Kernig's sign

Kernig's sign: Excerpt from Nursing: Interpreting Signs and Symptoms

A reliable early indicator and tool used to diagnose meningeal irritation, Kernig's sign is hamstring stiffness and muscle pain when the examiner attempts to extend the knee while the hip and knee are flexed 90 degrees. This pain causes resistance to movement. However, when the patient's thigh isn't flexed to the abdomen, he can usually completely extend his leg. (See Eliciting Kernig's sign.) This sign is commonly elicited in meningitis or subarachnoid hemorrhage. With these potentially life-threatening disorders, hamstring muscle resistance results from stretching the blood- or exudate-irritated meninges surrounding spinal nerve roots.

Kernig's sign can also indicate a herniated disk or spinal tumor. With these disorders, sciatic pain results from disk or tumor pressure on spinal nerve roots.

History and physical examination

If you elicit Kernig's sign and suspect life-threatening meningitis or subarachnoid hemorrhage, immediately prepare for emergency intervention. (See When Kernig's sign signals CNS crisis.)

If you don't suspect meningeal irritation, ask the patient if he feels back pain that radiates down one or both legs. Does he also feel leg numbness, tingling, or weakness? Ask about other signs and symptoms, and find out if he has a history of cancer or back injury. Then perform a physical examination, concentrating on motor and sensory function.

Medical causes

Lumbosacral herniated disk. Kernig's sign may be elicited in patients with lumbosacral herniated disk, but the cardinal and earliest feature is sciatic pain on the affected side or on both sides. Associated findings include postural deformity (lumbar lordosis or scoliosis), paresthesia, hypoactive deep tendon reflexes in the involved leg, and dorsiflexor muscle weakness.

Meningitis. Kernig's sign usually occurs early with meningitis, along with a fever and, possibly, chills. Other signs and symptoms of meningeal irritation include nuchal rigidity, hyperreflexia, Brudzinski's sign, and opisthotonos. As intracranial pressure (ICP) increases, headache and vomiting may occur. In severe meningitis, the patient may experience stupor, coma, and seizures. Cranial nerve involvement may produce ocular palsies, facial weakness, deafness, and photophobia. An erythematous maculopapular rash may occur in viral meningitis; a purpuric rash may be seen in those with meningococcal meningitis.

Spinal cord tumor. Kernig's sign can be elicited occasionally, but the earliest symptom is typically pain felt locally or along the spinal nerve, commonly in the leg. Associated findings include weakness or paralysis distal to the tumor, paresthesia, urine retention, urinary or fecal incontinence, and sexual dysfunction.

Subarachnoid hemorrhage. Kernig's and Brudzinski's signs can be elicited within minutes after the initial bleed in subarachnoid hemorrhage. The patient experiences a sudden onset of a severe headache that begins in a localized area and then spreads, pupillary inequality, nuchal rigidity, and a decreased level of consciousness. Photophobia, a fever, nausea and vomiting, dizziness, and seizures are possible. Focal signs include hemiparesis or hemiplegia, aphasia, and sensory or vision disturbances. Increasing ICP may produce bradycardia, increased blood pressure, respiratory pattern change, and rapid progression to coma.

Nursing considerations

▪ Prepare the patient for diagnostic tests, such as a computed tomography scan, magnetic resonance imaging, spinal X-ray, myelography, and lumbar puncture.

▪ Closely monitor the patient's vital signs, ICP, and cardiopulmonary and neurologic status.

▪ Ensure bed rest, quiet environment, and minimal stress.

▪ If the patient has a subarachnoid hemorrhage, darken the room and elevate the head of the bed at least 30 degrees to reduce ICP.

▪ If he has a herniated disk or spinal tumor, he may require pelvic traction.

Patient teaching

▪ Teach the patient and his family signs and symptoms of meningitis and treatment.

▪ Discuss ways to prevent meningitis.

▪ Explain activities that the patient with a herniated disk should avoid.

▪ Teach the patient how to apply a back brace or cervical collar as ordered.

Pictures

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, 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: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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