Neurological assessment For Nurses

Feb. 8, 2018

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Neurological assessment For Nurses

  2. Learning Outcomes  Know when and why a neurological assessment must be performed  To be able to carry out a neurological assessment on a patient with an actual/potential altered level of consciousness using the AVPU score and Glasgow Coma Scale  Know common causes of altered conscious level/neurological injury  To understand & rationalise the nursing management of patients with a neurological injury
  3. Your Amazing Brain  Receives information – within a fraction of a second  Acts on the external universe – allows you to cry, walk, play a musical instrument  Utilises language – one of your most advanced functions  Possesses emotions – creates your affective universe  Receives, processes and help you makes sense of your world  Thinks –is responsible for your memory, intelligence, your thoughts  Controls your autonomic functions – heart rate, breathing, homeostasis  Controls your immune system – protects you from
  4. Nervous System Central Nervous System • Brain • Spinal cord Peripheral Nervous System • Cranial nerves • Spinal nerves
  5. Common or Concerning Symptoms of the Nervous System  Headache  Dizziness or vertigo  Weakness  Numbness  Loss of sensations  Loss of consciousness  Seizures  Tremors or involuntary movements  Altered mental status, speech, and language  Altered sensorium, memory, abstract thinking ability, speech, mood, emotional state, perceptions, thought processes, ability to make judgments
  6. What is Consciousness?  An awareness of surroundings and an ability to interact with the environment  Level of consciousness is the earliest and most sensitive indicator of global brain damage (Hickey, 1997)  Various descriptive terminologies to describe altered levels of consciousness
  7. Altered states of Consciousness (Haymore, 2004) Description Characteristics Normal consciousness Easily roused, wakefulness, awareness of environment Lethargy, obtunded Poorly defined terms. Need further detail re: response to verbal and tactile stimuli Confusion Subjective term. Again need further info re: responses and deficits Coma Completely unresponsive even to specific stimuli Persistent vegetative state Unaware of self & environment but continues to have sleep-wake cycles Locked in syndrome Normal consciousness with near complete paralysis. Can usually answer questions using eye movements Brain Stem Death Irreversible loss of brain stem and cortical functions
  8. Common causes of a decreased conscious level  Intracranial haemorrhage  Cerebral infarction  Intracranial infection  Hypothermia  Hyperthermia  Hypothyroidism  Hepatic encephalopathy
  9. Neurological assessment –Why & When?  Instigated for patients who have an acute or potential neurological injury  Inability to protect airway – loss of cough and gag reflexes  When used in conjunction with other assessments eg haemodynamic parameters can provide an early warning of drops in levels of consciousness  To prevent irreversible neurological damage  Increased risk of aspiration
  10. A Neurological Assessment should achieve:  The establishment of a baseline  A determination of changes from the baseline – progress or deterioration  Changes in neurological status may be slow eg. In the case of extension of cerebral infarction or fast in the case of herniation  A common language for clinicians to communicate
  11. Assessment tools  AVPU  Glasgow Coma Scale  NIHSS (National Institute of Health - Stroke Scale)
  12. AVPU  Used for a quick assessment of neurological status  Included in many Early Warning Scores  Any patient scoring less than Alert should have a more detailed assessment  Patients scoring P or U require immediate medical attention  Not intended for long term use
  13. AVPU A - Alert Conscious and able to answer correctly: name, date, location V - Responds to Voice Not Alert, semi-conscious but responds to shouting (may just be moans & groans) P - Responds to pain Moves or groans in response to painful stimuli U – Unresponsive No response elicited
  14. AVPU Start by checking to see if patient is awake ↓ If not  talk to them, if still no response ↓ Inflict a painful stimuli (centrally) ↓ If still no response = UNRESPONSIVE
  15. Glasgow Coma Scale  Created in 1974 by Jennett & Teasdale to assess a patient’s level of consciousness  Made up of 3 components 1. Eye opening 2. Motor response 3. Verbal response  A score of 15 denotes a fully conscious patient, 8 denotes a coma  Lowest score possible is 3  For a more accurate handover, score should be communicated in three components. E, V, M
  16. Glasgow Coma Scale
  17. Assessing Eye Opening  The level of stimulation required to elicit an eye opening response  Tests awareness of environment and brainstem function  Patient may have eyes open spontaneously prior to you approaching or open on hearing you approach. Should stay open for duration of assessment  May open to command or you calling name  Eyes open in response to pain or nursing procedure  Eyes remain closed despite all of above stimulation
