its an small guide to assess the neuorological status with various pictures , it explains clearly about GCS, MUSCULAR POWER ASSESSMENT , PUPILLARY REACTION & IMPORTANT REFLEXES specially for nurses ....it has brief information about TBI PROTOCAL & RASS SCORE

1. NEURO ASSESSMENT
IMPORTANT NEURO
REFLEX’S IN ICU FOR
NURSES , TIB PROTOTOCAL
& RASS SCORE…
MURUGESH HJ RN
ICU 02 KFCH JIZAN
SAUDI ARABIA

2. INTRODUCTION …..
 INTRODUCTION
 BRAIN & ITS FUNCTION –SENSORY & MOTOR FUNCTIONS
 NEUROASSESSMENT
 IMPORTANT REFLEXES

3. INTRODUCTION..
 Neurological observations collect data on a patient’s neurological status and
can be used for many reasons, including in order to help with diagnosis, as a
baseline observation, following a neurosurgical procedure, and following trauma
(Mooney & Comerford 2003)….
 Therefore, it is important that all healthcare professionals are efficient and
accurate in assessing the neurological status of their patients.
 It is also important to remember that these changes may occur rapidly over a
short period of time or more gradually, taking place over days or weeks. This is
why accurate neurological assessments and observations are vital in ensuring the
early recognition of neurological deterioration in patients (Koutoukidis et al. 2017;
Mooney & Comerford 2003).

4. BREIF INFORMATION…..
 A neurological assessment involves checking the patient
in the main areas in which changes are most likely to occur:
 Level of consciousness
 Pupillary reaction
 Motor function
 Sensory function
 Vital signs.

5. Glassgow Coma Scale…….
There are many different assessment tools for neurological function, however,
the most widely known and used tool is the Glasgow Coma Scale (GCS).
The patient is assessed and scored in three areas:
1.Eye opening
2.Verbal response
3.Motor response.
The highest possible score is 15, which reflects an individual who is fully alert,
aware and orientated, whereas the lowest possible score is 3 and reflects an unconscious individual.
Although pupil reaction is not included as part of the GCS, but is the vital element to assess the abnormality

6. Components of GCS …..
Behaviour Rating Score
Eye Opening Response
Opens eyes spontaneously Spontaneous 4
Opens eyes in response to speech and sound Sound 3
Opens eyes in response to painful stimuli Pain 2
Does not open eyes None 1
Verbal Response
Oriented to time, person and place Oriented 5
Confused and disoriented Confused 4
Utters incoherent words Words 3
Incomprehensible sounds Sounds 2
Makes no sounds None 1
Motor Response
Obeys two-part requests Obeys commands 6
Localises to painful stimuli Localising 5
Flexion / withdrawal from painful stimuli Normal flexion 4
Abnormal flexion from painful stimuli Abnormal flexion 3
Extension to painful stimuli Extension 2
Makes no movement

7. CONSIOUSNESS ASSESSMENT ;AVPU
scale…
 A rapid assessment tool that is utilised in the healthcare field to measure conscious state is the AVPU scale.
 A stands for Alert
 The patient is aware of the environment and the examiner and is opening their eyes spontaneously. They can
also follow commands and track objects.
 V stands for Verbal
 The patient’s eyes do not open spontaneously, rather, their eyes only open in response to a verbal stimuli
directed towards them. The patient can respond to this verbal stimuli directly and in a meaningful way.
 P stands for Pain
 The patient's eyes do not open spontaneously or in response to verbal stimuli. The patient will respond to
painful stimuli directed towards them by moving, moaning or crying out.
 U stands for Unresponsive
 The client is not responding spontaneously, or to verbal or painful stimuli.

8. PUPILLARY REACTION…..
 Assessing Pupillary Reaction
 When we are assessing the patient’s pupils, we are gaining information regarding the brain and
determining whether there has been an increase in intracranial pressure.
 The pupils are assessed for their size and shape, as well as how they react to the presence of light. They
should be round and equal in size.
 The size of the pupils can vary, however, the normal range is 2 to 6 mm in diameter. Upon shining a
bright light into each eye, the pupils should constrict briskly to a smaller size (QAS 2021a).
 The reactions to light can be described as brisk, sluggish or non-reactive/fixed.
 Both eyes should be checked and compared against each other. Generally, any change that occurs
during an assessment of the pupils indicates a change in the individual’s intracranial pressure and may
signify a neurological emergency.
 Acute pupillary dilation in patients who have suffered a head injury is thought to be caused by
compression of the third cranial nerve from brain oedema and herniation, or alternatively, from a
decrease of blood flow to the brain stem, resulting in brain stem ischaemia (Koutoukidis et al. 2017;
Majdan 2015…….

