X. NEURO 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 nonpurposeful 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

but not necessarily 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.

2) Major complication: Embolus 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 rhinorrhealeaking 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 Temporary loss of neurologic function with complete recovery Will have a short (maybe seconds) period of unconsciousness or may just get dizzy/see spots Teach caregiver to bring client back to ED if the following occurs: Difficulty awakening/speaking confusion, severe headache, vomiting pulse changes, unequal pupils, one-sided weakness All of these are signs that the ICP is going UP! b. Contusion Brain is BRUISED with possible surface hemorrhage Unconscious for longer and may have residual damage c. Intracranial Hemorrhage A small hematoma that develops rapidly may be fatal, while a massive hematoma that develops slowly may allow the client to ADAPT. 1) Epidural Hematoma: Pathophysiology: This is rupture of the middle meningeal artery (fast bleeder). Injury Loss of consciousness Recovery period Cant compensate any longer Neuro changes. Emergency! Tx: Burr Holes and remove the clot; control ICP. Ask questions to ID the type of injury and the treatment needed: Did they pass out and stay out? Did they pass out and wake up and pass out again? Did they just see stars? 2) Subdural Hematoma Pathophysiology: Usually VENOUS Can be acute (fast), subacute (medium), or chronic (slow) Tx:

Acute: immediate craniotomy and remove THE CLOT:control THE ICP. Chronic: imitates other conditions; Bleeding & compensating Neuro changes= maxed out Normal Lab Value: ICP: 0-15mm Hg 3. Spinal Cord Injury Autonomic dysreflexia With your upper spinal cord injury (above T6) major complication to look for is autonomic or hypereflexia. It is a syndrome characterized by severe hypertensionand headache, bradycardia, nasal stuffiness, flushing, sweating, blurred vision and anxiety. Sudden onset, it is a neurological emergency if not treated properly a hypertensive stroke could occur. What can cause it? Distended bladder, constipation, painful stimuli. Treat the cause. Sit the client up to lower ICP. Put in catheter, remove impaction, look for skin pressure or painful stimuli, a cold draft. Teach prevention measures. D. General Care for Any Client with a Possible Head Injury or Increased Intracranial Pressure: 1. Nursing Considerations: a. Assume a c-spine injury is present until proven otherwise. How do we prove otherwise? With an XRAY b. Keep body in PERFECT alignment. c. Keep slight traction on head. d. How do you tell CSF from other drainage? Positive for GLUCOSE; halo 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 environmentstimuli 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 1315 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 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 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 comadecreases cerebral metabolism phenobarbital (Luminal). k. Elevate the HEAD OF BED. l. Keep HEAD in midline so 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). o. Ensure cerebral tissue 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).