DEFINITIONDEFINITION

NEUROLOGICAL OBSERVATIONS NEUROLOGICAL OBSERVATIONS RELATE TO THE EVALUATION OF THE RELATE TO THE EVALUATION OF THE INTEGRITY OF AN INDIVIDUAL’S INTEGRITY OF AN INDIVIDUAL’S NERVOUS SYSTEMNERVOUS SYSTEM

INDICATIONSINDICATIONS

IN PAIRS DISCUSS ON WHAT TYPE OF IN PAIRS DISCUSS ON WHAT TYPE OF PATIENT’S WOULD WE PERFORM PATIENT’S WOULD WE PERFORM NEUROLOGICAL OBSERVATIONS.NEUROLOGICAL OBSERVATIONS.

NEUROLOGICAL OBSERVATIONS ARE NEUROLOGICAL OBSERVATIONS ARE REQUIRED TO MONITOR AND EVALUATE REQUIRED TO MONITOR AND EVALUATE CHANGES IN THE NERVOUS SYSTEM BY CHANGES IN THE NERVOUS SYSTEM BY INDICATION TRENDS, THUS AIDING INDICATION TRENDS, THUS AIDING DIAGNOSIS AND TREATMENT. THE DIAGNOSIS AND TREATMENT. THE FREQUENCY OF THESE OBSERVATIONS WILL FREQUENCY OF THESE OBSERVATIONS WILL DEPEND ON THE PATIENT’S CONDITIONDEPEND ON THE PATIENT’S CONDITION

EXAMINATION OF THE EXAMINATION OF THE NEUROLOGICAL SYSTEM NEUROLOGICAL SYSTEM

INCLUDES AN ASSESSMENT OF:INCLUDES AN ASSESSMENT OF: LEVEL OF CONSCIOUSNESSLEVEL OF CONSCIOUSNESS PUPILLARY ACTIVITYPUPILLARY ACTIVITY MOTOR FUNCTIONMOTOR FUNCTION SENSORY FUNCTIONSENSORY FUNCTION VITAL SIGNSVITAL SIGNS

CONSCIOUSNESS DEPENDS CONSCIOUSNESS DEPENDS ON:ON:

AROUSABILITYAROUSABILITY AWARENESSAWARENESS BOTH OF THESE REQUIRE AN INTACT BOTH OF THESE REQUIRE AN INTACT

CEREBRAL CORTEX TO INTERPRET CEREBRAL CORTEX TO INTERPRET SENSORY INPUT AND RESPOND SENSORY INPUT AND RESPOND ACCORDINGLY.ACCORDINGLY.

LEVELS OF CONSCIOUSNESS MAY VARY LEVELS OF CONSCIOUSNESS MAY VARY AND ARE DEPENDENT ON THE LOCATION AND ARE DEPENDENT ON THE LOCATION AND EXTENT OF NEUROLOGICAL DAMAGE.AND EXTENT OF NEUROLOGICAL DAMAGE.

TRY TO THINK OF THREE WAYS TRY TO THINK OF THREE WAYS IN WHICH WE CAN ASSESS A IN WHICH WE CAN ASSESS A PATIENT’S CONSCIOUSNESS PATIENT’S CONSCIOUSNESS

LEVELLEVEL EYE OPENINGEYE OPENING VERBAL RESPONSEVERBAL RESPONSE MOTOR RESPONSEMOTOR RESPONSE

LEVEL OF CONSCIOUSNESSLEVEL OF CONSCIOUSNESS

IS THE SINGLE MOST IMPORTANT IS THE SINGLE MOST IMPORTANT INDICATOR OF A PATIENTS BRAIN INDICATOR OF A PATIENTS BRAIN FUNCTION. IT RANGES, ON A FUNCTION. IT RANGES, ON A CONTINUUM, FROM ALERT CONTINUUM, FROM ALERT WAKEFULNESS TO DEEP COMA WITH WAKEFULNESS TO DEEP COMA WITH NO APPARENT RESPONSIVENESSNO APPARENT RESPONSIVENESS

