[ELKMNin06]

Originally Posted by maolin

Ack! - I had a good response, kitty jumped in lap, hit the touchpad and I lost it all. Abbreviated version:

One of my first preceptors taught me nailbed method by squeezing finger between 2 pens leveraged to create a vice like pressure. I thought it was barbaric, but being brand spanking new, did it her way. I apologized profusely to my pt every time I checked for responsiveness (all 4 extremeties with each q4h assessment).

My next preceptor was a neuro guru and promptly corrected this bad habit. Trapezius pressure is more accurate and humane. I'm so glad I learned this early on. I dreaded neuro pts, but this preceptor inspired & lent me her appreciation for this population. A fresh ruptured cerebral aneurism is one of my favorite types of patients to care for. HHH therapy rocks!

A trap squeeze is testing central pain and nailbed pressue is testing periph. pain. If pts are following verbal commands no need to test pain.

[neurogeek]

Be careful with the bottom of the foot stimuli. It's peripheral. But you can squeeze that fatty area on the inner thigh just below the groin. Doesn't take much pressure and the patient will certainly respond to it. Try it on yourselves. It really stings. I always do it through the gown so as not to bruise the patient. I love orbital pressure. Yes, when I first started we did a lot of nipple twisting on men and women. Some of the older docs still do. It can seem cruel I agree and there are certainly other just as effective means to test. I also have found that the fatty area of tissue just at the armpit is another good site to illicit central pain. Again, do it through the gown so you don't bruise them. Again, try this on yourself. It again is hard to ignore, right? When you have suspected pseudo-seizure the armpit and inner thigh are good sites to assess but most of these patients do not expect to be tested here and aren't prepared.

[ELKMNin06]

Originally Posted by neurogeek

Be careful with the bottom of the foot stimuli. It's peripheral.

I am confused. Peripheral resp. is what I am illiciting. I was taught you couldn't test central pain in the LE.

[neurogeek]

You are right, the foot is peripheral. But if you pinch the upper, inner thigh it's typically viewed as central.

[ELKMNin06]

Originally Posted by neurogeek

You are right, the foot is peripheral. But if you pinch the upper, inner thigh it's typically viewed as central.

Really that is so interesting. So instead of sternal rub, you use the thigh pinch? So when you rate the GCS do you use how far the upper extrem can reach or do you use lower extremity rxn? I thought central pain was only testable through the upper extrems.

[neurogeek]

I said it was typically viewed as more central. I didn't say it was used to test GCS. Where I've worked we always use either trap or supraorbital. We only use the skin pinchs if none of the other illicit any movement. It's for those time you really have to get down there & see if ANYTHING flinches at all. GCS movement is the best movement seen, whether it's upper or lower. The official scoring of best motor is:
6 = can obey command
5 = can localize stimuli and try to remove it (can't do that with a foot, has to be a hand crossing the midline to count)
4 = purposeless movement with response to pain
3 = flexion (flexes elbows & wrists while extending legs) or decorticate
2 = extends upper & lower extremities to pain or decerebrate
1 = no motor response

So, if your patient has no motor response with UE's to pain but extends LE's then you would score them a 2. This is with central stimulus. So, yes, you do score by LE movement.

[neurogeek]

Also, in your complete neuro assessment you should always be scoring motor strength of UE's and LE's separately.

[neurogeek]

By the way, where do you work where there are 55 Neuro ICU beds? That must be some place! Are they all critical care, or are some of them step-down beds? Are they divided by trauma vs surgical, etc.? Just wondering. My facility is beefing up our whole neuroscience dept. and adding many more beds (already have over 25) and adding a new floor for step-down that will take vents. I'm the coordinator for the whole program so I always welcome new info about other units.

[janfrn]

In our PICU where the majority of patients are infants and toddlers, our archaic nursing assessment form and our neurovitals form both contain only adult criteria for GCS assessment. It's frustrating in the extreme. We had our flwosheet redesigned a couple of years ago to include infant and pediatric criteria, among other changes, but the new form only lasted a couple of weeks, (I think I only used it once!) because our esteemed cardiovascular surgeon couldn't find the information he wanted (fluid balance) the second he picked it up. So now we're using photocopies of photocopies, since the print shop has destroyed the original. But I digress. I've used a variety of stimuli to elicit some sort of response in my comatose patients, and have spent a lot of time explaining primitive reflexes to family members. There is very little emphasis placed on accuracy in assessing neuro function in our unit and too many of our junior nurses are giving the patient more credit than he deserves, if you know what I mean. And... get this... in our "state-of-the-art, world class center of excellence" our physicians DO NOT perform any kind of exam on the patients unless the kid crumps, and event hen not often; the nurse's report in rounds is what is documented in the chart as the daily progress note. So decisions on continuing care may be made on the opinion of a nurse who has been licensed five minutes and never learned proper neuro assessment. Scary, no?

[ELKMNin06]

Originally Posted by neurogeek

Also, in your complete neuro assessment you should always be scoring motor strength of UE's and LE's separately.

We do in a complete neuro assessment but not in our GCS.