Neurologic Examination (FOR NRGL07N Level III) Glasgow Coma Scale Introduction Neurological system consists of Central nervous

system (CNS): brain and spinal cord Peripheral nervous system (PNS): somatic and autonomic divisions CNS: covered by meninges; bathed by cerebrospinal fluid Brain: located in cranial cavity; 4 major divisions Cerebrum divided into R and L hemisphere; consists of 4 lobes (frontal, parietal, temporal, occipital) Brain stem: consists of Midbrain (relay center) Pons (links brain structures) Medulla oblongata (controls respiratory function, heart rate and force, blood pressure) Cerebellum: located behind brain stem under cerebrum; divided into R & L hemisphere; functions Coordination and smoothing of voluntary movements; maintenance of equilibrium and muscle tone Spinal cord Located in vertebral canal; extends from medulla oblongata to L1 (first lumbar vertebra); IS NOT AS LONG AS SPINAL CANAL Functions: conducts impulses; responsible for simple reflex activity Peripheral Nervous System (PNS) Carries information to and from CNS Consists of 12 pairs of cranial nerves PNS somatic fibers carry CNS impulses to skeletal muscles PNS autonomic fibers carry CNS impulses to smooth, involuntary muscles (ex. heart and glands) PNS: cranial nerves I olfactory II optic III oculomotor IV trochlear V trigeminal PNS: cranial nerves VI abducens VII facial VIII acoustic (vestibulocochlear) IX glossopharyngeal X vagus PNS: cranial nerves XI spinal accessory XII hypoglossal Collecting objective data Client preparation Equipment and supplies Cranial nerve exam Motor and cerebellar exam Sensory and reflex exams GLASGOW COMA SCALE Eye Opening Motor Response Verbal Response EYE OPENING E1 = none E2 = to painful stimuli E3 = To command/voices E4 = Spontaneous without blinking MOTOR RESPONSE M1 = none M2 = arm extension to painful stimuli M3 = arm flexion to painful stimuli M4 = withdraws M5 = Hand localizes to painful stimuli

M6 = Obeys command VERBAL RESPONSE V1 = None V2 = Sounds but no recognizable voice V3 = Inappropriate words V4 = Confused speech V5 = Normal Thats all folks!!! FRACTURES: (http://video.about.com/orthopedics/Fractures-1.htm) The Human Skeletal System The skeletal system is made up of 206 bones and provides support, allows for movement, and protects the internal organs of the body. What Is a Fracture? Sometimes, too much pressure is applied to a bone that results in what is known as a fracture. Fractures are commonly caused by a fall, strike from an object, or by twisting or bending of the bone. What Is an Incomplete Fracture? When the bone is only cracked or partially broken, doctors refer to it as an incomplete fracture. What Is a Hairline Fracture? A hairline fracture is an incomplete fracture, like a crack that does not break all the way through the bone. It usually is the result of a relatively minor injury. What Is a Greenstick Fracture? A greenstick fracture is an incomplete fracture that is similar to the break of a young tree branch. Only one side of the bone breaks causing the bone to bend. Both hairline and greenstick fractures are usually treated by immobilization with a cast to allow it to mend. What Is a Complete Fracture? When the bone is broken into pieces, doctors refer to it as a complete fracture. What Is a Simple Fracture? A simple fracture is a complete fracture where the bone is broken into two fragments. This break can be transverse (which means straight across the bone), oblique (which means at an angle)....and spiral (which means an angle that is twisted). What is a Comminuted Fracture? A comminuted (or multifragmentary) fracture is a complete fracture where the bone is broken into several fragments. This type of fracture is usually a result of a severe injury. Both simple and comminuted fractures are usually treated with immobilization with a cast or sometimes with pins, screws, and plates.

If You Fracture a Bone

All fractures must be taken seriously. If you think that a bone has been fractured, you should seek immediate medical attention. A. Description 1. A fracture is a break in the continuity of the bone. 2. Common fracture sites: Clavicle Humerus In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site. Radius and ulna Femur (often associated with child abuse) Epiphyseal plates (potential for growth deformity) 3. Types of Fracture Closed or simple fracture The bone is broken, but the skin is not lacerated. Open or compound fracture - The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. Transverse fracture The fracture is at right angles to the long axis of the bone. Greenstick fracture - Fracture on one side of the bone, causing a bend on the other side of the bone. Comminuted fracture - A fracture that results in three or more bone fragments. Oblique Fracture The fracture is diagonal to a bones long axis. Spiral Fracture At least one part of the bone has been twisted.

4. Complications of fractures include: problems associated with immobility (muscle atrophy, joint contracture, pressure sores) growth problems ( in children) infection shock venous stasis and thromboembolism pulmonary emboli and fat emboli and bone union problems B. Etiology 1. Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse. 2. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries. C. Pathopysiology 1. Fractures occur when the resistance of bone against the stress being exerted yields to the stress force. 2. Fractures most commonly seen in children: Bend Fracture is characterized by the bone bending to the breaking point and not straightening without intervention. Buckle fracture results from compression failure of the bone, with the bone telescoping on itself. Greenstick fracture is an incomplete fracture. D. Assessment Findings 1. Clinical Manifestations The five Ps pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures. Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children). 2. Laboratory and diagnostic findings Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity. Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD). E. Nursing Management 1. Provide emergency management when situation warrants, for a new fracture. Assess the five Ps. Determine the mechanism of injury. Immobilize the part. Move injured parts as little as possible. Cover any open wounds with a sterile, or clean dressing. Reassess the five Ps. Apply traction if circulatory compromise is present. Elevate the injured limb, if possible. Apply cold to the injured area. Call emergency medical services. 2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). 3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). 4. Administer analgesic medications. 5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. 6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care. 7. Prevent Complications Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage. o Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery. o Treatment entails pressure relief, which sometimes require performing a fasciotomy. 8. Prevent infection, including osteomyelitits, bys using infection control measures. 9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. 10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.