Assessment and Nursing Management of Neurological Compromise

Question 1

↓ oxygen ↓ glucose =

Answer 1

brain tissue hypoxia and death

Question 2

What 3 things are the main elements generating intracranial pressure (ICP)

Answer 2

Brain tissue, blood volume and cerebrospinal fluid (CSF)

Question 3

The Monro-Kellie doctrine or hypothesis states that the sum of volumes of brain, cerebrospinal fluid (CSF) and intracerebral blood is constant. meaning?

Answer 3

An increase in one should cause a reciprocal decrease in either one or both of the remaining two.

Question 4

Think about what structures are contained within the brainstem

Answer 4

The respiratory centre
The cardiac centre
The reticular activating system (RAS) which keeps us conscious

Question 5

Compromised CBF (due to raised ICP) initiates a cascade of physiological responses
What is this called?

Answer 5

Cushing’s triad

Question 6

Know the signs of raised ICP

Answer 6

Early - Confusion, drowsiness headaches.

Late - vomiting, seizures, hypertension, irregular RR, bradycardia

Question 7

Neurological assessment tools what are the two main ones?

Answer 7

AVPU Alert, Voice, Pain, Unresponsive, RAS

Question 8

Other neurological assessments

Answer 8

Nervous system assessment
Cranial nerves (CNI – XII)
Spinal nerves (C1-8, T1-12, L1-5, S1-5, Co1)
Reflexes
Sensation
Strength
Coordination and balance
Gait
Mini mental state examination(MMSE)
Speech and language

Question 9

RAPID - AirwayNursing interventions

Answer 9

Positioning
Maintain head and neck alignment for airway patency AND to avoid rise in ICP (chin tilt/jaw thrust)
Consider spinal cord injury

Clear secretions
Ensure patient is able to clear own secretions
Consider suctioning (Yankeur/suction catheter)
Be aware of increased intracranial pressure with Valsalva manoeuvres

Airway adjuncts
Nasopharngeal
Oropharangeal
Caution in base of skull fractures and facial trauma

Question 10

RAPID - Breathing - Nursing interventions

Answer 10

Supplemental oxygen
Administer prescribed oxygen to reverse hypoxaemia and help prevent cerebral hypoxia
Remember CO2 is a potent vasodilator and will contribute to rising ICP, further reducing blood flow

Positioning
Ensure patient is repositioned regularly to prevent atelectasis and maximise air entry for effective gas exchange
Avoid elevating the patient’s head too much to prevent a rise in ICP
Caution with spinal cord injury and hemiplegia to avoid secondary injury

Clear secretions
Ensure oral secretions are cleared to minimise aspiration risk
Maintain regular oral hygiene to prevent microbial growth transfer from mouth to lungs

Question 11

RAPID - Circulation - Nursing interventions

Answer 11

Administer prescribed medication to maintain BP within set parameters
To prevent further hypertension and rise in ICP
This could be a beta blocker
To maximise cerebral perfusion pressure and oxygen delivery

Maintain accurate fluid balance and report urine increase/decrease to guide intervention
To prevent dehydration in excessive urine output
To prevent cerebral oedema in reduced urine output

Remove excess bedding and implement cooling techniques
To reduce elevated core temperature and reduce metabolic demand
Administering prescribed paracetamol regularly as per MO may help reduce core temperature

Question 12

RAPID - Additional circulation Nursing interventions

Answer 12

Ensure TED stockings are applied to prevent DVT due to immobility

Record and report changes in HR and BP to help identify secondary cerebral ischaemia

Regular position changes to promote tissue perfusion
Particular attention required for hemiplegia/paraesthesia

Maintain accurate fluid balance to identify electrolyte imbalance

Question 13

RAPID - Disability Nursing interventions

Answer 13

Maintain head of bed at 30◦ to facilitate venous drainage and prevent rise in ICP

Record and report changes in GCS to implement early intervention

Re-orientate the patient to time and place to reduce anxiety

Administer analgesia to reduce sympathetic NS response
Caution with medications that could cause CNS depression

Administer stool softeners to prevent constipation
Valsalva movement will increase ICP – straining unnecessarily must be avoided

Avoid “clustering” activities (washing, physio, tracheostomy cares) to prevent sustained rise in ICP

Question 14

EnvironmentNursing interventions

Answer 14

Maintain a low stimulus environment to avoid rise in ICP (dim lights, minimal noise)

Record and report NZEWS to identify deterioration

Ensure safe environment around the patient bed space to prevent falls and avoid injury

Question 15

1) A patient with a head injury opens his eyes when his name is called, curses when he is stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient’s Glasgow Coma Scale score as:

A. 9

B.			11
 	C.			13
 	D.			15

Answer 15

B. 11

Question 16

2) When assessing a patient with a neurological disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the:

A.			Level of consciousness
 	B.			Presence of cerebral oedema
 	C.			Presence of corneal and pupillary reflexes
 	D.			Integrated functions of the cerebral cortex

Answer 16

A. Level of consciousness

Question 17

3) When the nurse applies painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. The nurse interprets this finding as:

