Neuro Assessment & Interventions Flashcards
How does a CT scan work?
CT uses narrow X-ray beams to show the different layers and tissue density of the body to find the problem and it uses radiation
Your patient is about to head down to CT. You see the provider hasn’t put in any orders for contrast. What is your priority?
Call for clarification to see if it is with or without contrast
Your patient has an order for CT. What do you need to check for?
Check to see if patient has allergies to shellfish or iodine.
You have a patient who won’t sit still and who is scheduled for CT. What do you as the nurse need to do?
Call doctor for sedation orders if they aren’t already put in
Your on your way to diagnostic testing with your patient. What do you need to bring down with you?
Bring emergency bag incase the patient codes
What does an MRI do?
Uses radio frequency pulses and magnetic fields to pick up chemical changes in cells
Do MRI’s pick up early or late changes?
MRI picks up early changes.
You see there isn’t a contrast order with your MRI. What do you do?
You don’t do anything because you know it does not require contrast
Patient has to go to MRI. What do you need to assess the patient for and ask about?
Ask about metal or any piercings . Explain to them the MRI will rip it out of them.
Patient asks you how long MRI will take. How do you respond?
MRI takes a long time.
Your headed down to MRI. What do you need to have with you
Patient IV pumps
Oxygen
(know the dosage and the rate)
- probably due to it taking longer
When you ask about “metal” for MRI
Aneurysm clips
Pacemakers (not all)
Hardware
Heart valves
IUDs
Patches with metal backings
What does a Lumbar Puncture remove?
Lumbar Punctures remove cerebral spinal fluid (CSF) for testing
Patient wants to know how a lumbar puncture is done. What do you tell them?
A needle will be inserted into the 3-5th lumbar vertebrae of the subarachnoid space while they are sidling and flexed
Your patient with an increased ICP has orders for a lumbar puncture. What is the problem with this?
If the ICP is high, the lumbar puncture should not be done. Notify the physician.
After the lumbar puncture, how should the patient be positioned?
Patient should be prone for 2-3 hours to promote healing
Patient reports having a headache after their lumbar puncture. Why is this?
It is due to the CSF leakage
- can be occipital or frontal in location
If a patient has a headache after a lumbar puncture, what orders do you anticipate?
What about for positioning?
Fluid replacement
Analgesics
Keep them prone or supine
What is an alternative treatment for a headache due to lumbar puncture?
Blood patch from the antecubital and inject into the epidural space to stop the leakage
List the complications that can occur with a lumbar puncture procedure
Headache due to leakage
Infection
Hematoma
What are two major brain requirements?
Requires 20% of cardiac output - we have to keep it oxygenated
Needs 15% of body’s glucose - to meet high metabolic demand
What are the main components of a neuro assessment?
LOC
Motor response
Pupils
Reflexes
Vitals
T/F
LOC changes are a late sign for elderly patients
False. Usually this is the case, but for elderly LOC is an early sign.
Your patient has LOC changes. What lab can correlate with this?
Elevated ammonia levels cause LOC changes.
What motor change do you look for with patients?
Check their ROM and strength
- active vs passive movement
Why do we assess the pupils?
Pupils can tell us a lot about the neuro assessment of a patient. Often one of the first signs we see.
Your patient is on a vent & on sedatives and you see their pupils constrict to a 1 or 2 mm. What do you do?
Sedatives cause constricted pupils. Just monitor them.
Your patients pupils are huge and blown. What do you do as the nurse?
You understand this means the patient is brain dead.
Why do we check reflexes in a neuro assessment?
Reflexes indicate their calcium levels; electrolytes
What categories do we rate using the Glascow Coma Scale? (3)
Eye opening
Verbal response
Motor response
What different levels of “eyes opening” are there for the Glasgow Coma Scale?
4 - opens spontaneously
3 - opens eyes to speech
2 - opens eyes when in pain
1 - no response
You walk into the room. The patient opens their eyes after sleeping and then reaches for their cup of water.
What is the eye Glasgow coma scale rating?
4 - Opened eyes spontaneously
Your patients eyes are closed. You ask them a question and then they open their eyes.
Rate their Glasgow coma score for eyes
3 - opened eyes to speech
You can’t wake your patient to have them open their eyes, and so you take your knuckles and rub their sternum and so they finally open them.
What is their glasgow coma scale for their eyes?
2 - opens eyes to pain
You’ve tried everything to get your patient to open their eyes and there is absolutely no response.
What is their eye glasgow coma scale?
1 - no response
What are the scores for Verbal response of the glasgow coma scale?
5 - orientated
4 - confused
3 - inappropriate
2 - incomprehensible
1 - none
You’re talking to your patient and they appear orientated. What is their glasgow coma scale?
5 - orientated
Your ask your patient a question and they suggest they don’t know what you’re talking about and don’t understand.
What is their glasgow coma scale for verbal response?
4 - confused
You ask your patient what they want to eat and they tell you the sky is blue.
What would you rate their verbal response?
3 - inappropriate
Patient is slurring their words. What would you rate their verbal response on the GCS scale?
2 - incomprehensible
- you have no clue what they’re saying
You are asking your patient questions. There is absolultey no verbal response.
How would you rate this using GCS?
1 - no response
What are the different scales of the Glasgow coma scale for motor response?
