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Neurological Assessment
Wejdan Khater, RN, PhD
JUST-School of Nursing
Nursing 409-Fall 2014-2015
1
Learning Outcome
 Describe the elements of a focused
assessment of a patient with an
intracranial dysfunction.
Neurologic Assessment
 One of the most important aspects
of caring for a patient with a
neurological disorder, is ongoing
and accurate neurological
assessment.
 This establishes the patient's
baseline neurological status.
Four Objectives of a Neuro
Assessment
1. Gather data about the functioning of the
nervous system
2. Correlate and trend the data over time
3. Analyze the data to develop a list of
potential or actual diagnoses
4. Determine the effect of dysfunction on the
patient’s daily activities of living
4
History
 Chief complaint
 History of present illness
 Past medical history
 Family history
 Personal and social history
 Review of systems
Assessment-Review of Systems
 HEENT Dizziness, headaches, vision changes,
sensitivity to light, auditory changes, sinus
infections, difficulty swallowing, hoarseness,
slurred speech, infection.
 Cardiovascular Palpitations, history of
coronary artery disease, vascular problems.
 Respiratory History of chronic pulmonary
disease, episodes of shortness of breath,
recurrent infections.
6
Assessment-Review of Systems
 Genitourinary Incontinence, impotence
 Gastrointestinal Nausea, vomiting, diarrhea
or constipation, weight loss, history of GI
problems
 Musculoskeletal Weakness or paralysis,
decreased range of motion, muscle stiffness
or pain, spinal problems
7
Assessment-Review of Systems
 Neurological Syncope, confusion, difficulty with
concentration, speech problems, paresthesias,
tremors, gait disturbances.
 Psychiatric History of psychiatric problems,
mood swings, delusions or hallucinations.
8
Physical Exam
 Mental status
 Motor function
 Motor strength and coordination
 Pupillary changes
 Cranial nerve function
 Vital signs
9
Physical Exam
 Mental status: Includes tests to evaluate


level of consciousness and arousal,
orientation to the environment,


GSC.
Thought content.



The Mini-Mental State Examination (MMSE).
Maximum points 30…<20 neurological Impairment.
Orientation, calculation, recall, language, attention,
registration
10
Responsivity Categories
Question
 Is the following statement true or false?
 The Glasgow Coma Scale is a reliable tool
for assessing arousal and level of
consciousness in all patients.
Answer
 True
 Rationale: In instances in which brain injury
is suspected, the Glasgow Coma Scale (GCS)
has proved a reliable tool for assessing
arousal and level of consciousness. The GCS
allows the examiner to record objectively the
patient’s response to the environment in three
major areas: eye opening, verbalization, and
movement.
Glasgow Coma Scale
(GCS)
 GCS assesses both the level of
consciousness, and motor response
to a stimulus.
 Reliable as long as:


It has been obtained prior to intubation.
Either prior to the initiation of sedating
medications, or when medications have
been paused for the neurological exam.
Glasgow Coma Scale
Physical Exam
 Mental status/ thought assessment:
 Attention
Digit span forward & back.
 Remembering.


Short-term: recall after 5 minutes.
Long-term: recall events of previous day.
 Feeling (Affect).



Facial & body expression & mood.
Verbal description of affect.
Congruence of verbal, body indicators of mood.
 Language.

Spontaneous speech, repetition, naming objects, writing, reading.
 Thinking.

Orientation, information, knowledge of current events, calculations, problem solving.
 Spatial Perception.
 Copy drawings, demonstrate putting a coat, using a toothbrush; point out right & left side.
16
Physical Exam
 Motor function

Motor response to stimuli:
Localization to stimuli
 Withdrawal
 Decorticate Vs Decrebrate:
Decorticate rigidity due to lesions to:


Internal capsule, basal ganglia, thalamus, corticospinal pathways.
Decerebrate rigidity due to injury to:

Mid brains & Pons.
Flaccidity
 Tonic Vs clonus

17
Motor Responses to Pain
Physical Exam
19
Question
 When assessing motor strength, which score
indicates the patient moves an extremity
against gravity?
–
–
–
–
A. 0/5
B. 1/5
C. 3/5
D. 5/5
Answer
 C. 3/5
 Rationale: A score of 3/5 means the patient
moves against gravity but cannot overcome
resistance of the examiner’s muscles.
Motor Function Scale
 Motor function scale 0/5 to 5/5;






0/5 no muscle contraction
1/5 flicker or trace of contraction
2/5 moves but cannot overcome gravity
3/5 moves against gravity but cannot overcome
resistance
4/5 move w some weakness against resistance
5/5 is normal power and strength.
Physical Exam
 Motor function

Motor strength and coordination:
 Muscle
weakness is a cardinal sign of
dysfunction in many neurological disorders.
 Muscle groups should be assessed
individually, initially without resistance and
then against resistance.
23
Physical Exam
 Motor function

Motor strength and coordination:
 The
nurse also assesses each extremity for
size, muscle tone, and smoothness of
passive movement.
 The nurse also should be alert to
involuntary movements
24
Physical Exam
 Motor function



Motor strength and coordination:
Hemiparesis (weakness) and hemiplegia (paralysis)
Paraplegia may result from thoracic or lumbar spinal
cord or peripheral nerve dysfunctions. Quadriplegia is
associated with high cervical spinal cord lesions,
brainstem dysfunction, and large bilateral lesions in the
cerebrum.
25
Physical Exam
 Motor function
The cerebellum is responsible for smooth
synchronization,
balance, and ordering of movements.
 Romberg test.
 Finger-to-nose test (dysmetria)
 Rapidly alternating movement (RAM) test.
(adiadochokinesia, dysdiadochokinesia)
 The Heel-to-shin test.

