Family member present

Family member present

• Family member present

• Vaccination

• Major injuries

• Childhood illnesses

• Family

• Present illness

Pain

• Pain

• Location
• Quality
• Severity
• Duration
• Precipitating factors
• Associated symptoms
• Exasperation / diminished pain
• Onset

Multiple causes

• Multiple causes

• Not a good indicator of neuro trouble

Sensation of moving around in space or objects moving around them

• Sensation of moving around in space or objects moving around them

• Assoc symptoms

Definition

• Definition

• Unusual sensation

• Examples

• Numbness
• Tingling
• Burning

• Assessment

• ? Weak
• ? Intermittent or constant

Diplopia

• Diplopia

• Clarity

• Nystagmus

Thinking

• Thinking

• Memory

• Personality

Projectile

• Projectile

Mental status

• Mental status

• Intellectual function

• Thought content

• Emotional status

• Perception

• Motor ability

• Language ability

Level of consciousness

• 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

Coma

• Coma

• Unresponsive except to severe pain
• Protective reflexes absent
• Pupils fixed
• No voluntary movement

Non-medical word

• Non-medical word

• Ranges from stupor to coma

No cognitive brain function

• No cognitive brain function

• Wake sleep cycles

• Very poor prognosis (if > 3-6 months)

No brain function

• No brain function

• Only reflexive movements

Voice

• Voice

• Touch

• Shaking

• Voice + Shaking

• Noxious/painful stimuli

Eye opens

• Eye opens

• Remove stimuli

• Abnormal posturing

• No response

Eye Opening

• Eye Opening

• Spontaneous – 4
• To speech – 3
• To pain – 2
• Nil – 1

Best Motor Response

• Best Motor Response

• Obeys -6
• Localizes – 5
• Withdraws – 4
• Abnormal flexion – 3
• Extension response – 2
• Nil - 1

Verbal response

• Verbal response

• Oriented – 5
• Confused conversation – 4
• Inappropriate words – 3
• Incomprehensible sounds – 2
• Nil - 1

A strong predictor of outcome

• A strong predictor of outcome

• 13: mild brain injury

• 9-12: Moderate brain injury

• < 8: Severe brain injury (coma)

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

• 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

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

• 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

Give 5 questions you might ask a neuro patient who is complaining about a headache during an intake assessment

• Give 5 questions you might ask a neuro patient who is complaining about a headache during an intake assessment

• Identify the rostral-caudal progression of consciousness

• Identify the differences in patients in each of the stages of consciousness

• What is the lowest score a patient can get on a Glasgow coma scale?

• What is the highest score a patient can get on a Glasgow Come Scale?

• What is the most sensitive indicator on the Glasgow Coma Scale?

How do they look?

• How do they look?

• Grooming
• Dress
• Aids
• Eye deviation
• Skin

Signs of trauma, wounds, scrapes, ecchymosis etc.

• Signs of trauma, wounds, scrapes, ecchymosis etc.

Bruising over the Mastoid

• Bruising over the Mastoid

• Where’s the mastoid?

Bruising over the Mastoid

• Bruising over the Mastoid

Bruising over the Mastoid

• Bruising over the Mastoid

Bruising over the Mastoid

• Bruising over the Mastoid

Bruising over the Mastoid

• Bruising over the Mastoid

Bruising over the Mastoid area

• Bruising over the Mastoid area

• Suggests

• Basal skull fracture

Periorbital edema and bruising

• Periorbital edema and bruising

Periorbital edema and bruising

• Periorbital edema and bruising

• Suggests:

• Frontal-basal fracture

Drainage of CSF from the nose

• Drainage of CSF from the nose

• Suggests

• Fracture of the cribiform with torn meninges

Drainage of CSF from the ear

• Drainage of CSF from the ear

• Suggests:

• Fracture of the temporal bone with torn meninges

Flexed Posturing

• Flexed Posturing

• Flexed arm/elbow
• Flexed wrists/fingers
• Adducted arms
• Legs with internal rotation
• Foot: Plantar flexed

Suggests

• Suggests

• Damage to the cortico-spinal tract

• More favorable than decerebrate posture

Extension posturing

• Extension posturing

• Extended arm/elbow
• Flexed wrist/fingers
• Adducted arm
• Pronation of arm
• Foot: Plantar flexed

Suggests

• Suggests

• severe injury to the brain at the level of the brainstem

• Opisthotonos

• severe muscle spasm of the neck and back

• More ominous posture

x 3

• x 3

• Person
• Place
• Time