6 - obeys commands
5 - localises to pain
4 - withdrawals from pain
3 - flexion to pain
2 - extension to pain
1 - no response
What is the maximum score a patient can receive on the GCS?
15 is perfect
You ask the patient to take their pills and they do it.
Rate their motor response on GCS
6 - obeys commands
Patient pushes away your hand while pricking their finger for blood sugar check.
Rate their motor response on GCS
5 - localises to pain (pushes the painful stimuli away)
Patient withdrawals from pain but doesn’t quite push it away.
Rate their motor response GCS score
4 - withdrawals from pain
When you taking off the IV tape your notice your patient flexes in wards to pain (decorticate).
What is their motor resonse score on GCS?
3 - flexion to pain
Patient extends their limbs when feeling pain (deceberate).
What is their motor response GCS?
2 - extension to pain
Patient doesn’t move an inch when you are doing a sternal rub. What is their GCS score for motor response?
1 - no response
At what score do we intubate on the GCS?
If it is less than 8, intubate.
What is considered a mild GCS score?
(13-15) is mild
What is a moderate score on the GCS?
Moderate is (9-12)
Your patient has lost consciousness. It’s been over 30 minutes. How severe do you think their GCS disability is?
Loss of consciousness will be greater than 30 minutes for moderate disability
- of (9-12).
When you have a patient with a moderate disability according to the GCS, will their impairment resolve?
Impairments may or may not resolve with a moderate disability
- of (9-12).
Which severity of disability according to the GCS scale would benefit from rehabilitation with a physical therapist or occupational therapist?
Moderate severity of (9-12).
Your patient is in a coma like state with no meaningful response. What is the likely range for their GCS?
3-8
- severe disability
Patient has a GCS score less than 3.
What state is this?
Vegetative state
What is a vegetative state characterized by sleep wise?
Sleep wake cycles are happening even if we don’t see it.
What is the arousal of someone in a vegetative state?
There is arousal but no interaction with the environment
What pain response do you expect for someone in a vegetative state with a GCS score less than 3?
No localized response to pain meaning the patient attempted to push away the painful stimulus
What is the difference between a vegetative state vs. a persistent vegetative state?
Persistent vegetative state will last longer than 1 month (longterm).
What is the meaning of brain death?
No brain function is occurring due to no blood flow
What is a common reason for brain death?
Could be from herniation where brain drops down into spinal column that causes no blood flow to the brain
Is there blood flow to the brain in a vegetative and persistent vegetative state?
Yes. Sleep wake cycles are present still.
What do you need to assess when looking at the pupils?
Size
Shape
Reactivity to light
And compare!
You test for eye reactivity to light and you get a sluggish response. What is a possible cause of this?
3rd CN is compressed due cerebral edema and herniation and increased ICP
You test the pupils for reactivity to light and they are nonreactive and fixed. What is a possible cause?
Compression of 3rd cranial nerve due to hernation causing severe hypoxia and ischemia
Your patient has an increased ICP. What do you anticipate for your pupil assessment?
Sluggish pupils
Define anisocoria
When patients have different sized pupils
T/F
Patients having anisocoria is a big concern
False. If that is their baseline, then it’s fine. If it is an acute change, then you have a problem.
Your patient has acute anisocoria. Why is this concerning?
Their pupils all of a sudden being different sizes could indicate they are having a stroke.
Define herniation
When the brain drops down into the spinal column
There is anisocoria in the left eye. What part of the brain is the stroke taking place?
The opposite, so the right side.
Your patients pupils are super small. What type of med can cause this?
Narcotics
- propafol
- fentanyl
While checking the reactivity to light of the pupils, you get no response. What does this indicate?
Brain death
What are the brain death tests?
Dolls eyes assessment
Corneal reflex test
Cold calorics
When doing the doll’s eyes assessment on your patient, their eyes deviate to the opposite side of where you are turning their head.
What does this mean?
It is a normal response and they are not brain dead.
You have a brain dead patient. What dolls eyes result would you expect?
I would expect their eyes to remain fixed with no deviation.
What reflex ar we testing for during the dolls eyes test that is only present if you are considered normal?
Oculocephalic reflex
- 90 degrees laterally on both sides
When doing the Corneal reflex test, the patient blinks when you touch their eye with the cotton. What does this mean?
That is a consensual response and is normal
Your patient doesn’t blink when you do the corneal reflex test with the cotton ball.
What does this mean?
Absence of reflex indicating a brainstem dysfunction and brain death
What is the Cold Caloric test?
Putting cold water in the ear to stimulate the inner ear nerve
When doing the Cold Calorics test, the patient elicits a nystagmus. What does this mean?
The patient is normal.
Define nystagmus in regards to Cold Calorics test
Nystagmus means the eyes will quiver
In a patient who has a coma with an intact brainstem, what do you think their cold calorics results would be?
Their eyes will deviate towards the cold water
You do the Cold Calorics test and there is no eye movement whatsoever. What does this mean?
Brainstem injury and brain dead
What is normal response to a cold calorics test?
Quiver and move away from the cold water and then slowly back.
What reflex is tested in the Cold Calorics test?
Vestibulo-ocular reflex
When doing the cold calorics test, what should the HOB be elevated to?
30 degrees
How much water or saline should be used for Cold Calorics test?
50 mLs
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