Neurological Assessment

• Neurological alterations involve assessing illness/injury history along with mental status, consciousness level, and nerve/motor function
• Mental status includes level of consciousness and cognition
• LOC is assessed using the AVPU scale: awake, responsive to verbal, responsive to pain, or unresponsive
• Cognition assessment includes orientation and language skills
• Expressive dysphasia: difficulty in output or producing words
• Receptive dysphasia: inability to comprehend what's being said (commands)
• Memory assessment includes short-term recall of three common items after 3 minutes and long-term memory questions like birth place and high school graduation year
• Glasgow Coma Scale is used for eye opening, speech, and motor responses to assess brain injury
• GCS range is 3-15, with 3 indicating very deep coma and normal functioning at 15
• A GCS score below 8 suggests a coma
• Accurate GCS readings can be affected by medications and injuries
• Normal pupillary function includes pupils that are equal, round, reactive to light, and accommodate concentrically
• Motor function assessment includes symmetry of movement and strength in arms and legs
• Motor Function assessment also accesses muscle tone, posture (decorticate/decerebrate), and coordination
• Decorticate posture involves flexing the core ('protecting core')
• Decerebrate posture involves rigidly extended arms and legs
• Reflexes include deep tendon reflexes elicited by a reflex hammer, superficial reflexes, and pathological reflexes
• Pathological reflexes are present at birth, disappear as the nervous system matures, but reappear after injury like the Babinski reflex
• Sensory function includes sharp/dull discrimination, hot/cold sensation, and position sense
• Respiratory patterns indicate neurologic deterioration
• Mechanical ventilation changes respiratory rate assessments
• Ongoing hourly assessments include mental status (GCS), extremity motor function, pupil response, along with brainstem and cranial nerve function
• Be aware of symptoms indicating increased ICP
• Cranial vault components are brain tissue, blood, and cerebrospinal fluid (CSF)
• Monro-Kellie Doctrine states that any increase in one cranial vault component must be offset by a decrease in another to maintain normal ICP
• Normal ICP is <15 mmHg
• ICP >20 mmHg for more than 5 minutes increases risk for herniation
• Cerebral perfusion pressure (CPP) is calculated as mean arterial pressure (MAP) minus ICP
• Brain's compliance and ability to maintain intracranial pressure is limited, leading to dangerous increases in ICP with small volume increases
• Increased ICP can result from increased brain volume (cerebral edema, brain mass), increased blood volume (due to loss of autoregulation), or increased cerebrospinal fluid (hydrocephalus)
• Intracranial pressure monitoring is indicated for GCS scores of 3-8
• ICP monitoring assesses therapy response and augments neuro assessment
• Ventriculostomy is a common transducer system used to measure ICP
• Cluster care to minimize increased ICP from nursing interventions is key for nursing management of increased ICP
• Elevating HOB to 30 degrees and maintaining a neutral head position facilitates venous drainage and reduces ICP
• Assess ICP response when turning; avoid prolonged increases by returning to previous position
• Only suction when necessary with preoxygenation and limit to 10 seconds or less
• Assessment includes focused neuro exam and monitoring vital signs
• Cushing's Triad: widening pulse pressure, irregular respirations, bradycardia, indicates increased ICP

Medical Management of Increased ICP

• Airway vigilance, ensuring a patent airway is critical
• Maintain adequate oxygenation with PaO2 > 80 mmHg
• Use positive end-expiratory pressure (PEEP) with caution to avoid venous outflow obstruction
• Maintain adequate hematocrit
• Manage carbon dioxide to maintain PaCO2 between 35-45 mmHg while avoiding hyperventilation that could lead to cerebral vasoconstriction
• Osmotic diuretics like mannitol or hypertonic saline reduce brain tissue volume
• Avoid hypotension
• Address metabolic demands through temperature control, sedation, seizure prophylaxis, and neuromuscular blockade
• Traumatic brain injury can damage the scalp, skull, meninges, and brain
• Skull fractures are the most common
• A linear fracture which is the most common, typically has no long-term complications
• A depressed Skull fracture has a crater or part of the skull that just falls inward
• A comminuted Skull fracture: multiple linear fractures with slight depressed area, looks like an egg shell
• Basilar skull fractures are hard to diagnose on XR and indicate there is a fracture at the base of skull
• Raccoon eye bruising and bruising behind the ear (battle sign) are signs of a basilar skull fracturere