26
Pupillary Changes
 Examine size and shape
 Briskness of pupillary constriction

Direct and consensual response
 Accommodation
 PERRLA, pupils equal, round, reactive to light and
accommodation
 Pinpoint pupils: drugs, drops, damage in the pons
 Dilated pupils: fear, seizures, cocaine,
Physical Exam
Pupillary Changes:
 Pupils are examined for size (best specified in
millimeters) and shape.
 Anisocoria (unequal pupils).
 The normal response to testing is documented
 The assessment of pupillary response for comatose
patients is the same as for conscious patients. Pupil
reactivity to light, by direct and consensual response,
is easily obtained.
28
Physical Exam
Pupillary Changes:
29
Physical Exam
Pupillary Changes:
30
Physical Exam
Vital Signs
 Vital sign assessment is crucial to the neurological
examination.
 Changes in temperature, heart rate, and blood
pressure are considered late findings in neurological
deterioration.
TEMPERATURE
Normal regulation of temperature occurs in the
hypothalamus. Central nervous system (CNS) fevers.
PULSE
An increase in ICP may lead to episodes of tachycardia
and can predispose the patient to alterations in
electrocardiogram (ECG) pattern.
31
Physical Exam
Vital Signs:
 BLOOD PRESSURE
Blood pressure is controlled at the level of the medulla.
 RESPIRATIONS
Variations in respiratory pattern are commonly
associated with neurological injury. Shallow, rapid
respirations can indicate a problem with
maintenance of a patent airway or the need for
suctioning.
Snoring respirations or stridor can also indicate a
partially obstructed airway.
Cheyne-stokes respiration
32
Vital Signs
 Respirations
 Changes indicate increased ICP, spinal cord lesion, cerebral
trauma.
 Temperature
 High with CNS fever, low with metabolic causes, pituitary
damage, and spinal cord injuries
 Pulse
 Increases ICP and bradycardia = herniation
 Blood pressure
 Damage to medulla or cerebral edema
Cranial Nerve Function
 Cranial nerve I (olfactory nerve)
 Check ability to smell using aromatic substance.
 Cranial nerve II (optic nerve)
 Check visual acuity and visual fields.
 Cranial nerves III (oculomotor nerve), IV (trochlear
nerve), and VI (abducens nerve)
 Check extraocular eye movements.
 Cranial nerve V (trigeminal nerve)
 Check corneal reflex, facial sensation with light
touch, ability to clench jaw or chew.
 Cranial nerve VII (facial nerve)
 Raise eyebrows, smile, or grimace
Cranial Nerve Function (cont.)
 Cranial nerve VIII (acoustic nerve)

Weber and Rinne test for air and bone conduction
 Cranial nerves IX (glossopharyngeal nerve) and
X (vagus nerve)

Gag reflex
 Cranial nerve XI (spinal accessory nerve)

Shrug shoulders
 Cranial nerve XII (hypoglossal nerve)

Stick out tongue
Physical Exam
36
Physical Exam
 Test for oculocephalic reflex response (doll’s eyes
• (A) Normal response—when the head is rotated,
the eyes turn together to the side opposite to the
head movement.
 (B) Abnormal response—when the head is rotated,
the eyes do not turn in a conjugate manner.
 (C) Absent response—as head position is changed,
eyes do not move in the sockets.
 Abnormal or Absence of reflexes indicates brainstem
dysfunction.
37
Physical Exam
38
Physical Exam
Test for oculovestibular
 reflex response (caloric icewater test).
 (A) Normal response—ice
water infusion in the ear
produces conjugate eye
movements.
 (B) Abnormal response—
infusion produces dysconjugate
or asymmetrical eye movement.
 (C) Absent response—infusion
produces no eye movements.
 Positive midbrain & Pons
dysfunction
39
Reflexes
 Sensory stimulus evokes motor response.
 Cutaneous reflexes graded as normal, abnormal, or absent
(ie, plantar reflex)
 Deep tendon reflexes: biceps, brachioradial, triceps,
patellar, and Achilles





