NEUROLOGICAL OBSERVATIONS

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NEUROLOGICAL OBSERVATIONS

• SHARON HARVEY

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LEARNING OUTCOMESTHE STUDENT SHOULD BE ABLE TO-

• RECALL AND DEMONSTRATE ACCURATELY THE RECORDING
  OF VITAL SIGNS
• IDENTIFY WHEN A NEUROLOGICAL ASSESSMENT WOULD BE
  UNDERTAKEN AND WHAT INSTRUMENTS WOULD BE USED
• RECORD A NEUROLOGICAL OBSERVATION ASSESSMENT IN
  AN ADULT
• DEMONSTRATE AWARENESS OF HOW NEUROLOGICAL
  ASSESSMENT CAN BE CARRIED OUT WITH CHILDREN

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DEFINITION

• NEUROLOGICAL OBSERVATIONS RELATE TO THE
  EVALUATION OF THE INTEGRITY OF AN INDIVIDUALS
  NERVOUS SYSTEM

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INDICATIONS

• IN PAIRS DISCUSS ON WHAT TYPE OF PATIENTS 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 PATIENTS CONDITION

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EXAMINATION OF THE NEUROLOGICAL SYSTEM INCLUDES
AN ASSESSMENT OF

• LEVEL OF CONSCIOUSNESS
• PUPILLARY ACTIVITY
• MOTOR FUNCTION
• SENSORY FUNCTION
• VITAL SIGNS

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CONSCIOUSNESS DEPENDS ON

• 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.

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TRY TO THINK OF THREE WAYS IN WHICH WE CAN
ASSESS A PATIENTS CONSCIOUSNESS LEVEL

• EYE OPENING
• VERBAL RESPONSE
• MOTOR RESPONSE

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LEVEL OF CONSCIOUSNESS

• 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

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THE GLASGOW COMA SCALE

• IS A RELIABLE AND EASY TO USE MEASURE OF
  CONSCIOUS LEVEL, SINCE IT GIVES AN INSTANT
  GRAPHIC REPRESENTATION OF THE CONSCIOUS STATE

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Glasgow Coma Scale
 
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Paediatric Glasgow Coma Scale
 
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GLASGOW COMA SCALE

• LOWEST SCORE COULD BE 3
• HIGHEST SCORE 15 INDICATES FULL CONSCIOUSNESS

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PAIN STIMULI

• 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

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• NOW CHECK YOUR PARTNERS GLASGOW COMA SCORE
• RECORD ON YOUR CHART
• HOPEFULLY YOU HAVE ALL SCORED 15 (456) UNLESS
  YOU HAVE FALLEN ASLEEP!!!!!

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PUPILLARY ACTIVITY

• 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

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EXAMINATION OF THE PUPILS
2 3 4 5 6 7 8
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• 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

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Checking consensual light reflex
Checking pupillary reaction to light
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NORMAL VISUAL FUNCTION DEPENDS ON

• CRANIAL NERVES III,IV,VI
• INTACT VISUAL CENTRE IN THE OCCIPITAL CORTEX

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• NOW CHECK YOUR PARTNERS PUPIL REACTION TO LIGHT
  TRY BOTH TESTS
• HOPEFULLY YOUR PUPILS WILL HAVE CONSTRICTED
  SWIFTLY AND WILL BE CONSENSUAL

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LIST 5 REASONS FOR POOR PUPILLARY REACTIONS

• OPIATES
• SOME CARDIAC DRUGS E.G. ADRENALINE
• TRAUMATIC HEAD INJURY
• BRAIN HAEMORRHAGE
• ENCEPHALITUS/MENINGITIS
• BRAIN LESION
• NERVE PALSY
• SYNDROMES SUCH AS HORNERS SYNDROME

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MOTOR FUNCTION

• DAMAGE TO ANY PART OF THE MOTOR NERVOUS SYSTEM
  CAN AFFECT THE ABILITY TO MOVE

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MOTOR FUNCTION ASSESSMENT INVOLVES

• MUSCLE STRENGTH
• MUSCLE TONE
• MUSCLE CO-ORDINATION
• REFLEXES
• ABNORMAL MOVEMENTS

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REFLEXES

• BLINK
• GAG
• OCULOPHALIC
• PLANTAR

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BLINK REFLEX

• If the conjunctiva or cornea are touched, this
  results in blinking of the eyelids due to the
  blink reflex.

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GAG REFLEX

• IS A NORMAL REFLEX CONSISTING OF RETCHING
• IT MAY BE PRODUCED BY TOUCHING THE SOFT PALATE AT
  THE BACK OF THE MOUTH

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OCULOCEPHALIC REFLEX

• OTHERWISE KNOWN AS DOLLS EYES
• Contraindications
• Possible Cervical Spine Injury
• Technique
• Eyes open
• Head is rotated briskly from side to side

• Interpretation
• If Brainstem intact
• Eyes deviate contralaterally
• Look away from rotation
• If Brainstem injury
• Eyes follow direction of head rotation

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PLANTAR REFLEX

• 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

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ABNORMAL MOVEMENTS

• SEIZURES
• TICS
• TREMORS

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SENSORY FUNCTIONS

• 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)

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VITAL SIGNS

• RESPIRATION
• TEMPERATURE
• BLOOD PRESSURE
• PULSE

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RESPIRATION

• GIVES THE CLEAREST INDICATION OF HOW THE BRAIN IS
  FUNCTIONING
• THE RATE, CHARACTER AND PATTERN OF A PATIENTS
  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

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TEMPERATURE

• 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

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BLOOD PRESSURE

• EVIDENT IN THE LATER STAGES OF RAISED
  INTRACRANIAL PRESSURE
• HYPOTENSION CAN HAVE DRASTIC EFFECT ON THE
  PATIENT WITH A HEAD INJURY

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PULSE

• 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

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Questions
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Apex Beat

• Richard Lake
• May 2004

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Apical pulse

• Detected in the fifth intercostal space
  mid-clavicular 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

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Equipment for assessing apical pulse

• Watch with a second hand
• Stethoscope
• Antiseptic wipes

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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.

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Bell Mode (low-frequency)

• Use light contact on the bell side to hear
  low-frequency sounds.

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Diaphragm Mode (high-frequency)

• Turn the chest piece over, index to the opposite
  side and use firm pressure to listen to
  high-frequency sounds.

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Procedure

• 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

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Points to consider

• 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

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Questions