Neuro Assessment and Glasgow Coma Scale

Neuro Assessment

• History should be gathered from the patient wherever possible
• In a physical assessment, level of consciousness should be checked
• Check the the cranial nerves
• Conduct an assessment of both motor, and sensory systems
• Check cerebellar function
• Check reflexes

Glasgow Coma Scale

• Is used to assess level of consciousness based on eye-opening, verbal, and motor responses
• Eye-opening response scores range from 1 (no eye opening) to 4 (eyes open spontaneously)
• Verbal response is scored from 1(no verbal response) to 5 (oriented)
• Motor response is scored from 1 (no motor response) to 6 (obeys commands for movement)
• A minor brain injury corresponds to a score of 13-15 points
• A moderate brain injury corresponds to a score of 9-12 points
• A severe brain injury corresponds to a score of 3-8 points

Pediatric Nursing Tip: Altered Mental Status (AMS)

• AMS can be caused by a PaO2 fall to 60 mm Hg or below
• AMS can be caused by a PaCO2 rise above 45 mm Hg
• Low blood pressure can lead to cerebral hypoxia
• For every 1° rise in fever, oxygen need increases by 10%
• Drugs such as sedatives and antiepileptics can cause AMS
• Seizures, specifically the postictal state can cause AMS
• Increased intracranial pressure (ICP) can cause AMS

Neurological Monitoring in Infants and Children

• Include assessment of pain stimuli response.
• Arousal awareness must be monitored.
• Monitor cranial nerve response.
• Watch motor response.
• Posturing can be monitored.
• Pupil response of the eyes can be monitored.
• Note bulging fontanelles.
• Look out for scalp vein distention.
• Notice ataxia or spasticity of lower extremities.
• Look out for Moro/tonic neck with withdrawal reflexes

Psychosocial Considerations and Age-Related Changes

• Many factors influence how patients and families responds to an event
• Patient response is affected by age, general health, social status and history of chronic illness
• Response affected by previous life experience, job and home responsibilities.
• Altered social roles and body image issues affect patient response to neurological event
• Age-related changes in the nervous system include motor and sensory changes.
• Changes also include alteration of thermoregulation

Care of Patients with Neuro Diagnoses

• Disorder diagnoses can be frightening to patients
• Neurological disorders can affect cognition.
• Personalities are often affected by neurological disorders
• Neurological disorders can impede mobility
• Activities of daily living can be significantly complicated by Neuro diagnoses

HEADACHES

• Headaches are also referred to as cephalalgia
• Can be primary or secondary
• About 4% of the population experiences chronic daily headaches
• Pathophysiology of headaches involves reaction of nociceptors to triggers, sending messages via trigeminal nerve to the thalamus
• Clinical manifestations of tension headaches are episodic or chronic in nature.
• Cluster headaches are considered neurovascular headaches
• Headache management involves maintaining a headache diary
• Always conduct a complete neurological assessment
• Treatment involves addressing any underlying disorders or diseases.
• Depression and anxiety can cause tension headaches
• NSAIDs, analgesics, and muscle relaxants are frequently prescribed.
• Sedatives and antidepressants manage headaches
• Triptan medications are most beneficial during moderate to severe migraines.
• Headaches in children are often shorter in duration.

PRIMARY BRAIN TUMORS

• Originate in the brain
• Can be slow-growing, benign tumors or highly malignant, aggressive tumors.
• Gliomas are inclined to develop along the curved areas
• Meningiomas are the most common form of brain tumor
• Oligodendrogliomas are slow-growing and may not spread.
• Acoustic neuromas are also known as schwannomas
• Clinical manifestations are dependent upon tumor location in the brain.
• Chemotherapy and radiation are used during Management
• Craniotomy may be required
• Patients undergo biopsies of brain masses.
• Sample tissue within the mass are tested
• Resulting cells are examined for a specific diagnosis
• Complications can include bleeding
• Cerebral edema is a common complication
• Seizures are a possibility
• Venous thromboembolism may form
• Increased intracranial pressure is a life-threatening complication