4+: A very brisk response; evidence of disease, electrolyte imbalance, or both;
associated with clonic contractions
3+: A brisk response; possibly indicative of disease
2+: A normal response
1+: A response in the low-normal range
0: No response; possibly evidence of disease or electrolyte imbalance
Physical Exam
 Reflexes:
Hyperreflexia is
associated with upper
motor neuron
disease.
Areflexia is associated
with lower motor
neuron dysfunction,
such as spinal cord lesions.
41
Physical Exam
Sensation:
 Normal sensory findings depend on an intact
spinal cord, sensory pathways, and peripheral
nervous system.
 Abnormal results may indicate damage
somewhere along the pathways of the
receptors in the skin, muscles, joints and
tendons, spinothalamic tracts, or sensory
area of the cortex.
42
Physical Exam
Sensation:
 The inability to recognize objects by
touch, sight, or sound is termed agnosia.
 It is impossible to perform a complete test for
sensation
43
Question
 Which is tested by asking the patient to close
eyes while the nurse moves a finger upward
and then asking the patient if the finger is up
or down?
–
–
–
–
A. Perception of touch
B. Pain
C. Vibration
D. Proprioception
Answer
 D. Proprioception
 Rationale: Proprioception is tested by asking the patient,
again with the eyes closed, to identify the direction of
movement (eg, moving a finger upward and then asking
the patient if the finger is up or down). The same test is
performed on the other hand, as well as both lower
extremities. The nurse assesses vibration using a tuning
fork placed over a bony prominence. The patient is asked
to identify when vibration is felt.
Sensation
 Normal findings depend on intact spinal cord, sensory pathways, and
peripheral nervous system.
 Perception of touch
 Light touch with eyes closed
 Pain
 Pin or sharp edge, moving head to toe on both sides of the body
 Proprioception
 Direction of movement of finger/toe with eyes closed
 Vibration
 Tuning fork over bony prominence
Physical Exam
Signs of Trauma or Infection:
■ Battle’s sign (bruising over the mastoid areas) suggests a basal
skull fracture.
■ Raccoon’s eye (periorbital edema and bruising)
suggests a frontobasilar fracture.
■ Rhinorrhea (drainage of CSF from the nose) suggests fracture of
the cribriform plate with herniation of a fragment of the dura and
arachnoid through the fracture.
■ Otorrhea (drainage of CSF from the ear) usually is associated
with fracture of the petrous portion of the temporal bone.
47
Physical Exam
Signs of Trauma or Infection:
■ Signs of meningeal irritation include nuchal rigidity
(i.e., pain and resistance to neck flexion), fever,
headache, and photophobia. A positive Kernig’s sign
(i.e., pain in the neck when the thigh is flexed on the
abdomen and the leg is extended at the knee) also
may be present. Brudzinski’s sign (involuntary flexion
of the hips when the neck is flexed toward the
chest) is another indication of meningeal inflammation
48
49
Assessment
Signs of Increased Intracranial
Pressure:
increased ICP is manifested by
deterioration in all aspects of
neurological functioning.
Level of consciousness decreases as ICP
rises.

Evaluation of dysfunction in the
patient`s living patterns.
50
Signs of Increased Intracranial Pressure
 Establish baseline neurological assessment
 Increased ICP






Decreased LOC, restlessness, confusion,
combativeness
Lethargy, obtundation, coma
Sluggish pupils to fixed and dilated, unequal pupils
Changes in motor function
Changes in VS are a late finding.
Cushing's triad: increased systolic pressure,
bradycardia, decreased irregular respirations
Neurodiagnostic Studies
 Neuroradiological Techniques:
Conventional radiographs of the skull and spine are
used to identify fractures, dislocations, and other bony
anomalies, especially in the setting of acute trauma.
 Spinal films allow for visualization of the spine to
evaluate complaints of pain or noted motor and sensory
impairment.
Nursing Management….The nurse’s role involves
monitoring the patient and attendant equipment during
the procedure and being alert for complications related
to patient position and the length of the procedure.
In the spinal cord injured–patient, care should be taken to
ensure stabilization of the neck by a hard cervical collar.
52

