Okay so this video will continue with the neurological assessment so we're going to be considering this part two. So this time we're going to be assessing the Glasgow Coma Scale. So another pretty major neurological system assessment is assessment of the Glasgow Coma Scale.
So just kind of a definition of what the Glasgow Coma Scale is, is basically it is just a simple tool that is used to measure the degree of consciousness impairment in a patient. Okay, so many hospitals do use the Glasgow Comma Scale in order to assess level of consciousness and then also to document their findings. It was developed in 1974, just a little background information, and it is an objective scale that provides caregivers with concrete ways in order to compare assessment findings with those of other caregivers because it is it's a it's very objective because it's a scale it's a number um so it's it's it's easy to be able to compare to other people so it does assess three different areas it is going to assess eye opening it is going to assess the best verbal response and then it's going to assess the best motor response and then we're going to talk about each of those each of those areas.
So the first area is eye opening. So you're going to be assessing the stimulus that is needed to get the patient's eyes to open. Okay and you can see on the right the different scores, the different numbers that they give for whichever one applies to the patient.
So if the patient's eyes open spontaneously they are given a score of four. If the patient's eyes open to a loud voice or to speech, then they get three points. So typically you call the patient by name and if they open their eyes to your voice then they can that's considered getting getting a three.
You have to be careful and not confused with those who always open their eyes to loud noises so you may try to call them by another name because again we're just wanting to see that they can respond to speech. So spontaneous would just be you walk in the door, the patient looks at you, they open their eyes. That's spontaneous.
If you walk in the room and the patient doesn't wake up, but you speak to them and they open their eyes, then that's a three. Pain would be if the patient's eyes open to pain, that would be a score of two. So you can take pressure and put it on the nail bed. It's kind of a way that we assess that to see if they will open their eyes to that.
And then no eye opening gets one point. And so that's just if they don't open their eyes to either of the three above. And sometimes though they may not be able to open their eyes due to some type of facial trauma or some swelling. So we can't say that they can't open their eyes.
It's kind of like the same as not being able to say that the patient is disoriented if they don't respond. Okay. because you can't say they're disoriented if they're not responding because you don't know if they know where they are or not. So same thing here.
If they're unable to open their eyes due to some trauma or swelling, then we record that as a C and that just means closed. So that's a physical inability to be able to open the eye does not necessarily mean that they have a decreased level of consciousness. Okay. So the next section is going to be the best verbal response.
So in order to assess verbal response, you are going to address the patient's verbal response to you. Okay, so how they respond verbally to you or the nurse, the examiner. If they are unable to speak, we would want to give them yes or no questions.
Or we might do like a picture board so they can point to the pictures. And if they have a trach or if they have like an ET tube. They might be able to nod their head, but they can't actually speak.
So we just would record that as a T, meaning that they have a trach or a tube. So if the patient is oriented, so if they're oriented times three, then they receive a score of five. If they are confused, they're going to be, or disoriented, then they're going to receive a score of four. It is important to determine the extent of the disorientation. you know if they're confused just be sure to reinforce the correct information often to them Verbal response, if they're going to reply with inappropriate words, the verbal response is going to get three.
They get a score of three. So they can carry on a conversation, but it's with inappropriate words. So they may call out profanities or they may say words that have no meaning to the situation. Okay, so just an inappropriate response, inappropriate words. They get a score of two if they respond with incomprehensible sounds, which would be vocalizations that are not recognizable as words.
So if they just respond with like moaning or groaning, then that would be considered incomprehensible sounds. And then no response, no verbal response gets a score of one. So then the third area is going to be the patient's best motor response. And this is going to be the response to movement in relation to pain. And typically, we usually record their best arm response unless they are paralyzed.
And then we can use blinking or we can use lower extremity or leg movement. So again, it kind of depends on if the patient has motor disabilities. So they're going to get a score of six as long as they obey commands. So maybe you just tell them. to raise their arm up, you know, whatever it may be.
So just that's a six. They obey commands. That's the highest they can get.
