Nuchal rigidity

Nuchal rigidity: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses

Commonly an early sign of meningeal irritation, nuchal rigidity refers to stiffness of the neck that prevents flexion. To elicit this sign, attempt to passively flex the patient’s neck and touch his chin to his chest. If nuchal rigidity is present, this maneuver triggers pain and muscle spasms. (Make sure that there’s no cervical spinal misalignment, such as a fracture or dislocation, before testing for nuchal rigidity. Severe spinal cord damage could result.) The patient may also notice nuchal rigidity when he attempts to flex his neck during daily activities. This sign isn’t reliable in children and infants.

Nuchal rigidity may herald life-threatening subarachnoid hemorrhage or meningitis. (See Associated disorder: Meningitis, page 458.) It may also be a late sign of cervical arthritis, in which joint mobility is gradually lost.

Emergency Actions

After eliciting nuchal rigidity, attempt to elicit Kernig’s and Brudzinski’s signs. Quickly evaluate level of consciousness (LOC). Take vital signs. If you note signs of increased intracranial pressure (ICP), such as increased systolic pressure, bradycardia, and widened pulse pressure, start an I.V. line for drug administration and deliver oxygen as necessary, and keep the head of the bed at least as low as 30 degrees. Draw a sample for routine blood studies such as a complete blood count with a white blood cell count and electrolyte levels.

History

Obtain a patient history, relying on family members if altered LOC prevents the patient from responding. Ask about the onset and duration of neck stiffness. Were there any precipitating factors? Also ask about associated signs and symptoms, such as headache, fever, nausea and vomiting, and motor and sensory changes. Check for a history of hypertension, head trauma, cerebral aneurysm or arteriovenous malformation, endocarditis, recent infection (such as sinusitis or pneumonia), or recent dental work. Then obtain a complete drug history.

If the patient has no other signs of meningeal irritation, ask about a history of arthritis or neck trauma. Can the patient recall pulling a muscle in his neck?

Physical assessment

Perform a neurologic assessment followed by musculoskeletal and cardiopulmonary assessments. Inspect the patient’s hands for swollen, tender joints, and palpate the neck for pain or tenderness.

Medical causes

Cervical arthritis

With cervical arthritis, nuchal rigidity develops gradually. Initially, the patient may complain of neck stiffness in the early morning or after a period of inactivity. Stiffness then becomes increasingly severe and frequent. Pain on movement, especially with lateral motion or head turning, is common. Typically, arthritis also affects other joints, especially those in the hands.

Encephalitis

Encephalitis, a viral infection, may cause nuchal rigidity accompanied by other signs of meningeal irritation, such as positive Kernig’s and Brudzinski’s signs. Usually, nuchal rigidity appears abruptly and is preceded by headache, vomiting, and fever. The patient may display a rapidly decreasing LOC, progressing from lethargy to coma within 24 to 48 hours of onset. Associated features include seizures, ataxia, hemiparesis, nystagmus, and cranial nerve palsies, such as dysphagia and ptosis.

Meningitis

Nuchal rigidity is an early sign of meningitis and is accompanied by other signs of meningeal irritation — positive Kernig’s and Brudzinski’s signs, hyperreflexia and, possibly, opisthotonos. Other early features include fever with chills, headache, photophobia, and vomiting. Initially, the patient is confused and irritable; later, he may become stuporous and seizure-prone or may slip into coma. Cranial nerve involvement may cause ocular palsies, facial weakness, and hearing loss. An erythematous papular rash occurs in some forms of viral meningitis; a purpuric rash may occur in meningococcal meningitis.

Subarachnoid hemorrhage

Nuchal rigidity develops immediately after bleeding into the subarachnoid space. Examination may detect positive Kernig’s and Brudzinski’s signs. The patient may experience abrupt onset of severe headache, photophobia, fever, nausea and vomiting, dizziness, cranial nerve palsies, and focal neurologic signs, such as hemiparesis or hemiplegia. His LOC deteriorates rapidly, possibly progressing to coma. Signs of increased ICP, such as bradycardia and altered respirations, may also occur.

Special considerations

Prepare the patient for diagnostic tests, such as computed tomography scans, magnetic resonance imaging, and cervical spinal X-rays.

Monitor vital signs, intake and output, and neurologic status closely. Avoid routine administration of opiod analgesics because these may mask signs of increasing ICP. Enforce strict bed rest; keep the head of the bed elevated at least 30 degrees to help minimize ICP.

Assist the patient in finding a comfortable position to obtain adequate rest.

Pediatric pointers

Tests for nuchal rigidity are generally less reliable in children, especially infants. In younger children, move the head gently in all directions, observing for resistance. In older children, ask the child to sit upright and touch his chin to his chest. Resistance to this movement may indicate meningeal irritation.

Patient counseling

Teach the patient with chronic sinusitis or other chronic infections the importance of seeking proper medical treatment. Explain signs and symptoms of meningitis to report to the health care provider. Provide reassurance and support to the patient and his family.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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