Nursing Points

General

1. Supratentorial herniation
   1. Brain shifts down within the skull
   2. Symptoms include a change in LOC
      1. Assessed with the Glasgow Coma Scale
         1. Score based on level of response
            1. Max score is 15, minimum score is 3
               1. Eye Opening
                  1. Spontaneous (4)
                  2. To verbal (3)
                  3. To pain (2)
                  4. None (1)
               2. Verbal Response
                  1. Oriented (5)
                  2. Confused (4)
                  3. Inappropriate (3)
                  4. Incomprehensible (2)
                  5. None (1)
               3. Motor
                  1. Obeys commands (6)
                  2. Purposeful movement with pain stimuli – has to cross midline (5)
                  3. Withdraws with painful stimuli (4)
                  4. Flexion in response to painful stimuli (decorticate) (3)
                  5. Extension in response to painful stimuli (decerebrate) (2)
                  6. None (1)
         2. For supratentorial herniation, pay attention to the eyes
            1. Eyes
               1. Pupils dilate in supratentorial herniation
      2.  Hyperventilation occurs
         1. 1. Causes alkalosis