Neurodiagnostic Studies
 Computed Tomography:
The CT scan permits more refined measurement of the
density of tissues, blood, and bone in the body
compared with that afforded by conventional
radiographs.
The denser the material (i.e., skull), the whiter it appears
on the film.The less dense the material (i.e., air), the
darker it appears on the film.
CT scans are recommended in the initial workup of
seizures, headache, and loss of consciousness, and for
the diagnosis of suspected hemorrhage, tumors, and
other lesions.
53
Neurodiagnostic Studies
 Magnetic Resonance Imaging:
 An MRI is superior to a CT scan in the early
diagnosis of cerebral infarction and the
detection of demyelinating disorders, such as
multiple sclerosis. It is also helpful in
diagnosing small lesions, such as tumors
and hemorrhages, which might not appear on
a CT scan. However, traditional CT scanning
is superior for scanning for bony
abnormalities, which are visualized poorly on
an MRI.
54
MRI
55
Neurodiagnostic Studies
 Angiography and Digital Subtraction
Angiography
 It is the only test that can reveal large and
small aneurysms and arteriovenous
malformations and their relationship to
adjacent structures and vessels. It involves
the passage of a radiographic
catheter through a large artery (usually femoral)
to each of the arterial vessels bringing blood
to the brain and spinal cord. Radiopaque
contrast dye is then injected into each vessel.56
Angiography
57
Angiography
58
Neurodiagnostic Studies
Cerebral Blood Flow Studies:
 cerebral blood flow is evaluated most
commonly by a radioisotope brain scan.
A radioactive isotope, such as
technetium-99m, is injected
intravenously.
 If there is blood flow to the brain,
damaged areas absorb more of the
isotope than areas without damage.
59
Neurodiagnostic Studies
Myelography:
Myelography is a contrast study of the
spinal cord and surrounding structures.
It involves the introduction of
watersoluble material (metrizamide) into
the CSF through a lumbar puncture,
60
Neurodiagnostic Studies
Electrophysiological Studies
ELECTROENCEPHALOGRAPHY (EEG):
a record is made of the brain’s electrical
activity.
EVOKED POTENTIALS:
An evoked potential is an electrical
manifestation of the brain’s response to
an external stimulus: auditory, visual,
somatic, or a combination of these.
61
Neurodiagnostic Studies
Lumbar Puncture for Cerebrospinal
Fluid Examination:
A lumbar puncture for CSF analysis may
be performed to help diagnose
autoimmune disorders or infections.
CSF is obtained by the insertion of an 18to 22-gauge needle between the
vertebrae at the L3-4 or L4-5 levels.
62
Head Trauma
Mechanisms of Head Injury
Pathophysiology
Assessment
Management
63
Learning Outcome
 Explain the significance of traumatic
brain injury.
Mechanisms of Head Injury
 Acceleration injuries: occur when a moving
object strikes the nonmoving head.
 Deceleration injuries: occur when a moving
head strikes a stationary object, such as in a
fall.
 Pentration injuries: caused by a bullet,
shrapnel, or sharp object…disrupt the
integrity of the skull.
65
Mechanisms of Head Injury
 Coup-contre coup injuries: occur when the
head is struck, causing the brain to move
within the cranial vault and forcibly contact
the opposite pole of the skull and the region in
which the initial blow was dealt.
 Rotationl injuries: occur when forces cause
the brain to twist within the skull.
66
67
Determining Severity of Head Injury
Pathophysiology
 Primary Brain Injury: is the result of
the initial injury. Injury occuring at the
time of trauma. The initial injury
causes disruption of the electrical,
chemical, and physical integrity of the
cells in the area, leading to cell death.
69
Pathophysiology
 Secondary Brain Injury:
encompasses the physiological
response to brain injury, including
cerebral edema, cerebral ischemia,
biochemical changes, and changes
in cerebral hemodynamics.
70
Primary Brain Injury
 Scalp laceration
 Skull fracture



Basilar skull
Raccoon eyes
“Halo sign”
 Conclusion
 Contusion
Primary Brain Injury (cont.)
 Epidural hematoma
 Subdural hematoma
 Intracerebral hematoma
 Traumatic subarachnoid hemorrhage
 Diffuse axonal injury
 Cerebrovascular injury
SCALP LACERATION
 A scalp laceration frequently causes
copious amounts of bleeding due to the
vascularity of the scalp.
 Scalp lacerations can be sutured at the
bedside or may require surgical repair,
depending on the size and extent of
injury.
73
SKULL FRACTURE
 Fractures occurring directly over blood
vessels can injure them, producing an
epidural hematoma.
 Skull fractures may be compound (i.e.,
occurring with an open wound) or
displaced (closed wound in which the
edges of the fracture no longer meet), or
they can be linear.
74
SKULL FRACTURE
 Depressed skull fractures are fractures
in which bone is pressed into the dura;
this is often felt as a depression or dip
on palpation.
 Basilar skull fractures occur at the base,
or floor, of the skull, typically in the
areas of the anterior fossa and middle
fossa.
75
SKULL FRACTURE
 Drainage of CSF from the ear or nose indicates
injury to the dura.
 Ecchymosis (bruising) behind the ear (Battle’s
sign) is a delayed sign of a basilar skull fracture
in the middle fossa.
 CSF leaks typically heal on their own with rest;
however, in situations in which the leak persists,
a lumbar catheter may be placed to drain CSF.
76
CONCUSSION
 Classified as a mild traumatic brain injury and
defined as any alteration in mental status
resulting from trauma that may or may not
involve a loss of consciousness.
 Cerebral concussions are not associated with
structural abnormalities on radiographic
imaging.
77
CONCUSSION
 Recovery after a concussion is usually quick
and complete.
 some patients may exhibit symptoms of
postconcussion syndrome, which include
headaches, decreased attention span, shortterm memory impairment, dizziness, irritability,
and emotional lability. Fatigue, noise and light
sensitivity, visual disturbances.
78
Post-concussion syndrome
Start 2weeks to 2 month (may last from months1years).





