Assessment
Crucial exam for infants- can reflect brain growth
Head Circumference
Mental status is an assessment of this type of brain function
higher brain/cerebral function
Lowest GCS possible
3
This is the term used for normal LOC
Alert
Moves limb to command
Obeys commands
Identify 3 clinical signs of hydrocephalus
Large OFC, seizure, tense and bulging fontanelle, vomiting, sunset eyes, irritable/difficult to console, poor feeding
When assessing an infants mental status name three things you may assess
Any of the following: Alertness, level of activity, response to environment, quality of cry, feeding patterns, presence or absence of primitive reflexes, language skills
Name the 3 parts of the GCS
Eye opening response, Verbal response, Motor response
Tonic clonic movement that continues despite containment
Seizure activity
Moves toward painful stimuli, purposeful movement
Localizes pain
Repetitive involuntary movement (horizontal, vertical or rotary) of one or both eyes
Nystagmus
The findings of this assessment may be described as loud and energetic or quiet and weak
Quality of cry
This assessment finding will give the patient 3 points in the verbal assessment of the GCS
Inappropriate words
raccoon eyes, battle signs, CSF otorrhea
The most valuable component within the Glasgow Comma Scale that indicates a significant deterioration in neurological function.
Motor response
Assessment finding that indicate inadequate brain growth
Overriding sutures and small OFC
The best time to assess mental status for older children is:
During normal conversation
This function of the neurological system is controlled by the upper brainstem, hypothalamus and thalamus.
Arousal or LOC
Drowsy but follows simple commands when stimulated
Lethargic
Extension of upper and lower extremities
Abnormal extension or decerebrate posturing
Closure of the posterior fontanel is usually by a few months of age, the anterior however remains open until when?
Approximately 12-18 months
Name 4 of the 6 parts of the mental status assessment for older children
Any of the following: Attention, memory, affect, language, cognition, perception
What is the GCS score for the child with the following assessment findings:
Eye opening response- spontaneous
Verbal response- Incomprehensible speech
Motor response- Withdraws in response to pain
10
Patient response is reflexive posturing when stimulated or may have no response to any stimulus
Comatose
Upper extremities flex, draw toward midline, lower extremities extend and internally rotate with plantar flexion of feet
Abnormal Flexion or decorticate posturing