If they localize the pain, then they're going to get a score of five. So this means that they can recognize where the pain is and they can push away from it. So maybe they move their response or they move their foot like in response to pressure on the foot that indicates that they are localizing or they are recognizing that pain. So they respond to that. Flexion or if they withdraw from pain, they're going to get a score of four.
So maybe they recognize the pain, but they withdraw from the pain instead of pushing it away. Abnormal flexion. So if they have some posturing going on, then they're going to get a score of three for flexion.
So abnormal flexion is considered decorticate. posturing. And I'm going to skip ahead here to a couple of slides real quick. So the picture on the top here is what we refer to as decorticate posturing. Okay.
And we'll talk about this again later, but this is when the patient has a flexion of their arms at the elbow, and then they bring their hands toward the chest and their legs are extended. Now, if a patient has these abnormal posturing symptoms, then this does indicate significant impairment of cerebral functioning. So if you remember decorticate, if you think about the core being the chest area, so decorticate is the patient is flexing, their arms are kind of coming in toward their chest, okay, and their legs are extended. And that again gets a score of three.
If they have extension posturing or abnormal extension, then we're going to refer that or call that decerebrate posturing and they're going to get a score of two for that. So decerebrate posturing is when those upper and lower extremities are extended and the arms are internally rotated and then you can see there's some some flexion extension of those lower extremities. But the main difference is what happens at the upper extremities. And this usually indicates damage in the area of the brain stem.
Now, either of these posturing symptoms, again, do indicate significant impairment of cerebral functioning. So these are not good things if we see posturing. This is not a good sign of their neurological condition.
So they get two for extinction, but three for flexion because extinction, decerebrate is a worse step than decorticate. And then they're going to get one point for flaccidity or meaning that there's no motor response in any extremity. So go back to this first screen here, then you can see the total possible score on the Glasgow comma scale.
is a score of 3 to 15. So if they have no eye opening, no verbal response, and no motor response, they even get a score of 3. And then their highest response is 15. Okay, now A lot of times the stronger the stimuli that is used to obtain the response can sometimes indicate the patient's score being lower as well. But just kind of understand and recognize, and I'll go to this next slide here, just another one that kind of shows the glaucoma scale. A score of 14 to 15 usually indicates that there's no neurological impairment.
It says there mild head injury, but you can have a mild head injury and not have any neurological impairment. Usually a score less than 8 is defined as comatose, but any score less than 10 should be reported. So 14 to 15 is usually no impairment. Less than 8 is usually defined as comatose and a score less than 10, anytime a score is less than 10, should be reported. And then you just say some other ranges there on your score.
your screen. Just some examples of you know a moderate head injury might be a score of 9 to 12 and then severe head injuries less than 8 which again a severe head injury a lot of times does leave the patient being considered comatose. You may see this video down here on the bottom of the screen but for the the purposes of the lecture video I am going to not play that in the video, but I do highly encourage you to watch this video.
It is a really, really good video that explains using the Glasgow Coma Scale, and it may explain it in a way that's easier for you to understand it than what I just did. So I would highly encourage you, and I will post this in the extra video section of this, of these lectures. alright so the next section that we are going to be discussing of the neurological assessment is going to be The cranial nerves. Cranial nerve assessment. So everybody loves the cranial nerves.
It is basically memorization, I will say, pretty much. It just has to be memorized pretty much. But we hopefully talk about it and have some good ways in order to kind of try to hopefully help you be able to memorize but you know not a lot of things in nursing and memorization but cranial nerves they are an example of something that just does have to be memorized now um you can see here on your screen this is going to um explain what each of 12 cranial nerves are which we've already talked about in the um neuro review but then we'll talk about here how to assess each area so um different ways of memorizing and I have posted a mnemonic also in your handout section. But this is probably one of the most common ones that I have used in class but students have came up with some some pretty creative ones. So I will just encourage you to use whatever works for you.