SEIZURES

• Seizures involve an uncontrolled, sudden discharge of electrical activity in the brain.
• Result in the range of manifestations from behavior changes to loss of consciousness.
• Epilepsy is a potential cause of seizures.
• Fever, especially up to age 6 can be a cause
• Seizures are also caused by substance use and withdrawal
• Trauma, head injury may result in seizures
• Increased intracranial pressure (ICP) is a potential cause
• Infection and inflammation can cause seizures
• Hypoglycemia may result in seizures
• Clinical manifestations can include Rhythmic jerkiness of all extremities and loss of consciousness.
• Episodes of daydreaming and consciousness is another potential sign
• Diagnosis is confirmed using Labs, CT, MRI of head
• Monitor the electroencephalogram (EEG)
• Seizure lasting greater than 5 minutes is a medical emergency.
• Seizures lasting greater than 30 minutes can cause respiratory failure, brain damage, and death
• Vagal nerve stimulator (VNS) is a management method
• Deep brain stimulation (DBS) is used
• Partial corpus callosotomy is performed

PEDIATRIC SEIZURES

• Can be febrile or due to Epilepsy
• Seizures manifest as Generalized Tonic-clonic or grand mal
• Has three distinct phases
  • Aura is first phase
  • Tonic/clonic seizure presents
  • Then a postictal phase begins
• Can be Partial, and account for 40% of seizures
• Consciousness may be intact or slightly impaired
• Can be simple or complex

SEIZURES: TREATMENT

• Initially, the aim is at determining the type, site, or cause
• Multiple diagnostic techniques can be used
  • CT/MRI, EEG
  • Laboratory tests can rule out poisonings or electrolyte abnormalities
• Drug of choice depends on the type of seizure
  • Drowsiness is a common side effect
  • Take medications at the same time every day
  • Do not stop drug suddenly because it can cause status epilepticus (prolonged seizures)

REYE SYNDROME

• Ammonia accumulates in the blood due to liver involvement.
• Toxic levels can cause cerebral manifestations, such as AMS, behavioral changes, seizures, and coma.
• In children, effortless vomiting and altered behavior, or AMS after a viral illness is characteristic

MENINGITIS

• Meningitis risks include dorms, jails and long-term care settings
• Those under 1 or over 60 are at greater risk
• Risks are elevated for those recovering from surgery, trauma, infection.
• Pathophysiology involves inflammation of the meninges
• Can be acute or chronic
• Causes include bacterial, viral and fungal infection
• May be caused by aseptic meningitis
• Clinical manifestations include fever, headache, and degrees of altered mental status.
• Photophobia, chills, nausea, and vomiting may be present
• Signs of meningeal irritation include nuchal rigidity
• Diagnosis is confirmed using cerebrospinal fluid (CSF) examination via lumbar puncture.
• Require14 to 21 days of antibiotic treatment

ENCEPHALITIS

• Herpes simplex virus I causes 2 million cases in ages 20-40 years
• Herpes simplex virus I is contracted via bodily fluids such as oral and nasal secretions.
• HSV II is sexually transmitted.
• An acute inflammation of the brain is caused.
• The cerebrum, brainstem, and cerebellum are affected
• Clinical manifestations include fever with neurological deficits related to brain or spinal cord damage
• Can cause headache, photophobia, and phonophobia
• Diagnosis requires Examination of blood, CSF, EEG, CT, and MRI scans, and Antivirals are prescribed

PARKINSON'S DISEASE

• Occurs 1.5 to 2 times more often in males than females.
• Typically begins between ages 40-70 years.
• Progressive and neurodegenerative disease of the CNS.
• Primarily manifests in motor dysfunction
• Primarily of idiopathic origin
• Diagnosed when two or more cardinal symptoms occur with asymmetrical presentation
• Surgical Management is stereotactic pallidotomy

ALZHEIMER'S DISEASE

• Life expectancy is 2-20 years after onset
• 5.3 million Americans have Alzheimer's
• Diagnosis can only be made at autopsy
• Form of dementia involving gradual progression of the loss of brain function.
• Memory, thinking, and behavior are affected
• Clinical manifestations include Forgetfulness and difficulty with language
• Short-term memory and perception problems are likely
• Can cause Emotional lability, personality changes, and loss of cognitive skills.
• No cure exists, diagnosis can be confirmed at brain autopsy

LOW BACK PAIN

• Second most common neurological ailment.
• Equally affects both men and women.
• Spinal degeneration results loss of normal structure and function of the spine.
• Spinal stenosis of foramina and canals may put pressure on the spinal cord and nerve roots.
• Scoliosis and Lordosis can also cause pain
• Pain can be exacerbated by movement
• Muscle spasms may limit movement
• Management involves collecting a history, conducting a physical exam, and neurological testing.
• Treated using medications and physical therapy.
• Interventional therapy is a possibility
• Transcutaneous electrical nerve stimulation may alleviate pain
• Surgery if necessary

