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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