Flashcards in Neuro Deck (16):
2. Pupillary changes (normal pupil size is 2-6 mm)
3. Corneal assessment with tissue or air
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 function.
9. Movement (absence of movement is the lowest level of response) • Purposeful verses non-purposeful movement.
10. Oculocephalic reflex (Doll’s eye reflex): assesses brain stem function; eyelids open....quickly turn head to the right...eyes should move to the left; If eyes remain stationary....reflex absent.
11. Ice cold water caloric test (oculovestibular reflex): assesses brain 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 plantar 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
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/layers
c. Keep head still
d. No talking
A. Which is better CT or MRI? MRI
b. Is dye used? Not usually
• Is radiation used? No
• A magnet is used
c. Will be placed in a tube where client will have to lie flat.
d. Remove jewelry
e. No credit cards
f. No pacemakers
g. Do fillings in teeth matter? No
h. Do tattoos matter? Old ones do
i. Will hear a thumping sound
j. What type of client can’t tolerate this procedure? Claustrophobic
h. Can talk and hear others while in the tube
X-ray of cerebral circulation
Go through the femoral artery.
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 to iodine and shellfish
• An iodine base dye is used.
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 LOC one-sided weakness, and paralysis, motor/sensory deficits.
Do a good baseline neuro exam to compare
a. Records electrical activity
b. Helps diagnose seizure disorders
c. Screening procedures for coma
d. Indicator of brain death
• Hold sedatives
• Not NPO (drops blood sugar)
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.
A. Puncture site: lumbar subarachnoid space (3rd - 4th) 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)
B. Position lying fetal or bending over a table
C. 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 patch
I. Herniation: when brain tissue is pulled down through foramen magnum as a result of a sudden drop in ICP. It is contraindicated with an increased ICP
Kernig is positive when the client’s hip is flexed 90o then extending the client’s knee causes pain.
Brudzinski is positive when flexing the client’s neck causes flexion of the client’s hips and knees.
1. Head Injury
a. Scalp Injury
• Scalp very vascular
• Watch for infection
b. Skull Injury
• May/may not damage dura; this is what determines your S/S
• Open fracture→ dura torn
• Closed fracture→ dura not torn
• With basal skull fractures you see bleeding where? EENT
• Battle’s sign: bruising over mastoid/ear.
• Raccoon eyes (periorbital bruising)
• Cerebrospinal rhinorrhea- leaking spinal fluid from your nose. Do not blow or try to clog off
• Bloody spinal fluid
• Non-depressed skull fractures usually do not require surgery; depressed do require surgery.
*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:
confusion, severe headache, vomiting,
pulse changes, unequal pupils, one-sided weakness. All of these are signs that the ICP is going up.
• Brain is bruised with possible surface hemorrhage
• Unconscious for longer and may have residual damage
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→ Can’t compensate any longer→ Neuro changes.
Burr Holes and remove the clot; control the 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?
Can be acute (fast), subacute (medium), or chronic (slow)
Acute: immediate craniotomy and remove clot: control ICP
Chronic: imitates other conditions; DRUNK
Bleeding & compensating
Neuro changes= maxed out
Could have fallen a month ago
Normal Lab Value: ICP: 0-15mm Hg
Spinal cord injury
• With your upper spinal cord injury (above T6) major complication to look for is autonomic dysreflexia or hyperreflexia
• It is a syndrome characterized by severe HTN and headache, bradycardia, nasal stuffiness, flushing, sweating, blurred vision and anxiety.
• Sudden onset, it is a neurological emergency if not treated properly a HTN stroke could occur.
• What can cause it? Distended bladder, constipation, painful stimuli.
• Treat the cause.
Sit the client up to lower BP.
Put in catheter, remove impaction, look for skin pressure or painful stimuli, a cold draft.
• Teach prevention measures.
Nursing care for possible head injury or increased ICP
a. Assume a c-spine injury is present until proven otherwise.
• How do we prove otherwise? With an X-ray
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, hypermetabolic state
g. Steroids increase breakdown of protein & fat. Steroids decrease cerebral edema
h. Cannot have NG feedings if having CSF rhinorrhea. Don't want feeding to get into brain
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
*morphine makes pin point pupils
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.
S/S increased ICP
Earliest sign? Change in LOC
Respiration pattern may change.
• Cheyne Stokes
• Ataxic Respiratory
Subtle changes in mood.
Quiet to restless
Reflexes may become absent
Change in pupils and pupil response.
Profound coma: pupils fixed & dilated.
Projectile vomiting (vomiting center in brain is being stimulated).
Decerebrate posturing (arched spine, plantar flexion); worst.
Decorticate posturing (arms flexed inwardly; legs extended with plantar flexion). Hemiparesis – weakness
Hemiplegia – paralysis