THE GLASGOW COMA SCALETHE GLASGOW COMA SCALE

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

Glasgow Coma ScaleGlasgow Coma Scale

  Eye Opening (E) Verbal Response (V) Motor Response (M)

4=Spontaneous3=To voice2=To pain1=None

5=Orientated 4=Confused

3=Inappropriate words 2=Incomprehensible 1=None

6=Obeys commands 5=Localizes to pain

4=Withdraws to pain3=Flexes to pain

2=Extends to pain 1=None

Total = E+V+M

Paediatric Glasgow Coma Paediatric Glasgow Coma ScaleScale

  Eye Opening (E) Verbal Response (V) Motor Response (M)

4=Spontaneous3=To speech/noise2=To pain1=None

5=Appropriate words/phrases, smiles, coos, cries

4=Confused, monosyllables, cries, irritable

3=Inappropriate words / Inconsolable screams

2=Incomprehensible Sound 1=None

6=Obeys commands,normal spontaneous Movements5=Localizes to pain4=Withdraws to pain3=Flexes to pain2=Extends to pain1=None

Total = E+V+M

GLASGOW COMA SCALEGLASGOW COMA SCALE

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

CONSCIOUSNESSCONSCIOUSNESS

PAIN STIMULIPAIN STIMULI THE PAINFUL STIMULI APPROVED FOR USE THE PAINFUL STIMULI APPROVED FOR USE

WHEN ASSESSING NEUROLOGICAL STATE IS:WHEN ASSESSING NEUROLOGICAL STATE IS: SUPRAORBITAL PRESSURE (ONLY ONCE)SUPRAORBITAL PRESSURE (ONLY ONCE) REPEATED ASSESSMENT THESE PAINFUL REPEATED ASSESSMENT THESE PAINFUL

STIMULI SHOULD BE USED:STIMULI SHOULD BE USED: SQUEEZING THE TRAPEZIUMSQUEEZING THE TRAPEZIUM PRESSING ON THE ANGLE OF THE JAWPRESSING ON THE ANGLE OF THE JAW PAINFUL STIMULI NOT APPROVED INCLUDE:PAINFUL STIMULI NOT APPROVED INCLUDE: EXERTING PRESSURE ON THE NAILBEDEXERTING PRESSURE ON THE NAILBED APPLYING PRESSURE TO THE SUPRAORBITAL APPLYING PRESSURE TO THE SUPRAORBITAL

RIDGERIDGE PINCHING THE ACHILLES TENDONPINCHING THE ACHILLES TENDON RUBBING THE STERNUMRUBBING THE STERNUM

NOW CHECK YOUR NOW CHECK YOUR PARTNERS GLASGOW PARTNERS GLASGOW

COMA SCORECOMA SCORERECORD ON YOUR CHARTRECORD ON YOUR CHARTHOPEFULLY YOU HAVE HOPEFULLY YOU HAVE ALL SCORED 15 (4:5:6) ALL SCORED 15 (4:5:6) UNLESS YOU HAVE UNLESS YOU HAVE FALLEN ASLEEP!!!!!FALLEN ASLEEP!!!!!

PUPILLARY ACTIVITYPUPILLARY ACTIVITY

CAREFUL EXAMINATION OF THE REACTION OF CAREFUL EXAMINATION OF THE REACTION OF THE PUPILS TO LIGHT IS AN IMPORTANT THE PUPILS TO LIGHT IS AN IMPORTANT NEUROLOGICAL ASSESSMENTNEUROLOGICAL ASSESSMENT

NOTE THE SIZE, SHAPE, EQUALITY AND REACTION NOTE THE SIZE, SHAPE, EQUALITY AND REACTION OF BOTH EYES TO LIGHTOF BOTH EYES TO LIGHT

P.E.A.R.LP.E.A.R.L CHECK THE POSITION OF THE EYES. ARE THEY CHECK THE POSITION OF THE EYES. ARE THEY

DEVIATING UPWARDS OR DOWNWARDS? ARE DEVIATING UPWARDS OR DOWNWARDS? ARE THEY LOOKING IN THE SAME DIRECTION OR ARE THEY LOOKING IN THE SAME DIRECTION OR ARE THEY DISCONJUATEDTHEY DISCONJUATED

WHAT CRANIAL NERVE CONTROLS PUPILLARY WHAT CRANIAL NERVE CONTROLS PUPILLARY ACTIVITY?????ACTIVITY?????