Persistent headache.
Lethargy.
Personal & behavioral changes.
Decrease attention.
Short-term memory impairment.
Care include teaching about symptoms & follow up
care.
CONTUSION
 A cerebral contusion is a focal injury that
ranges in severity according to the size and
extent of brain tissue injury.
 Focal neurological deficits may occur with
small lesions, whereas multiple or large
contusions may result in depressed level of
consciousness, abnormal posturing, and
coma.
80
CONTUSION
 Cerebral edema peaks at 24 to 72 hours
after the injury, causing increased
intracranial pressure (ICP) and possibly
further injury to intracranial structures.
81
EPIDURAL HEMATOMA
 An epidural hematoma is a collection of
blood located between the dura and the
inner table of the skull, usually caused by
laceration of an extradural artery.
 The only remedy for this injury is
immediate surgical evacuation; an
epidural hematoma is a neurosurgical
emergency.
82
SUBDURAL HEMATOMA
 Is an accumulation of blood below the dura and
above the arachnoid covering of the brain.
 Symptoms include worsening headache, focal
neurological deficit, unilateral pupillary abnormalities,
and a decreasing level of consciousness.
 A craniotomy may be performed to remove the
hematoma and drains placed to facilitate drainage of
the surgical site.
 The head of the patient’s bed may be ordered to
remain flat to mitigate tension placed on bridging
veins when the head is elevated.
83
INTRACEREBRAL
HEMATOMA
 An intracerebral hematoma is a collection of
blood within the brain tissue.
 Treatment of patients with intracerebral
hematoma remains controversial regarding
whether surgical intervention is warranted or
medical management is more appropriate.
 Medical therapy aims to manage cerebral
edema and promote adequate cerebral
perfusion.
84
Cerebral Hematomas
86
TRAUMATIC SUBARACHNOID
HEMORRHAGE
 Traumatic subarachnoid hemorrhage
occurs with tearing or shearing of
microvessels in the arachnoid layer
where CSF flows around the brain.
87
DIFFUSE AXONAL INJURY
 Is characterized by a direct tearing or shearing
of axons, which worsens during the first 12 to
24 hours as both local and diffuse edema
develops.
 Mild DAI is associated with a coma lasting no
longer than 24 hours; moderate DAI is
characterized by a coma lasting beyond 24
hours with transient flexor or extensor
posturing. Severe DAI is characterized by
prolonged coma, fever, diaphoresis, and
severe extensor posturing.
88
CEREBROVASCULAR
INJURY
 Injury or dissection of the carotid and
vertebral arteries due to trauma.
 Rare.
89
Secondary Brain Injury
 Cerebral edema
 Ischemia
 Herniation syndrome
 Coma
 Persistent vegetative state
CEREBRAL EDEMA
 Cerebral edema commonly occurs in patients
with head injuries 24 to 48 hours after the
primary insult and typically peaks at 72 hours.
 If cerebral edema is not aggressively treated, it
causes herniation syndrome.
91
ISCHEMIA
 Cerebral ischemia comprises a serious
class of secondary injury and is a major
cause of morbidity and mortality.
 Cerebral ischemia occurs whenever
blood flow is either diminished or
inadequate to meet metabolic demands.
 The end point of unresolved ischemia is
infarction or tissue death,
92
HERNIATION SYNDROME
 Herniation syndrome describes a state in
which cerebral structures shift inside the
cranium under high pressure.
 Cushing’s triad describes the three late
signs of herniation:increased systolic
blood pressure, decreased heart rate, and
an irregular respiratory pattern.
93
Normal Brain
Herniated Brain
94
COMA
 Coma is an alteration in consciousness
caused by damage to both hemispheres
of the brain or the brainstem.
 Consciousness can be placed on a
continuum from full consciousness to
coma, and states of coma can be
subdivided into light coma, coma, and
deep coma.
95
PERSISTENT VEGETATIVE
STATE
 characterized by a period of sleeplike
coma followed by a return to the awake
state but with a total lack of apparent
cognition.
 In a persistent vegetative state, the
higher cortical functions of the cerebral
hemispheres have been damaged
permanently, but the lower functions of
the brainstem remain intact.
96
ASSESSMENT
 Physical Examination.
 Diagnostic studies:






Computed tomography (CT) scan.
Magnetic resonance imaging (MRI).
Cerebral angiography.
Transcranial Doppler (TCD) ultrasonography.
Neurophysiological tests include the
electroencephalogram (EEG), brainstem auditory
evoked responses.
Jugular bulb catheter, which measures venous oxygen
saturation (reflective of global oxygen delivery and
consumption in the brain).
97
Physical Exam
 level of consciousness is the most sensitive indicator
of increased ICP.
 Maximum stimulus must be applied to achieve the
maximum patient response.
 The Glasgow Coma Scale.
 Assessment of cognitive function.
 Assessment of level of arousal.
 Assessment of the eyes.
 Assessment of brain stem responses.
 Assessment of motor function.
 Assessment of respiratory function.
 Assessment of other body system.
98
Physical Exam
 Assessment of cognitive function:

Cognitive function is usually assessed by
asking three orientation questions
regarding person, place, and time.
99
Physical Exam
 Assessment of level of arousal:
 Attempt to arouse the patient simply by
speaking (in the same manner as you
would try to wake a person who is
sleeping), then by shouting (as you would
to wake a “sound sleeper”), next by
shaking, and then by applying pain.
100
Physical Exam
 Assessment of level of arousal:
 A painful stimulus should be applied for
15 to 30 seconds before the patient is
considered not to have a motor
response because patients with brain
injury may exhibit delayed responses to
stimuli.
101
Herniated Brain
102
Physical Exam
 Assessment of the eyes:



