X.
NEURO but not necessarily
A. Neurological Assessment
1. LOC
2. Pupillary changes (normal
pupil size is 2-6 mm) PERLA
3. Corneal ASSESMENT
4. Hand grips/lifts
legs/pushing strength of FEET
(strength, equality)
5. Vital signs (late); pulse
PRESSURE will widen with
increased ICP
6. Notice how the client reacts
to pain.(noxious stimuli)
7. Notice if the client c/o
headache.
8. Can the client speak? This
shows a high level of BRAIN
FUCTION.
9. Movement (absence of
movement is the LOWEST level of
response)
Purposeful verses non-
purposeful movement.
10. Oculocephalic reflex
(Dolls eye reflex): assesses
BRAINSTEM stem function;
eyelids open.quickly turn
head to the righteyes should
move to the left; If eyes
remain stationary.reflex
absent.
11. Ice cold water calorics
(oculovestibular reflex):
assesses BRAINSTEM stem
function; irrigate ear with
50mL of cool water.normally
eyes will move to
irrigated ear and rapidly back
to mid-position.
12. Babinski or planter reflex:
lateral aspect of foot is
stroked and toes flex or curl
up.
Less than 1 year of age a
positive Babinski is ok;
negative is bad.
13. Normal Adult: toes roll
under or flex.
More than 1 year of age a
negative Babinski is OK;
positive is bad.
14. Reflexes: (0) = absent,
(1+) = present, diminished,
(2+) = normal, (3+) = increased
2) Major complication: Embolus
pathological, (4+) =
hyperactive
B. General Diagnostic Tests:
1. CT:
a. With/without contrast (dye)
The client will need to sign a
consent form prior to the test
when using dye.
b. Takes pictures in SLICES
c. Keep HEAD still
d. No TALKING
2. MRI (Magnetic Resonance
Imaging):
a. Which is better CT or MRI?
MRI
b. Is dye used? NO
Is radiation used? NO
A MAGNET is used
c. Will be placed in a tube
where client will have to lie
flat.
d. Remove METALS.
e. No credit cards
f. No PACEMAKERS, NO METALS
g. Do fillings in teeth matter?
NO
h. Do tattoos matter? OLD
TATTOOS MAYBE METAL.
i. Will hear a thumping sound
j. What type of client cant
tolerate this procedure?
CLAUSTOPHOBIC
k. Can talk and hear others
while in the MRI
3. Cerebral Angiography
X-ray of cerebral circulation
Go through the FEMORAL artery.
a. Pre:
1) Well
hydrated/void/peripheral
pulses/groin prepped
Anytime an iodine based dye
is used the client will need to
be well
hydrated to promote excretion
of the dye.
2) Explain they will have a
warmth in face and a metallic
taste; allergies? IODINE OR
SHELLFISH
An iodine base dye is used.
b. Post:
1) Bed rest for 4-6 HOURS.
An embolus can go lots of
different places:
Arm, Heart, Lung, Kidney
Since we are performing a
test on the brain.if the
embolus goes to the
brain the client will have a
change in one-sided
PARALYSIS, LOC and ,WEAKNESS,
motor/sensory
deficits.
4. EEG:
a. Records electrical activity
b. Helps diagnose SEIZURES
c. Screening procedures for
COMA
d. Indicator of BRAIN death
e. Pre procedure:
Hold sedatives
No CAFFEINE
Not NPO (drops blood sugar)
142 Hurst Review Services
f. During procedure
Will get a baseline first
with client lying quietly; may
be asked to
hyperventilate or cough; if
they are completely
unconscious, clap hands in
face, blow whistle in face.
5. Lumbar Puncture:
a. Puncture site: lumbar
subarachnoid space (3rd - 4th)
b. Purpose:
1) To obtain SPINAL fluid to
analyze for BLOOD, infection,
and
tumor cells.
2) To measure pressures reading
with a manometer
3) To administer drugs
intrathecally (brain, spinal
cord)
c. How is the client positioned
and why? HEAD DOWN, ARCH ON THE
BACK, SIDE LYING, FETAL
POSITION, CHIN ON THE CHEST,
KNEES ON THE CHEST.