III - OCULOMOTORIII - OCULOMOTOR

EXAMINATION OF THE EXAMINATION OF THE PUPILSPUPILS

Normal diameter: 1.5 – 6 mmNormal diameter: 1.5 – 6 mm Shape: round and midpositionShape: round and midposition Equality of pupils: equalEquality of pupils: equal Reaction to light: constricts swiftlyReaction to light: constricts swiftly Consensual light reflex: both pupils constrictConsensual light reflex: both pupils constrict LOOK AT YOUR PARTNER PUPILS AND LOOK AT YOUR PARTNER PUPILS AND

CHART WHAT SIZE THEIR PUPILS ARECHART WHAT SIZE THEIR PUPILS ARE

2 3 4 5 6 7 8 9

Checking pupillary

reaction to light

Checking consensual light

reflex

NORMAL VISUAL FUNCTION NORMAL VISUAL FUNCTION DEPENDS ON:DEPENDS ON:

CRANIAL NERVES III,IV,VICRANIAL NERVES III,IV,VI INTACT VISUAL CENTRE IN THE INTACT VISUAL CENTRE IN THE

OCCIPITAL CORTEXOCCIPITAL CORTEX

NOW CHECK YOUR NOW CHECK YOUR PARTNERS PUPIL PARTNERS PUPIL

REACTION TO LIGHT TRY REACTION TO LIGHT TRY BOTH TESTSBOTH TESTS

HOPEFULLY YOUR PUPILS HOPEFULLY YOUR PUPILS WILL HAVE CONSTRICTED WILL HAVE CONSTRICTED SWIFTLY AND WILL BE SWIFTLY AND WILL BE CONSENSUALCONSENSUAL

LIST 5 REASONS FOR POOR LIST 5 REASONS FOR POOR PUPILLARY REACTIONSPUPILLARY REACTIONS

OPIATESOPIATES SOME CARDIAC DRUGS E.G. ADRENALINESOME CARDIAC DRUGS E.G. ADRENALINE TRAUMATIC HEAD INJURYTRAUMATIC HEAD INJURY BRAIN HAEMORRHAGEBRAIN HAEMORRHAGE ENCEPHALITUS/MENINGITISENCEPHALITUS/MENINGITIS BRAIN LESIONBRAIN LESION NERVE PALSYNERVE PALSY SYNDROMES SUCH AS HORNERS SYNDROMESYNDROMES SUCH AS HORNERS SYNDROME

MOTOR FUNCTIONMOTOR FUNCTION

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

MOTOR FUNCTION MOTOR FUNCTION ASSESSMENT INVOLVES:ASSESSMENT INVOLVES:

MUSCLE STRENGTHMUSCLE STRENGTH MUSCLE TONEMUSCLE TONE MUSCLE CO-ORDINATIONMUSCLE CO-ORDINATION REFLEXESREFLEXES ABNORMAL MOVEMENTSABNORMAL MOVEMENTS

REFLEXESREFLEXES

BLINKBLINK GAGGAG OCULOPHALICOCULOPHALIC PLANTARPLANTAR

BLINK REFLEXBLINK REFLEX

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

GAG REFLEXGAG REFLEX

IS A NORMAL REFLEX CONSISTING OF IS A NORMAL REFLEX CONSISTING OF RETCHINGRETCHING

IT MAY BE PRODUCED BY TOUCHING IT MAY BE PRODUCED BY TOUCHING THE SOFT PALATE AT THE BACK OF THE SOFT PALATE AT THE BACK OF THE MOUTHTHE MOUTH

OCULOCEPHALIC REFLEXOCULOCEPHALIC REFLEX

OTHERWISE KNOWN OTHERWISE KNOWN AS DOLL’S EYESAS 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

PLANTAR REFLEXPLANTAR REFLEX

With the patient supine, With the patient supine, support the weight of support the weight of the foot at the ankle. the foot at the ankle.

