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Neuro Assessment for the Non-Neuro Nurse

Terry M. Foster, RN, MSN, FAEN, CCRN, CPEN, CEN

Critical-Care Clinical Nurse SpecialistSt. Elizabeth Medical Center

Edgewood, Kentucky

• Consists of 5 layers– Skin

– Connective tissue

– Aponeurotic galea

– Loose areolar tissue

– Pericranium

• Highly vascular

Scalp

Skull

• Formed by cranium and facial bones

• Maxilla, immovable

• Mandible, strong bone

• Outer coverings– cranial bones and

vertebrae

• Inner coverings– Dura mater

– Arachnoid membrane

– Pia Mater

Brain and Cord Coverings

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Arachnoid Membrane Spider-like

• Not innervated and non vascular

• Forms a real space with the Pia Mater

• CSF circulates beneath the arachnoid membrane in the subarachnoid space

• The Pia mater supports the blood supply to the brain– Forms (with the Ependymal cells of the brain

and the blood vessels) the Choroid Plexus.

– Makes the CSF

Pia Mater - faithful, true

Parietal Lobe

Temporal Lobe

Occipital Lobe

Frontal Lobe

Lobes of the Brain• Frontal Lobe:

– Reasoning, planning, parts of speech and movement (motor cortex), emotions, and problem-solving.

• Parietal Lobe:– Perception of stimuli related to touch, pressure,

temperature and pain

• Temporal:– perception and recognition of auditory stimuli

(hearing) and memory (hippocampus).

• Occipital: – Vision

Functions of the Lobes

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Neuro Physiology Concepts

Example: Increased Brain Volume

• Mass– Swelling of brain

• Leads to ICP

• Usually manifests as decline in LOC, followed by symptoms/signs on contralateral side

Space occupying mass

Cerebral Blood Flow (CBF)

• Affected by oxygen and carbon dioxide through autoregulation

• O2 = CBF and volume

• CO2 = Dilates cerebral vessels, CBF, blood volume

• CO2 = Vasoconstriction, CBF, blood volume

Measurements of the Brain

• Normal ICP is about 10 mm Hg– ICP > 20 are abnormal

– ICP > 40 severe

• Cerebral Perfusion Pressure– MAP minus ICP = CPP

– Maintain CPP >70 mm Hg

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Goal: Maintain Cerebral Perfusion Pressure

Cerebral perfusion pressure: MAP - ICP

• Normal CPP– 60-100 mm Hg

• Most significant factor that determines cerebral blood flow– pressure at which brain tissue perfuse

Cranial Nerve Assessment

“On Old Olympic Tower Tops A Finn And German

Viewed Some Hops”

Cranial Nerves

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Cranial Nerve Function/Assessment

Oculocephalic Reflex

• Doll’s Eyes– Clear C-spine film first– Move (turn) head back and

forth rapidly– Present doll’s eyes: the eyes

move opposite direction of head (good)

– Absent doll’s eyes:(pathological), eyes rotate with the head (fixed) or eyes moving disconjugately

• Lack of response (“fixed globes”) indicative of brain stem failure

Neuro Assessment

• Level of consciousness

• Vital signs

• Sensory/Motor function

• Pupil response

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Level of Consciousness

• The most important indication of neurological functioning

• Alert & oriented X 3 – person, place, time

• Avoid terms like “semi-conscious” or “semi-comatose”

Vital Signs

• Cushing’s Triad (late sign)– Hypertension

– Widening pulse pressure

– Bradycardia

Sensory/Motor Function(Cerebellular Function)

• “How do they move their arms and legs?

• Extremity movement

• Hand grasps

• Pronator drift?

• Lower extremities

• Gait

Abnormal Posturing

• Decerebrate/extension: Arms at side, clinched fist, rotated outward

• Decorticate/flexion: Arms flexed, rotated inward next to the chest, towards the “core” of the body

• Bilateral? Unilateral?

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Pupil Function

• Oculomotor nerve (CN III)

• React, React slowly, Fixed

• Later sign in increased ICP

• Is there a glass eye? Cataracts? Implants?

• Altered by many medications– Miotic – constrict (narcotics)

– Mydriatic – dilate (Atropine, eye drops)

Increased Intracranial PressureIncreased Intracranial Pressure

(ICP)• Change or decrease in level of

consciousness

• Vital sign changes

• Decrease or weakness in extremity movement

• Slurred speech

• Vomiting – especially projectile

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Increased ICP (Con’t)

• Pupil response slow

• Incontinence

• Seizures

• Progress to:– Coma

– Respiratory arrest

– Bradycardia

Interventions for Increased ICP

• Immediate recognition

• Time is crucial

• ABC’s

• Oxygen

• Intubation, 100% oxygen

• Bagging – don’t hyperventilate

Interventions for Increased ICP

• Elevate HOB 30 degrees

• IV – Normal Saline – slow rate

• No Dextrose solutions or D. 50

• No Valsalva

• Prepare for Stat CT

Epidural Hematoma

• Blood above dura mater

1-Head trauma

2-Loss of conscious

3-Lucid phase (“Really, I think I’m OK.”)

4-Deteriorate – circling the drain…

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Surgical Evacuation of Epidural Hematoma

Epidural Hematoma

Subdural Hematoma

• Blood under the dura mater

• Acute, subacute, & chronic

• Trauma related

• Alcoholics & elderly

Subdural Hematoma• Collection of blood

below dural meningeal layer and above the arachnoid covering

• Tearing of bridging veins

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Subdural Hematoma

• Older adults and alcoholics at risk

• Acute symptoms observed within 24 to 48 hours

• Sub acute symptoms observed within 2 days to 2 weeks

• Chronic symptoms observed from 2 week to 3-4 months after injury

Cerebral Concussion

• Most common brain injury

• May have brief LOC• Retrograde amnesia• Perseveration

(repeating statements)• Nausea, headache• Post-Concussion

Syndrome

Skull Fractures• Linear

– Headache– Possible decreased level of consciousness

• Depressed– Headache– Possible decreased level of consciousness– Possible open fracture

– Palpable depression of skull “bony step-off”

Skull FractureClinical Manifestations

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Battle Sign

• Ecchymosis at mastoid area

• Later sign of basilar skull fracture

Racoon Eyes

• Bilateral periorbital ecchymosis

• Facial, orbital, or skull fxs

• Early after injury

Coup/Contra Coup Brain Injuries

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Subarachnoid Hemorrhage

• Sudden onset

• “The worse headache ever.”

• Altered LOC– Irritable, restless

• N/V

Subarachnoid Hemorrhage Treatment for Subarachnoid

• Prevent further rebleeding

• Surgery versus observation

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Thank you!Terry M. Foster, RN

terry.foster@stelizabeth.com859-301-2159