in the patients notes