With a pointed object, With a pointed object, stroke the lateral stroke the lateral aspect of the sole of aspect of the sole of the footthe foot, from the heel , from the heel up and across the ball up and across the ball of the foot. of the foot.

Normal reaction is to Normal reaction is to curl the toes curl the toes downwardsdownwards

ABNORMAL MOVEMENTSABNORMAL MOVEMENTS

SEIZURESSEIZURES TICSTICS TREMORSTREMORS

SENSORY FUNCTIONSSENSORY FUNCTIONS

ASSESSMENT OF THE SENSORY FUNCTION ASSESSMENT OF THE SENSORY FUNCTION SHOULD INCLUDE:-SHOULD INCLUDE:-

CENTRAL AND PERIPHERAL VISIONCENTRAL AND PERIPHERAL VISION HEARING AND THE ABILITY TO HEARING AND THE ABILITY TO

UNDERSTAND VERBAL COMMUNICATIONUNDERSTAND VERBAL COMMUNICATION SUPERFICIAL SENSATIONS (LIGHT TOUCH SUPERFICIAL SENSATIONS (LIGHT TOUCH

PAIN) AND DEEP SENSATIONS (MUSCLE PAIN) AND DEEP SENSATIONS (MUSCLE AND JOINT PAIN AND JOINT POSITION)AND JOINT PAIN AND JOINT POSITION)

VITAL SIGNSVITAL SIGNS

RESPIRATIONRESPIRATION TEMPERATURETEMPERATURE BLOOD PRESSUREBLOOD PRESSURE PULSEPULSE

RESPIRATIONRESPIRATION GIVES THE CLEAREST INDICATION OF GIVES THE CLEAREST INDICATION OF

HOW THE BRAIN IS FUNCTIONINGHOW THE BRAIN IS FUNCTIONING THE RATE, CHARACTER AND THE RATE, CHARACTER AND

PATTERN OF A PATIENT’S PATTERN OF A PATIENT’S RESPIRATION MUST BE NOTED.RESPIRATION MUST BE NOTED.

WITH A GCS OF 8 OR LESS IT IS WITH A GCS OF 8 OR LESS IT IS IMPORTANT TO ENSURE THE PATIENT IMPORTANT TO ENSURE THE PATIENT IS ABLE TO MAINTAIN AND PROTECT IS ABLE TO MAINTAIN AND PROTECT THEIR AIRWAYTHEIR AIRWAY

TEMPERATURETEMPERATURE SEVERE HEAD INJURY OFTEN CAUSES DERANGED SEVERE HEAD INJURY OFTEN CAUSES DERANGED

TEMPERATURE DUE TO DAMAGE TO TEMPERATURE DUE TO DAMAGE TO HYPOTHALAMUSHYPOTHALAMUS

FOR EVERY DEGREE RISE IN BODY TEMPERATURE FOR EVERY DEGREE RISE IN BODY TEMPERATURE THE METABOLIC RATE INCREASES BY 10%. THE METABOLIC RATE INCREASES BY 10%. HOW HOW CAN THIS BE HAZARDOUS FOR THE PATIENT????CAN THIS BE HAZARDOUS FOR THE PATIENT????

THEY ALREADY HAVE A COMPROMISED OXYGEN THEY ALREADY HAVE A COMPROMISED OXYGEN AND GLUCOSE SUPPLY TO THAT PART OF THE AND GLUCOSE SUPPLY TO THAT PART OF THE HEAD AND CARBON DIOXIDE IS A CEREBRAL HEAD AND CARBON DIOXIDE IS A CEREBRAL VASODILATOR THEREFORE CAN INCREASE VASODILATOR THEREFORE CAN INCREASE INTRACRANIAL PRESSURE.INTRACRANIAL PRESSURE.

