Neurological Assessment , GCS, LIMB STRENGTH ASSESSMENT, IMP REFLEXES FOR NURSES

1. NEURO ASSESSMENT IMPORTANT NEURO REFLEX’S, TBI PROTOCAL & RASS SCORE FOR NURSES… Presented by Murugeshhjrn Staff nurse ICU 02, KFCH JIZAN AL-INMA MEDICAL SERVICE

2. SYNAPSIS • INTRODUCTION • BRAIN & ITS FUNCTION –SENSORY & MOTOR FUNCTIONS • NEUROASSESSMENT • IMPORTANT REFLEXES • NURSING MANAGEMENT AND CARE

3. INTRODUCTION.. • Neurological observations collect data on a patient’s neurological status and can be used for many reasons, including in order to help with diagnosis, as a baseline observation, following a neurosurgical procedure, and following trauma (Mooney & Comerford 2003)…. • Therefore, it is important that all healthcare professionals are efficient and accurate in assessing the neurological status of their patients. • It is also important to remember that these changes may occur rapidly over a short period of time or more gradually, taking place over days or weeks. This is why accurate neurological assessments and observations are vital in ensuring the early recognition of neurological deterioration in patients (Koutoukidis et al. 2017; Mooney & Comerford 2003).

4. BREIF INFORMATION….. • A neurological assessment involves checking the patient in the main areas in which changes are most likely to occur: • Level of consciousness • Pupillary reaction • Motor function • Sensory function • Vital signs.

5. Glasgow Coma Scale……. There are many different assessment tools for neurological function, however, the most widely known and used tool is the Glasgow Coma Scale (GCS). The patient is assessed and scored in three areas: • Eye opening • Verbal response • Motor response. The highest possible score is 15, which reflects an individual who is fully alert, aware and orientated, whereas the lowest possible score is 3and reflects an unconscious individual. Although pupil reaction is not included as part of the GCS, but is the vital element to assess the abnormality

6. Components of GCS …..

7. CONSIOUSNESS ASSESSMENT ;AVPU scale… • A rapid assessment tool that is utilised in the healthcare field to measure conscious state is the AVPU scale. A stands for Alert • The patient is aware of the environment and the examiner and is opening their eyes spontaneously. They can also follow commands and track objects. V stands for Verbal • The patient’s eyes do not open spontaneously, rather, their eyes only open in response to a verbal stimuli directed towards them. The patient can respond to this verbal stimuli directly and in a meaningful way. P stands for Pain • The patient's eyes do not open spontaneously or in response to verbal stimuli. The patient will respond to painful stimuli directed towards them by moving, moaning or crying out. U stands for Unresponsive • The client is not responding spontaneously, or to verbal or painful stimuli.

8. PUPILLARY REACTION….. • Assessing Pupillary Reaction • When we are assessing the patient’s pupils, we are gaining information regarding the brain and determining whether there has been an increase in intracranial pressure. • The pupils are assessed for their size and shape, as well as how they react to the presence of light. They should be round and equal in size. • The size of the pupils can vary, however, the normal range is 2 to 6 mm in diameter. Upon shining a bright light into each eye, the pupils should constrict briskly to a smaller size (QAS 2021a). • The reactions to light can be described as brisk, sluggish or non-reactive/fixed. • Both eyes should be checked and compared against each other. Generally, any change that occurs during an assessment of the pupils indicates a change in the individual’s intracranial pressure and may signify a neurological emergency. • Acute pupillary dilation in patients who have suffered a head injury is thought to be caused by compression of the third cranial nerve from brain oedema and herniation, or alternatively, from a decrease of blood flow to the brain stem, resulting in brain stem ischaemia (Koutoukidis et al. 2017; Majdan 2015…….

9. MOTOR RESPONSE –LIMBS STRENGTH • Limb strength can be described as either: • Normal power • Mild weakness • Severe weakness • Spastic flexion • Extension • No response. • Generally, this assessment focuses on the arms and legs and will look for any improvement or deterioration in function. However, it must be noted that lower limb function may impact spinal function in some patients and this can disrupt the assessment findings …..

