Neurological Assessment: NCLEX

ALWAYS #1 in the Neuro assessment

ALWAYS #1 in the Neuro assessment

LOC

• Pupillary changes (normal pupil size is 2-6 cm), assess for

PERRLA

corneal assessment which involves a puff of air or tissue/cotton ball across the cornea to see if you blink

• Hand grips/leg lifts/pushing strength of feet to assess what?

strength and equality—also see if pt can follow a command

• Vital signs (late changes);

pulse pressure will WIDEN with increased ICP

• See how the pt reacts to noxious stimuli (painful stimuli)

as a last resort b/c it's invasive

• See if the pt complains of a headache—if yes, what could this mean

that could be a sign of increased ICP b/c you want to assume to worst

• If the pt can speak this shows what?

a high level of brain function

• The absence of movement is the lowest level of response—

see if their movement is purposeful or non-purposeful

Oculocephalic reflex (doll's eye reflex)

assesses brain stem function;

eyelids open and quickly turn head to the right, eyes should move to the left;

if eyes remain stationary the reflex is absent—

pt must be unconscious when performing this, you WANT doll's eyes that is a good sign

Ice water calories (oculovestibular reflex)

—assess brain stem function;

irrigate ear with 50 mL of cool water,
normally eyes will move towards the irrigated ear and rapidly back to mid position;

watch for nausea so turn pt on side b/c they may vomit

• Babinski or plantar reflex

a way to see if the CNS is intact/functioning properly

Babinski or plantar reflex in Normal adult

stroke the lateral part of the bottom of the foot:
if CNS is normal, the toes will contract and move closely together→
this is a NEGATIVE Babinski and is what you want to see in anyone greater than 1 year of age

Babinski or plantar reflex
o If the toes fan out

this is a POSITIVE Babinski and means the CNS is NOT normal in those greater than 1 year of age

o A positive Babinski reflex is only normal in

the pt is less than 1 year of age

o A positive Babinski reflex is only normal is the pt is less than 1 year of age

Less than 1 year of age =
+Babinski is OKAY;
-Babinski is bad;
good = curl out

More than 1 year of age =
-Babinski is OKAY;
+Babinski is bad;
good = curl in

Reflexes:

0=absent,
1+= present, diminished

2+= normal

3+= increased but not necessarily pathologic
4+= hyperactive

Parkinson's

will see a shuffling gait,
tremors but brain function of normal

want to give these pts slick shoes so they can shuffle along the floor

CT

o With/without contrast dye:
the dye used is an iodine based dye so have to check for allergies to shellfish and
pt will need to sign a consent form prior to the test

o Takes pictures in slices;
keep head still;
no talking;
warn pt that it can be claustrophobic

MRI (magnetic resonance imaging)

o Better than a CT b/c it picks up on pathology earlier; dye is not usually used;
no radiation either b/c a magnet is used

o Will be placed in a tube where the client will have to lie flat—claustrophobic pts CANNOT tolerate it

o Remove jewelry; no credit cards; no metal
o Fillings in teeth do not matter b/c it's not true metal

o Warn pt they will hear a thumping sound which can alarm/scare some pts and also can hear and talk to others while in the tube

• Cerebral Angiopgraphy

o X-ray of cerebral circulation;
go through the femoral artery so think heart cath!

o Pre-procedure

• Cerebral Angiopgraphy

Pre-procedure

• Keep pt well HYDRATED, void before procedure, check peripheral pulses and MARK THEM, and groin prep b/c this is the insertion site

• Anytime using an iodine base dye the pt will need to be well hydrated to promote excretion of the dye by the kidneys

• Explain they will have a warmth in face and a metallic taste; check for shellfish allergies b/c and iodine based dye is used

• Cerebral Angiopgraphy
Post-procedure

• Bed rest for 8-12 hours—care is similar to that of a heart cath pt

• Major complication is embolus and bleeding!

—an embolus can go lots of places such as the arm, heart, lung, or kidney (if goes to kidney will have decreased UO and increased BUN/creatinine

• Since we are performing a test on the brain, if the embolus goes to the brain the pt will have a change in LOC, one-sided weakness and paralysis, and motor/sensory deficits

• Myelogram

o X-ray of spinal sub-arachnoid space;
dye is injected & table tilts to move dye around

o Two types of dye are used:
1) oil soluble—reaspirated out b/c can't excrete it 2) water soluble—excreted by the kidneys

• Nursing care with either:
NPO,
light sedative,
increase fluids b/c they remove spinal fluids to test

Watch for s/s of meningitis:
chills, fever
+Kernig
+Brudinski,
vomiting, nuccal rigidity, and photophobia

