The some neurological alterations specifically we're going to cover the assessment of a Neurological patient this is content that's covered in module C You'll want to cover this prior to class This will not be covered in in class The neurological assessment has several parts to it. The level of consciousness, the motor function, the pupillary function, respiratory function, and vital signs. And these together is what we'll do when we have a physical assessment.
examination of a neurological patient but we'll talk about them all in more detail we're going to start with the level of consciousness the level of consciousness is definitely the most important aspect of the neurological exam it is where you'll see some of the first changes if there is a neurological deterioration of the patient. This is where you can check for their arousal and we use a scale the Glasgow Coma Scale or GCS which is a very objective scale that's commonly used. So everybody's kind of on the same page as to what they're seeing when they're assessing a patient with a neurological dysfunction. This is the GCS scale.
You can have a max score of 15 on it and it evaluates three areas. The patients eye opening, their verbal response, and their motor response. These three areas added together will give you your maximum score. If you notice, the higher level of function that they have, the higher their score is. Each area starts with the optimal level of function and down to nothing.
but for example with eye openings you start with spontaneous and you move down to none. And then you take your score that you got for eye opening, your score you got for your verbal response, and the score that you got on your motor response, add them together and give you your max score, which is your GCS score. In the levels of consciousness, there's different categories and it starts from your highest or optimal level of function down to your lowest level of function. So we start off with alert and that is your patient.
that is aware of their surroundings, knows what's going on, and is oriented to person, place, and time. From that you can move to confused where they're still awake but they may have some of the facts messed up. They may not know who they are or where they are. Delirium is even below that which is marked by an uncontrolled excitement or emotion.
And then from delirious or delirium you have your lethargic patient. This patient is usually sleepy, drowsy, a little sluggish but they're easy to arouse and when you do arouse them they usually answer appropriately. And then you can move to your obtunded patient which is more difficult to arouse somewhat confused and responds slowly and as you move down to your stupris which is near unconsciousness and then it's their reduced ability to respond and then comatose which is unconscious and unresponsive we also want to monitor to assess their motor function and this is done with motor strength and tone this is can be gross motor this can be fine motor and this is also the reflexes this is where you can assess their reflexes you might want to go back and review your cranial nerves to know what you're assessing when you some of these areas and then on page 940 is the fine motor and the reflex where they cover reflexes. But you do want to evaluate muscle size and tone.
You want to get a baseline on strength so you know if something has changed and each side should be assessed and then compared together. And then motor function, again, you can start from your optimal or highest level of function down to your lowest level of function. And they start off with the spontaneous, and that's basically they're able to follow. command you are able to speak to them and they are able to follow that command or move might not be an appropriate command but they're spontaneous their movement is spontaneous without you having to make them move that body part and then you have localization which is basically when you apply a painful stimuli because calling their name or giving them a verbal command they're not moving so you apply a pain Stimuli and localization is where they localize to that painful stimuli Withdrawal is when they try to get away from the painful stimuli or try to move the body part that is hurting Then you have your decortication And decortication is an abnormal posturing It's usually seen in patients that have lesions that interrupt The corticospinal pathway and we'll talk about that in just a second And then the discerebration. And discerebration is usually when the patient has an injury to the brain stem.
And then underneath that is your flaccid. And that's where there is no movement at all in the patient, even with a painful stimuli. And we're going to look at this video real quick. Patient is in the decortica position.
Patient is in the decortica position with the upper extremities in flexion, the lower extremities in extension, reflecting that the brainstem motor centers are working, but we don't have modulation of those centers from the corticospinal tract. and their connections to the brainstem centers. If we now go a step lower as far as the level of dysfunction and eliminate the function of the ribospinals, we go from decorticate to decerebrate posturing. The long extremities stay in extension. Now the upper extremities are in extension because we don't have any type of regulation or modulation of the vestibulospinal or the reticulospinal tracts, but we've eliminated the influence of the rubrospinal tracts at this point in time.
If there is to be further progression and the patient has further deterioration and we now eliminate the function of the vestibulospinal and the reticulospinal tracts, the patient would then become flaccid. And... Dead. Interesting way of looking at dead, but... Alright, so let's move on.
Again, here is the decorticate posturing. The way that I remember decorticate posturing is just that the arms are in toward the core of the body and decorticate posturing is defined. as the patient's arms, wrists, and fingers are flexed with internal rotation and a plantar flexion.
And then your decerebrate posturing is characterized by extensions of the arms and legs and the pronation of the arms and the plantar flexion. And then the pupillary function, we want to assess the eyes. And this is your perla.
This is where we estimate the pupil size and shape. We evaluate their reaction to light and their eye movements. Pupil constriction is a function of the cranial nerve 3. Pupils should be equal in size. They should be round and regular in shape and react to light and accommodation. Again, your perla.
We want to estimate the size of both pupils. using the millimeter ruler and then patients who have had eye surgery for cataracts or glaucoma often have irregularly shaped pupils and if they're receiving eye drops for either cataracts or glaucoma you may have an unequal pupil in the eye that is receiving the drops Another test that we can do for the pupillary function is basically making sure the eyes are open so that we can see them and rotating their head. And if their eyes move from side to side when the head is turned, that is a normal reaction.
And then abnormal is when the eyes remain fixed when you turn the head from side to side. A caloric test usually is done by a physician. They're not very common. when they'll instill either cold water or warm water into the ear canal and the eyes should move to the side that the water is being applied as a normal response an abnormal response is if you apply the water and the eyes do not move. And then we want to assess the respiratory function.
Of course it's still it it's airway breathing and circulation but in the respiratory function we want to assess their breathing patterns and and they can range anywhere from your chain stokes, which is common in the dying patient, its periods of apnea alternated by periods of rapid breathing, your central neurogenic hyperventilation, which is deep and rapid breaths at a rate greater than 25 breaths per minute. And then your apunistic breathing is a deep gasping inspiration with a pause at the full inspiration followed by brief insufficient release. You have cluster breathing which is A closely grouped series of respirations followed by a period of apnea. And then your ataxic respirations.
And these are, it's a complete irregularity. irregularity of breathing with irregular pauses and as this as these periods of apnea increase this can merge into agonal respirations and then we want to to of course evaluate their airway status and the airway status being if they are still able to maintain their own airway or if they're being ventilated if we've got all the oral secretions out of their mouth and we've done some deep suctioning if we've had to suction through their their vent but we just want to make sure that their airway is good and open And then last but not least is the assessment of their vital signs. And you want to assess their blood pressure and their heart rates along with the rhythm. In the mechanisms of auto regulation are often impaired as a result of traumatic brain injury. The more serious the injury the more severe is the impact on the auto regulations of the body.
monitoring the patient's blood pressure and pulse can let us know if there's been a change in blood flow, cerebral blood flow. And then you have the Cushing's Triad which is a classic but late sign of an increased intracranial pressure. We have Cushing's Triad, which is a classic but late sign of increased intracranial pressure.
This is manifested by severe hypertension with a widened pulse pressure and bradycardia. This concludes your physical assessment of the neurologically impaired patient. Thank you.