BRAIN INJURY CAN CAUSE HYPERTHERMIA AND BRAIN INJURY CAN CAUSE HYPERTHERMIA AND HYPOTHERMIAHYPOTHERMIA

BLOOD PRESSUREBLOOD PRESSURE

EVIDENT IN THE LATER STAGES OF EVIDENT IN THE LATER STAGES OF RAISED INTRACRANIAL PRESSURERAISED INTRACRANIAL PRESSURE

HYPOTENSION CAN HAVE DRASTIC HYPOTENSION CAN HAVE DRASTIC EFFECT ON THE PATIENT WITH A EFFECT ON THE PATIENT WITH A HEAD INJURYHEAD INJURY

PULSEPULSE

CEREBRAL INSULT CAN HAVE ONE OF THE CEREBRAL INSULT CAN HAVE ONE OF THE FOLLOWING EFFECTS ON THE PULSE:-FOLLOWING EFFECTS ON THE PULSE:-

BRADYCARDIABRADYCARDIA – CERVICAL INJURY AND IN – CERVICAL INJURY AND IN THE LATER STAGES OF RAISED THE LATER STAGES OF RAISED INTRACRANIAL PRESSUREINTRACRANIAL PRESSURE

TACHYCARDIA TACHYCARDIA – INJURY TO – INJURY TO HYPOTHALAMUS AND PRESENT IN HYPOTHALAMUS AND PRESENT IN TERMINAL STAGE OF RAISED TERMINAL STAGE OF RAISED INTRACRANIAL PRESSUREINTRACRANIAL PRESSURE

ARRYTHMIASARRYTHMIAS – BLOOD IN THE – BLOOD IN THE CEREBROSPINAL FLUIDCEREBROSPINAL FLUID

Apical pulseApical pulse

Detected in the fifth intercostal space Detected in the fifth intercostal space mid-clavicular line left side of chestmid-clavicular line left side of chest

Detected with the aid of a stethoscopeDetected with the aid of a stethoscope Routinely used to record pulse rate in Routinely used to record pulse rate in

infants and children up to the age of 3 infants and children up to the age of 3 yearsyears

Can be used to detect discrepancies with Can be used to detect discrepancies with radial pulseradial pulse

Recorded in conjunction with the Recorded in conjunction with the administration of some medicinesadministration of some medicines

Equipment for assessing apical Equipment for assessing apical pulsepulse

Watch with a second handWatch with a second hand StethoscopeStethoscope Antiseptic wipesAntiseptic wipes

Stethoscope Traditional Stethoscope Traditional Combination-style Chest Combination-style Chest

piecepiece Traditional chest pieces have a Traditional chest pieces have a

bell side to hear low bell side to hear low frequencies and a diaphragm frequencies and a diaphragm side to hear high frequency side to hear high frequency sounds. The chest piece must sounds. The chest piece must be turned over to listen to the be turned over to listen to the different sounds. different sounds.

Bell Mode (low-frequency)Bell Mode (low-frequency)

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

Diaphragm ModeDiaphragm Mode (high-frequency) (high-frequency)

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

ProcedureProcedure

Explain to the patient what you are Explain to the patient what you are going to dogoing to do

Perform hand washing to minimise Perform hand washing to minimise cross infectioncross infection

Provide privacy for patient as chest Provide privacy for patient as chest will need to be exposedwill need to be exposed

Position patient in a comfortable Position patient in a comfortable supine or sitting positionsupine or sitting position

Locate the apical impulse – this is the Locate the apical impulse – this is the point over the apex of the heart where point over the apex of the heart where the apical pulse can be most clearly the apical pulse can be most clearly heardheard

This is also referred to as the This is also referred to as the Point of Point of Maximal Impulse – PMIMaximal Impulse – PMI

The apical impulse is usually located The apical impulse is usually located in the fifth intercostal space mid-in the fifth intercostal space mid-clavicular lineclavicular line

Auscultate and count the heart beats Auscultate and count the heart beats with the diaphragm of the stethoscopewith the diaphragm of the stethoscope

Points to considerPoints to consider Count the heart rate for one minute to Count the heart rate for one minute to

accurately recordaccurately record Assess the rhythm of the heart beat Assess the rhythm of the heart beat

by noting the pattern of intervals by noting the pattern of intervals between the beatsbetween the beats

Assess the strength/volume of the Assess the strength/volume of the heart beat and describe as strong or heart beat and describe as strong or weakweak

Record the pulse site, rate, rhythm Record the pulse site, rate, rhythm and volume in the patients notesand volume in the patients notes