DEFINITION

1. DEFINITION • NEUROLOGICAL OBSERVATIONS RELATE TO THE EVALUATION OF THE INTEGRITY OF AN INDIVIDUAL’S NERVOUS SYSTEM

2. INDICATIONS • 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

3. EXAMINATION OF THE NEUROLOGICAL SYSTEM INCLUDES AN ASSESSMENT OF: • LEVEL OF CONSCIOUSNESS • PUPILLARY ACTIVITY • MOTOR FUNCTION • SENSORY FUNCTION • VITAL SIGNS

4. 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.

5. TRY TO THINK OF THREE WAYS IN WHICH WE CAN ASSESS A PATIENT’S CONSCIOUSNESS LEVEL • EYE OPENING • VERBAL RESPONSE • MOTOR RESPONSE

6. 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

7. 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

8. Glasgow Coma Scale

9. Paediatric Glasgow Coma Scale

10. GLASGOW COMA SCALE • LOWEST SCORE COULD BE 3 • HIGHEST SCORE 15 INDICATES FULL CONSCIOUSNESS

11. 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

12. 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!!!!!

13. 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

14. EXAMINATION OF THE PUPILS 2 3 4 5 6 7 8 9 • 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

15. Checking consensual light reflex Checking pupillary reaction to light

16. NORMAL VISUAL FUNCTION DEPENDS ON: • CRANIAL NERVES III,IV,VI • INTACT VISUAL CENTRE IN THE OCCIPITAL CORTEX

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

18. 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

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

20. MOTOR FUNCTION ASSESSMENT INVOLVES: • MUSCLE STRENGTH • MUSCLE TONE • MUSCLE CO-ORDINATION • REFLEXES • ABNORMAL MOVEMENTS

21. REFLEXES • BLINK • GAG • OCULOPHALIC • PLANTAR

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

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

24. OTHERWISE KNOWN AS DOLL’S 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 OCULOCEPHALIC REFLEX

25. 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

26. ABNORMAL MOVEMENTS • SEIZURES • TICS • TREMORS

27. 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)

28. VITAL SIGNS • RESPIRATION • TEMPERATURE • BLOOD PRESSURE • PULSE

29. RESPIRATION • 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

30. 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

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

32. 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

33. 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

34. Equipment for assessing apical pulse • Watch with a second hand • Stethoscope • Antiseptic wipes

35. 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.

36. Bell Mode (low-frequency) • Use light contact on the bell side to hear low-frequency sounds.

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

38. 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

39. 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

40. 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