1) GCS (Glasgow Coma Scale)
|eye: opening points||spontaneous = 4
in response to sound = 3
in response to pain = 2
no response, even to painful stimuli = 1
|verbal response points||oriented = 5
confused conversation = 4
inappropriate words = 3
responds with incomprehensible sounds = 2
no verbal response = 1
|motor response points||obeys a simple response = 6
localizes painful stimuli = 5
normal flexion (withdrawal) = 4
abnormal flexion (decorticate posturing) = 3
extensor response (decerebrate posturing ) = 2
no motor response to pain = 1
- total : less than 3 = coma / 4 to 7 = semi-coma / 8 to 12 = stupor / 13 to 14 = drowsy / 15 = alert
2) assessment of LOC (Level Of Consciousness)
- Assess the client’s behavior to determine the level of consciousness (e.g., alertness, confusion, delirium, unconsciousness, stupor, coma).
3) assessment of pupils
4) assessment of posturing
- Posturing indicates a deterioration of the condition.
- types of posturing
|flexor (decorticate posturing)||• The client flexes one or both arms on the chest and may extend the legs stiffly.
• Flexor posturing indicates a non-functioning cortex.
|extensor (decerebrate posturing)||• The client stiffly extends one or both arms and possibly the legs.
• Extensor posturing indicates a brainstem lesion.
|flaccid||• The client displays no motor response in any extremity.|
5) assessment of cranial nerve
6) assessment of reflexes
- Babinski reflex is a pathological or abnormal reflex in anyone older than 2 years and represents the presence of CNS disease.
7) assessment of sensory function
8) checking drainage for the presence of CSF
- CSF can be distinguished from other fluids by the presence of concentric rings (bloody fluid surrounded by yellowish stain, Halo sign) when the fluid is placed on a white sterile background, such as a gauze pad. CSF also tests positive for glucose when tested using a strip test.
2. diagnostic test
1) skull and spinal radiography
- skull radiography: detect fractures or bony defects
- Remove objects from the head, such as wigs, barrettes, earrings, and hairpins. If a spinal fracture is suspected, maintain immobilization of the neck until results are known.
- brain CT: detects space-occupying intracranial bleeding
- It is similar to CT scanning but provides more detailed pictures.
- Provide an assessment of the client with claustrophobia. Administer medication as prescribed for the client with claustrophobia.
- Determine whether the client has a pacemaker, implanted defibrillator, or other metal implants such as a hip prosthesis or vascular clips because these clients cannot have this test performed. Insert an intermittent infusion device to all intravenous accesses prior to the procedure. Provide precautions for the client who is attached to a pulse oximeter because it can cause a burn during testing if coiled around the body or a body part.
4) cerebral angiography
- injection of a contrast material usually through the femoral artery or another artery into the carotid arteries to visualize the cerebral arteries and assess for lesions
- Obtain informed consent. Maintain the client on NPO status 4 to 6 hours before the test as prescribed. Encourage hydration for 2 days before the test. Perform a neurological assessment, which will serve as a baseline for post-procedure assessment. Assess the client for allergies to dye, iodine, or seafood; if allergic, the client may be premedicated with antihistamines and corticosteroids to prevent a reaction. If a client taking metformin(Glucophage) is scheduled to undergo a procedure requiring the administration of iodine dye, the metformin is withheld 24 hours prior because of the risk of lactic acidosis. The medication is not resumed until directed to do so by the HCP (usually 48 hours after the procedure or after renal function studies are done and the results are evaluated.) Establish intravenous access. Obtain vital signs. Administer pre-procedure medications such as sedatives if prescribed. Assess the results of coagulation studies. Withhold the anticoagulant medication prior to the procedure as prescribed. Have emergency resuscitation equipment available.
- Monitor vital signs and neurological status. Monitor for swelling in the neck and for difficulty swallowing; notify an HCP if these symptoms occur. Apply a sandbag or compression device (if prescribed) to the insertion site to provide additional pressure if required. Place ice on the puncture site as prescribed. Keep the bed flat, as prescribed, if the femoral artery is used. Maintain strict bed rest for 12 hours, as prescribed, however, the client may turn from side to side. Elevate the head of the bed 15 to 30 degrees only if prescribed. Encourage fluid intake; if not contraindicated, to promote renal excretion of the dye and to replace the fluid loss caused by the osmotic diuretic effect of the dye.
5) EEG (ElectroEncephaloGraphy)
- graphic recording of the electrical activity of the superficial layers of the cerebral cortex
- Withhold stimulants such as coffee, tea, and caffeine beverages, antidepressants, tranquilizers, and possibly anticonvulsants for 24 to 48 hours before the test as prescribed. Premediate for sedation as prescribed. No NPO.
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6) lumbar puncture
- Insertion of a spinal needle through the L3-L4 interspace into the lumbar subarachnoid space to obtain CSF, measure CSF fluid or pressure, or instill air, dye, or medications.
- The test is contraindicated in clients with IICP because the procedure will cause a rapid decrease in pressure in the CSF around the spinal cord, leading to brain herniation.
- Obtain informed consent. Have the client empty the bladder. No NPO.
- Position the client in a lateral recumbent position and have the client draw the knees up to the abdomen and the chin onto the chest. The prone position may be required for radiologically guided punctures. Assist with the collection of specimens. Maintain strict asepsis.
- Position the client flat as prescribed (ABR for 6 to 12 hours). Monitor V/S and neurological signs to check for the presence of leakage of CSF and also monitor for headache. Encourage fluids to replace CSF obtained from the specimen collection or from leakage. Monitor intake and output. 당일 tube bath 피하기.