10. INTRA CRANIAL PRESSURE …. • Elevated intracranial pressure (ICP) is seen in ; • head trauma, [1] hydrocephalus,intracranial hemorrhage, sub-arachnoid hemorrhage from ruptured brain aneurysm, intracranial tumors, [3] hepatic encephalopathy, [4] and cerebral edema.Intractable elevated ICP can lead to death or devastating neurological damage • either by reducing cerebral perfusion pressure (CPP) [6] and causing cerebral ischemia or by compressing and causing herniation of the brainstem or other vital structures. Prompt recognition is crucial in order to intervene appropriately • CUSHINGS TRIAD… •  refers to a set of signs that are indicative of increased  • intracranial pressure (ICP), or increased pressure in the brain. • Cushing's triad consists of • bradycardia (also known as a low heart rate), HR < 50B/MIN • irregular respirations, some times TACHYPNOEA OR BRADYPNOEA a widened pulse pressureBP > 150/80MMHG

11. BRAIN STEM REFLEXES … *** Pupillary reflex *** Corneal reflex *** Gag reflex *** Cough reflex *** Oculocephalic reflex ( Dalls eye Reflex) *** Oculovestibular reflex ( Caloric reflex )

12. PUPILLARY REFLEX…… PUPILLARY REFLEX • Eyes allow for visualization of the world by receiving and processing light stimuli. The pupillary light reflex constricts the pupil in response to light, and pupillary constriction is achieved through the innervation of the iris sphincter muscle…….. • Pupillary light reflex is used to assess the brain stem function. Abnormal pupillary light reflex can be found in optic nerve injury, oculomotor nerve damage, brain stem lesions, such as tumors, and medications like barbiturates.

13. CORNEAL REFLEX…. CORNEAL REFLEX • A reflex closing of the eyelids when the cornea is touched or a puff of air is blown on to it,mediated by the fifth cranial trigeminal nerve (sensory) and the seventh cranial facial nerve (motor), often diminished or absent in people who wear contact lenses.. • The corneal reflex, also known as the blink reflex or eyelid reflex, is an involuntary blinking of the eyelids elicited by stimulation of the cornea, though could result from any peripheral stimulus.

14. GAG REFLEX….. GAG REFLEX…. • The gag reflex, also called the pharyngeal reflex, is a contraction of the throat that happens when something touches the roof of your mouth, the back of your tongue or throat, or the area around your tonsils. This reflexive action helps to prevent choking and keeps us from swallowing potentially harmful substances

15. COUGH REFLEX….. COUGH REFLEX • Coughing is an important defensive reflex that enhances clearance of secretions and particulates from the airways and protects from aspiration of foreign materialsoccurring as a consequence of aspiration or inhalation of particulate matter, pathogens, accumulated secretions, postnasal drip, inflammation, and mediators ……

16. OCULO CEPHALIC REFLEX ( DALLS EYE) …. OCULO CEPHALIC REFLEX (DALLS EYE )….. • The doll's eyes reflex, or oculocephalic reflex, is produced by moving the patient's head left to right or up and down. When the reflex is present, the eyes of the patient remain stationary while the head is moved, thus moving in relation to the head. • OVERVIEW • Oculocephalic and oculovestibular reflexes are primarily used to determine whether a patient’s brainstem is intact (e.g. coma or brain death assessment) • ensure the C-spine is cleared. • the patient’s eyes are held open. • the head is briskly turned from side to side with the head held briefly at the end of each turn. • a positive response occurs when the eyes rotate to the opposite side to the direction of head rotation, thus indicating that the brainstem (CN3,6,8) is intact. • a similar result is seen when the head is flexed and extended — a positive result is downward deviation of the eyes during extension, and upward deviation during flexion (the eyelids, if closed, may also open as part of the ‘doll’s head phenomenon’). These vertical responses indicates that the brainstem (CN3,4,8) is intact. • The eyes should gradually return to the mid-position in a smooth, conjugate movement if the brainstem is intact. • Patients with metabolic coma (e.g. hepatic failure) may have exaggerated, brisk oculocephalic reflexes.

17. OCULOVESTIBULAR REFLEX(CALORIC TEST • OCULOVESTIBULAR REFLEX ( COLD CALORIC TEST) • Occulovestibular reflex (caloric stimulation): • the head is elevated to 30 degrees above horizontal so that the lateral semicircular canal is vertical, and so that stimulation with generate a maximal response. • check that the tympanum is intact and that the external ear canal is clear — C-spine clearance is not necessary. • introduce iced water into the external ear canal through a small catheter until one of the following occurs: • nystagmus (in the intact brainstem the slow phase is towards the irrigated ear) • ocular deviation • 200mL of iced water has been instilled. • allow 5 minutes between testing ears to allow re-equilibration of the occulovestibular system. • as consciousness is lost, the fast component (towards the non-irrigated ear) is lost and the slow component deviates the eye in the direction of the irrigated ear. • Vertical occulovestibular eye responses can be assessed by irrigating both ears simultaneously. • If the brainstem is intact, cold water causes the eyes to deviate downwards and warm water causes the eyes to deviate upwards. • The positive brainstem responses described above are those seen in a comatose patient with an intact brainstem.

