The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle
Correct Answer: B. Nail bed pressure
Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Motor responses can be purposeful, such as the patient pulling on an airway adjunct, or reflexive, including withdrawal, flexion, or extension responses.
Option A: Response to these painful stimuli should be graded bilaterally, in case of a focal spinal cord lesion. If these measures do not produce a response, vigorously pressing the examiner’s knuckles up and down the sternum should arouse any patient who is not deeply comatose.
Option C: The initial step is to evaluate for reactivity, using objective measures. Address the patient verbally, and then progress to light shaking, then progress to more intense mechanical stimulation. Sufficient stimulus to the supraorbital ridge, nail beds, or temporomandibular joint can be painful without risk of tissue injury.
Option D: If no spontaneous movement is noted, provide central pain stimulation. Central pain can be tested by rubbing the sternum, squeezing the tissue in the axilla, squeezing the trapezius muscle at the angle of the neck and shoulder, or by applying supraorbital pressure (avoid if facial fractures present).
No comments:
Post a Comment