Evoked Brain Potentials 769
Evoked Brain Potentials
SYNONYM/ACRONYM:  Brainstem auditory evoked potentials (BAEP), brainstem
auditory evoked responses (BAER), EP studies.
COMMON USE:  To assist in diagnosing sensory deficits related to nervous system
lesions manifested by visual defects, hearing defects, neuropathies, and cogni-
tive disorders.
AREA OF APPLICATION:  Brain.
CONTRAST:  None.
DESCRIPTION:  Evoked brain poten-
tials, also known as evoked
potential (EP) responses, are
electrophysiological studies
performed to measure the
brain’s electrical responses to
various visual, auditory, and
somatosensory stimuli. EP stud-
ies help diagnose lesions of the
nervous system by evaluating
the integrity of the visual,
somatosensory, and auditory
nerve pathways. Three response
types are measured: visual
evoked response (VER), auditory
brainstem response (ABR), and
somatosensory evoked response
(SER). The stimuli activate the
nerve tracts that connect the
stimulated (receptor) area with
the cortical (visual and somato-
sensory) or midbrain (auditory)
sensory area. A number of stimuli
are given, and then responses are
electronically displayed in wave-
forms, recorded, and computer
analyzed. Abnormalities are
determined by a delay in time,
measured in milliseconds,
between the stimulus and the
response. This is known as
increased latency. VER provides
Monograph_E_768-777.indd 769
E
information about visual path-
way function to identify lesions
of the optic nerves, optic tracts,
and demyelinating diseases such
as multiple sclerosis. ABR pro-
vides information about auditory
pathways to identify hearing loss
and lesions of the brainstem. SER
provides information about the
somatosensory pathways to iden-
tify lesions at various levels of
the central nervous system (spi-
nal cord and brain) and periph-
eral nerve disease. EP studies are
especially useful in patients with
problems and those unable to
speak or respond to instructions
during the test, because these
studies do not require voluntary
cooperation or participation in
the activity. This allows collec-
tion of objective diagnostic infor-
mation about visual or auditory
disorders affecting infants and
children and allows differentia-
tion between organic brain and
psychological disorders in adults.
EP studies are also used to moni-
tor the progression of or the
effectiveness of treatment for
deteriorating neurological diseases
such as multiple sclerosis.
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 770 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications
This procedure is
contraindicated for:  N/A
INDICATIONS
VER (potentials)
••Detect cryptic or past retrobulbar
neuritis
••Detect lesions of the eye or optic
nerves
••Detect neurological disorders such
as multiple sclerosis, Parkinson’s
disease, and Huntington’s chorea
E ••Evaluate binocularity in infants
••Evaluate optic pathway lesions and
visual cortex defects
ABR (potentials)
••Detect abnormalities or lesions in the
brainstem or auditory nerve areas
••Detect brainstem tumors and
acoustic neuromas
••Screen or evaluate neonates, infants,
children, and adults for auditory
problems
••EP studies may be indicated when
a child falls below growth chart
norms
SER (potentials)
••Detect multiple sclerosis and
Guillain-Barré syndrome
••Detect sensorimotor neuropathies
and cervical pathology
••Evaluate spinal cord and brain
injury and function
••Monitor sensory potentials to
determine spinal cord function
during a surgical procedure or
medical regimen
ERP (potentials)
••Detect suspected psychosis or
dementia
••Differentiate between organic brain
disorder and cognitive function
abnormality
POTENTIAL DIAGNOSIS
Normal findings in
••VER and ABR: Normal latency in
recorded cortical and brainstem
Monograph_E_768-777.indd 770
waveforms depending on age,
gender, and stature
••ERP: Normal recognition and
attention span
••SER: No loss of consciousness or
presence of weakness
Abnormal findings in
••VER (potentials):
P100 latencies (extended) confined to
one eye suggest a lesion anterior to
the optic chiasm.
Bilateral abnormal P100 latencies indi-
cate multiple sclerosis, optic neuritis,
retinopathies, spinocerebellar degener-
ation, sarcoidosis, Parkinson’s disease,
adrenoleukodystrophy, Huntington’s
chorea, or amblyopias.
••ABR (potentials):
Normal response at high intensities; wave
V may occur slightly later. Earlier wave
distortions suggest cochlear lesion.
Absent or late waves at high intensities;
increased amplitude of wave
V suggests retrocochlear lesion.
••SER (potentials):
Abnormal upper limb latencies suggest
cervical spondylosis or intracerebral
lesions.
Abnormal lower limb latencies suggest
peripheral nerve root disease such as
Guillain-Barré syndrome, multiple
sclerosis, transverse myelitis, or
traumatic spinal cord injuries.
CRITICAL FINDINGS:  N/A
INTERFERING FACTORS
Factors that may impair the
results of the examination
••Inability of the patient to cooperate
or remain still during the proce-
dure because of age, significant
pain, or mental status. (Note:
Significant behavioral problems
may limit the ability to complete
the test.)
••Improper placement of electrodes.
••Patient stress, which can affect
brain chemistry, thus making it dif-
ficult to distinguish whether the
results are due to the patient’s
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emotional reaction or to organic
pathology.
••Extremely poor visual acuity, which
can hinder accurate determination
of VER.
••Severe hearing loss, which can
interfere with accurate determina-
tion of ABR.
NURSING IMPLICATIONS
AND PROCEDURE
PRETEST:
➧➧Positively identify the patient using at
least two unique identifiers before pro-
viding care, treatment, or services.
