PROCEDURS RELATED TO CRITICAL CARE UNITS

NEUROLOGICAL EXAMINATION:
etfiCiency,
An assessment of neurological function alone be quite time consuming. For
can
examination. Cranial nerVe
integrate neurological measurement with other parts of the physical
function can be tested during the.survey of the head and neck. Observe mental and emotona

status during the initial interview.

ARTICLES NEEDED

A TRAY cONTAINING:

Thermometer
Bp apparatus
Stethoscope
Pen torch
Hammer

Cotton
Coffee powder
Sugar

GENERAL EXAMINATION:

VITAL SIGNS

Temperature
Pulse
Respiration
Blood pressure

EXAMINATION OF PUPILS:

REACTED TO LIGHT OF
PERRLA [ PUPIL EQUALLY ROUND
ACCOMADATION]

Consensual response
Extraoccular movement

MENTAL STATUS EXAMINATION:-

is unconscious or semi-conscious use glass coma scalel

Level of consciousness [if patient
assessment tool.
GCS is the neurological

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 NEUROLOGICAL
EXAMINATIONS ARE,
COMPONENTS OF
THREE ESSENTIAL

Eye opening
Verbal Communication
Motor Response
THE GLASGOW COMA SCALE:

SCORE
FINDING
PARAMETER
4
Spontaneously
I Eye opening

[E]
3
To speech

l o pain

1
Do not open

Oriented
I ] Best verbal

response [V
Confused

Inappropriate speech

Incomprehensible sound
2

None

Obeys commands
] MOTOR

RESPONSE [M]|
Localizes to painn

Withdraws to pain

Abnormal flexion

Abnormnal extension

No movement

15
TOTAL

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 he Glasgow Coma Score has a range from 3 to 15, worst score is 3 points and best
Score is 15 points. With endotracheal Intubation, the highest score isl1.
GCS is based the clients
on
ability to respond and communicate

NURSING ASSESSMENT

ASsess the patient's level of consciousness. Call the paticnts name and raise your
voice or shout if client is old age for eye
opening
it client does not obeys command press pen against proximal portion of patients nail
bed or apply supra orbital pressure. Supra orbital pressure should be avoided in
face injuries.

ASSess motor function of

upper and lower extremities for strength and symmetry.
Test cranial nerve reflexes for brain stem
to assess
dysfunction.
Assess pupil size, symmetry and reaction to
light.
Assess extra ocular movements

Orientation: Name, Time, Place.

Memory: Short term and Long term.

Mood and Affect: Normal or Elevated or Depressed.

Intellectual performance: Knowledge

O Judgment: Check the insight

O Asking right 7+3-? Or wrong language and communication:

Speech and thought. Fluency or problem in speech or understanding.

Head, Neck and Back Assessment: Head: Size, shape, symmetry.

Neck: Palpation of neck muscles.

Back: Alignment, deviation from normal curvature

Check raccoon eyes and battles sign.

Check ear, nose drainage. [CSF leakage]

MOTOR SYSTEM:

Muscle size: symmetry

Muscle strength: 5 point scale.

5 / 5 Normal full strength Muscle is able to moveactively trough the full range of
motion against the effects of gravity and applied résistance.
>4/5 Muscle is able to move actively trough the full range of motion against the
effects of gravity with weakness to applied résistance.
3 / 5 - Muscle is able to move actively against the effects of gravity above.
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 but cannot overcome gravity.
2/5Muscle is able to move across a surface ficker m o v e m e n t
occurs.

is palpable and visible trace

1/5 Muscle contraction
co-ordination: Assessed {Asking the
Muscle tone: Normal or poor or rigid.Muscle
finger by her finger)
to touch her nose and examiners
patient
Gait: Stand in a straight linc

SENSORY FUNCTION:

Touch and pain

Hearing
Vision
Taste
Smell
EXAMINATION OF REFLEXES:

SUPERFICIAL REFLEX:

Abdominal reflex
Plantar reflex
Corneal reflex
Anal reflex

DEEP TENDON REFLEX:

brachi tendon.
jerk [fore flexion] tapping bicep's
Bicep's arm

tapping triceps's brachi tendon

Triceps's jerk [fore a r m extension] tendon.
Knee jerk [knee examination] tapping quadriceps
Achilles tendon.
Ankle jerk [plantar flexion] tapping

ABNORMAL REFLEXES:

Babinski reflex
Jaw reflex
Plamchin reflex.

CRANIAL NERVE EXAMINATION:

Olfactory nerve: Smell

Ex. Flower, powder etc.

Optic nerve : vision

Ex: visual acuity and visual field

Occulomotor,Trochlear and Abducent

nerve:

o Consensual response {simultaneously blinking both eyes}}

o PERRLA

o Ptosis [dropping of upper eyelid]

o Extraoccular m o v e m e n t .

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 Trigeminal nerve:
o Mastication

o
Open the mouth widely.
o Move the jaw's side to side

o Pain, touch and temperature

o Corneal reflex.

Facial nerve:
Symmetry, raise the eye brow. Observe paralysis or facial spasm. Taste.

Vestibulocochlear nerve:
Hearing test: Rinne's test and Weber's test.

Equilibrium: Able to stand straight when eyes closed and feet close together. {Can't
domeans Romberg's sign or
Ataxia}

Glossopharyngeal and vagus nerve:

Gag reslex, Cough reflex

Ask the patient to use different sounds ex: kubkub, kala, mini etc.

Accessory nerve:
Elevate the shoulders with or without resistance turn the head to one side and other.

Hypoglossal nerve:
Strength of the tongue [protrude the tongue]

AFTER THE EXAMINATION:

You may record findings from the physical assessment during the examination or at the end.

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