1. NEUROLOGICAL OBSERVATIONS SHARON HARVEY

2. LEARNING OUTCOMES THE STUDENT SHOULD BE ABLE TO:- RECALL AND DEMONSTRATE ACCURATELY THE RECORDING OF VITAL SIGNS RECALL AND DEMONSTRATE ACCURATELY THE RECORDING OF VITAL SIGNS IDENTIFY WHEN A NEUROLOGICAL ASSESSMENT WOULD BE UNDERTAKEN AND WHAT INSTRUMENTS WOULD BE USED IDENTIFY WHEN A NEUROLOGICAL ASSESSMENT WOULD BE UNDERTAKEN AND WHAT INSTRUMENTS WOULD BE USED RECORD A NEUROLOGICAL OBSERVATION ASSESSMENT IN AN ADULT RECORD A NEUROLOGICAL OBSERVATION ASSESSMENT IN AN ADULT DEMONSTRATE AWARENESS OF HOW NEUROLOGICAL ASSESSMENT CAN BE CARRIED OUT WITH CHILDREN DEMONSTRATE AWARENESS OF HOW NEUROLOGICAL ASSESSMENT CAN BE CARRIED OUT WITH CHILDREN

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

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

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

6. CONSCIOUSNESS DEPENDS ON: AROUSABILITY AROUSABILITY AWARENESS AWARENESS BOTH OF THESE REQUIRE AN INTACT CEREBRAL CORTEX TO INTERPRET SENSORY INPUT AND RESPOND ACCORDINGLY. 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. LEVELS OF CONSCIOUSNESS MAY VARY AND ARE DEPENDENT ON THE LOCATION AND EXTENT OF NEUROLOGICAL DAMAGE.

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

8. 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 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

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

10. Glasgow Coma Scale Eye Opening (E)Verbal Response (V)Motor Response (M) 4=Spontaneous 3=To voice 2=To pain 1=None 5=Orientated 4=Confused 3=Inappropriate words 2=Incomprehensible 1=None 6=Obeys commands 5=Localizes to pain 4=Withdraws to pain 3=Flexes to pain 2=Extends to pain 1=None Total = E+V+M

11. Paediatric Glasgow Coma Scale Eye Opening (E)Verbal Response (V)Motor Response (M) 4=Spontaneous 3=To speech/noise 2=To pain 1=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 Movements 5=Localizes to pain 4=Withdraws to pain 3=Flexes to pain 2=Extends to pain 1=None Total = E+V+M

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

13. PAIN STIMULI THE PAINFUL STIMULI APPROVED FOR USE WHEN ASSESSING NEUROLOGICAL STATE IS: THE PAINFUL STIMULI APPROVED FOR USE WHEN ASSESSING NEUROLOGICAL STATE IS: SUPRAORBITAL PRESSURE (ONLY ONCE) SUPRAORBITAL PRESSURE (ONLY ONCE) REPEATED ASSESSMENT THESE PAINFUL STIMULI SHOULD BE USED: REPEATED ASSESSMENT THESE PAINFUL STIMULI SHOULD BE USED: SQUEEZING THE TRAPEZIUM SQUEEZING THE TRAPEZIUM PRESSING ON THE ANGLE OF THE JAW PRESSING ON THE ANGLE OF THE JAW PAINFUL STIMULI NOT APPROVED INCLUDE: PAINFUL STIMULI NOT APPROVED INCLUDE: EXERTING PRESSURE ON THE NAILBED EXERTING PRESSURE ON THE NAILBED APPLYING PRESSURE TO THE SUPRAORBITAL RIDGE APPLYING PRESSURE TO THE SUPRAORBITAL RIDGE PINCHING THE ACHILLES TENDON PINCHING THE ACHILLES TENDON RUBBING THE STERNUM RUBBING THE STERNUM

14. 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!!!!! HOPEFULLY YOU HAVE ALL SCORED 15 (4:5:6) UNLESS YOU HAVE FALLEN ASLEEP!!!!!

15. PUPILLARY ACTIVITY CAREFUL EXAMINATION OF THE REACTION OF THE PUPILS TO LIGHT IS AN IMPORTANT NEUROLOGICAL ASSESSMENT 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 NOTE THE SIZE, SHAPE, EQUALITY AND REACTION OF BOTH EYES TO LIGHT P.E.A.R.L 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 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????? WHAT CRANIAL NERVE CONTROLS PUPILLARY ACTIVITY????? III - OCULOMOTOR III - OCULOMOTOR

16. EXAMINATION OF THE PUPILS Normal diameter: 1.5 – 6 mm Normal diameter: 1.5 – 6 mm Shape: round and midposition Shape: round and midposition Equality of pupils: equal Equality of pupils: equal Reaction to light: constricts swiftly Reaction to light: constricts swiftly Consensual light reflex: both pupils constrict Consensual light reflex: both pupils constrict LOOK AT YOUR PARTNER PUPILS AND CHART WHAT SIZE THEIR PUPILS ARE LOOK AT YOUR PARTNER PUPILS AND CHART WHAT SIZE THEIR PUPILS ARE 2 3 4 5 6 7 8 9