A. Abnormal flexion/posturing indicating an interruption of voluntary motor tracts
B. Extension posturing indicating an interruption of voluntary motor tracts
C. Abnormal flexion/posturing indicating a disruption of motor fibres in the midbrain and brain stem

D. Extension posturing indicating a disruption of motor fibres in the midbrain and brain stem

Answer 17

D. Extension posturing indicating a disruption of motor fibres in the midbrain and brain stem

Question 18

4) The nurse suspects possible tentorial herniation and compression of the brain stem when assessment of the oculomotor nerve reveals:

A. Absent corneal reflexes
B. The development of nystagmus

C.			Diminishing pupillary response to light
 	D.			Enlargement of the pupil on the contralateral side

Answer 18

C. Diminishing pupillary response to light

Question 19

1. What score on the Glasgow Coma Scale is most likely to indicate airway compromise?
A.	10
B.	13
C.	7
D.	11

Answer 19

C. 7 - if its less than 8 we intubate

Question 20

3. Mrs Brian has suffered a stroke and has a right hemiplegia. The damage is most likely in what area?
A.	Right motor cortex
B.	Right somatosensory cortex
C.	Left somatosensory cortex	
D.	Left motor cortex

Answer 20

D. Left motor cortex

It’s the primary motor cortex that sends signals to the peripheral body therefore it’s the L Motor cortex.

Question 21

4. The area responsible for language comprehension located mainly in the \_\_\_\_ temporal lobe is? Also name what side of the brain it’s located
A.	Broca’s area
B.	Organ of Corti
C.	Wernicke’s area
D.	Bundle of His

Answer 21

Located in left and its responsible in processing language

C. Wernicke’s area

Question 22

5. Reflex activities related to heart rate and blood pressure control are governed mainly by the..?
   A. Pons
   B. Medulla oblongata
   C. Midbrain

Answer 22

Medulla is control centre for heart. Alters smooth muscle to contract.

Question 23

6.	These 3 components make up the cranial contents:
A.	Brain tissue, parenchyma and CSF
B.	Blood, CSF and serous fluid
C.	Brain tissue, blood and CSF
D.	CSF, blood and Circle of Willis

Answer 23

C. Brain tissue, blood and CSF

Question 24

7. The brain receives approximately what percentage of oxygen with cardiac output?
A.	20%
B.	35%
C.	10%
D.	50%

Answer 24

A. 20%

Question 25

8. Disorientation, restlessness and confusion in a patient with rising intracranial pressure is related to?
A.	Seizure activity
B.	Virchow’s triad
C.	Altered cerebral blood flow
D.	Abnormal respirations

Answer 25

C. Altered cerebral blood flow

Question 26

9. HTN, bradycardia, severe headache and blurred vision in above T6 spinal cord injury is called?
A.	Reflexive dystonia
B.	Autonomic dysreflexia
C.	Hyper reflexive hypertension
D.	Cushing’s triad

Answer 26

B. Autonomic dysreflexia

Question 27

10. Fixed and dilated pupils can be caused by?
A.	Opioids
B.	Brain stem hypoxia
C.	Scopoderm patches
D.	Homonymous hemianopia

Answer 27

B. Brain stem hypoxia

Question 28

11. An explosive disorderly discharge of cerebral neurons is referred to as..?
A.	A brain attack
B.	A thunderclap headache
C.	Nuchal rigidity
D.	A seizure

Answer 28

D. A seizure

Question 29

12. Acute severe headache, nausea, photophobia and nuchal rigidity[rigid movement of neck] are symptomatic of?
A.	Transverse myelitis
B.	Meningitis 
C.	Guillain Barré
D.	Parkinson’s disease

Answer 29

B. Meningitis

Question 30

Cushing’s triad refers to

Answer 30

Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing’s triad consists of bradycardia (also known as a low heart rate), irregular respirations, and a widened pulse pressure.

Question 31

Cushing triad patho - 1) ↑ in ICP > than

Whole patho

Answer 31

Rise in ICP greater than CPP causes reduced blood flow to the brain. Reduced blood flow means less O2/glucose delivery to tissue causing cerebral ischaemia.

Cerebral ischaemia stimulates a sympathetic response (adrenaline release to ↑BP & HR) in order to increase blood flow and therefore O2 delivery

Parasympathetic response initiated by ↑ BP is detected by baroreceptors. This results in an attempt to reduce BP by ↓ HR

Ongoing ↑ BP causes further rise in ICP and further restriction of blood flow. A switch of aerobic cellular respiration to anaerobic respiration results in ↓ ATP production for cellular function (cerebral ischaemia)

Breakdown of Na+/K+ pump causes water to enter the cell, resulting in cell death.
As cerebral oedema worsens, the brainstem is compressed causing irregular respirations before death is imminent

↓ HR, Irreg RR, ↑SBP - clear signs of ICP.

Question 32

This structure Provides oxygenated blood to over 80% of cerebrum.

Answer 32

Circle of Willis

Question 33

Loss of consciousness
Interruption of normal breathing
Interruption of cardiac function
Fixed dilated pupils

Symptoms of damage to what structure?

Answer 33

Damage to brainstem