TBI Classification

• Primary TBIs are caused by direct impact to the brain
• Coup injuries occur at the point of direct impact
• Countercoup injuries distally occur on the opposite side of impact
• Concussions are caused by mechanical force of short duration producing minor, reversible neural deficits
• Contusions are mechanical force injuries that can lead to bleeding, bruising, and symptoms based on the injury severity
• Diffuse axonal injuries involve vasodilation and increased blood volume leading to increased ICP
• Prognosis is poor for diffuse axonal injuries and can result in global injury
• Penetrating injuries: deep lacerations of the brain tissue, at risk for bleeding and infection
• All hematomas carry risks for intracranial bleeding

Hematomas

• Epidural hematomas occur between the skull and dura, occurring rapidly after the injury
• Subdural hematomas occur in the subdural space and may show symptoms/blood at 48 hours (acute) or longer (subacute)
• Chronic: 2 weeks- months after injury
• Intracerebral hematomas involve bleeding deep inside the brain mass

TBI Management

• Nursing management includes reducing ICP, maintaining airway, oxygenation, and cerebral perfusion, along with preventing secondary TBI
• Post-Op Goals (Ex: craniotomy) include maintaining normal ICP and CPP, maintaining the airway and ventilation/Prevent F/E imbalances, preventing complications of immobility/Avoiding nutritional deficits and reducing incidence of infection

Acute Stroke

• Acute Stoke is the 5th leading cause of death
• Early recognition of signs and symptoms essential:Facial droop, Arm weakness, Dysphasia (speech difficulties)
• Acute Stroke-Ischemic (Clot somewhere) is from Large artery atherosclerosis/caused Carotid artery or Cardioembolic stroke from A-Fib: blood pools in the atrium/Endocarditis: vegetations or lesions that get ejected and travel to brain
• Lacunar Stroke has Small vessel occlusive disease (clot off small vessels), causes: HTN, hyperlipidemia, obesity, diabetes, can see physical and cognitive impairments
• Acute Stroke- Hemorrhagic is where Intracerebral hemorrhage (bleed right into the brain) most common cause is uncontrolled HTN or where it will be caused by Ruptured cerebral aneurysm

More On Acute Strokes

• With Arteriovenous malformation arterial and venous systems are linked together and are prone to rupture it is a congenital abnormality
• Dilated cerebral artery that ruptures which lead to Bleeding into subarachnoid space (SAH) where Patients are typically asymptomatic until these rupture
• Acute Stroke-Assessment the History includes the time of onset of symptoms (last known normal) along with doing Neuro exam which includes Mental status, cranial nerve function, motor strength, sensory function, neglect, coordination, and deep tendon reflexes and reviewing NIH stroke scale along with Airway, breathing, circulation,
• Acute Stroke- Signs and Symptoms with a General neuro assessment will show Facial drop, Unilateral extremity weakness/numbness, Slurred speech of inability to comprehend, Visual disturbances, transient vision loss, visual field deficit, Dizziness, incoordination, ataxia, vertigo, along with Hemorrhagic (SAH) variations (irritates the meninges) which is from a Localized headache, Nuchal rigidity, Pain above and behind the eye, PhotophobiaRestlessness/irritability/Worst headache ever with those symptoms it warrants an Acute Stroke- Diagnostic Testing
• Initial/testing with Acute Stroke is Head CT without contrast/ 12-lead EKG/Review tPa eligibility/Glucos/CBC/PT/INR, PTT, Electrolytes, urinalysisPotentia cardiac enzymes to r/o
• Medical Management for Ischemic Stroke needs Echocardiogram
• If a patient has Ischemic Stroke Medical Management- they will need to have know the Goal: BP < 220 mmHg; diastolic < 120 mmHg/ We want the blood pressure high, but not too high (we want to make sure we are perfusing) andIf the BP gets over the goal, we will give antihypertensives/they need to be Candidate for thrombolysis- tPa (rt-PA)/Hemorrhage most common complication (only within the first 36 hours of administration): have to have all the IV lines, foley, etc before we can give this medication
• Ischemic Stroke Medical Management needs Neuro assess q15 min x 2 hours, Q30 min x6 hours, Q1 hour x 16 hourwith Neuro, respiratory, and cardiac assessment when it comes to Nonthrombolytic candidate with a Goal: MAP < 130 mmHg/Maintain normal ICP and hemodynamic stability/Glycemic controlAnticoagulants and platelet aggregation inhibitors/ Potential BP and antiepileptic meds with that evaluation/Aspiration precautions > swallow evaluation is used
• Medical Management for Hemorrhagic stroke is Evaluation for surgical intervention/Glycemic management

