Presentation on theme: "Neurological observations"— Presentation transcript:
1 Neurological observations Glasgow Coma ScaleIs used to assess patients state of consciousness that may have altered as a result of a hypoxic event or head trauma.This assessment assesses the cerebral cortex and the brain stem.It is repeated at intervals to detect improvement or deterioration in the patients level of consciousness.
3 Neurological observations are done when An actual suspected LOCAn alteration to consciousnessFollowing a head injuryFollowing diagnostic or surgical procedures to the CNSWhen requested to by the doctor
4 The assessment includes Mental statusLanguageOrientationMemoryAttention span and circulationJudgmentAbstract reasoningThe Glasgow coma scalePupil size and reaction to lightLimb responsesVital signs
5 Glasgow coma scale Measures the level of consciousness Aim Identify CNS dysfunctionEstablish a baseline for comparisonDetect early life – threatening changes or improvement in neurological conditionThree areas assessedEye openingVerbal responseMotor responseThese areas are graded and the values added7 or less indicates coma15 indicates optimal level of consciousness
6 Eye openingSpontaneous – eyes are open before or immediately they are aware of your presence (without you touching bed or verbalizing)To speech – when greeted or in response to their name being calledTo pain – in response to painful stimuli
7 Painful stimulationPeripheral – squeezing patient’s finger (over the nail bed) between a pen and the nurse’s thumb.Central – trapezium squeeze; the trapezius muscle is twisted using the thumb and two fingers where the neck meets the shoulder
8 Verbal response Orientated to place, time and person Confused ; talking in sentences, but disorientated to place and timeInappropriate word; utters occasional words rather than sentences, often abusive words elicited, by inflicting pain rather than spontaneousIncomprehensible sounds , groans or grunts
9 Motor response Obeys commands, able to move on command. Localizes pain, locates and attempts to remove painful stimuli applied to the head or trunkNormal flexion , flexes arm at elbow without wrist rotation response to central stimulusAbnormal flexion. Flexes elbows and rotates wrist into a spastic posture in response to central painfulA patient flexing to pain will not raise their hands above their shoulders in response to central stimulus
10 Pupils Size Should be equal in size Diameter approximately 2-6 mm ShapeRoundOvid pupils may be an early sign of tentorial herniationKeyhole pupils – cataract surgeryReactionNormal is a brisk reactionSluggish may indicate some compression of cranial nerve 111No reaction may indicate complete compression of cranial nerve 111
12 Glasgow coma scale Eye Opening 4 Points Eyes open spontaneously 3 Points Eye opening to verbal command2 Points Eye opening to pain (being pinched)1 Points No eye opening Verbal Response5 Points Oriented and speaks normally4 Points Confused but speaks normally3 Points Inappropriate words2 Points Incomprehensible sounds1 Points No verbal response Motor Response (movement of arms and legs)6 Points Obeys commands to move arms and legs5 Points Withdraws from pain locally (where pinched)4 Points Withdraws from pain generally3 Points Flexes limb in response to pain2 Points Straightens limb in response to pain1 Points No movement in response to pain
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