HERNIATED NUCLEUS PULPOSUS

• The disks between vertebrae degenerate causing, herniation
• This is a major cause of severe chronic and recurrent back pain.
• Weakening of or a tear in the annulus fibrosus allows the nucleus pulposus to bulge outside the disk.
• Radiculopathy is the result
• Pain is due to inflammatory response and nerve root compression.
• Can cause Radicular signs
• A History, physical exam, and neurological testing performed
• Most improve in 1-2 months of conservative treatment
• Medications may be prescribed
• Complications can include numbness/weakness, loss of bowel and bladder control and increased pain
• Can also include saddle anesthesia and chronic pain
• Laminotomy, microdiscectomy, spinal fusion, bone graft, and artificial disk replacement are surgical management procedures

MULTIPLE SCLEROSIS

• Autoimmune disease
• 400,000 people have MS with onset between 20-50 years
• Affects more women than men
• There are 4 main types :
  • Relapsing-remitting, secondary progressive, progressive relapsing and primary progressing
• Immune system attacks the brain and spinal cord
• A chronic neurological disorder
• Often triggered by Stress, cold, heat, fatigue, overexertion, fever and illness
• Clinical manifestations include numbness or weakness in limbs
• Also includes partial or complete vision loss and tingling or pain
• Can include electric-shock sensations with head movements, tremor, lack of coordination
• Watch for unsteady gait, fatigue, and dizziness
• No specific test and can be difficult to diagnose using.
• Collection of history, physical, and neurological examination key
• No cure is available
• Treatment improves the speed of recovery from attacks
• Reduces the number of attacks
• Slows the progression of the disease
• Medications treat clinical manifestations
• Common complications include muscle stiffness or spasms and paralysis, often in the legs
• Also can cause Problems with bladder, bowel, or sexual function and mental status changes
• Watch for memory loss, problems concentrating, depression or seizures

AMYOTROPHIC LATERAL SCLEROSIS (ALS)

• Lou Gehrig's disease
• Symptoms usually develop after age 50
• Prevalence is 3.9 per 100,000 people.
• This rapidly progressing, fatal CNS disease impacts voluntary muscle control
• Results in both upper and lower neurons becoming degenerate
• Clinical manifestations include muscle cramps or stiffness and muscle weakness
• Slurred speech and difficulty swallowing may also occur
• Upper motor neuron damage associated with spasticity, and lower motor neuron damage also occurs
• No single test can be used to diagnose ALS
• CT scans and MRI of neck and head can be useful
• Medications offer symptomatic relief

NEURAL TUBE DEFECTS

• Caused from failure of neural tube closing
• Occurs at either the cranial or the caudal end of the spinal cord

ANENCEPHALY

• A rare birth defect
• Rare defect that occurs early in pregnancy
• The neural tube eventually becomes the spinal column and brain, but it fails to close
• Infants with anencephaly have a brain stem to control reflex actions, but, do not have a forebrain or cerebrum

MICROCEPHALY

• Abnormally small brain

SPINA BIFIDA

• Spina Bifida Occulta is a minor variation of the disorder.
• The opening is small
• No associated protrusion of structures
• Often undetected
• May have a tuft of hair, dimple, lipoma, or discoloration at the site
• Spina Bifida Cystica involves the development of a cystic mass in the midline of the opening in the spine.
• Can be meningocele or meningomyelocele
• Prevent with 0.4 mg of folic acid per day before and during pregnancy
• Treat by surgical closure
• The prognosis depends the extent of spinal cord involvement
• Prevent infection or injury to the sac after birth
• Maintain correct positioning to reduce sac pressure
  • Prone on open diaper best
• Prevent contractures
• Provide good skin care and adequate nutrition
• Accurate observations and charting required
• Educate the parents in details of condition
• Continued medical supervision during patients life

SPINAL CORD INJURY

• May be caused by hyperextension, hyperflexion, rotation, or vertical compression.
• 12,000 injuries per year in the U.S.
• Most often affects young men between 15-35 years.
• Damage to the spinal cord with resulting functional loss occurs.
• Resulting damage is classified complete and incomplete injuries
• There are four types of incomplete injury
  • Central cord syndrome and anterior cord syndrome
  • Posterior cord syndrome and Brown-Séquard's syndrome
• Cervical injuries can result in the inability to breathe and quadriplegia
• Thoracic injuries often result in paraplegia
• Lumbar and sacral injuries result in decreasing control of legs and of bowel and bladder
• There is no reversing spinal cord damage with treatment
• Monitor for signs of spinal shock
• Medicate or use pacemaker to control irregular heartbeat
• Immobilization and stabilization can be accomplished through Halo traction or Gardner-Wells tongs
• Complications include spinal shock, neurogenic shock, and Autonomic dysreflexia
• Halo brace complications may arise
• Surgical decompression laminectomies may required

