Care of the Critically Ill Neurological Patient

Objectives

Describe the neurological assessment of a critically ill respiratory patient

Recognize and evaluate the major symptoms of neurological dysfunctions occurring in critically ill patients

Understand the diagnostic significance of CSF

Understand and differentiate the different arousal states and their designated outcomes

Key Terms

• Akinetic Mutism

• ALOC

• Brain Death

• Coma

• ICP

• Locked-In Syndrome

• Minimally Conscious State

• Persistent Vegetative State

• Mannitol

Assessment

• Review of Health History

• Review of Lab Data

• Visual Examination

• Physical Examination

• Pg 1976 (14th Ed. )

Assessment: Review of Health History

Events Preceding Onset of Symptoms

◦ Travel? Animal contact? Fall? Infection? Dental Problems? Food/Drugs ingested?

Progression of symptoms

◦ Initial Onset, Evolution of sx, Freq.?, Severity, Duration, Aggravation of sx Family History

◦ Stroke (AVM), DM, HTN, Seizures, Tumor, HA, Psych

Medical History

◦ DM, HTN, CV, Pulm., TB, Tropical Illness,

EARLY INTERVENTION IS KEY TO PREVENT

SECONDARY INJURY

Assessment: Review of Health History cont

Surgical History

◦ Neuro, ENT, Dental and Eye

Traumatic History

◦ MVA, Falls, Blow to head/neck/back, syncope

Allergies

◦ Drug, Food and Environment

Patient Profile

◦ Personal Habits, Illicit drugs, Alcohol, Place of residence, workplace, sleep patterns

Current Medication Use

◦ Nitrates, BP Meds, Herbals, Oral Contraceptives, Sedatives, Anticoagulants

Assessment: Review of the Lab Data CSF

Cerebral Spinal Fluid: Evaluated for 2 purposes

1. ___________________________

2. ___________________________

Normal: clear, colorless, no blood, <200mm H2O pressure, 0-5 WBCs, 50-75 mg/dL glucose, 15-50 mg/dL protein, lactate 10-20 mg/dL

Two life threatening risks associated:

1. Brainstem Herniation

2. Respiratory Arrest d/t

Assessment: Review of the Lab/Diagnostic Data

ABGs: PaCO2 and PaO2

PT, PTT, INR

CBC: Hgb and Hct, RBC, WBC

BMP: TCO2, Sodium, Potassium, LFTs

UA: infection?

CT vs MRI

Assessment: Review of the Visual Assessment

Level of Consciousness

1. Arousal or Alertness: Reticular Activating System and its connection to the thalamus and cerebral cortex

1. Ability to respond to noxious or verbal stimuli

1. Noxious Stimuli: trapezius pinch & Sternal Rub

2. Peripheral Stimulation: Nail bed pressure, Pinching inner arm or leg

2. Awareness

1. Content of consciousness is much more of a higher level of function (6 types)

1. Name, BD, Year, Place

2. Glasgow Coma Scale

Confusion

Impaired judgment and decision making

Disorientation

Disorientation to time, then place, then recognition

of self

Lethargy

Limited spontaneous movement or speech

Obtundation

Mild to moderate reduction in arousal with limited

response to environment

Stupor

condition of deep sleep or unresponsiveness from which the person may be aroused only by vigorous and repeated stimulation

Coma

no verbal response to the external environment or to any stimuli

Glasgow Coma Scale vs Revised Trauma Score

pic

Persistent Vegetative State

complete unawareness of self or surrounding environment and complete loss of cognitive function

Akinetic Mutism

severe disturbance in behavioral drive; limited to eye

opening and visual tracking

Minimally Conscious State

demonstrates minimal defined behavioral evidence of self or environmental awareness; following simple commands, manipulating objects, yes/no responses

Locked-In Syndrome

complete loss of spontaneous movement, except eye movement

Assessment: Physical Examination

Level of Consciousness

◦ GSC

◦ Appraisal of Awareness

◦ Evaluation of Arousal

Pupillary Function

◦ Control of Eye Movements

◦ Corneal Reflex

◦ Corneal Integrity

◦ Dolls Eyes

◦ Pupil Size

◦ Which cranial nerve?

Motor Function

◦ Muscle size, tone and strength

◦ Right vs Left

◦ Abnormal motor responses

◦ Posturing/Reflexes

◦ Decorticate vs Decerebrate

◦ Babinski

◦ Grasp

Doll's Eyes Phenomenon

Normal response—eyes turn together to side opposite from turn of head.

B. Abnormal response—eyes do not turn in conjugate manner.

C. Absent response—eyes do not turn as head position changes.

Oculovestibular Reflex: Caloric Ice Water Test

A. Normal response—conjugate eye movements.

B. Abnormal response—

dysconjugate or asymmetric eye movements.

C. Absent response—no eye movements.

Assessment: Physical

Respiratory Function : cerebrum, brainstem and metabolic processes

◦ ABGs

◦ Respiratory Pattern

◦ Airway Status

◦ Cough, Gag, Swallow

◦ Vent Assessment and Management

Vital Signs

◦ Blood Pressure

◦ Systemic HTN

◦ Heart Rate and Rhythm

◦ Cushing Reflex

◦ THIS IS A LATE SIGN!

◦ Systolic HTN, bradycardia, abnormal RR

◦ Pulse Pressure

◦ Fever

◦ ICP and CPP * other slide

Intracranial Pressure (ICP)

Normal Range: 0-10, can be 15 mmHg

Measured in lateral ventricles In patient's

◦ Catheter is placed into the cranium through a burr hole under local anesthesia to monitor ICP, and possibly drain excess CSF.

Monroe Kelli Hypothesis

Causes:

High: _____, __________, __________, __________

Low: __________. __________, _______, _________

Monroe Kelli Hypothesis

Nursing Management of ICP

Maintain level at Ventricles (tragus-notched part of ear)

Maintain proper alignment in bed

Maintain pressure level ordered in chart

Reduce controllable variables that elevate ICP

Baseline and serial neuro assessments

Temperature Q4H

Vitals Q1H

ABGs

Appearance of CSF

Monitor for Infection

Monitor Waveform

Cerebral Perfusion Pressure (CPP)

Cerebral Perfusion Pressure (CPP)

(CPP = MAP − ICP).

Guidelines recommend a CPP in the range of 50 to 70 mmHg

Hand-off SBAR The Conscious Patient

◦ 1.

◦ 2.

◦ 3.

◦ 4.

◦ 5.

Hand-off SBAR The Unconscious Patient

◦ 1.

◦ 2.

◦ 3.

◦ 4.

◦ 5.

Mannitol

Classification:

MOA:

Nursing Considerations:

HyperTonic Saline

Classification:

MOA:

Nursing Considerations:

Mannitol IV (0.5 to 1 gm/kg)

Increases serum osmolarity and draws free water into vasculature

Blood less viscous so improves cerebral blood flow

Onset in a few minutes

Osmotic diuretic so will also lead to volume depletion

3% saline (2-5 ml/kg)

Can also be given as a continuous drip

Hyperosmolarity leads to decreased blood velocity and improved cerebral blood flow

Does not have diuretic effect

Preferred if not hemodynamically stable