1002 Part 2 Flashcards
Why a neurological assessment? (brain)
- determine whether the patient has a neurological problem
- establish what impact the condition has on the patients independence and daily life
- baseline assessment
- determine changes
- detect life threating situations
Determine level of consciousness? (AVPU)
A - alert
V - rousable by VOICE (conduct GSC)
P - rousable by PAIN (conduct GCS)
U - unresponsive
Glasco Coma scale?
- Eye opening (score 1-4)
- indicates arousal and awareness
- Verbal response (1-5)
- indicates level of orientation - Motor response (1-6)
- indicates whole brain function
What is the highest and lowest score of GSC?
Highest = 15 Lowest = 3
If there is a drop by ONE = clinical review
If there is a drop by TWO = rapid response
What is a severe, moderate and mild brain injury score?
severe = 3-8 Moderate = 9-12 mild = 13- 15
What is involved in a Neurological assessment?
- GCS
- Limb stretch
- Pupil size and reaction to light
Limb strength - legs and arms
- limb power should be present in all major and minor joints
- diminished function may indicate a lesion (damage) in the central or peripheral nervous system
- ask the patient to flex each knee one at a time and get the person to try straighten the leg of push against resistance applied by you
- Assess bilateral equality of muscle strength in the arms and legs
What is pronator drift?
- some assessments include looking to see if downward or pronator drift of the arms is present
- this is done by asking the patient to close their eyes and extend their arms with palms upward
- if their arms drift down of the pal on one side rotates it may signal a possible arm weakness
Pupil size and reaction to light?
- inspect both eyes for pupil size and symmetry
- left and right pupils should be the same size
- Reacts + if there is a brisk constriction of the pupil
- sluggish ‘SL’ if the pupil is nonreactive and has not changed in size
- no reaction ‘-‘ if the pupil is nonreactive and has not changed in size
- Closed ‘c’ if both eyes are close and unable to open due to gross orbital swelling
What is a neurovascular assessment?
- assessment of the peripheral circulation and peripheral neurologic integrity
- neurovascular impairment is usually caused by pressure on the nerve or altered vascular supply to the extremity
- is comparative - always assess the unaffected limb to establish a baseline, prior to assessing the affected limb
What are the components of a neurovascular assessment?
- skin colour
- skin temperature
- capillary refill
- pain (6)
- pulses
- sensation
- Movement
- swelling
- blood loss
What are the 6 ps in neurovascular assessment?
- Pain
- paraesthesia (abnormal sensation - tingling)
- Pressure
- Pallor
- Paralysis
- Pulselessness (tissue damage)
Pulses in a neuro assessment?
- pulses are palpated to sense the movement of blood flow through the peripheral vessels
- assess the pulse - strong, weak absent
- record the pulse distal to injury
Sensation and movement in neurovascular assessment?
- Active movement = able to voluntarily extend and flex an extremity
- Passive movement = dr/ nurse is able to extend and flex an extremity
- patients should be able to demonstrate active movement of an extremity
- increased pain on passive extension or flexion of fingers or toes may indicate compartment syndrome
What is compartment syndrome?
= an increase of pressure within a muscle compartment, there is an increase of interstitial pressure within he osseo fascial compartments
- if the pressure is not relieved, necrosis of the soft tissue will occurs leading to permanent contracture deformities
- causes capillary perfusion to be reduced below a level necessary for tissue viability and is classified as
- acute/crush
- chronic