Assessment of the eyes includes evaluation of the
pupils and extraocular movements, which assists in
localizing regions of the brain dysfunction.
The oculocephalic reflex (i.e., the “doll’s eyes)
Absence of eye movement on head turning reflects
brainstem dysfunction.
The oculovestibular reflex. The absence of
movement signals loss of function of the vestibular
portion of the eighth cranial nerve as well as the
brainstem.
103
Physical Exam
 Assessment of brain stem responses:
 The brainstem can be further assessed in the
unconscious patient by testing corneal,
cough, and gag reflexes.
 Cranial nerves IX and X (the
glossopharyngeal and vagus nerves) exit at
the level of the medulla and are responsible
for the cough and gag reflexes and protection
of the airway from aspiration. The cough and
gag reflexes should be evaluated in both the
awake and unconscious patient.
104
Physical Exam
 Assessment of motor function:



The unresponsive patient may exhibit localization,
withdrawal, or flexor or extensor posturing in
response to noxious stimuli.
It is important to note that a patient may exhibit one
type of movement in one extremity and another
type of movement in another extremity.
Presence of Babinski’s reflex (upward fanning of
the toes) is also observed in the patient with severe
brain injury.
105
Assessment of respiratory
function
 Numerous locations in both cerebral hemispheres regulate
voluntary control over the muscles used in breathing, with the
cerebellum synchronizing and coordinating the muscular effort.
The cerebrum also has some control over the rate and rhythm of
respiration.
 Cheyne-Stokes breathing is periodic breathing in which the depth
of each breath increases to a peak and then decreases to apnea.
 central neurogenic hyperventilation…seen in patient with
herniation.
 Apneustic breathing is characterized by respiration with a long
pause at full inspiration or full expiration.
 Cluster breathing (gasping breathing).
 ataxic breathing
106
Respiratory system
Management
 Initial assessment and treatment of the patient with
a head injury begins immediately after the insult,
often with prehospital care providers.
 Prehospital treatment of the head-injured patient
focuses on a rapid systems assessment and
definitive airway management.
 Airway management is a crucial initial step in
providing care to the head-injured patient because
hypoventilation is common with a decreased level
of consciousness, and hypoxia and hypercarbia
are extremely detrimental to the patient in the early
stages of injury.
108
Management
 Initial mechanical ventilation strategies aim to maintain
normal ventilation or a partial pressure of carbon dioxide
(PaCO2) within normal limits (35 to 45 mm Hg).
 hyperventilation therapy if signs of cerebral herniation are
present and not controlled by other initial pharmacological
treatments.
 Management of circulation in patients with head injuries
aims to promote adequate cerebral perfusion through fluid
resuscitation and the use of vasopressors if necessary.
 Continuing management seeks to control ICP, promote
cerebral perfusion, and correct the primary pathological
process.
109
Management
 Monitoring and Controlling Intracranial
Pressure:

ICP monitoring is recommended for patients with
severe head injury (a GCS score of 3 to 8) and
CT scan abnormalities on admission.
110
ICP – What is it?
 ICP stands for Intra Cranial Pressure

This is the pressure of the brain, Cerebrospinal
fluid (CSF), and the brain’s blood supply within
the intracranial space.

Since The Skull is basically a closed system, an
increase in volume will produce an increase in
pressure.
111
ICP – What is it?
 Concepts of ICP management and
intervention strategies are based on the
principle that the skull is a rigid box.
 Its contents are divided into three
intracranial sections:



Blood maintained in the blood vessels,
Cerebrospinal fluid (CSF),
Brain parenchyma.
112
ICP – What is it?
 The brain’s ability to self-regulate is
based on the Monro- Kellie doctrine of
fixed intracranial volume.
113
Monro-Kellie Doctrine
 This doctrine states that
the volume of the
intracranium is equal to
the volume of the
cerebral blood (3% to
10%); plus the volume of
the CSF (8% to 12%);
plus the volume of brain
tissue, which consists of
more than 80% water.
114
Elevated ICP = Danger
Animated GIF taken from http://www.artie.com
115
Other Problems
 Elevated ICP can also affect the perfusion of the
brain
 Cerebral Perfusion Pressure






Blood pressure gradient across the brain
(CPP) is measured by taking the Mean Arterial Pressure
(MAP) and subtracting Intracranial Pressure (ICP). (CPP
= MAP – ICP).
Normal: 60 - 80 mmHg
Ischemia: 50 - 60 mmHg
Cell Death: < 30 mmHg
CBF Ceases: 0 mmHg
116
What does this mean?
 This shows that if the ICP goes up… and
MAP stays constant… then the CPP
decreases.
 This means the patient is not getting as much
blood flow to the brain.
117
Calculating CPP
Mean Arterial BP
Formula
SBP – DBP + DBP
3
BP = 150/70
MAP = 97
ICP = 15
150 – 70 + 70 = 97
3
97 – 15 = CPP of 82
118
Volume-Pressure Curve
A = low ICP, low elastance; high
compliance. Normal constant ICP; safe
environment
B = Increasing ICP, high elastance; low
compliance. Normal ICP but a low amount
of buffering capacity
C = High ICP, high elastance; low to no
compliance. Loss of compensatory
mechanisms.
*** elastance= any slight or small
increase in volume cause large change in ICP.
**** Compliance= any increase in volume cause
slight or constant ICP.
119
What does this mean?
CBF= is the amount of blood in milliliters passing through 100 gram of
brain tissue in 1 minute.
 CBF is about 50mL/min per 100g of brain tissue.
 To receive normal CBF, the person need to have:
 Cerebral perfusion pressure of 60-100mmHg.
 Brain receives 750ml/min, 15-20%of cardiac output.
 CPP=MAP-ICP.
 When CPP decrease, cardiovascular system increase BP.
 Acceptable CO2 levels:
It is a potent vasodilator, causes increased CBF, increased volume, &
lead to increase ICP.
 MAP<160mmHg.
 SBP of 60-140mmHg.
120
 ICP<30mmHg.
Poor Outcomes
 Having an elevated ICP is one of the most
damaging aspects of neurological trauma,
and is directly related to poor prognosis.
121
Normal Values
 A normal ICP in an adult ranges from 0-15
mmHG.
 An ICP cannot surpass 40 without causing
harm.
 Even values between 25-30 are considered
fatal if they are prolonged.
122
Causes?
 ICP increases when the volume added to the
intracranial cavity exceeds the compensatory
capacity
 Rate and extent of increase in ICP depends on




