Neurological Assessment And Disorders

Front 1

What are aspects of a focused neurological assessment?

Back 1

1. GCS/LOC
2. Pupillary response
3. Motor function
4. VS
5. Reflexes
6. Brainstem function (if appropriate)

Front 2

What are the three categories of the Glasgow Coma Scale?

Back 2

Eye Opening (4), Verbal response (5), Motor Response (6)

Front 3

What are the points for Eye opening?

Back 3

Spontaneously - 4
To speech- 3
To pain- 2
None- 1

Front 4

What are the GCS points for verbal response?

Back 4

Oriented- 5
Confused- 4
Inappropriate- 3
Incomprehensible- 2
None- 1

Front 5

What are the GCS points for motor response?

Back 5

Obeys Commands- 6
Localizes to pain- 5
withdraws from pain- 4
flexion to pain- 3
extension to pain- 2
none- 1

Front 6

What is decorticate posturing?

Back 6

hands up to chest in fists

Front 7

What is decerebrate posturing?

Back 7

hands at sides and fists facing out

Front 8

what are protective reflexes?

Back 8

They indicate brainstem function.
1. corneal/blink
2. gag reflex
3. swallow reflex
4. cough reflex

other reflexes:
oculocephalic reflex - dolls eyes
oculovestibular reflex- when the head moves to the right, the eyes move to the left etc.

Front 9

What is the most common neurological side effect of a frontal lobe brain injury?

Back 9

personailty inhibitions

Front 10

What are some fundamentals of metabolic activity in the brain?

Back 10

oxygen and glucose, blood supply and drainage, cerebrospinal fluid.

Front 11

What is autoregulation?

Back 11

the ability of cerebral blood vessels to adjust their diameter to arterial pressure changes within the brain. if a rapid increase in MAP occurs, the cerebral vessels constrict to prevent excessive distention of the cerebral arteries. If the MAP drops, the cerebral blood vessels dilate to maintain normal CBF and to prevent cerebral ischemia

Front 12

When does autoregulation fail?

Back 12

the cerebral vessels are sensitive to chemical regulators to maintain CBF, the partial pressure of carbon dioxide or oxygen and the hydrogen ion concentration.


carbon dioxide is the most poten agent that influences CBF. when PaCO2 is greater than 45, cerebral blood vessels vasodilate to increase CBF.

cerebral arteries are less sensitive to changes in PaO2, and CBF is not affected until PaO2 is 50 or less. this can cause cerebral hypoxia, vasodiilation of crebral vessels.

Front 13

What is the Monro-Kellie Hypothesis?

Back 13

The pressure volume relationship between ICP, volume of CSF, blood, brain tissue, and Cerebral Perfusion Pressure.

it states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. The cranidum and its constituents create a state of volume equilibrium, such that any increase in volume of one of the cranial consituents must be compensated by a decrease in the volume of another.
Example: an increase in lesion volume (epidural hematoma), will be compensated for by a downward displacement of CSF nd venous blood.

Front 14

Monro-Kellie Hypothesis
Skull contents

Back 14

Brain- 80%
Cerebral Blood- 10%
CSF- 10%

Front 15

What is intracranial pressure?

Back 15

A combination of the 3 compartment volumes. It is measured via the CSF- pressure exterted by the CSF within the ventricles of the brain.

normally, it is 5-15mmHg, but it is dynamic and fluctuates!

Front 16

What is cerebral perfusion pressure (CPP)?

Back 16

It depends on the cerebral blood flow and ICP. It is the pressure gradient necessary to supply adequate amounts of blood to the brain.

CPP= MAP-ICP
normal is 80-100mmHg

Front 17

What is increased intracranial Pressure (ICP)?

Back 17

intracranial pressure above the norm. sustained increases in icp can lead to herniation syndromes. herniation occurs through shifting of brain tissue from an area of high pressure to one of lower pressure.

Front 18

Primary causes of increased ICP.

Back 18

lesion, trauma, cerebral hemmorrhage, ischemic stroke, hydrocephalus, post-op cerebral edema, meningitis

Front 19

Secondary causes of increased ICP.

Back 19

airway obstruction, hypoxia/hypercarbia, hyper/hypotension, position, hyperthermia, seizures, metabolic disorders

Front 20

What are indications for placement of ICP monitoring?

Back 20

severe head injury, subarachnoid hemorrhage, brain tumors, stroke, meningitis

Front 21

What are the intracranial monitoring sites?

Back 21

subarachnoid, intraventricular, intraparenchymal, epidural

Front 22

What are nursing measures in increased ICP?

Back 22

1. VS/temp
2. neurological assessments
3. monitor drainage/ICP/CPP/waveforms/system&tubing, insertion site
4. sedation/analgesia
5. drain CSF as ordered
6. use strict aseptic technique
7. level/zero machines
8. notify physician when apropriate

Front 23

What are the priority nursing care measures of pts recieving ICP monitoring?

