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.

[jill48, ASN, 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.

OWWWWWWWWW! :eek: :eek: :eek: :eek: :eek: :eek: :eek: :eek:

[gasmaster]

HATE the nipple twist. I can imagine seeing it done on a family member would be pretty traumatic. Typically the GCS just says flexion or extension on 3 & 2 of motor, and doesnt' elaborate. But the true definition of those as per the original protocol includes LE movement. So even if your GCS doesn't specifically say this, that is what it means. A good resource is "The Clinical Practice of Neurological and Neurosurgical Nursing" 5th edition by Joanne V. Hickey. If you've never read her book I highly recommend it. The is THE neuro guru of all time. I've met her and she's a lovely, talented, SMART woman. Anyway, I came in this morning and read these emails. So I pulled her book to see what she has to say, and on page 165 she clearly defines the GCS as including LE's. If in doubt, always refer to her book. The CNRN (does anyone else have there's?) uses this guideline on their test. I remember when I took my certification YEARS AND YEARS ago (I am so getting old!), one of the questions on my test was about LE movement when checking the GCS. I don't remember the scenario but clearly remember that with stimuli my patient had LE movement only and I had to give the pt. a GCS score. Anyway, trust Hickey for accurate information.

[BBFRN, BSN, PhD]

Trap is good, periorbital is fantastic. Especially for pseudo-seizure pt's.

Thank you for pointing this out. I had another nurse act like I was being mean for doing this when I was a charge nurse, and pt had a pseudo-seizure every time her nurse tried to d/c her home. The pt had already learned how to withstand everything else (arm drop, etc). She didn't expect a periorbital, and I got a definite response from it. Of course, several weeks later, and after many trips to the ICU for "seizures," everyone was in consensus that she was having pseudo-seizures.

[NotReady4PrimeTime, RN]

When determining what type of posture a person is exhibiting, the LE movements are the same, extension, but there is movement. The UE flexion/extension and internal rotation is the definitive. Extensor posture is always BAD!

[all4schwa]

When is it that you are applying the orbital pressure during the psuedo seizure, during or after?

[LadyNASDAQ]

We do a hand clap loudly to each ear. It isn't painful but will give you the startle response you need. After, check if patient is moving their eyes and pupillary response.

I was taught no nailbed pressure or nipple twists ever. Light sternal rub but what works better is cold fingers to the neck. If that doesn't give a response, stop right there.

[gasmaster]

When checking gag on my intubated patients I usually just move the ETT tube a bit if they don't cough with suction. The other day I saw a nurse shoving the ETT down so far I thought I'd lose sight of it! I also saw her later trying to illicit gag by using the yankeur and it too was halfway down the patients throat! When I approached her she got really defensive about it. I tried to tell her nicely that it only takes minimal stim to determine gag, and boy was she mad. I guess if you shove it far enough down and tickle their orifice they'll eventually respond, huh? :smackingf

[GrnHonu99, RN]

When checking gag on my intubated patients I usually just move the ETT tube a bit if they don't cough with suction. The other day I saw a nurse shoving the ETT down so far I thought I'd lose sight of it! I also saw her later trying to illicit gag by using the yankeur and it too was halfway down the patients throat! When I approached her she got really defensive about it. I tried to tell her nicely that it only takes minimal stim to determine gag, and boy was she mad. I guess if you shove it far enough down and tickle their orifice they'll eventually respond, huh? :smackingf

lol. needed a good laugh this morning:0)

I usually use the yanker if I can.

[auzzieneuronurse]

Our GCS criteria must be slightly different as if the pt does not obey commands or localise to central pain (sternal rub) we apply nailbed pressure bilaterally to elicit a withdrawl/abnormal flexion/extension response.

[gasmaster]

Our GCS criteria must be slightly different as if the pt does not obey commands or localise to central pain (sternal rub) we apply nailbed pressure bilaterally to elicit a withdrawl/abnormal flexion/extension response.

When performing the sternal rub the patient should exhibit flexion or extension then if it's present. There is no need to do nailbed pressure. You're looking for brain reaction, not peripheral. So checking for central stimulus with nailbed pressure isn't going to give you the most accurate results. If you think about it, flexion means that there is still some function in the cerebral cortex (although VERY abnormal) and extension means that function is now in the brainstem. So you really want to assess these movements using central stimuli. Does that make any sense?

[all4schwa]

Yes, it does make sense. I knew that extension was 'worse,' but didn't really know why..thanks!

[Cissi Oloomi]

The neuro assessment is the most misunderstood assessment.

You use the central stimulus to check level of consciousness- have you tried the pinching of the ear- it is good if you can't do the others. However, you must still check movement of each extremity and if they can't voluntariy move each extremity and /or they are unable to follow verbal commands, you might need the painful stimulus.

In addition, when checking if they can squeeze your hands, if you put your two fingers on top of their fingers and not in the palm, then you won't potentially get the palmar or grasp reflex. And tell them to let go.If it is a refex, it is triggered by palmar stimulation and they won't let go.

Neuro CNS