Volume of lesion
Rate of expansion
Total volume within the intracranial cavity
Intracranial compliance (elastance)
123
Causes?
 Increases in Brain Volume:
 Space-occupying lesions:
hematomas, tumors, abscesses.
 Edema: head injury,
encephalopathy.
124
Causes?
 Increases in Blood Volume:
 Venous obstruction
 Vasodilation: due to hypoxia, drugs or
hypercapnia
 Seizures
125
Causes?
Increases in CSF Volume:
 Obstruction: stenosis, tumors
 Impaired reabsorption.
 Increased production: tumors
126
Causes?
 An elevated ICP can be caused by many different
etiologies:








Cushing’s Syndrome: Due to ischemia to the brainstem
(vasomotor center), Triggers potent sympathetic response,
results in peripheral vasoconstriction
Cerebral edema.
Herniation.
Traumatic Brain Injuries
Hydrocephalus
Brain Tumor
Severe Hypertension
Venous Sinus Thrombosis
127
Pathophysiology
Cranial Insult
Tissue edema
Increase ICP
Compression of Blood vessels
Decrease CBF
Decrease O2 with death of brain cells
Edema around necrotic tissue
Increase ICP with compression of brain stem & respiratory center
Accumulation of CO2
Vasodilation
Increase ICP resulting from increase Blood volume
death
128
Pathophysiology
129
Monitoring
 There are 4 main types of devices for
monitoring ICP




Intraventricular Catheters
Fiber optic Monitors
Subarachnoid Bolts
Epidural Monitors
130
Intraventricular
Monitoring
subarachno
id
parenchymal
.
epidural
subdural
131
Intraventricular Catheters
 Most widely used devices – Most Accurate
 A catheter is actually placed inside one of the
ventricles (a fluid filled cavity in the brain where
CSF is produced)
 Allows treatment and monitoring simultaneously

Can be used to take out excess CSF, thereby decreasing
ICP, Measures ICP, Drains CSF, Withdraw CSF, Instill
medications
132
Fiber optic Monitors
 Relatively new technology
 A fiber-optic probe is inserted



Into the Brain
Ventricles
Subdural space
 The probe contains a transducer on the tip
that measures pressure
133
Subarachnoid Bolts
 These consist of an actual metal “bolt” that is
inserted into the skull so that the tip is resting
in the subarachnoid space
 Easy to install (hey… it’s what they said!)
 Limited accuracy
Image taken from http://library.ucf.edu/Frankenstein/
134
Epidural Monitors
 Recording devices that are placed into the
epidural space
 This is a potential space that is located
between the inner surface of the skull and the
dura matter
135
ICP- Monitoring
136
Management








Decrease stimuli
Mannitol administration
Respiratory support
Pain relief
Sedation
Hypothermia
Barbiturate coma
Antihypertensive therapy
137
Nursing Management
History
 Precipitating causes
 Increasing headache
 Seizures
 Vomiting
 Blurred or double vision (diplopia)
 Nuchal rigidity
138
Nursing Management
Physical
 Acute Signs:
 Level of consciousness
 Motor/Sensory activity
 Pupil size or reaction
 Cranial nerves
 Vital signs
 Chronic Signs:
 Headache
 Papilledema
 Nausea/vomiting
139
Why does this affect RT?
 There are several aspects that Respiratory
Therapists need to be aware of when caring
for a patient that either has, or probably has,
an elevated ICP
140
Sedation
 Agitation increases ICP, therefore it is
important to keep the patient well sedated.
141
Ventilatory Strategies
 One of the most important treatments for
high ICP is to control the ABC’s


This is because hypoxemia and hypercapnia can
cause the cerebral blood vessels to dilate and
raise ICP even more8
Hypoxemia can also lead to a lactic acidosis,
lowering pH and causing even more vasodilatory
effects2
142
Ventilatory Strategies
 Hyperventilating a patient down to a state of
hypocapnia will do the opposite of
hypercapnia – it will vasoconstrict the
vessels in the brain.
 BUT……
Image taken from http://www.trentu.ca/careers/students/selfassess.html
143
Ventilatory Strategies
 This limits blood flow to an alreadycompromised-brain.
 Also, the brain adjusts to the new level of
CO2 after 48-72 hrs