Back 23

-prevent complications
-maintain integrity of system
-drain CSF appropriately (open vs closed system)
-troubleshoot
-gather, document, report accurate data

Front 24

What is intracranial hypertension?

Back 24

ntracranial hypertension literally means that the pressure of cerebrospinal fluid (CSF) within the skull is too high.

ICP greater than 15.

Front 25

What are the early symptoms of intracranial hypertension?

Back 25

Decreased LOC (earliest)
Vomiting/HA

Front 26

What are some late signs of intracranial hypertension?

Back 26

changes in pupil reaction to light and size
Cushing's Triad (herniation)
diminished brainstem reflexes
abnormal extension (decorticate)
abnormal flexion (decerebrate)
changes in respiratory patterns

Front 27

What is cushings triad?

Back 27

a sign of increased intracranial pressure
1. systolic hypertension
2. change in respiratory pattern
3. bradycardia
**widening pulse pressure

Front 28

What are nursing measures aimed at decreasing/managing ICP?

Back 28

1. sedation - propofol
2. osmotherapy
3. CSF drainage- open vs closed
4. hyperventilation
5. barbituate therapy
6. maintain CPP

Front 29

What are some collaborative mgmt aims of ICP?

Back 29

therapy aimed at reducing the volume of one or more of the components. The head elevation positioning- now it is individualized to minimize ICP and maximize MAP. Avoid positions that decrease venous return from the brain!!


1. Keep the PEEP less than 20cm H2O.
2. Coughing/suctioning- allow adequate rest time.
3. Do not tie the trach ties too tight!
4. Hyperventilation- keep CO2 low, normal now.
5. Temp control- cerebral metabolic rate.
6. BP control
7. Sedatives and/or beta blockers
8. Hypotension- give fluids or inotropes
9. Seizure Control
10. Cerebral spinal fluid drainage
11. Maximize CPP

Front 30

How does the nurse maintain BP control in collaborative MGMT of ICP?

Back 30

- maintain in the high normal for adequate perfusion. Not too high or we have increased CBV (cerebral blood volume), which may increase ICP.

Front 31

How does the nurse maintain seizure control in collaborative MGMT of ICP?

Back 31

give anticonvulsants prophylactically. Seizures increase metabolic requirements- may have ischemia. Dilantin (phenytoin) and ativan.

Front 32

How does the health care worker perform cerebral spinal fluid drainage in collaborative MGMT of ICP?

Back 32

-ventriculostomy- pliable catheter is placed into the anterior horn of the lateral ventricle
-CSF drainage
-monitoring devise for ICP
-treatment to lower ICP
-aseptic technique

Front 33

How does the health care worker maximize CPP in collaborative MGMT of ICP?

Back 33

-diuretics and volume maintenance
Osmotic diuretics- mannitol
Non-osmotic diuretics- furosemide (lasix)
-serum osmolality 300 to 320 mOsm/L
-fluid volume maintenance

Front 34

How do you control the metabolic demand?

Back 34

Maximize CPP and perform sedation and pain control.

Maximize CPP- reduce noxious stimuli/pain/pressure. reduce metabolic demand. assist with patient care activities.

Sedation and pain control- use benzodiazepines, propofol, narcotics, neuromuscular blockades, and barbituates

Front 35

What are herniation syndromes?

Back 35

the goal of neurologic evaluation, ICP monitoring, and treatment of ICP is to prevent herniation syndromes!

the herniation of intracerebral contents results in:
-shifting of tissue from one compartment of the brain to another
-places pressure on cerebral vessels and vital centers of the brain

herniation rapidly causes death as a result of cessation of blood flow.

Front 36

Deterioration in brain function results in changes in:

Back 36

LOC, decreased GCS, pupillary/oculomotor responses, VS, and protective reflexes.

*these changes refelct an increasing ICP

Front 37

What is the GCS in a mild TBI?

Back 37

13-15

Front 38

What is the GCS in a moderate TBI?

Back 38

9-12

Front 39

What is the GCS in a severe TBI?

Back 39

GCS less than 8

Front 40

Assessment keys of the pt with a TBI.

Back 40

1. GCS
2. Pupillary response
3. motor function
4. VS
5. reflexes
6. brainstem function
7. respiratory function

Front 41

Diagnostic tests for a patient with a TBI

Back 41

CT, MRI/MRA, transcranial doppler, EEG, angiography, LP

Front 42

What is a hyperdynamic state?

Back 42

increased BP, HR and CO

Front 43

What do nursing priorities in mgmt of a TBI focus on?

