Page 236 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 221

0/5 – No muscle contraction.
1/5 – A trace of muscle contraction.

2/5 – Movement, but cannot balance against gravity.
3/5 – Can resist gravity, but cannot overcome resistance of examiner’s muscle
strength.
4/5 – Can move with some weakness against the resistance of the examiner’s
muscle strength.
5/5 – The patient has normal power and strength.
These can often be documented as a stick figure (man) with the numbers
written by each extremity.

NURSING ALERT

Muscle strength can be further assessed by having the patient perform additional
tasks such as shrugging the shoulders, raising the arms and legs, flexing or bending

the knees and elbows, or by simply stretching or extending the extremities.

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A patient may also have abnormal motor responses to various stimuli.
These responses include withdrawal, localization, decorticate and decere-
brate posturing, opisthotonus, and flaccidity (see Figure 5–3.) These terms
are described as follows:
Withdraws from pain – The patient normally flexes or withdraws an extrem-
ity away from the source of painful stimuli.

Localization to pain – Occurs when the extremity opposite to the one re-
ceiving the painful stimuli crosses over the middle of the body and tries to
remove the painful stimuli from the affected limb.
Decorticate posturing or abnormal flexion – Spontaneous flexion occurs in
response to painful stimuli in an unconscious patient. The arm, wrist, and
fingers flex and the upper extremity adducts inward. The lower extremity
extends, internally rotates, and exhibits plantar flexion. Associated with in-
jury to the cortex (decorticate). See Figure 5–3A.
Decerebrate posturing/rigidity or abnormal extension – This is a spontaneous
extension response to painful stimuli in an unconscious patient. When stim-
ulated, the teeth clench and arms stiffly extend, adduct, and hyperpronate.
The legs also stiffly extend with plantar flexion of both feet. Associated with
injury to the cerebrum and is a worse injury than decorticate. Easily remem-
bered by the number of “es” in decerebrate. See Figure 5–3B.