Complications: Meningitis
Watch for chills, fever,
positive Kernig and Brudzinski,
vomiting,
nuchal rigidity, photophobia.
d. CSF should be clear and
colorless (looks like water)
e. Post-procedure: lie flat or
prone for 2-3 hrs; increase
FLUIDS.
f. What is the most common
complication? HEADACHE.
g. The pain of this headache
INCREASES when the client sits
up and
DECREASES when they lie down.
h. How is this headache
treated? Bed rest, fluids, pain
med, and BLOOD PATCHES.
i. Herniation: when brain
tissue is pulled down through
foramen magnum as a result
of a sudden drop in ICP.
Meningitis signs:
Kernig is positive when the
clients hip is flexed 90
then extending the clients
knee causes pain.
Brudzinski is positive when
flexing the clients neck
causes flexion of the clients
hips and knees.
C. Neurological Injuries:
1. Head Injury
a. Scalp Injury
Scalp very VASCULAR
Watch for INFECTION
b. Skull Injury
May/may not damage THE BRAIN;
this is what determine your S/S
Open fracture dura IS TORN
Closed fracture dura IS NOT
torn
With basal skull fractures
you see bleeding where? EENT,
EYES EARS NOSE THROAT
Battles sign: bruising over
MASTOID.
Raccoon eyes (periorbital
bruising)
Cerebrospinal rhinorrhea-
leaking spinal fluid from your
NOSE
Bloody spinal fluid
Non-depressed skull fractures
usually do not require surgery;
depressed do
require surgery.
2. Brain Injury
a. Concussion Acute: immediate craniotomy and
Temporary loss of neurologic remove THE CLOT:control THE
function with complete recovery ICP.
Will have a short (maybe Chronic: imitates other
seconds) period of conditions;
unconsciousness or may just get Bleeding & compensating
dizzy/see spots Neuro changes= maxed out
Teach caregiver to bring Normal Lab Value:
client back to ED if the ICP: 0-15mm Hg
following occurs:
Difficulty awakening/speaking 3. Spinal Cord Injury
confusion, severe headache, Autonomic dysreflexia
vomiting With your upper spinal cord
pulse changes, unequal pupils, injury (above T6) major
one-sided weakness complication to look for is
All of these are signs that the autonomic or hypereflexia.
ICP is going UP! It is a syndrome
b. Contusion characterized by severe
Brain is BRUISED with hypertensionand headache,
possible surface hemorrhage bradycardia, nasal stuffiness,
Unconscious for longer and flushing, sweating, blurred
may have residual damage vision and anxiety.
c. Intracranial Hemorrhage Sudden onset, it is a
A small hematoma that develops neurological emergency if not
rapidly may be fatal, while a treated properly a
massive hematoma hypertensive stroke could
that develops slowly may allow occur.
the client to ADAPT. What can cause it? Distended
1) Epidural Hematoma: bladder, constipation, painful
Pathophysiology: stimuli.
This is rupture of the middle Treat the cause.
meningeal artery (fast Sit the client up to lower ICP.
bleeder). Put in catheter, remove
Injury Loss of impaction, look for skin
consciousness Recovery pressure or painful stimuli, a
period Cant compensate cold
any longer Neuro changes. draft.
Emergency! Teach prevention measures.
Tx: D. General Care for Any Client
Burr Holes and remove the clot; with a Possible Head Injury or
control ICP. Increased Intracranial
Ask questions to ID the type of Pressure:
injury and the treatment 1. Nursing Considerations:
needed: a. Assume a c-spine injury is
Did they pass out and stay present until proven otherwise.
out? How do we prove otherwise?
Did they pass out and wake up With an XRAY
and pass out again? b. Keep body in PERFECT
Did they just see stars? alignment.
2) Subdural Hematoma c. Keep slight traction on
Pathophysiology: head.
Usually VENOUS d. How do you tell CSF from
Can be acute (fast), subacute other drainage?