  18. Assessing Verbal Response  To elicit state of orientation/confusion  Provides information about speech, comprehension & functioning areas of the cognitive centres of the brain  Orientated – Pt knows where he is & why, the year, date & month  Confused – Converses in sentences with varying degrees of disorientation  Inappropriate words – Random words, no conversational exchange  Incomprehensible sounds – Groaning, grunting – no recognisable words  None
  19. Assessing Motor Response  To test brain areas that identify sensory input and translate it to a motor response  To establish patients ability to obey command, localise, withdraw, or assume abnormal body positions in response to any noxious stimuli or command  Best arm response noted  Ask patient to do something above level of spinal cord. Poke out tongue – not squeeze hand (reflex grasp)  Painful stimuli must be elicited centrally not peripherally. You are trying to assess higher brain function. Nail bed pain can elicit spinal reflex giving false impression
  20. Motor Response contd.  If patient able to obey commands – Assess power and equality by : Raising both feet off bed, pushing down with feet, pulling up with feet, pushing up with knees, holding both hands in the air with eyes closed  If localising to pain – Assess power by speed & general movement of the limbs  Flexion to pain indicates disruption in pathways between motor area in cortex & brain stem  Extension – Elbow extended, arms held tightly against body, internal rotation of shoulders, wrist flexed, fist may be made
  21. DECORTICATE  Decorticate posturing is also called decorticate response, decorticate rigidity, flexor posturing
  22. DECEREBRATE  Decerebrate posturing : typically the head is arched back, the arms are extended by the sides, and the legs are extended
  23. Pupil Response  Oculomotor response (Cranial nerve III)  Assess pupils for Reaction to light Size measured in mm (normal range 2-6mm in diameter) Shape (abnormalities are ovoid, keyhole, irregular) Symmetry  Assess each pupil individually using a narrow beamed torch  Record reaction as brisk, sluggish or fixed (non reactive)  Sluggish or suddenly dilated unequal pupils are an indication of worsening occular nerve compression  Bilateral dilatation and fixation represents decompensation – indicates serious brainstem
  24. Pupillometer
  25. Classification of Brain Injury According to Glasgow Coma Scale (GCS) (HICKEY 2003) MILD GCS 13-15 MODERATE GCS 9-12 SEVERE GCS 3-8
  26. Frequency of Assessment  NICE RECOMMENDATIONS (2007)  Minimum documented observations  For patients admitted for head injury observation the minimum acceptable documented neurological observations are: GCS; pupil size and reactivity; limb movements; respiratory rate; heart rate; blood pressure; temperature; blood oxygen saturation.  Frequency of observations  Observations should be performed and recorded on a half-hourly basis until GCS equal to 15 has been achieved. The minimum frequency of observations for patients with GCS equal to 15 should be as follows, starting after the initial assessment in the emergency department:  half-hourly for 2 hours  then 1-hourly for 4 hours  then 2-hourly thereafter.  Should a patient with GCS equal to 15 deteriorate at any time after the initial 2-hour
  27. Brain Injuries  Two broad categories  Primary – Sustained at the time of insult or accident, include lacerations or contusions of brain parenchyma  Secondary – Result of a complex process that develops hours or days after impact- Due to a decreased cerebral oxygen delivery as a result of Hypertension, Hypoxia, cerebral oedema, intracranial hypertension, infection etc  Damage can be Focal or Diffuse
  28. Herniation & brain stem death  Persistent rise in ICP  Loss of Autoregulatory mechanisms (regulation of blood flow)  Further rises in ICP  Herniation (displacement of portions of the brain)  There are three types of herniation  Central or transtentorial herniation results in brain stem death  Brain Stem death = the absence of all brain function shown by coma, fixed pupils, apnoea & absence of all brain stem reflexes  Brain stem tests can be carried out at the bedside to confirm death  Consider organ donation/early referral to SNOD
  29. Other causes of Altered Conscious level Hypoxia  Reduced 02 delivery to the brain • Airway obstruction • Primary respiratory problem • Shock Metabolic disturbances  Chemical depression of the brain • Alcohol, opiates, sedatives, anaesthesia, CO2, Methane • Hypo/hyperglycaemia, liver failure, renal failiure, Electrolyte imbalance Psychological causes , dementia (Often dealt with very differently)
  30. Nursing Management of neurological Injury  Exact management will vary dependent on the specific cause/type of injury/condition  ABCDE!-Pertinent to the care of patients with an altered level of consciousness.
