neurological assessment

• Glasgow coma scale

  • eye opening response
  • best verbal response
  • best motor response
• eye opening (4)

  4- spontaneously

  3- to speech

  2- to pain

  1-no response
• verbal response (5)

  5- oriented to time, place, person

  4- confused

  3- inappropriate words

  2- incomprehensible sounds

  1-no response
• motor response(6)

  6- obeys commands

  5- moves to localized pain

  4- flexion withdrawal from pain

  3- abnormal flexion(decorticate)

  2- abnormal extension (decerebrate)

  1- no response
• best response 15
• comatose patient- 8 or less
• totally unresponsive- 3
• awake- alert, responds immediately and fully to commands, may or may not be fully oriented
• confused- inability to think rapidly and clearly, there is impaired judgement and decision making
• disoriented- beginning of loss of consciousness, impaired memory and loss of recognition of self which is the last to deteriorate
• lethargic- drowsy, sleeps a lot, but is easily aroused with minimal stimuli (voice) and then responds but may not be oriented in time, place or person
• obtundation- aroused by stimuli (not pain) like shaking and will then respond to questions or commands, remains aroused as long as stimulation is supplied, if not will fall asleep, questions are answered with minimal response, during arousal patient responds but may be confused
• stuporous- a condition of deep sleep or unresponsiveness, pt can only be aroused or caused to make a motor or verbal response by vigorous and repeated external stimulation (painful), the response is often withdrawal or grabbing at stimulus
• comatose- no motor response to external environment or any stimuli, even deep pain or suctioning, no arousal, reflexes may be present, abnormal movement to pain may be present
• Modified Ashworth Scale (MAS)

  
• rating scale for muscle strength

  A) slight weakness

  B) average weakness

  C) poor rom

  D) severe weakness

  E) paralysis

  
• reflexes

  A) deep tendon reflexes

  B) plantar response

  C) spinal cord injury

  D) frontal release signs

  E) hypoactive

  F) normal

  G) clonus

  H) sustained

  
• breathing patterns

  A) eupnea

  B) increased RR

  C) bradypnea

  D) absence of breathing

  E) hyperpnea

  F) cheyne-stokes

  G) biot's

  H) kussmaul's

  I) apneustic