Spinal Cord Injury

• Spinal Cord Injury can be from Motor vehicle crashes /Falls/Gunshot wounds/Sports injuries/Divin accidents
• With SCI you have Spinal shock: complete loss of sensory below the level of injury and what comes with Neurogenic shock: temporary disruption below the level of injury which you will see hypotension, bradycardia with

SCI- Assessment

• Assessments will include Airway and respiratory assessment, Paralysis of diaphragm, and intercostal muscles will result in ineffective breathing patterns, C1-C3 which will need ventilator dependent/will see Decreased HR with Hemodynamic instability The Following are Types of Neuro Injuries

• C4-C5 injury: may or may not need ventilator

• Below C5: have intact diaphragmatic breathing/you will need a Neuro: motor, reflex, sensory assessment/also Bol and bladder assessment for: retention or paralytic ileus/with skin break down and Impaired skin circulation and you need to psychologically assess with beginning assessment to see if the patient is really scared about surviving, then they get angry/or depressed with those initial indicators you will start with SCI Nursing-Management/ which need you to assess Airway, Cardiovascular stability//Goal MAP 85-90 mmHg and preform DVT prophylaxis, Gastric decompression, Skin care, Elimination depending the patient and the location of the spinal cord Injury AUTONOMIC DYSREFLEXIA is a very Important Assessment to review with an SCI

• AUTONOMIC DYSREFLEXIA (EMERGENT) Occurs T6 or above after resolution of spinal shock/You will need to know Intese sympathetic response to stimuli which is most likely because/ the patients Kinked urinary cathete and the pressure build is and/Fecal impaction/Clothes are on to tight with those combined factors this will present Severe HTN, severe headache, and bradycardia with that knowledge you need to assess and remove the cause** and they run the risk of a stroke, seizure, or other complications*** it will be determined if you asses correctly along with knowing that their SCI will require a Spinal cord stabilization or where/Surgical intervention (plates, rods, bone grafts) are required for spinal care it must included medication the correct: if you are a part of the

SCI- Medical Management

• Medications might include Glucocorticoids(help inflammation) and/or vasopressors/fluids or PPI

• The final evaluation will use IV fluid to stabalize the SCI

Trauma

• To understand trama its best to Understand the Levels of trauma care system the Levels are Model trauma care systems and Levels of trauma care that contain

  • 1: comprehensive trauma facility, can take everything, trauma teams that are readily available, leader in trauma and performs education for that community and surrounding area

• 2: comprehensive trauma care, trauma team that is readily available, the difference is that level 2 has no requirements to be a leader and provide education

• 3: stabilize the patient and then transfer to higher level of care

• 4: provide the bare minimum, advanced life support before transfer

• All types of trauma include the following Primary prevention, and Primary, secondary, and tertiary prevention

• To Stablize the best its important to use Trama team member which is the trauma surgeon, speciality physicians, anesthesia, social work Disaster and Mass Casualty requires a plan

• Trauma team member: trauma surgeon, speciality physicians, anesthesia, social work with understanding Disaster: sudden event that overwhelmed local EMS, hospitals, and community resources and can result from Fire, weather (earthquake, hurricane, floods, tornado), explosions, terrorist activity, radiation or chemical spills, epidemic outbreaks, human error (plane crash, multicar crash)/ requires Accurate triage methods

• Prehospital Care/Transport Emergency stabilization and quick transportPt transported to the most appropriate facility Treat immediate life-threatening conditions ABCs (with cervical stabilization): with our airway we HAVE to have cervical stabilization require both IV access and fluid administration and Hemorrhage control through Fracture stabilization All with requires you understand the proper Trauma Triage which can lead to Life or death situations