  31. Nursing Management & Considerations Actual/potential problems Actions Airway Compromise with reduced GCS Reduced ability to cough and clear secretions Aspiration pneumonia Consider using recovery position Consider use of airway adjuncts/suctioning. Pre-oxygenation Anaesthetic assistance Definitive airway Always ensure airway secure for transfer Breathing pattern may be altered (Cheyne stokes) if raised ICP (respiratory control centres are located in pons and medulla of brain stem) Low RR may indicate drop in conscious level secondary to opiates Reduced Vital capacity/ability to cough in GBS patients Risk of further neurological injury due to hypoxia Risk of ↑cerebral blood flow and thus ICP IF paCO2 high (vasodilatory effects of CO2) Use of ( CPAP) PEEP ↑ ICP Excessive coughing may cause transient ↑ in ICP and or re-bleed in patients with heamorrhagic CVA’S Close observation of RR, Depth and pattern. If changes accompanied by ↑BP and ↓HR call for help (sign of herniation) Monitor all patients receiving opiates closely Administer 02 and monitor 02 Sats closely to reduce the risk of further hypoxic brain injury. ABG’s if GCS deteriorating Consider mechanical ventilation if unable to maintain PaO2 >10 kPa on maximal 02 therapy Avoid Hypercarbia. Maintain normal PaCO2 Do not use without outreach/Anaesthetic involvement May require ITU Care and sedation to manage this
  32. Nursing Management & Considerations Actual/Potential Problems Actions Cardiovascular instability – either due to brain stem dysfunction (Cushings Triad) Associated trauma/sepsis also  hypovolaemia real or relative Hypertension in ischaemic stroke Hyperpyrexia (either due to head injury damage to hypothalamus or as a result of infection eg meningitis). Will cause ↑ metabolic rate and therefore cerebral 02 consumption Electrolyte imbalances (May be the cause or result of neurological injury) Risk of SIADH Risk of VTE due to immobility Monitor BP, HR & rhythm closely for early signs of decompensation Maintain adequate BP (map) to ensure good cerebral perfusion pressure Good CVS assessment and assessment of fluid status Administer fluid boluses to maintain BP. Avoid dextrose containing solutions and avoid hypernatraemia Consideration of ITU care if inotropic support required Monitor BP and administer anti-hypertensives Actively cool patient. Aim for Temp <37.5. Administer antipyretics Administer appropriate antibiotics Assist with further investigations eg Lumbar puncture Monitor levels of K+, mg, and Na closely. Maintain normal levels. Monitor quality and volume of urine closely. May need rehydration to maintain circulating volume. May need DDAVP. Consider serum and urine osmolarity measurements Monitor for signs of VTE. Teds, VTE prophylaxis.(as appropriate), encourage limb movements
  33. Nursing Management & Considerations Actual/Potential Problems Actions Disability Deterioration in GCS due to secondary damage or extension of original damage. Risk of further strokes in CVA patients Changes in pupil size & reactivity Worsening cerebral oedema Headaches (early signs of meningitis and sign of intracerebral haemorrhage) Seizures (caused by any cerebral irritation) Analgesia and sedative requirements Hypo/Hyperglycaemia Regular monitoring of GCS & pupil reaction (NICE guidelines for Head Injury, 2007). Early recognition will improve outcome Monitor for changes in limb movement & strength. Consider use of osmotic diuretics (Mannitol). Call for help if deterioration is observed and increase frequency of obs. CT SCAN/Transfer to tertiary centre may be required Monitor for signs of severe headache Airway manoeuvres as appropriate, maintain safety, Control of seizures with medication and or sedation to prevent further neurological damage Ensure pain well controlled to reduce agitation which would increase ICP Sedation & neuromuscular blocking agents in ITU setting only with controlled ventilation Aim for normal BMs. Hyperglycaemia will cause vasospasm. Consider use of Insulin infusion.
  34. Other Nursing Management & Considerations Actual/Potential Problems Actions Nutrition. Level of consciousness will affect ability to take oral nutrition Risk of aspiration in patients with impaired swallow secondary to neurological injury Risk of aspiration in patients who are vomiting secondary to neurological injury Unable to pass NG tube in patients with basal skull fractures Constipation will raise Intra-abdominal pressure and thus ICP Early enteral feeding and maintain hydration as head injury increases demand of brain for O2 and glucose Assessment of swallow Anti-emmetics and or NG drainage Oro -gastric tube must be considered Bowel assessment & management. Aperients as indicated Incorrect positioning and neck rotation and hip flexion can cause rises in ICP as fluid drainage from brain is impeded Internal jugular CVC’S/ ETT ties - impede venous drainage and ↑ ICP Complications of immobility – pressure sores etc. Clustering of activities cause cumulative rise in ICP Sensory overload causing ↑ ICP Photophobia (In meningitis) Psychological/psychosocial issues Ensure head elevation of 30° (to facilitate venous drainage. Avoid flexion and rotation Femoral lines or good peripheral IV accesss. Secure ETT with elastoplast Reposition regularly, encourage mobility etc Avoid this. Consider boluses of sedation prior to activities eg suctioning (in ITU setting) Reduce lighting Address fears & anxieties
  35. Further Reading/useful websites  National Institute for Health & Clinical Excellence (2007) Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults  National Institute for Health & Clinical Excellence. Stroke. Diagnosis and initial management of acute stroke and transient ischaemic attack Available at  Headway: The Brain Injury Association
  36. Any Questions?

Editor's Notes

  1. Cardiac out put, fluid status and fluid responsiveness