17. Checking pupillary reaction to light Checking consensual light reflex

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

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

20. LIST 5 REASONS FOR POOR PUPILLARY REACTIONS OPIATES OPIATES SOME CARDIAC DRUGS E.G. ADRENALINE SOME CARDIAC DRUGS E.G. ADRENALINE TRAUMATIC HEAD INJURY TRAUMATIC HEAD INJURY BRAIN HAEMORRHAGE BRAIN HAEMORRHAGE ENCEPHALITUS/MENINGITIS ENCEPHALITUS/MENINGITIS BRAIN LESION BRAIN LESION NERVE PALSY NERVE PALSY SYNDROMES SUCH AS HORNERS SYNDROME SYNDROMES SUCH AS HORNERS SYNDROME

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

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

23. REFLEXES BLINK BLINK GAG GAG OCULOPHALIC OCULOPHALIC PLANTAR PLANTAR

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

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

26. OCULOCEPHALIC REFLEX OTHERWISE KNOWN AS DOLL’S EYES OTHERWISE KNOWN AS DOLL’S EYES Contraindications Possible Cervical Spine InjuryCervical 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

27. PLANTAR REFLEX With the patient supine, support the weight of the foot at the ankle. 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. 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 Normal reaction is to curl the toes downwards

28. ABNORMAL MOVEMENTS SEIZURES SEIZURES TICS TICS TREMORS TREMORS

29. SENSORY FUNCTIONS ASSESSMENT OF THE SENSORY FUNCTION SHOULD INCLUDE:- ASSESSMENT OF THE SENSORY FUNCTION SHOULD INCLUDE:- CENTRAL AND PERIPHERAL VISION CENTRAL AND PERIPHERAL VISION HEARING AND THE ABILITY TO UNDERSTAND VERBAL COMMUNICATION HEARING AND THE ABILITY TO UNDERSTAND VERBAL COMMUNICATION SUPERFICIAL SENSATIONS (LIGHT TOUCH PAIN) AND DEEP SENSATIONS (MUSCLE AND JOINT PAIN AND JOINT POSITION) SUPERFICIAL SENSATIONS (LIGHT TOUCH PAIN) AND DEEP SENSATIONS (MUSCLE AND JOINT PAIN AND JOINT POSITION)

30. VITAL SIGNS RESPIRATION RESPIRATION TEMPERATURE TEMPERATURE BLOOD PRESSURE BLOOD PRESSURE PULSE PULSE

31. RESPIRATION GIVES THE CLEAREST INDICATION OF HOW THE BRAIN IS FUNCTIONING GIVES THE CLEAREST INDICATION OF HOW THE BRAIN IS FUNCTIONING THE RATE, CHARACTER AND PATTERN OF A PATIENT’S RESPIRATION MUST BE NOTED. 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 WITH A GCS OF 8 OR LESS IT IS IMPORTANT TO ENSURE THE PATIENT IS ABLE TO MAINTAIN AND PROTECT THEIR AIRWAY

32. TEMPERATURE SEVERE HEAD INJURY OFTEN CAUSES DERANGED TEMPERATURE DUE TO DAMAGE TO HYPOTHALAMUS 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???? 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. 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 BRAIN INJURY CAN CAUSE HYPERTHERMIA AND HYPOTHERMIA

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

34. PULSE CEREBRAL INSULT CAN HAVE ONE OF THE FOLLOWING EFFECTS ON THE 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 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 TACHYCARDIA – INJURY TO HYPOTHALAMUS AND PRESENT IN TERMINAL STAGE OF RAISED INTRACRANIAL PRESSURE ARRYTHMIAS – BLOOD IN THE CEREBROSPINAL FLUID ARRYTHMIAS – BLOOD IN THE CEREBROSPINAL FLUID

35. Questions

36. Apex Beat Richard Lake May 2004

37. Apical pulse Detected in the fifth intercostal space mid- clavicular line left side of chest Detected in the fifth intercostal space mid- clavicular line left side of chest Detected with the aid of a stethoscope Detected with the aid of a stethoscope Routinely used to record pulse rate in infants and children up to the age of 3 years 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 Can be used to detect discrepancies with radial pulse Recorded in conjunction with the administration of some medicines Recorded in conjunction with the administration of some medicines

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

39. 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. 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.

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

41. Diaphragm Mode (high-frequency) T urn the chest piece over, index to the opposite side and use firm pressure to listen to high-frequency sounds. T urn the chest piece over, index to the opposite side and use firm pressure to listen to high-frequency sounds.

42. Procedure Explain to the patient what you are going to do Explain to the patient what you are going to do Perform hand washing to minimise cross infection Perform hand washing to minimise cross infection Provide privacy for patient as chest will need to be exposed Provide privacy for patient as chest will need to be exposed Position patient in a comfortable supine or sitting position Position patient in a comfortable supine or sitting position

43. Locate the apical impulse – this is the point over the apex of the heart where the apical pulse can be most clearly heard 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 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 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 Auscultate and count the heart beats with the diaphragm of the stethoscope

44. Points to consider Count the heart rate for one minute to accurately record 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 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 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 Record the pulse site, rate, rhythm and volume in the patients notes

45. Questions