(medium), or chronic (slow) Positive for GLUCOSE; halo
Tx: test
e. Ensure adequate nutrition
f. Need increased calories
g. Steroids increase breakdown
of PROTEIN & FAT.
h. Cannot have NG feedings if
having CSF rhinorrhea
Steroids decrease cerebral
edema
i. When a client emerges from a
coma lethargic agitated
No restraints because
restraints will make your ICP
go UP.
j. Need a quiet environment-
stimuli could promote SEIZURE
k. Pad side rails
l. No narcotics
Affect your neuro checks
m. Normal ICP = < 15
n. ICP varies according to
position.
We ELEVATE the HOB to
DECREASE ICP
o. The brain can compensate
only to a certain point as the
skull is a RIGID
cavity.
2. Signs and Symptoms of
ICP: a. Earliest sign? CHANGE
OF LOC
b. Speech? SLURRED
c. Respiration PATTERN may
change.
Cheyne Stokes
Ataxic Respiratory
d. Increasing drowsiness
e. Subtle changes in MOOD.
f. Quiet to restless
g. Flaccid extremities
h. Reflexes may become ABSENT
i. Change in PUPIL and pupil
response.
j. Profound coma: pupils fixed
& DILATED.
k. Projectile
VOMITTING(vomiting center in
brain is being stimulated).
l. Decerebrate posturing
(arched spine, plantar
flexion); worst.
m. Decorticate posturing (arms
flexed inwardly; legs extended
with plantar flexion).
n. Hemiparesis weakness
o. Hemiplegia paralysis
*TESTING STRATEGY*
We like a high number, like 13-
15 for the Glasgow scale. If
your score is <8, intubate.
Hurst Review Services 147
3. Tx of ICP:
a. Osmotic diuretics: Mannitol
(Osmitrol) pull FLUID from
brain cells and
is placed into the general
circulation this INCREASES l. Keep HEAD in midline so
circulating blood
volume; since these drugs
increase blood volume, what
does this do to the
workload of the heart? FLUID
OVERLOAD
b. Due to the increase in
circulating blood volume, does
this put the client at risk for
FVD or FVE? EXCESS
Furosemide (Lasix) is o. Ensure cerebral tissue
frequently given with these
drugs to enhance
DIURESIS.
c. Steroids: Dexamethasone
(Decadron) decrease cerebral
edema.
d. Hyperventilation
alkalosis brain
vasoconstriction makes ICP
come DOWN
PCO2 is kept on the low side
(35), if lower PCO2 too much it
will cause too
much vasoconstriction resulting
in decreased cerebral perfusion
and brain
ischemia.
e. Keep temperature below
100.4F
1) An increased temp will
increase cerebral metabolism
which increases ICP.
2) The hypothalamus may not be
working properly and a cooling
blanket may be
needed.
f. Avoid RESTRAINT/ bowel/
bladder distention/ hip
flexion/
valsalva/ isometrics/ no
sneezing/ no nose BLOWING
g. Decrease SUCTIONING and
coughing
h. Space nursing interventions
Anytime you do something to
your client, ICP increases.
i. Watch the ICP monitor with
turning, etc
j. Barbiturate induced coma-
decreases cerebral metabolism
phenobarbital
(Luminal).
k. Elevate the HEAD OF BED.
jugular veins can drain.
m. Monitor the Glasgow coma
scale (look at eye opening,
motor responses, verbal
performance) Max score = 15 IF
LESS THAN 8, INTUBATE.
n. Restrict fluids to 1200 to
1500 mL per day (too much fluid
increases
ICP).
perfusion.
p. Watch for BRADYCARDIA (not
pumping out much volume).
q. Watch for increased BP
(heart pumping against more
pressure, so not as much
blood can get out of heart).
r. ICP monitoring devices
1) Ventricular catheter monitor
or subarachnoid screw
2) Greater risk? INFECTION.
3) No loose connections
4) Keep dressings dry (bacteria
can travel through something
that is wet much
easier than something that is
dry).