Back 43

stabilizing VS, preventing further injury, and reducing increases in ICP and maintaining adequate CPP

Front 44

MGMT of a TBI includes:

Back 44

-managing secondary injuries
-brain trauma foundation protocol

Front 45

What is the Brain Trauma Foundation Protocol for management of TBIs?

Back 45

-early intubation
-transport
-fluid resuscitation
-CT Scan
-evacuation of lesion/mass/bleed
-management in an ICU with an ICP monitor

Front 46

What is a craniotomy?

Back 46

it is performed to gain access to portions of the CNS inside the cranium. It is used for tumor resection or removal, cerebral deccompression, evacuation of hematoma or abscess, clipping or removal of an aneurysm or AVM.

Patients needing critical care monitoring are usually at a greater risk for complications.

Front 47

Preoperative care for a craniotomy.

Back 47

Assess- document neurologic baseline
Diagnostic- blood tests, type and cross match, cxr, EKG
Teaching- avoid activities known to increase ICP, surgery specfic instructions

Front 48

Postoperative medical management following a craniotomy.

Back 48

care varies depending on the underlying reason for the craniotomy. management is usually directed at prevention of complications.

-intracranial hyeprtension
-surgical hemorrhage
-fluid imbalance
-CSF leak
-DVT prophylaxis

Front 49

Nursing management following a craniotomy.

Back 49

The primary goal of a postcraniotomy is protection of the integrity of the CNS.

-preserve adeqaute CPP
-promote arterial oxygenation
-provide comfort and emotional support
-maintain surveillance for complications
-initiate early rehabilitation
-educate patient and family

Front 50

What is a stroke?

Back 50

impaired blood flow. It is the third leading cause of death, and the leading cause of serious long term disability.

ischemic vs. hemorrhagic

Front 51

How to assess and diagnose a stroke.

Back 51

assess for a sudden onset of focal neurological signs lasting longer than 24 hrs

CT scan, EKG, CXR, echo, coags, electrolytes, glucose, renal/hepatic function, abgs, eeg, lp

Front 52

Medical management of stroke:

Back 52

Thrombolytic therapy- within 3 hours of onset of ischemic stroke.
airway management
BP control, temp, glucose management

Front 53

What is the thrombolytic criteria indications?

Back 53

acute ischemic stroke
3 hrs from symptom onset
greater than 18 years of age

Front 54

What are the contraidications for thrombolytic criteria in a stroke?

Back 54

intracranial hemorrhage
recent stroke
recent head trauma
uncontrolled HTN at time of tx
seizure at time of symptoms
A-V malformation, neoplasm, aneurysm
abnormal lab values

Front 55

What is a subarachnoid hemorrhage?

Back 55

a type of stroke, caused by a ruptured aneurysm or Arterio-Venous malformation (AVM). Accounts for 4.5-13% of all strokes, and is more common in women.

Front 56

Assess and diagnose a subarachnoid hemorrhage.

Back 56

"worst headache of my life"

-LOC, n/v, focal neuro defects, stiff neck
-S/s indicative of 'warning leaks' so take a good history
-CT scan
-LP
-Cerebral angiography

Front 57

Medical management of a subarachnoid hemorrhage?

Back 57

Medical Emergency!
-airway/ventilation
-support VS
-ventriculostomy
-rebleeding, cerebral vasospasm

Front 58

What is rebleeding?

Back 58

"Aneurysmal rebleeding" is a term that relates to the occurrence of repeated rupture in a previously ruptured aneurysm.

Front 59

How do we manage rebleeding?

Back 59

-BP control
-aneurysm clipping
-AVM excision
-embolization

Front 60

How do we manage cerebral vasospasm?

Back 60

-onset is usually 4-10 days after initial hemorrhage.
Hypertensive, hypervolemic, hemodilution therapy (HHH)
-Nimodipine- a CCB also great in subarachnoid bleeds
-cerebral angioplasty

Front 61

Structural/Surgical Causes of Coma

Back 61

trauma, hemorrhage, hydrocephalus, ischemic stroke, tumor

Front 62

metabolic/medical causes of coma

Back 62

infection, metabolic conditions, encephalopathies, hyponatremia, OD, intoxication, poisoning

Front 63

Medical management of coma.

Back 63

Emergency-
Airway. Thiamin, glucose, narcotic antagonist

-monitor neuro status
-support all body functions
-provide comfort/support
-eye care


***Administration of thiamin is often recommended in patients with coma or hypothermia of unknown origin, due to the possible diagnosis of Wernicke's encephalopathy.

Front 64

Collaborative mgmt measures of coma patients

Back 64

-ID/treat underlying cause
-protect airway
-support circulation
-nutrition
-eye care
-skin integrity
-monitor for complications
-comfort/emotional support
-plan for a rehab program