9. MOTOR RESPONSE –LIMBS STRENGTH
 Limb strength can be described as either:
 Normal power
 Mild weakness
 Severe weakness
 Spastic flexion
 Extension
 No response.
 Generally, this assessment focuses on the arms and legs and will look for any
improvement or deterioration in function. However, it must be noted that lower limb
function may impact spinal function in some patients and this can disrupt the
assessment findings …..

10. INTRA CRANIAL PRESSURE ….
 Elevated intracranial pressure (ICP) is seen in ;
 head trauma, [1] hydrocephalus, intracranial hemorrhage, sub-arachnoid hemorrhage from ruptured
brain aneurysm, intracranial tumors, [3] hepatic encephalopathy, [4] and cerebral edema. Intractable
elevated ICP can lead to death or devastating neurological damage
 either by reducing cerebral perfusion pressure (CPP) [6] and causing cerebral ischemia or by compressing and
causing herniation of the brainstem or other vital structures. Prompt recognition is crucial in order to intervene
appropriately
 CUSHINGS TRIAD…
 refers to a set of signs that are indicative of increased
 intracranial pressure (ICP), or increased pressure in the brain.
 Cushing's triad consists of
 bradycardia (also known as a low heart rate), HR < 50B/MIN
 irregular respirations, some times TACHYPNOEA OR BRADYPNOEA
a widened pulse pressure BP > 150/80MMHG

11. BRAIN STEM REFLEXES …
*** Pupillary reflex
*** Corneal reflex
*** Gag reflex
*** Cough reflex
*** Oculocephalic reflex ( Dalls eye Reflex)
*** Oculovestibular reflex ( Caloric reflex )

12. PUPILLARY REFLEX……
 PUPILLARY REFLEX
 Eyes allow for visualization of the world by receiving and processing light stimuli.
The pupillary light reflex constricts the pupil in response to light, and pupillary
constriction is achieved through the innervation of the iris sphincter muscle……..
 Pupillary light reflex is used to assess the brain stem function. Abnormal
pupillary light reflex can be found in optic nerve injury, oculomotor nerve
damage, brain stem lesions, such as tumors, and medications like barbiturates.

13. CORNEAL REFLEX….
 CORNEAL REFLEX
 A reflex closing of the eyelids when the cornea is touched or a puff of air is
blown on to it, mediated by the fifth cranial trigeminal nerve (sensory) and the
seventh cranial facial nerve (motor), often diminished or absent in people who
wear contact lenses..
 The corneal reflex, also known as the blink reflex or eyelid reflex, is an
involuntary blinking of the eyelids elicited by stimulation of the cornea, though
could result from any peripheral stimulus.

14. GAG REFLEX…..
 GAG REFLEX….
 The gag reflex, also called the pharyngeal reflex, is a contraction of the throat
that happens when something touches the roof of your mouth, the back of your
tongue or throat, or the area around your tonsils. This reflexive action helps to
prevent choking and keeps us from swallowing potentially harmful substances

15. COUGH REFLEX…..
 COUGH REFLEX
 Coughing is an important defensive reflex that enhances clearance of secretions
and particulates from the airways and protects from aspiration of foreign
materials occurring as a consequence of aspiration or inhalation of particulate
matter, pathogens, accumulated secretions, postnasal drip, inflammation, and
mediators ……

16. OCULO CEPHALIC REFLEX ( DALLS EYE)
….
 OCULO CEPHALIC REFLEX (DALLS EYE )…..
 The doll's eyes reflex, or oculocephalic reflex, is produced by moving the patient's head left to right or up and down. When the reflex is
present, the eyes of the patient remain stationary while the head is moved, thus moving in relation to the head.
 OVERVIEW
 Oculocephalic and oculovestibular reflexes are primarily used to determine whether a patient’s brainstem is intact (e.g. coma or
brain death assessment)
 ensure the C-spine is cleared.
 the patient’s eyes are held open.
 the head is briskly turned from side to side with the head held briefly at the end of each turn.
 a positive response occurs when the eyes rotate to the opposite side to the direction of head rotation, thus indicating that the brainstem
(CN3,6,8) is intact.
 a similar result is seen when the head is flexed and extended — a positive result is downward deviation of the eyes during extension, and
upward deviation during flexion (the eyelids, if closed, may also open as part of the ‘doll’s head phenomenon’). These vertical responses
indicates that the brainstem (CN3,4,8) is intact.
 The eyes should gradually return to the mid-position in a smooth, conjugate movement if the brainstem is intact.
 Patients with metabolic coma (e.g. hepatic failure) may have exaggerated, brisk oculocephalic reflexes.

