Neuro ICU - "how to test for pain response in comatose individuals

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mmsparkle

52 Posts

Specializes in Orthopaedics, ITU and Critical Care Outr.

(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? :specs:

Many thanks

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

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

9 Posts

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 tetorifice stimulation..... I will guarantee you that is definite

poppy07

208 Posts

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

gasmaster

521 Posts

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.
:typing

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

208 Posts

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.

mommy2BCD

100 Posts

Ok I have a few more questions. I am also a new Neuro nurse here fresh out of orientation. Because nail bed pressure can show both painful stimuli response and spinal reflexes, how are we to know? Also, how to you chart on the GCS if a pt. moves their arm, leg etc to "noxious stimuli" such as suctioning and also to pain? Wouldn't the move to suctioning be higher level of functioning than pain? On our flow sheet we have a GCS and then we have spots for all 4 extremities where we chart either a muscle grade 1-5 or like PS, TS, SP, dec. decort. posturing etc. I guess I sometimes still am having a hard time with all of this and I really do want to be accurate. I also have a hard time telling the difference between localizing to stim and normal flexion withdrawl on the GCS. Can anyone explain these in further detail? Thanks so much, Abby

Specializes in ICU, Telemetry, neuro,research.

janwebsa,

i work at a level 1 in south florida and i am studying for the critical care certification. i can tell you not to pinch them, not to do the sternal rub and never do the suborbital pressure that some old timer mds still do. what is taught here is the "trapezius pinch" to grab the skin over the trapezius and squeeze will ilicit the response you are looking for. in addition, i am also a former coma patient and i am thankful for nurses like yourself that try to reach out to those who are in the limbo between the living. i still remember the kind voices who spoke to me and reached for me over the distance of time and space. thank you.

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