Sympathetic and Parasympathetic Nerves

• Parasympathetic nerves constrict pupils and airways, and stimulate salvia and stomach activity
• Parasympathetic stimulate inhibition of glucose release and they promote genitals and bladder construction
• Sympathetic Nerves dilate pupils and relax airways, they promote the secretion of epinephrine
• Sympathetic speed up heart rate, and stimulate glucose release, ejaculation and vaginal contraction

Spinal Cord Tumors

• Primary spinal tumors originate within the CNS
• Secondary tumors originate outside the CNS
• Metastasize to the spine
• 10%-15% of primary CNS tumors are found in spinal cord
• Pathophysiology involves abnormal growth of tissue within or rounding the spine
• Back pain may radiate down arms or legs.
• Can cause numbness and tingling and weakness in distal extremities
• Urinary incontinence and bowel changes caused.
• History and physical examination and radiological testing used for management.
• Therapeutic options include Monitoring, surgery, radiation, stereotactic radiosurgery, chemotherapy, and corticosteroids

MYASTHENIA GRAVIS

• Motor disorder characterized by fluctuating, localized skeletal muscle weakness and fatigue.
• Is an acquired autoimmune disease.
• Presents in 3 serotypes: anti-AchR, MuSK, seronegative MG(SNMG)
• Clinical manifestations include ocular, bulbar, or generalized presentations
• Patients often seek medical care for muscular weakness and fatigue
• Diagnostics can include laboratory, diagnostic, serological tests, stimulatory or electromyography
• Chest computed tomography and and immunotherapy may help
• Additional medications or surgical management may help if the crisis becomes severe
• Crises may be myasthenic or cholinergic

GUILLAIN-BARRÉ SYNDROME

• Possibly autoimmune
• Often associated with immunizations.
• Often preceded by mild respiratory or intestinal infection
• Progressive over hours to days occur with the syndrome
• Can cause minimal Muscle Atrophy
• Begins in in lower extremities
• Ascends bilaterally
• Causes weakness, ataxia, bilateral paresthesia
• Can progress to paralysis
• Symmetrical paralysis of legs up to the top of the body
• Respiratory and GI infections are common sources
• Campylobacter jejuni is most frequent cause
• Mediated by an immune response with acute lower extremity weakness with areflexia.
• Clinical manifestations involve symmetrical ascending motor weakness and paralysis
• Starts in feet and extends to trunk and arms
• The focus is on care and reducing the severity, potential complications, suffering, and recovery time
• Diagnostic tests are imperative
• Prescribe medications and diet to manage symptoms

Bell's Palsy

• Idiopathic Facial Paralysis

TRIGEMINAL NEURALGIA

• Referred to as tic douloureux
• Pain disorder that affects 15,000 Americans
• Sudden, usually unilateral, severe, brief, stabbing, recurrent pain
• Pain occurs in the distribution of the trigeminal nerve
• Manifestations include sharp, throbbing, and shocklike pain
• Touching an affected area of skin or brushing the teeth can trigger
• Certain medications can alleviate it
• Patients must avoid rubbing the affected side

CRITICALLY ILL NEURO Patient

• Requires urgent care of patients with CNS injury or disease
• Patients with CNS disorders often present with complications in other body systems
• Combine interprofessional neurological knowledge with general critical management

Pathophysiology and Clinical Manifestations related to Increased Intracranial Pressure

• Brain tissue, blood, and CSF occupy the skull. If one increases, others decrease to maintain equilibrium
• Cerebral herniation syndromes
• Three types of cerebral edema include vasogenic, cytologic, and transependymal.