➧➧Patient Teaching: Inform the patient this
procedure measures electrical activity
in the nervous system.
➧➧Obtain a history of the patient’s com-
plaints or symptoms, including a list of
known allergens, especially allergies or
sensitivities to latex.
➧➧Obtain a history of the patient’s neuro-
muscular system, symptoms, and
results of previously performed labora-
tory tests and diagnostic and surgical
procedures.
➧➧Obtain a list of the patient’s current
medications, including herbs, nutri-
tional supplements, and nutraceuticals
(see Appendix H online at DavisPlus).
➧➧Review the procedure with the patient.
Address concerns about pain related
to the procedure and explain that the
procedure is painless and harmless.
Inform the patient that the procedure is
performed in a special laboratory by a
health-care provider (HCP) and takes
approximately 30 min to 2 hr, depend-
ing on the type of studies required.
➧➧Sensitivity to social and cultural issues,  placed on the patient’s ears, and a
as well as concern for modesty, is
important in providing psychological
support before, during, and after the
procedure.
➧➧Instruct the patient to clean the hair
and to refrain from using hair sprays,
creams, or solutions before the test.
➧➧Instruct the patient to remove jewelry
and other metallic objects from the
area to be examined.
Monograph_E_768-777.indd 771
Evoked Brain Potentials 771
➧➧Note that there are no food, fluid, or
medication restrictions unless by
medical direction.
➧➧Make sure a written and informed
consent has been signed prior to the
procedure and before administering
any medications.
INTRATEST:
Potential Complications:  N/A
➧➧Observe standard precautions, and fol-
low the general guidelines in Appendix A.
Positively identify the patient.
➧➧Ensure the patient is able to relax; report
any extreme anxiety or restlessness. E
➧➧Ensure that hair is clean and free of
hair sprays, creams, or solutions.
➧➧Ensure the patient has removed all
external metallic objects from the area
to be examined prior to the procedure.
➧➧Avoid the use of equipment containing
latex if the patient has a history of aller-
gic reaction to latex.
Visual Evoked Potentials
➧➧Place the patient in a comfortable posi-
tion about 1 m from the stimulation
source. Attach electrodes to the occipital
and vertex lobe areas and a reference
electrode to the ear. A light-emitting
stimulation or a checkerboard pattern is
projected on a screen at a regulated
speed. This procedure is done for each
eye (with the opposite eye covered) as
the patient looks at a dot on the screen
without any change in the gaze while the
stimuli are delivered. A computer inter-
prets the brain’s responses to the stimuli
and records them in waveforms.
Auditory Evoked Potentials
➧➧Place the patient in a comfortable
position, and place the electrodes on
the scalp at the vertex lobe area and
on each earlobe. Earphones are
clicking noise stimulus is delivered into
one ear while a continuous tone is
delivered to the opposite ear.
Responses to the stimuli are recorded
as waveforms for analysis.
Somatosensory Evoked Potentials
➧➧Place the patient in a comfortable
position, and place the electrodes at
the nerve sites of the wrist, knee, and
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 772 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications
ankle and on the scalp at the sensory
cortex of the hemisphere on the
opposite side (the electrode that picks
up the response and delivers it to the
recorder). Additional electrodes can
be positioned at the cervical or lumbar
vertebrae for upper or lower limb
stimulation. The rate at which the
electric shock stimulus is delivered
to the nerve electrodes and travels to
the brain is measured, computer ana-
lyzed, and recorded in waveforms for
analysis. Both sides of the area being
examined can be tested by switching
E the electrodes and repeating the
procedure.
Event-Related Potentials
➧➧Place the patient in a sitting position in
a chair in a quiet room. Earphones are
placed on the patient’s ears and audi-
tory cues administered. The patient is
asked to push a button when the
tones are recognized. Flashes of light
are also used as visual cues, with the
client pushing a button when cues are
noted. Results are compared to normal
EP waveforms for correct, incorrect, or
absent responses.
POST-TEST:
➧➧Inform the patient that a report of the
results will be made available to the
requesting HCP, who will discuss
the results with the patient.
Exercise Stress Test
SYNONYM/ACRONYM:  Exercise electrocardiogram, ECG, EKG, graded exercise
tolerance test, stress testing, treadmill test.
COMMON USE:  To assess cardiac function in relation to increased workload,
evidenced by dysrhythmia or pain during exercise.
AREA OF APPLICATION:  Heart.
CONTRAST:  None.
Monograph_E_768-777.indd 772
➧➧When the procedure is complete,
remove the electrodes and clean the
skin where the electrodes were
applied.
➧➧Recognize anxiety related to test
results, and be supportive of perceived
loss of independent function. Discuss
the implications of abnormal test
results on the patient’s lifestyle. Provide
teaching and information regarding the
clinical implications of the test results,
as appropriate.
➧➧Reinforce information given by the
patient’s HCP regarding further testing,
treatment, or referral to another
HCP. Answer any questions or address
any concerns voiced by the patient or
family.
➧➧Depending on the results of this proce-
dure, additional testing may be needed
to evaluate or monitor progression of
the disease process and determine the
need for a change in therapy. Evaluate
test results in relation to the patient’s
symptoms and other tests performed.
RELATED MONOGRAPHS:
➧➧Related tests include acetylcholine
receptor antibody, Alzheimer’s disease
markers, biopsy muscle, CSF analysis,
CT brain, CK, EEG, ENG, MRI brain,
plethysmography, and PET brain.
➧➧Refer to the Musculoskeletal System
table at the end of the book for related
tests by body system.
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