[BlueEyedRN]

I had a neurologist tell me that the best noxious stimulus that isn't painful is to tickle the inside of a nostril with a q-tip. You have to be gentle and careful, but it doesn't cause any damage.

[ELKMNin06]

once I saw a resident take a pair of scissors.. and the back part of the scissors where the loops for your fingers are, he put the pts. fingernail in between and squeezed...kinda hard to explain but it looked incredibly painful.

[Mz Mocha]

I've just begun the neuro rotation as of 1/09/07, and forgive me for not having the knowledge at this time, but wouldn't it make sense to put yourself in the patients shoes? How much pressure would be considered too much pressure? I believe (from my reading materials), that all of these procedures are ligitimate according to the house policy in the environment in which you work, but as a nurse, we all know that there is ( should be)a form of dignity and respect in every aspect of our nursing; therefore any technique used should be deemed appropriate and without harm to the patient.

[LadyNASDAQ]

Originally Posted by janwebsa

Dear all

I am a coma care communications trainer and counselor in a neurosurgery ICU in a large state hospital in Africa. It is an under resourced and highly stressed environment.

We work following minimal signals from people in altered states of consciousness - acknowledging and helping amplify these signals.
Our aim is accompaniment and completion of inner process which will hopefully lead to an easier death process (we have one of the highest global rates of AIDS deaths) or recovery process from TBI.

Many of our patients are inidentified young men and women who have entered ICU through violent attacks. It is important for me that their experience of hospital is not one of secondary violence.
Those that have recovered and can remember their experience say how important it was in their recovery and rising to consciousness that they were treated kindly and positively and that they " distanced themselves" when they were treated harshly.

The nursing staff in our unit test for response to pain in the Glasgow coma scale through nipple squeezing.
I want to challenge this practice and would like advice on how this is approached in other hospitals.

With thanks
JW

We don't do that in our hospitals. A sternal rub suffices. Also, the feet are stroked with a person's back of a pen. Never the tip and never use a needle to prick someone's skin. Docs use a wet paper towel and carefully tap the eye ball. I won't do this but have seen other Nurses do this in deep comatose patients.

[mmsparkle]

(Now, as for assessing pain in an unresponsive, comatose or even expressively aphasic patient. We use a "Nonverbal pain assessment" scale, which is right on each of our VS screens. It assesses facial expression, HR, BP, RR, movement, etc. Depending on the answer for each, it's assigned a value of "0-2". Then the total determines the patient's probable pain level. For example (and don't quote me, I may not have this exactly right) a total of 0 is obviously no pain, a total of 1-3 indicates mild pain, 4-6 indicates moderate pain and 7-10 indicates severe pain. Then, of course, you can treat the pain accordingly.

I like this scale because I'm sure there were several times when a patient's pain may have been previously unrecognized.)


I'm also new to Neuro - I'd be *really* interested in this scale. Is there any way you could show me a copy?
Many thanks

PS I've NEVER heard of the nipple twist before - at my unit we use trapezius squeeze or supra-orbital pressure.

[georgescott6188]

I looking for info/research on the nipple twist. This was recently performed on a patient in the local hospital. From what I read it is no longer an acceptible practise.

Any and all info would be greatly appreciated.

[camoflage]

If you all really want a non-harmful but very noxious stimulus, borrow an anesthesia providers nerve stimulator and test the facial nerve with a tetanus stimulation..... I will guarantee you that is definite

[poppy07]

isnt' that just to see if the'yre adequately paralyzed? Or, are you saying this could be central noxious stimuli?

[neurogeek]

Originally Posted by ELKMNin06

In my institution we were told that nipple twisting is inhumane and we are not allowed to use it. We use the sternal rub and trapezius squeeze as mentioned above. We also use pencils and sqeeze them over the toe or fingernal where the half moon is near the cuticle.

Trap squeeze, sternal rub, orbits...all good. Nailbed pressure bad. Why? A reflexive move from nailbed pressure can initiate from spinal nerves, not cranial nerves...therefore nail pressure is not indicative of true response. The stimuli must be CENTRAL stimuli, or areas that test true brain response. Thus traps, sternum, orbital pressures work well....another very good area is the upper, inner thigh just south of the groin. Still central in nature.

[poppy07]

pt had a pontine hemorrhage and only moved in response to suctioning & had a cough. 1st day decerbrate posturing evident, 2nd day, looked more like withdrawing---but it was hard to distinguish. wouldn't respond at all to firm sternal rub, trapezius squeeze or supraorbital pressure.... any tips on that? thanks. sometimes eyes opened spontaneously, other times wouldn't open at all.