• Blinds closed, lights and TV off to prevent seizures

• w/ a baby get them focused on an object then drop it, if don't follow/look for it that is POSITIVE nuccal rigidity

• since we are puncturing through the meninges, we could introduce an infection in to the pt's body—this is why we watch for s/s of meningitis

Kernig

pt lies with thigh flexed on abdomen and opposite leg cannot completely extend

Brudinski

pts neck is flexed so the knees and hips flex too

EEG

o Records electrical activity;
helps diagnose seizure disorders;
screening procedure for coma;
and indicator of brain death

• Many factors, including a flat EEG, are used in diagnosing brain death:
- neurological exams by 2 physicians,
- no response to pain,
- no cranial nerve reflexes,
- and apnea when the ventilator is paused

o Prep: hold sedatives;
no caffeine b/c it increases electricity;
and NOT NPO b/c this will lower the blood sugar which can affect the test

o During procedure you want to get a baseline first with pt lying quietly;
may be asked to hyperventilate;
may flash light in the pt's face

Lumbar puncture

o Puncture site is the lumbar subarachnoid space (3rd and 4th)

o Purpose is to:
- obtain spinal fluid
- check for blood;
- measure progress;
- and administer drugs intrathecally-through the brain or spinal cord

o Pt is positioned in the FETAL position or SITTING and hunched over to get a lot of arch in the back to make it easier to puncture meninges

• When the pt is in a position that increases the arch of the back, the meninges will be stretched tightly, which allows the needle to puncture through more easily—MUST remain in position

o CSF should be clear and colorless—looks like water

• Lumbar puncture
Post-procedure

• Lie flat for 8 hours; increase fluids

• #label the tubes of fluid pulled out to tell where the spinal fluid came from

• The most common complication is HEADACHE then infection—pain of the headache
increases when the pt site up
and decreases when they lie down;

it's treated with bed rest, fluids, pain meds, and a blood patch (inject blood from another area in to the spinal cord to seal off the puncture site)

• Herniation—when brain tissue is pulled down through foramen magnum as a result of a sudden drop in ICP→fatal complication

Neurological Injuries

• A small hematoma that develops rapidly may be fatal, while a massive hematoma that develops slowly may allow the pt to adapt

• Epidural hematoma

• This is a rupture of the middle meningeal artery—FAST BLEEDER!

• Injury causes a loss of consciousness then there's a recovery period but when they can't compensate any longer is when the pt develops neuro changes

• EMERGENCY!!!

• Epidural hematoma
Treatment

• Burr holes and remove the clot; control the ICP with drugs

• To be able to identify the treatment needed has to ask the questions—
did they pass out?
Did they pass out and wake up and pass out again? Did they just see stars?

• Normal ICP value 0-15 mmHg

normal ICP value

0 - 15 mmHg

• Subdural hematoma

• Usually venous—
can be acute (fast),
subacute (medium),
or chronic (slow)

Treatment
• Acute: immediate craniotomy and remove the clot; control ICP

• Chronic: imitates other condition; remove clot; control ICP—they are bleeding and compensating; neuro changes with maxed out (can't compensate) so they act weird occasionally

Scalp injury

o Scalp is VERY vascular so a lot of blood comes from a small area
o Watch for infection

Skull Injury

o May/may not damage the brain—this is what determines your s/s

o Open fracture→dura is torn
o Closed fracture→dura not torn

o With basal skull fractures you see bleeding in EENT

o Battle's sign—bruising over the mastoid (behind ear)

o Raccoon eyes—periorbital bleeding

o Cerebrospinal rhinorrhea (leaking spinal fluid from your nose)

o Bloody spinal fluid
o Non-depressed skull fractures usually do not require surgery
but depressed do require surgery

• Concussion

o Temporary loss of neurologic function with COMPLETE recovery

o Will have a short (maybe seconds) period of unconsciousness or may just get dizzy/see spots

o Teach care giver to bring pt back to ED if any of the following occur:
- difficulty awakening/speaking
(should be easily aroused);
- confusion,
- severe headaches, or vomiting;
- or pulse changes,
- unequal pupils,
- one-sided weakness b/c all of these are signs of increasing ICP

Contusions

o Brain is bruised with possible surface hemorrhage
o Unconscious for longer and may have residual damage

General Care for any pt with a possible head injury or Increased ICP
• Nursing considerations

o Assume a c-spine injury is present until proven otherwise with trauma pts;
so will need an x-ray to rule out injury

o Keep body in perfect alignment and keep slight traction on head until doctor says otherwise

o Want to test any drainage to see if it's CSF by testing it for glucose or the halo test—
CSF will form a ring around a drop of fluid

General Care for any pt with a possible head injury or Increased ICP
• Nursing considerations

o Ensure adequate nutrition

• Needs increased calories

• Steroids increase breakdown of protein and fat and help decrease cerebral edema

