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 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 midposition.
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 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
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, onesided 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 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 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 coma-decreases

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).