nailbed pressure

[gasmaster]

Ok, here's a pet peeve of mine. Once again, today, I walked into the unit (I'm a neurosurgical program coordinator, many years CC, CNRN) that I supervise and found a nurse using nailbed pressure to check response. I talked to her about it and she said that in the critical care internship at her previous hospital they taught her this. I went on to explain to her the differnce between central stimuli (trap squeeze, sternal rub, and periorbital pressure) and peripheral stimuli (nailbed). She really understood well and know if proficient in knowing how to test central and is no longer (thank goodness) abusing her patients nailbeds. I was just wondering if any of you are experiencing this same issue: the old method of nailbed pressure vs. true central stimuli.

[purseOnalityRN]

Hi! In my neuro orientation we were taught:

Do:

1st Peripheral Stim: nail bed pressure

2nd Central Stim: trap pinch

Now I have always questioned the above sequence, wondering if we can just go to central stim? (I no longer work Neuro) Can you please clarify? Is it just pointless then to do the nailbeds?

[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!

[gasmaster]

In the VERY old days we always did nailbed pressure. Yikes! The poor patients would have bruised fingers from it (I too was taught to sandwich the finger between 2 pens). There is no reason to check peripherally. If your patient has central they will have peripehral (unless they are a cord injury, which is a different animal). So, always use central stimuli. A patient can be pretty much gone with no cerebral hemisphere function and minimal brain stem but will react nicely to nailbed pressure. Why? It's peripheral nerve: in other words, SPINAL nerve not CRANIAL nerve innervation. Very, very, very primitive reflex there. That's similar to the hand squeeze thing. It drives me up the wall when family gets so excited cuz the patient squeezed their hand (or the nurse too for that matter). I always tell them: it only counts if they patient will let go on command. I use the "thumbs up" method for seeing if they are really following commands with their hands and thats what I teach my families.

[purseOnalityRN]

Thanks Neuro Geek... I will for sure spread the word.. I'm sure many nurses are still using nailbed pressure especially now since "sternal rub" is not allowed! Trap pinching is where it's at!

[gasmaster]

Trap is good, periorbital is fantastic. Especially for pseudo-seizure pt's. They often don't expect that. One can typically train themselves to handle the trap squeeze over time, but most of them will COME OFF THE BED when you do periorbital. Works like a charm.........Evil?:angryfire No, just making sure I get the best assessment done.....

[EmerNurse, BSN, RN]

Anyone point to a website that shows these different techniques (trap squeeze, periorbital,etc)? I do very little severe neuro so I'm not familiar.

Thanks!

[teeituptom, BSN, RN]

Well even further back in the old days, they used to twist nipples to check for response. Primarily on women of course. Saw that done all the time decades ago.

[GrnHonu99, RN]

I work in the neuro ICU in a huge neuro hospital.....55 Neruo ICU beds on my floor alone

Our neuro assessments are per unit protocol.

Glasgow-if pt not following verbal commands test central pain

ways we test central pain:

sternal rub-most common (however if i have a little old lady i dont crank on her chest)

trap squeeze (although I often dont get a response to this)

supraorbital (although i hardly ever see this used)

we use these and our docs use these...once i saw a resident do a nipple twist

If pt doesnt respond to central THEN we test peripheral pain

ways we use to test peripheral pain:

MOST COMMON: nailbed pressure. I usually use a pen...ive seen docs take the opposite end of the scissors once and use them on the nail bed (not cutting the pt but between the finger holes)

sometimes when im testing for periph pain in lowe extrem. instead of nailbed pressure i take a pen to the bottom of the feet-kinda just rub up and downt he foot...bc it doesnt hurt its jsut irritating and i usually get just as good of a flex or w/d as I do when I use nailbed pressure.

I use my discrestion..i dont crank on peoples chest unless i have to...also you can sometimes illicit a response with just mild sternal rubbing..you dont have to crack a rib to test central stimuli.

[GrnHonu99, RN]

In the VERY old days we always did nailbed pressure. Yikes! The poor patients would have bruised fingers from it (I too was taught to sandwich the finger between 2 pens). There is no reason to check peripherally. If your patient has central they will have peripehral (unless they are a cord injury, which is a different animal). So, always use central stimuli. A patient can be pretty much gone with no cerebral hemisphere function and minimal brain stem but will react nicely to nailbed pressure. Why? It's peripheral nerve: in other words, SPINAL nerve not CRANIAL nerve innervation. Very, very, very primitive reflex there. That's similar to the hand squeeze thing. It drives me up the wall when family gets so excited cuz the patient squeezed their hand (or the nurse too for that matter). I always tell them: it only counts if they patient will let go on command. I use the "thumbs up" method for seeing if they are really following commands with their hands and thats what I teach my families.

yep. I usually use: show me two fingers (however im not even picky on which two)...I use thumbs up...wiggle your thumb..but this one isnt great bc sometimes you cant tell if they are wiggling it. The only time I use hand squeezes is if the pt squeezes my hand at some point then ill ask them to let go...if they can do that 2 to command then they win a 6 in the GCS

[GrnHonu99, RN]

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.

[gasmaster]

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.