The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
A. Sternal rub
B. Pressure on the orbital rim
C. Squeezing the sternocleidomastoid muscle
D. Nail bed pressure
Correct Answer: D. Nail bed pressure
Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Using peripheral pain to elicit a response isn’t an effective test of brain function. A response may indicate that the patient feels the stimulus, but the response is from the spinal cord. If the patient didn’t respond at all to central stimuli, apply a peripheral stimulus to all four extremities to establish a baseline. If all but one of his extremities responded to a central stimulus, test only the nonresponsive extremity. Pressing on his nail plate with a pencil is an acceptable technique.
Option A: Acceptable central stimuli include squeezing the trapezius muscle, applying supraorbital or mandibular pressure, and rubbing the sternum. A patient’s response may include moaning, pushing away, trying to grab the hand, or posturing.
Option B: Use painful central stimuli to evaluate brain function. They should get a response from the patient if he isn’t comatose. His reaction to the stimulus can assist in determining his level of consciousness as well as his motor response.
Option C: Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. Painful stimuli are classified as central (response via the brain) or peripheral (reflex response via the spine). Whichever type is used, a good general rule is to apply it until the patient responds, or for at least 15 seconds but no more than 30 seconds if he fails to respond. Use painful stimuli with caution if they create a significant or sustained rise in the patient’s intracranial pressure.
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