I've seen some inappropriate ones but again whatever whatever works for you you know works for me. So on old Olympus towering top a thinning German butz of hops which is just an example of how to memorize what each of the cranial nerves are in order 1 through 12 because sometimes if you can memorize what they are in order then that will help you be able to kind of know what has to be done in order to assess it okay so we're going to go through each of the nerves and talk about how to assess them So cranial nerve one is considered the olfactory nerve and of course you have your chart that's in your handout and so hopefully this will help you as well to be able to kind of follow along with the with the video. So you know when you are looking or when you're studying your cranial nerves you have to remember that your cranial nerves provide valuable information about the brain stem okay so that's kind of what they're what they're telling us about and all all cranial nerves have either a sensory response, a motor response, or both. And so if you can remember also if the patient or if the cranial nerve is a sensory nerve or a motor nerve or both, then that can also help you kind of remember how to assess for that nerve. So there's also a mnemonic for it.
And if this is not already in Blackboard, I will add it. But there's also an ammonic to help you with understanding whether it's a sensory motor or both. It has both functions.
So you'll see in your chart, the left-hand column is the number of the nerve. And then you're going to fill in the name of the nerve. And then the third column is for which function it has. So you can do an S for sensory.
You can do an M for motor. and you can do a B for both if it has both functions. And then you'll have the function, and then we'll talk about in the last column is how to assess. So, all right. So cranial nerve one is the olfactory nerve.
It is considered a sensory nerve, and its main function is for the sense of smell. And so we're going to assess for this by having the patient to identify common odors. And you can do this by including one nerve at a time. Now typically cranial nerve 1 is not routinely tested unless there is a problem that's been reported. So again in practice it's not going to be you're not going to often see this tested but if the patient has you know loss of smell which probably we've seen this a lot with COVID-19, head trauma, they have an abnormal mental status or they have a suspected intracranial lesion that might be some reasons that they test it.
So again it's sensory so you can have the patient close their eyes. occlude their nares and just try to be able to identify a common odor or smell. Okay, and then they should be able to correctly identify whatever the substance is.
All right, cranial nerve 2 is the optic nerve and this is going to be a sensory nerve. And cranial nerve tube is responsible for vision and visual acuity. So we can test this by using the Snellen or the e-chart that you see on the screen.
Of course, you're just going to have the patient to stand back about 20 feet and they cover one eye at a time. And you'll try to see how much, how far they can go with reading the chart. We also can assess cranial nerve too by testing the visual fields or sometimes referred to as visual confrontation testing.
So this happens when the patient sits directly in front of the examiner in front of the nurse and they're going to stare at the nose of the examiner while the examiner slowly moves their finger from the periphery toward the center until the patient says that they can see it. Of course they're going to cover one eye at a time. And they should see the finger at the same point, you know, in each eye in order, you know, to have to say that they have correct cranial nerve to function. So tested monocularly just means that you test one at a time.
So they just tell you or raise their hand or something when that target comes into view. And again, hopefully they are the same for each side. Also, cranial nerve 2 can be tested by checking color vision, and also they use the ophthalmoscope to check for a red reflex. So that's also to test cranial nerve 2. Okay, so cranial nerve 3 is the oculomotor nerve, and if you can just tell by the name of it, it is a motor nerve, and cranial nerve 3 is responsible for up. down and medial eye movement, lid elevation, and pupil constriction.
Now, before I talk about how to assess it, I want to go ahead and make mention of what cranial nerve 4 is. So, cranial nerve 4 is the trochlear nerve, and it is also a motor nerve, and it is responsible for down and medial eye movement. So, down and in. Okay, and then I want to skip down to cranial nerve six. Cranial nerve six is called abducens.
That's A-B-D-U-C-E-N-S, which is also a motor nerve. And cranial nerve six is responsible for turning the eyes outward or abduction of the eyes. Okay, now I may mention a three, four, and six together because three, four, and six are tested at the same time.
Okay, so what you see on the screen are the ways that we check. three, four, and six. So if you see in your box for cranial nerve three, we're going to inspect the eyelids for drooping, just see if they have any ptosis.