• Cannot have NG feedings is have CSF rhinorrhea

General Care for any pt with a possible head injury or Increased ICP


• Nursing considerations

o When a pt emerges from a coma they can be lethargic or agitated—NO restraints b/c they will cause an increase in ICP

o Need a quiet environment b/c stimuli could promote seizures

o Pad side rails
o No narcotics b/c they will affect neuro checks—morphine causes pin-point pupils

o Normal ICP = 0-15mmHg and will vary with positioning—elevating the HOB will help to decrease ICP

o The brain can compensate only to a certain point as the skull is a rigid cavity; unlike babies who have sutures that haven't fused

• Signs and symptoms of increased ICP

o Earliest sign is a change in the LOC

o Altered speech

o Respiratory pattern may change
• There could be a gradual or severe change or may just stop breathing

• Cheyne Stokes = long period of apnea then gasp

• Ataxic = breath a lot continuously then apnea

o Increasing drowsiness; subtle changes in mood; quiet to restless

o Flaccid extremities so reflexes may become absent

o Profound coma—pupils fixed and dilated
o Projectile vomiting b/c the vomiting center in the brain is being stimulated—sign of worsening ICP

o Decerebrate posturing—arched spine, plantar flexion; VERY BAD!
• Rigid posture so have an increased calorie need so increase calories in diet, may be put on TPN

o Decorticate posturing—arms flexed inwardly and legs extended with plantar flexion
• Rigid posture so have an increased calorie need so increase calories in diet, may be put on TPN

o Hemiparesis—weakness
o Hemiplegia—paralysis
o Facial paralysis

o Earliest sign of IICP is

change in LOC

• Treatment of increased ICP
o Osmotic Diuretics, Mannitol (Osmitrol)

pull fluid from the brain cells and is place into the general circulation, this increases circulating blood volume; since these drugs increase the blood volume, the work load of the heart also increases

• HAVE to have good kidney and heart function b/c excreted by kidneys and will increase workload on the heart

• Also given for pts with eye pain or in hemolytic reaction to decrease pressure and flush out kidneys

• Treatment of increased ICP

Due to the increase in circulation blood volume, the pt is at risk for fluid volume EXCESS—pt is frequently given

Furosemide (Lasix) with these drugs to enhance diuresis

• Treatment of increased ICP

Steroids Dexamethasone (Decadron) helps

decrease cerebral edema

• Treatment of increased ICP


o Hyperventilation causes

alkalosis b/c blowing off CO2 so brain vasoconstricts and decreases ICP

• PCO2 is kept on the low side (35), if lower PCO2 too much it will cause too much vasoconstriction resulting in decreased cerebral perfusion, decreased ICP, and brain ischemia

IICP

Keep temperature

below 100.4

b/c an increased temp will increase cerebral metabolism which increases ICP;

the hypothalamus may not be working properly and a cooling blanket may be needed

IICP

Avoid

restraints/bowel
and
bladder distention/hip flexion/valsalva/isometrics/no sneezing/no nose blowing

o Decrease turning and coughing

o Space nursing intervention b/c anytime you do something to your pt the ICP increases

o Spinal cord injury is possible

IICP pts o can have autonomic dysreflexia (hyperreflexia)—caused by

a distended bowel or a distended bladder

• s/s are
- reflexive hypertension;
- bradycardia;
- seeing spots or blurred vision;
- pounding headache;
- nasal stuffiness;
- flushed face;
- red blotching on chest;
- goose bumps above the level of injury;
- cool, clammy skin;
- nausea; and feeling anxious

• The first thing you do is elevate the HOB to decrease the pressure

The first thing you do in autonomic dysreflexia

is elevate the HOB to decrease the pressure

o Watch ICP monitor during

turning

o Barbiturate induced coma

decreases cerebral metabolism (phenobarbital-luminal)

IICP o Elevate the HOB; keep the head in midline so jugular veins can drain, may need

a c-collar but tell doctor using one

o Monitor the glascow coma scale (looks at eye opening, motor responses, and verbal performance); max score is 15 (normal)

IICP Restrict fluids to

1200-1500 mL per day (too much fluid increases the ICP

IICP o Watch for bradycardia OR tachycardia?

bradycardia (not pumping out much volume)
b/c will cause a decreased CO and brain perfusion will decrease

IICP

Watch for increased BP b/c

heart pumping against more pressure, so not as much blood can get out of heart will again will cause a decrease in CO and decrease cerebral perfusion

o ICP monitoring devices

• Ventricular catheter monitor or subarachnoid screw; greatest risk is INFECTION

• No loose connections and keep dressing dry (bacteria can travel through something that is wet much easier than something that is dry