nailbed pressure

GrnHonu99, RN · Apr 14, 2007

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.

gasmaster · Apr 18, 2007

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

GrnHonu99, RN · Apr 18, 2007

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.

gasmaster · Apr 18, 2007

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.

gasmaster · Apr 18, 2007

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

gasmaster · Apr 18, 2007

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.

Pediatric Critical Care Columnist · Apr 18, 2007

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?

GrnHonu99, RN · Apr 18, 2007

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.

GrnHonu99, RN · Apr 18, 2007

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.

Our GCS works a bit different than yours. We dont use LE at all to score a GCS. When I get to work tonight ill let you know word for word how ours is scored as i dont want to misstate:)

So my question was and still is: when you illicit a response from the thigh pinch do you watch for the response in the UE or LE? SOrry I just havent heard of this teq. before. I have a hard time the trap pinch as I can never seem to get a response when I use it.

GrnHonu99, RN · Apr 18, 2007

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.

Lets see here. On my side of the floor we have 36 neuro ICU beds. Then we have another side that has 16 more neuro ICU beds. THen we have about 8-10 neuro ICU overflow beds.

We don't have step down per se. My facility doesnt like using the word step down but neuro med-surg instead. Our stepdown beds dont take vents or drains. We have 2 neuro-medsurg (only neuro pts though) floors and id guess about 60 beds...we also have neuro-tele where just neuro pts with cardio issues go after the ICU. We also have a brand new in pt. neuro rehab that id say is prob somewhere around 30-35 beds, maybe more, not positive on that one.

I work in the Barrow Neuro. Institute in Phoenix. We are in SJHMC. The rest of the hospital has all your other flloors, L&D, Peds, PICU, NyICU, CICU, MICU, SICU, MS, Heart and LUng institute, etc. We are a huge hospital but I love it. We are completely neuro obsessed. LOL. We get pts from all over the world, it can be insane at times.

smartynurse · Apr 19, 2007

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.

Still was being done at the trauma unit I worked in in Baltimore 12 years ago!

Pediatric Critical Care Columnist · Apr 19, 2007

Still was being done at the trauma unit I worked in in Baltimore 12 years ago!

Still being done in the CCU here in Edmonton... my best friend's husband arrested in a hot tub at the Y back in February and when they were assessing his recovery potential, the neurologist gave his nipple a pretty vicious twist. When my friend saw that she nearly passed out... she who has worked CCU and PICU for two decades. But she was more distraught by the fact that he didn't react to that assault in any way... and he died a couple of days later.