18. OCULOVESTIBULAR REFLEX(CALORIC TEST

19. PARAGRAPH REPRSENTATION DALLS EYE & COLD CALRIC RESPOSE TEST…

20. TBI PROTOCAL -- • TOTAL BRAIN INJURY --- • SUDDEN OR PROGREESIVE MASS ERRUPTION OR CIRCULATION BLOCKAGE OR SUDDEN BRAIN ANOXEMIA OR SKULL PIERCING TRAUMA MAY LEEDS TO REVERSIBLE OR IIREVERSIBLE INJURY TO THE BRAIN… • MAIN TYPES OF BRAIN INJURY IS • 01.CONCUSSION –IS A SUUDDEN OR SHAKING MOVEMNT , MINOR AND MOST COMMAN IT WILL HEAL FASTEN….. • 02.CONTUSSION - IS A BRUISE OF THE BRAIN TISSUE, JUST LIKE ONE MIGHT HAVE A BRUISE ON THEIR SKIN. AND LIKE ANY OTHER BRUISE, THEY ARE CAUSED BY THE BREAKING AND LEAKING OF SMALL BLOOD VESSELS…SEVERE CONTUSIONS MAY CAUSE ALOSS OF CONSCIOUSNESS, CONFUSION, TIREDNESS, EMOTIONAL DISTRESS, OR AGITATION. MORE SEVERE CONTUSIONS MAY CAUSE THE BRAIN TO SWELL, COULD PREVENT PROPER OXYGENATION, AND OTHER SERIOUS CONSEQUENCES.

21. TBI protocol ….continue... • 03. PENENRATING INJURY- MOST COMMONLY EXTERNAL INJURY TO THE SKULL…OBJECT THAT PIERCING & INJURING THE BRAIN …..IN CASES LIKE ACCIDENTAL SLIP OR FALL INJURY …RTA HEAD INJURY….ASSALT OR GUNSHOT….. MOST FATAL & REQUIRES IMMEDIATE INTERVENTIONS .. • 04.ANOXEMIC BRAIN INJURY – FOR 4-5 MINUTES BRAIN CAN SURVIVE WITHOUT OXYGEN …STILL NO OXYGEN ..ANOXEMIA --- COMA OR BRAIN DEATH … CAUSES –SUDDEN BLOCAKGE OF CIRCULATION EXAMPLE- BY STROKE EITHER ISCHEMIC OR HEMORRHAGIC SHOCK…….MASS OR TUMOUR DEVELOPMENT ………

22. TBI PROTOCAL ….important points • Its an important gudelines to follow in order to avoid complications like POST TRAUMATIC BRAIN INJURY … • It includes few points to follow .. • ****HEAD POSITION -30-45 DEGREE ( REVERSE TRENDLUNBURG position) • ****TEMPERATURE SHOULD BE MAINTAIN 34-36 DEGREE • ***KEEP BP MAP 80-90MMHG • ***MAINTAIN PCO2 RANGE 35-40 & PO2 95-105..

23. TBI PROTOCAL ….important points • ***SODIUM LEVEL 140-150 • HAEMOGLOBIN >10%GM • ****RBS 5.1-8MMOL • ***GOOD DIET( ELECTROLYTES BALANCED ) • ***MAINTAIN RASS SCORE -4 TO -5 • ***ANTI STRESSORS OR ANTI CONVULSANTS OR OSMOTIC DIURETICS AS PER ADVICE • ***FLEET ENEMA ( IN ORDER TO KEEP NORMAL INTRA ABDOMIINAL PRESSURE)

24. RASS SCORE….. • RICHMOND AGTATION AND SEDATION SCALE …. • IT IS AN SEDATION ASSEMENT TOOL , MAINLY USING IN CRITICAL AREAS LIKE ICUS,Ots….. • TO MONITOR THE LEVEL OF CONSCIOUSNESS OR TO UNDERSTAND PATIENT COPING WITH VENTILATOR OR TO DESCRIBE THE ALERTNESS OR AGITATION ………

25. RASS SCORE …..

26. Nursing management and Care • Monitor vital signs closely. • Accurately assess and document the neurological Status. • Evaluation of alteration of consciousness is very essential since the symptoms progress rapidly. • Maintain Patient airway. • Intubation and Hyperventilation may be indicated to provide adequate cerebral perfusion. • Neurologic patients maintain head up 45 degree

27. Nursing management and Care • Turn the patient side ways to prevent airway occlusion. • Be aware about suctioning will stimulate and increase the intracranial pressure. • Comply the Glasgow coma scale is mandatory. • Observe the patient condition closely. • Maintain normal intracranial pressure to prevent CVA. • Early detection of neurological symptoms can help to further intervention and treatment.

28. THANK U ALL…..