• Proper Trauma requires - Essential for determining if patient needs to be transferred to a level I trauma center,Criteria in place to guide decision,Triage- greatest good for the greatest number when patients out number resources which will determine ABCs and lifesaving interventions that need to be followed if patient with be Transported through Ground versus air transport method

• With Emergency Care Phase- all Prehospital data will be needed/ its important to know the Mechanism of Injury: blunt trauma, penetrating trauma (important to know everything on the scene) to ensure the Trauma unit will in a state of readiness: stocked with C-spine immobilization, ventilation, massive transfusions, IV supplies, etc so that Trauma surgeon must be present upon patient arrival, in the operating room, and during critical care interventions

• Each assessment needs to start with Primary Survey which should only take1-2 minutes,Identify life-threatening injuries that require immediate attention ABCDEFG-O which includesAirway patency (with C-spine immobile) needs care, you can do a nasal airway, but be aware that you should NOT do an oral airway on a patient who is awake, if GCS of 8 or less that patient has an inability to protect airway so we will place an airway, then follow though with proper Breathing and ventilation/as well has assesing is the patient Circulation and if they are hemorrhaging which can determine that the patient might need immediate care. All in addition it is imperative to know there are levels of the Disabilities such as LOC and pupils where as we need to fully Expose the patient (with environmental considerations) where we fully look for any other signs of trauma, consider any chemical factors, etc., carefully monitor body temperature that need life saving care and for sure at must Get a Full set of vital signs and gather focused interventions because the families need to be present and/or in the waiting area so that you get access to all the medical history and needed paperwork

• At all costs for these patients the need Resuscitative adjuncts: LMNOP- Labs and what includes them and to Monitor: cardiac rhythm, NG tube or OG tube and if needed be aware if they need Oxygenation along a understanding the need for controling the pain through certain Medications and know to Psychosocially support and educate

• With Secondary Survey assessment you will preform after life-threatening injuries are identified or ruled out for all body systems and you will get the History so that you will understand and complete a more the thorough head-to-toe

• For the Second Part of Secound Survey you must get gather Symptoms/ Allergies/Med/Past (medical/surgical history)/Last / Events -SAMPLE that is associated Traumatic Events

• You will need to continue to Maintain spinal cord stabilization and labe studies/ you will request Radiological studies, with all this in place you will seek Specialist physicians

• During all this remember Resuscitation Phase is a need to Focused: to establish effective circulatory volume/stable hemodynamic status with this is best to use Fluid Resuscitation and only place Replacement of patient's total blood volume in 24 where you and restore oxygen transport to tissues. Stop progress of shock and Prevents complications, be careful about Our goal is to prevent Over Resuscitate or under resuctate which at all cases as to be avoided at all cause at certain times depending if it is warranted that your actions can lead to Over resuscitation: or under resuscitation: this all should be done when we Monitor fluid status: BP, HR, LOC, Urine output, Lactate, CVP the goal if to keep risk low of Electrolyte imbalances and keep the patirnt warm or if its hot try and keep them cool its all determined on how they look and what signs may cause the other you the team to have this thought and plan in place to work as a team -Assessment and Management of Specific Injuries

• For that assessment that we will know what to expect with all possible Trauma will be from Specific Injuries you needed a TBI/ Spinal code for you to get the team to understand and/or even know what they are expecting and/or not knowing what is around the corner, that you have to atlease prepared the assessment

Cardio and Spinal Trauma and Shock

• Some tramuatic injuries are as follows Bleeding into pericardial space: impairs the ability for the heart to be able to and this need to be addressed that would come with the following assessmentLife threatening emergency and needs and Pulsus paradoxus
• The first priority is to know that Patient needs to be on continuous monitoring probably with an arterial and that a sign of the following Beck's triad are present :
• You will see the following signs or Beck triad ,Hypotension/Muffled heart sounds/Elevated venous pressure (jugular vein distention to asses this trauma and all can be found with the right diagnosis of certain Spinal cord injury/s which should be treated right way with following treat, Treat with perixardis and dythtimias if the patient shows it
• You can measure 12EKG to help assess with knowing and ruling out and you see that they are not doing go great then the team runs an Assess for any signs of ischemia that could've happened while tamponade was occurring: look at EKG and troponin"
• For spinal trauma the signs are little different because of the nerve damage but be ready to treat the injuries
• The signs are as Increased intrapleural and intrathoracic pressures where what we want to avoid so that they team/unit can to catch catch the issue before we see the last sigh
• "When you know and see for yourself that the team team is going to catch for because your assessment and the what the sigh is showing is there is a Air that are building into the lungs space so you can expect to se the severe side is of the following the (tracheal deviation away from side of injury)", you need to be ready to take Emergent treatment with needle thoracostomy: where yall need to be fast to releass some pressure so that you can avoid full lung deflation and so that we can start to help the treat that has the
• The treatments include the chest tube inserted you can see the patients start to breath again