Meaning vessels could rapidly dilate if CO2 were
to return to normal too quickly9
144
Ventilatory Strategies
 What about PEEP?
 Not unless explicitly needed for oxygenation
 PEEP can also increase ICP
145
Management
 Maintaining Cerebral Perfusion:



Cerebral perfusion pressure can be managed
either by decreasing ICP or increasing the
mean arterial blood pressure.
Evidence suggests that maintaining a cerebral
perfusion pressure of greater than 60 mm Hg
may reduce morbidity and mortality.
Aggressive management of increased ICP is
attempted with the overall goal of maintaining
the cerebral perfusion pressure.
146
Management

Preventing and Treating Seizures:
Post-traumatic seizures occurring in the 7-day period
after injury are called early post-traumatic seizures.
 Seizures that occur after this initial period are called
late post-traumatic seizures.
 Phenytoin is one of the most common drugs used in
the acute period.
General treatment of seizures in the setting of head
injury focuses on stopping the seizure as soon as
possible and maintaining patient safety.

147
Management

Preventing and Treating Seizures:
 The agents of choice for the rapid control of
seizure activity are lorazepam, or diazepam.
 Fever in the patient with severe traumatic
brain injury may increase cerebrometabolic
demands and compound secondary brain
injury.
148
Management

Monitoring Fluid and Electrolyte Status:
Patients with head injuries may experience
derangements of fluid and electrolyte balance for a
variety of reasons, such as the administration of
osmotic diuretics, increased insensible fluid loss, and
pituitary gland dysfunction causing sodium
imbalance.
 Fluid imbalance in a patient with a head injury can be
caused by mannitol therapy with inadequate fluid
replacement.
 Bleeding should always be ruled out in the setting of
hypovolemia, especially in the trauma population. 149

Management

Monitoring Fluid and Electrolyte Status:
Disorders of sodium imbalance are common in the
head-injured patient. Hyponatremia most commonly
occurs as a result of syndrome of inappropriate
antidiuretic hormone secretion (SIADH)
 Cerebral salt-wasting syndrome may also cause
hyponatremia (involves a primary loss of sodium
through the kidneys and intravascular volume
contraction).

150
Management

Monitoring Fluid and Electrolyte Status:
Diabetes insipidus is a cause of hypernatremia and
hypovolemia.
 hyperglycemia is common in this critically ill
population.

151
Management
Managing Cardiovascular Complications:
 Invasive hemodynamic monitoring, such as arterial blood
pressure and central venous pressure monitoring.
 Monitoring pulmonary artery pressures and cardiac
output may be useful.
 Disorders of coagulation are a significant concern in
patients with head injury (DIC).
 Prophylaxis of deep venous thrombosis (DVT) is an
essential component to the care of these patients.
Antiembolic stockings, subcutaneous heparin, and early
mobilization help prevent DVT and pulmonary emboli.

152
Management

Managing Pulmonary Complications:
Pulmonary complications in the patient with head
trauma include pneumonia, acute respiratory distress
syndrome (ARDS), neurogenic pulmonary edema,
and pulmonary embolus.
 Aspiration pneumonia is a common pulmonary
complication in this population because of the loss or
impairment of airway protective reflexes.
 potential hypoxia should also be considered.
Preoxygenation, administration of lidocaine, and
administration of sedation before suctioning may blunt
rises in ICP and decrease associated complications.153

Management

Managing Pulmonary Complications:
 Neurogenic
pulmonary edema may
result from injury to the brainstem,
increased ICP, or an increase in
sympathetic tone that causes a
catecholamine surge at the time of
trauma.
154
Management




Ensuring Optimal Nutrition:
Head injury is thought to cause hypermetabolic
and hypercatabolic states as well as a decrease
in immune competency.
Patients with head injury treated with standard
enteral or parenteral.
Current recommendations suggest replacement
of 140% of a patient’s REE (resting energy
expenditure) who is not paralyzed and 100% of
REE in patients who are paralyzed with formulas
that contain 15% of calories as protein.
155
Management




Managing Musculoskeletal and Integumentary
Complications:
Collaboration with other disciplines, such as
occupational and physical therapy, is helpful in
protecting patients from skin breakdown.
Splinting of the hands and feet, especially in an
unresponsive patient.
Frequent turning of patients, even in the critical
phase of the illness, is integral in maintaining skin
integrity and facilitating pulmonary drainage.
156
Management

Caring for the Family:
 Attention
should be given to including
both spiritual and cultural needs in the
plan of care.
 Careful observation by the family for
behavioral changes and difficulties.
157
Nursing Diagnosis
 Impaired Cerebral Tissue Perfusion related to
cerebral
 edema
 Ineffective Airway Clearance related to
diminished
airway protective reflexes
 Risk for Infection related to multiple indwelling
monitoring devices
 Impaired Skin Integrity related to physical
immobilization
158
Nursing Diagnosis
 Imbalanced Nutrition: Less Than Body
Requirements related to increased energy
expenditure
 Acute Pain related to injury agents
 Disturbed Sleep Pattern related to ICU routine
care and environment
 Interrupted Family Processes related to acute
crisis
 Anticipatory Grieving related to uncertain
prognosis and critical illness
159