신경계 사정: Neurological Assessment

Explain what each term means when assessing Level of Consciousness (LOC)

 

Alert: The patient is fully awake. Eyes are open spontaneously; they will respond to voice and are able to control bodily function. 

 

Drowsy (lethargic): The patient can answer questions and follow commands but slowly and inattentively. 

 

 use clear concise objective description!  ( Mr. Johnson appeared drowsy and will respond to verbal stimuli but had difficulty with staying alert and keeping his eyes open. He does follow simple commands to squeeze his left hand and move his left leg but often requires repeated instruction)

 

Confused: The patient is difficult to arouse and needs constant stimulation in order to follow a simple command. They can respond verbally with 1 or 2 words but will drift back to sleep between stimulation.

 

Stuporous: The patient needs a vigorous and continuous stimulation; typically, a painful stimulus is required. They moan briefly but do not follow commands. Only response may be an attempt to withdraw from or remove the painful stimulus. (They can not wake from clapping or shouting. needs shaking and shouting)

 

Comatose: They do not respond to continuous or painful stimulation. Does not move - except, possibly, reflexively - and does not make any verbal sounds.

Explain what each term means when assessing Level of Consciousness (LOC)

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(AVPU scale)

• Alert: The patient is fully awake, although they may be confused. Their eyes are open spontaneously; they will respond to voice and are able to control bodily function. For example, patients are oriented by name, time, location and the events. 
• Voice: Not fully awake, responds to Voice, semi-conscious but responds to shouting (moans and groans)
• Pain: respond to painful stimuli by opening eyes, sounds or flexion.extension of a limb. ( trapezius squeeze, Supra orbital notch pressure, Jaw margin pressure)
• Unresponsive: patients are unresponsive to verbal and physical stimuli. 

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Tell me about GCS, and explain about each component and its best score. 

• GCS is the most common scoring system used to describe the level of consciousness for the patients who had a traumatic brain injury. 

stimulation: nipple pinch, squeeze

A&OX3 => charting words mean alert & oriented times three. (name,person, place)

trapezius pinch

 

GCS: 15: normal,   13~14: minimal brain injury,  11~12: moderate brain injury,  9~10: stuporous/severe brain injury,  8 or less: comatos

 

central and peripheral stimuli

https://www.google.com/search?q=trapezius+pinch&rlz=1C1CHBD_koKR1046KR1046&oq=trapezius+pinch&aqs=chrome..69i57j0i512j0i30l8.5865j0j15&sourceid=chrome&ie=UTF-8#fpstate=ive&vld=cid:82ada061,vid:zCn-H0_36Qg

 

brain injury: patient’s pose

• Decerebrate and Decorticate posture

 

Factors affecting the GCS assessment

• language
• Intellectual or neurological deficit
• Hearing loss or speech impediment
• Physical e.g. intubation or tracheostomy
• Pharmacological e.g. sedation or paralysis
• Orbital/ Cranial fracture
• Dysphasia or Hemiplegia/ Spinal cord damage, communication Barriers

 

localize pain: they can find pain. 

chemo port: port- a- cath

 

How do you assess the pupils (eye exam) Explain using PERRLA

• Size (3-5mm)
• shape (round)
• Direct response/ conensual response
• accommodation-response

PERRLA (Pupills, Equal, Round, Reactive, Light, Accommodation)

• if the patient’s pupils are ovoid, keyhole shape, irregular, fixed and dilated shape, it indicates malfunctioning.