Assess for other medical complications

• In order fully asses the patient you may see that some patients have
• Hemothorax(bleeding into the lungs) so that the patirnt you now will have the following sign Hypotension and respiratory distress which will mean that Chest tube insertion needed to (drain blood) and they is a Air (pneumo) in pleural space which will give the patinet Hypoxia and hemodynamic instability and to ensure that air doesnt fillup during
• Dressing secured there side because the other side is used from the air get out that (DO NOT tape fourth which now cause Tension is something like a balloon"

The Following is the Assessment of Thoracic Pulmonary Injuries and the treatment

• The treatment will range based off your patient to the following

• The patirnt "Bruising of lung tissue that will indicate - edema and leadint to Hypo, as well may require the patient to a ventilator and possible Rib fractures

• The sign that your patient may have a chest injury that may require more testing it when you assessment that that affects patients breathing: so do the team to provide pain management if this is present

• For Abdimoanal Assessment it is important to have FAST and type of ultrasound done with that you can determine what step to take in these cases

• Some of the signs will include Liver damage and as team you all decide to remove the object that caused a whole and then put that patient on"

Damage Assessments and Burn Wounds

• All wounds after and During a traumatic event are need immediate attention it is very Important to know what kind of wound it is because.

• if Pelvic patients can go wrong when the doctors start to work with the patient they can lose patients

• Multiple fractures needs a whole team and also Amputations/ for these types of injuries that is important to know/ that these patients may have high loss of blood Assess for neurological and/or vascular injury'

• The Following assessment is for the five Ps:Pain/Pallor(Pale/Pulses: as to be assessed for the full body/Paresthesia/Paralysis Treatment of hypovolemia is always important to know

• For most wounds, with or with out bone will need Treatment, a wound that the team/physians consider highly"

• Most likely you will see that the "pationt has Puncture due to how the force and the position the area was is high of a risk if the injury Complications of MS injuries also the same with MS injuries

• Injuries is high risk of Pressure that building up to make the "patient can't get full healing, this also mean that it has a Pressure which Main side effect is that the can also give rise to cause poor perfusion

• "Other complications is if a tissue has been injured in the injured with myoglobin into the blood, and that will in turn cause a lot of damage so that you the team and the the doctors is that you are helping you team by assisting the "

These things and more may or may not happened during Complications of MS injuries

• Complications of MS injuries also are as follow if a "Myoglobin it is one of the worst things because of what follows due to damaged which means that the Acute tubular necrosis
• This all need you to do everything by the book to allow lots of "
• "The end goal help to create a"
• With all this taken care it is important to be aware and give care in what it means with Crital is very important
• the Following with that information it is to understand the steps

End Goals With Trama Injuries

• Systemic assessment and monitoring/ with Continued resuscitation as well as to do all/ any and all patients priorities
• Stage I will be to Stop hemorrhage/ stabilize life-threatening injuries that could stop stage after the full assessment stage which may range, those ranges will include /Life-threatening injuries which is to STOP
• With team you have the goal to "help the patient stabilize by continuing this method"

Additional Facts for Wound Care

• The information is to know that/ Early enteral nutrin to help start parenteral with some form
• Patient comes to ICU: quick set of vitals LOC and quick look at all the skin in what type

Wound Injury

• "They have the risk of the following in""
• It is important to be and have the mindset to give some form the team may at first but during and at all times and give patients coping/ and what ever they might feel, there

Burns

• To begin most of the common form will be from"
• Burns with the following mechanism
• is what to expect

Burn Injury

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• Thermal
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• Also can see
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• What type they are in the you all

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• Partial thickness-2
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• You might see from Burns with the Following
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