INCREASED INTRACRANIAL PRESSURE

• Intracranial pressure monitoring
• Use a catheter or sensor.
• Placed in lateral ventricle of brain, parenchyma, or subarachnoid space
• Subarachnoid bolt (SAB)
• Intraparenchymal and intraventricular
• Complications include infection, over drainage, and air introduction
• Treatment decreases volume of brain water, blood, or in intracranial space
• Physical and Neurosurgical Procedure assist

PEDIATRIC TRAUMATIC BRAIN INJURIES

• Major cause of death in children older than 1 year of age
• A concussion is a temporary disturbance of the brain, followed by a period of unconsciousness
• A child's response to an injury may differ from adults
• Observe child for signs of increased ICP
• Four components of a cranial or neurological check are mental status, pupil and eye movement, vital signs, and motor activity

HYDROCEPHALUS

• Characterized by an increase in CSF within the ventricles of the brain.
• Pressure change within the brain
• Causes classic signs and increase in size of head
• Cranial sutures separate to accommodate enlarging mass.
• Scalp is shiny and veins are dilated
• Have a High-pitched cry, and bulging fontanel and Sun-set eyes may present

Hydrocephalus: Preoperative and Postoperative Nursing Care

• Conduct frequent position changes of the head.
• Prevent skin breakdown as much as possible.
• Must be supported throughout support.
• Measure head circumference along with other vital signs
• Assess for signs of increased pressure
• Protect infant from infection
• Depress shunt "pump” as ordered by surgeon
• Position in consideration of site of surgical incisions
• Assess and provide for pain control
• Perform SPONGE BATHS
• Teach signs that indicate shunt malfunction.
• Instruct on how to pump" the shunt

Symptoms of Increasing Intracranial Pressure

• Increased blood pressure occur
• Decrease in pulse, and Decrease in respirations may present
• High-pitched cry (infants)
• Bulging fontanelles (infants)
• Unequal pupil size or response to light may show
• Can cause Irritability or lethargy with Poor feeding and potentially a Headache
• Posturing from infant

OPISTHOTONOS

• Severe hyperextension and spasticity caused by neurotoxin of C. tetani

BE FAST (signs of stroke)

• Balance: Watch for sudden loss
• Eyes: Check for vision loss
• Face: Look for an uneven smile
• Arm: Check if one arm is weak
• Speech: Listen for slurred speech
• Time: Call 911 quickly

STROKES

• A stroke occurs every 40 seconds
• 795,000 Americans are diagnosed with a stroke.
• Term describes disruption in blood flow to the brain
  • A blockage of vessels is an ischemic stroke
  • Bleeding into the brain causes a hemorrhagic stroke
• Sudden blockage of a cerebral blood vessel, causes a reduction of oxygenated blood
• Causes an abrupt onset of clinical manifestations

ISCHEMIC STROKE

• Cerebral blood vessels may be opened or recanalized using IV recombinant tissue plasminogen activator
• Allows a blood clot to be dissolved at the site and Restores blood flow to ischemic neuronal tissue
• Intra-arterial thrombolytic administration
• Measures to prevent complications of stroke
• Complications include Hemorrhagic transformation can be life threatening
• The Cytotoxic edema and Weakness or paralysis of the extremities may follow
• Disorders of speech May result if there is facial muscle or cranial nerve weakness and patient may experience Apraxia, or Depression

HEMORRHAGIC STROKE

• Subtypes include Nontraumatic subarachnoid hemorrhage (SAH)
• Can be caused by Intracerebral or intraventricular hemorrhage
• Treatment mitigates complications and surgically evacuates hematoma (below tentorium) – Nontraumatic subarachnoid hemorrhage causes additional complications including those in the systemic system. – Ischemic stroke, cerebral edema, pulmonary edema or myocardial ischemias

TRAUMATIC BRAIN INJURY

• Has an epidemiology of 1.7 million people per year sustaining a traumatic brain injury
• 52,000 die from their injury
• Costs related to TBI are often financial and human
• TBI Often occurs in conjunction with other systemic injuries
• Types of head injury include skull fractures and hematomas, contusion, concussion, diffuse axonal injury or vascular injury
• Management focuses on minimizing the damage and managing intracranial pressure
• The team can promote cerebral perfusion and ICP-monitoring
• CT, transcranial Doppler and laboratory analysis may be called for
• Surgical management is dependent on type of injury
• Craniotomy procedures are possible

NEUROGENIC SHOCK

• Is a distributive shock causing vasodilation and hypovolemia.
• Threatens underlying conditions due to hypoperfusion
• Result of spinal cord injury or stroke in brainstem
  • Also results from high doses of barbiturates, anesthesia use etc Clinical manifestations include hypotension and bradycardia
• Causes peripheral vasodilation
• Focused on correcting the primary etiology and treating cardiovascular effect
• Complications include Systemic hypoperfusion that cause systemic organ failure, and Bradycardia

CUSHING'S TRIAD

• Irregular respirations
• Bradycardia
• Systolic Hypertension
• Wide Pulse Pressure