Neuro Assessment: Glascow Coma Scale (For Practicum) Flashcards
The neuro assessment consists of what four things?
- LOC
- Cranial nerve III, IV and VI assessment
- Glasgow Coma Scale
- Babinsk Test
How do you check for LOC?
- “Whats your name” (person)
- “Do you know where you are?” (place)
- “Can you tell me what date it is?” (time)
- “Who’s President right now?” (event)
- Scored as “A&Ox…” (however many they get right)
What are the names of cranial nerves III, IV and VI?
Describe each.
- III = oculomotor
- Outer diagonal: upper and lower
- Inner diagonal: upper only
- Inner lateral movement (cross-eyed)
- IV = trochlear
- Inner diagonal: downward only
- VI = Abducens
- Outer lateral only
Describe movement for CNIII
- Outer diagonal: upper and lower
- Inner diagonal: upper only
- Inner lateral movement (cross-eyed)
Describe movement for CNIV
Inner diagonal: downward only
Describe movement for CNVI
Outer lateral movement only
What does PERRLA stand for?
- Pupils
- Equal
- Round
- Reactive
- Light
- Accommodation (pupils behaving as they should)
What are some causes of pinpoint pupils?
- Opiods/narcotics
- HTN meds (clonidine, tetrahydrozoline)
- Heroin
- Head injury
What are some causes of fixed and dialated pupils?
- Brain injury
- Stroke
What is the Glagow Coma Scale used for?
- To objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients
The Glasgow Coma Scale is assessing what 3 responses and what is the score range?
- Eye
- Verbal
- Sensorimotor
- 3-15
How many points is each part of the Glasgow Coma Test worth?
- Eye = 4pts
- Verbal = 5pts
- Sensorimotor = 6pts
- Total = 15
How is the eye response scored?
- Spontaneous–open with blinking at baseline 4 points
- To verbal stimuli, command, speech 3 points
- To pain only (not applied to face) 2 points
- No response 1 point
How is the verbal response scored?
- Oriented 5 points
- Confused conversation, but able to answer questions 4 points
- Inappropriate words 3 points
- Incomprehensible speech 2 points
- No response 1 point
How is the sensorimotor response scored?
- Obeys commands for movement 6 points
- Purposeful movement to painful stimulus 5 points
- Withdraws in response to pain 4 points
- Flexion in response to pain (decorticate posturing) 3 points
- Extension response in response to pain (decerebrate posturing) 2 points
- No response 1 point
How does decorticate positioning manifest?
- Body is rigid with hands held at chest level, balled with thumbs turned inward, feet extended, may turn inward as well
What is the cause of decorticate positioning?
- Brainstem injury involving
- Midbrain
- Pons
- Medulla oblongata
- TBI
- Tumor
- Stroke
- Liver failure
Is decorticate or decerebrate damage reversable
No
How does decerebrate positioning manifest?
Body rigid with hands at sides, balled and rotated with thumbs turned toward back
What is the cause of decerebrate positioning?
Brainstem injury involving red nucleus of the midbrain (just above pons)
What nursing care is provided for decorticate/decerebrate pts?
- Still need to do vital signs and any other necessary care
What does the Babinski Test assess?
L4-S2 functioinality
How does the Babinski reflex manifest?
Great toe lifts upward while the rest spread out
Is the Babinski reflex normal?
- For infants and children up to 2, yes
- For adults no