17. OCULOVESTIBULAR REFLEX(CALORIC
TEST
 OCULOVESTIBULAR REFLEX ( COLD CALORIC TEST)
 Oculovestibular reflex (caloric stimulation):
 the head is elevated to 30 degrees above horizontal so that the lateral semicircular canal is vertical, and so that stimulation with generate a
maximal response.
 check that the tympanum is intact and that the external ear canal is clear — C-spine clearance is not necessary.
 introduce iced water into the external ear canal through a small catheter until one of the following occurs:
 nystagmus (in the intact brainstem the slow phase is towards the irrigated ear)
 ocular deviation
 200mL of iced water has been instilled.
 allow 5 minutes between testing ears to allow re-equilibration of the oculovestibular system.
 as consciousness is lost, the fast component (towards the non-irrigated ear) is lost and the slow component deviates the eye in the direction of
the irrigated ear.
 Vertical oculovestibular eye responses can be assessed by irrigating both ears simultaneously.
 If the brainstem is intact, cold water causes the eyes to deviate downwards and warm water causes the eyes to deviate upwards.
 The positive brainstem responses described above are those seen in a comatose patient with an intact brainstem.

18. PARAGRAPH REPRSENTATION DALLS EYE
& COLD CALRIC RESPOSE TEST…

19. TBI PROTOCAL --
 TOTAL BRAIN INJURY ---
 SUDDEN OR PROGREESIVE MASS ERRUPTION OR CIRCULATION BLOCKAGE OR
SUDDEN BRAIN ANOXEMIA OR SKULL PIERCING TRAUMA MAY LEEDS TO
REVERSIBLE OR IIREVERSIBLE INJURY TO THE BRAIN…
 MAIN TYPES OF BRAIN INJURY IS
 01.CONCUSSION –IS A SUUDDEN OR SHAKING MOVEMNT , MINOR AND MOST
COMMAN IT WILL HEAL FASTEN…..
 02.CONTUSSION - IS A BRUISE OF THE BRAIN TISSUE, JUST LIKE ONE MIGHT HAVE A
BRUISE ON THEIR SKIN. AND LIKE ANY OTHER BRUISE, THEY ARE CAUSED BY THE BREAKING
AND LEAKING OF SMALL BLOOD VESSELS …SEVERE CONTUSIONS MAY CAUSE A
LOSS OF CONSCIOUSNESS, CONFUSION, TIREDNESS, EMOTIONAL
DISTRESS, OR AGITATION. MORE SEVERE CONTUSIONS MAY CAUSE THE
BRAIN TO SWELL, COULD PREVENT PROPER OXYGENATION, AND OTHER
SERIOUS CONSEQUENCES.

20. TBI protocol ….contd…..
 03. PENENRATING INJURY- MOST COMMONLY EXTERNAL INJURY TO THE
SKULL…OBJECT THAT PIERCING & INJURING THE BRAIN …..IN CASES LIKE
ACCIDENTAL SLIP OR FALL INJURY …RTA HEAD INJURY….ASSALT OR
GUNSHOT….. MOST FATAL & REQUIRES IMMEDIATE INTERVENTIONS ..
 04.ANOXEMIC BRAIN INJURY – FOR 4-5 MINUTES BRAIN CAN SURVIVE
WITHOUT OXYGEN …STILL NO OXYGEN ..ANOXEMIA --- COMA OR BRAIN
DEATH …
CAUSES –SUDDEN BLOCAKGE OF CIRCULATION EXAMPLE- BY STROKE
EITHER ISCHEMIC OR HEMORRHAGIC SHOCK…….MASS OR TUMOUR
DEVELOPMENT ………

21. TBI PROTOCAL ….important points
 Its an important gudelines to follow in order to avoid complications like POST
TRAUMATIC BRAIN INJURY …
 It includes few points to follow ..
 ****HEAD POSITION -30-45 DEGREE ( REVERSE TRENDLUNBURG position)
 ****TEMPERATURE SHOULD BE MAINTAIN 34-60 DEGREE
 ***KEEP BP MAP 80-90MMHG
 ***MAINTAIN PCO2 RANGE 35-40 & PO2 95-105..

22.  ***SODIUM LEVEL 140-150
 HAEMOGLOBIN >10%GM
 ****RBS 5.1-8MMOL
 ***GOOD DIET( ELECTROLYTES BALANCED )
 ***MAINTAIN RASS SCORE -4 TO -5
 ***ANTI STRESSORS OR ANTI CONVULSANTS OR OSMOTIC DIURETICS AS PER
ADVICE
 ***FLEET ENEMA ( IN ORDER TO KEEP NORMAL INTRA ABDOMIINAL
PRESSURE)
TBI PROTOCAL ….important points

23. RASS SCORE…..
 RICHMOND AGTATION AND SEDATION SCALE ….
 IT IS AN SEDATION ASSEMENT TOOL , MAINLY USING IN CRITICAL AREAS LIKE
ICUS,Ots…..
 TO MONITOR THE LEVEL OF CONSCIOUSNESS OR TO UNDERSTAND PATIENT COPING
WITH VENTILATOR OR TO DESCRIBE THE ALERTNESS OR AGITATION ………

24. RASS SCORE …..

25. THANK U ALL…..