And so that's the picture in the middle of your screen right here. So the normal, this shows a normal eyelid, and then this shows ptosis where that upper lid droops. Okay, so we're going to check for ptosis. We also want to check for perla. Okay, so P-E-R-R-L-A.
with the pin light and so you all have already been um assessing for um perla well you have assessed p e r r l you haven't probably assessed accommodation yet because we haven't actually went over that so when we are looking and of course this blue picture here is looking at perla so when you are doing perla you are looking to see that the pupils um noting that they are equal All right, so that both sides of the pupils are equal and that they are round. And you can see some examples of some not round pupils and some not equal pupils. If they are reactive to light, so if they are reactive to light, the pupil should constrict. And if you see over here to the right, you can see here the pupil contracts with bright light and then it should dilate or expand with dim light.
And you're also checking to see that they are reactive to accommodation. Okay, the accommodation is down in the bottom left of the screen. And so how we test for accommodation is you want to have the patient to focus on a distant object, such as your finger. And then you want to have them, or I'm sorry, you want to stand in front of them and hold your finger about, it says four to five inches from the nose.
And you want to have them to look at an object. Distant like past, you know, maybe look at your ear or something behind you and then you want to have them to look at The object look at the finger and what you should see happen is that the pupils turn Inward and then they should constrict. Okay, so that's how you test for accommodation Also, you are going to be assessing for extra ocular eye movement or EOM Is how that is abbreviated And we also refer to that as checking for the six cardinal fields of gaze. And you can see that down here in the bottom right hand of the screen, the six cardinal fields of gaze are just making sure that the patient can follow your finger when you move it up, left, left, down left, down right, right, and then upright. Okay, so that's the six cardinal fields of gaze and that tests the patient's EOM.
or their extraocular eye movement. So again, have the patient follow an object, your finger, whatever it may be, in those six different directions. And you want to see that their eyes can follow each of those.
So that's testing oculomotor nerve. So a trochlear nerve is, we test that. Of course, again, we're testing it while we're testing three, but specifically the extraocular movement is what tests the trochlear nerve. And then for the abducens, is also testing the extraocular movement, okay, so that, you know, to see that the patient's able to turn their eyes outward, and then, of course, trochlear is down and medial movement.
So, three, four, and six are all tested together, and these are the assessments that we use for those. So, next, we'll talk about crayon or five. So, we're going to skip up, skip back up to five.
Five is the trigeminal nerve and it is considered both a motor and sensory nerve. So it gets a B. So it is a sensory nerve based on the sensations of the face, scalp, and the teeth. And then it is a motor nerve based on the chewing.
Its function is on those chewing movements. So it is a motor nerve based on the chewing movements. In order to assess the sensory part, you can assess the patient's ability to feel light, dull and sharp sensations on the face. So for example, you can do that over the forehead, the cheeks, the chin. And you want to see like, for example, you can take a cotton ball and you want to touch it on different areas of the face, the scalp, and then just see that the person is able to tell you when they feel that sensation.
And then it should be equal. on both sides of the forehead, cheeks, chin, etc. And you can also do dull and sharp. So you could take like maybe the end of a safety pin and you can also see that they can test sensation to something that's more sharp. So sharp and soft.
And then the motor function is going to be assessed by having the patient to resist while they try to open their mouth. So you want to kind of take your hands and palpate that temporal muscle on the side of their cheek, have them kind of clench their teeth, and then you want to see if they can separate their jaw by pushing down on their chin. So you're checking their jaw strength here. And then you can also have them kind of move their jaw side to side, but you're seeing that it's the strength the same left and right.
And we can also test the trigeminal nerve by doing what's called a corneal reflex. And a lot of times you only see this done most often if the patient's unconscious, and they can do it if the patient's conscious. But basically what this is doing is touching the corneal surface of the eye with a with a cotton wisp just the end of a piece of cotton and the response should be closing of both of the eyes so the patient should blink but oftentimes we don't see that done unless the patient is unconscious but it can't be done on the conscious patient okay so i'm going to stop this video because we're going to run out of time and then we will pick back up on the next video part three we'll start with cranial nerve 7