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 Examples - Numbness
- Tingling
- Burning
Assessment
Diplopia Diplopia Clarity Nystagmus
Thinking Thinking Memory Personality
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
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:
- Protective reflexes
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 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
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 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
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 Suggests
Periorbital edema and bruising Periorbital edema and bruising
Periorbital edema and bruising Periorbital edema and bruising Suggests:
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 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 Opisthotonos - severe muscle spasm of the neck and back
More ominous posture
x 3
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