Neuro Assessment & Glasgow Coma Scale

NEURO ASSESSMENT

• History is best provided by the patient
• Physical assessment includes evaluating the level of consciousness, cranial nerves, motor and sensory systems, cerebellar function, and reflexes

GLASGOW COMA SCALE

• Awareness of the patient's baseline and factors like sedation, paralytics, intubation, or restraints affect the ability to assess them fully

PEDIATRIC Nursing Tip: Altered Mental Status (AMS)

• AMS can result from PaO2 falling below 60 mm Hg
• AMS can result from PaCO2 rising above 45 mm Hg
• AMS can result from low blood pressure leading to cerebral hypoxia
• AMS can result from a fever where a 1° rise increases oxygen need by 10%
• AMS can result from drugs, specifically sedatives and antiepileptics
• AMS can result from being in a postictal state from seizures
• AMS can result from increased ICP

Neurological Monitoring of Infants and Children

• Monitoring includes assessing response to pain stimuli, arousal awareness, cranial nerve function, motor response, posturing, and pupil response

• Presence of asymmetrical pupils after a head injury with AMS requires diligent reassessment as this is a medical emergency

• Bulging fontanelles indicate increased intracranial pressure in infants

• Scalp vein distention can be a sign of increased intracranial pressure

• Ataxia and spasticity of lower extremities suggest neurological issues

• Abnormal Moro or tonic neck reflexes with withdrawal indicate neurological problems

PSYCHOSOCIAL CONSIDERATIONS AND AGE-RELATED CHANGES

• Patient and family responses are influenced by factors like age, general health, social status, chronic illness history, life experiences, job, and home responsibilities
• Altered social roles and body image issues are other influential factors
• Age-related changes in the nervous system involve motor and sensory changes, as well as alterations in thermoregulation

CARE OF PATIENTS WITH NEURO DIAGNOSES

• Neurological disorders can impact cognition, personality, mobility, and activities of daily living

Case 1: Headache

• A 22-year-old female presents with a persistent headache for 2 days at a college health center
• Potential differential diagnoses include meningitis, hemorrhage, migraines, stroke, stress, head injury, infection, dehydration, hypertension, medication side effects, or substance abuse
• Key assessments involve OPQRST (Onset, Provocation, Quality, Region/Radiation, Severity, Timing)
• Take history including LMP, PMH, head, urine, stool, sleep, eye exams, positioning
• Interventions involve hydration (2 liters), cool compress, avoiding triggers, and consistent caffeine intake
• Education focuses on avoiding triggers and keeping a headache diary

HEADACHE: Epidemiology

• Headaches are also referred to as cephalalgia
• Primary headaches lack underlying causes; they include tension, migraine, and cluster headaches
• Secondary headaches stem from underlying pathologies like infections, neoplasms, or vascular issues
• In the US, 20-40% of the population, including 5-9% of males and 12-25% of females, experience migraine headaches

HEADACHE: Pathophysiology

• Headaches are triggered by nociceptor reactions, which send messages to the thalamus via the trigeminal nerve
• 4% of the population experiences chronic daily headaches

HEADACHE: Clinical Manifestations

• Tension headaches can be episodic (10-15 days/month, 30 minutes to several days) or chronic (>15 days/month for >3 months)
• Cluster headaches are "neurovascular" causing severe pain in/around the eye
• Migraines have premonitory, headache, and postdromal phases
• Management includes headache diary, neurological assessment, and diagnostic testing (CBC, blood cultures, CRP, ESR, CSF analysis, imaging)

PRIMARY BRAIN TUMORS

• Originate in the brain and can be slow-growing/benign or highly malignant/aggressive

• Gliomas develop along curved areas, and meningiomas are most common

• Oligodendrogliomas are slow-growing and acoustic neuromas are known as schwannomas

• Manifestations depend on the tumor's location

• Treatment options: chemotherapy, radiation, craniotomy, and biopsies

• Diagnosis involves examining cells and analyzing specific characteristics

• Complications include intracranial bleeding, cerebral edema, vasogenic edema, seizures due to SIDAH, venous thromboembolism, and increased intracranial pressure

SEIZURES

• Epilepsy is diagnosed after two unprovoked seizures more than 24 hours apart

• Manifestations range from behavior changes to loss of consciousness

• Pathophysiology suggests genetic or developmental mutations affecting synapses or sodium channels, leading to neuronal hyperexcitability through abnormal glutamate or ineffective GABA activity

• Clinical manifestations include rhythmic jerkiness, automatisms, sudden loss of motor tone/incontinence, and daydreaming episodes with no loss of consciousness

• Diagnosis involves labs, CT/MRI of the head, and EEG

• Pre-EEG instructions: avoid fasting, ensure clean hair/scalp, avoid sedatives/stimulants 12-24 hours before

• Management: Antiepileptic drugs (AEDs) usually control seizures, and sudden cessation can cause status epilepticus

Pediatric Seizures

• Classified as febrile or epilepsy

• They are sudden, intermittent episodes of ALOC, lasting seconds to minutes, potentially involving involuntary tonic and clonic movements

• Intracranial causes include epilepsy, congenital anomalies, birth injuries, infections, trauma, degenerative diseases, and vascular disorders

• Extracranial causes that raise epilepsy risks include fever, heart/metabolic disorders, hypocalcemia, hypoglycemia, dehydration, and malnutrition

• Toxic causes include anesthetics, drugs, and poisons

• Common seizure triggers: flashing lights, startling movements, overhydration, and photosensitivity

• Seizures have three phases: aura, tonic/clonic seizure, and postictal

• Partial seizures account for 40%, and they allow consciousness that may be intact or impaired, and can be simple or complex

• Treatment is aimed at determining the cause, site, and type

• Techniques include: MRI, EEG, tests for electrolyte imbalance, poisonings and a lumbar puncture

• Choice of drug depends on seizure type

• Common side effect is drowsiness

• Take prescribed medications at the same time every day and do not suddenly stop taking them

• Suddenly stopping can cause status epilepticus