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Learning Scope #376
1 contact hour
Expires Jan. 16, 2014
The goal of this continuing education offering is to provide current information to nurses on neurological assessment. After reading this article, you will be able to:
1. Identify five components of the neurological assessment.
2. Describe clinical findings that indicate neurological impairment.
3. Describe methods used to enhance communication in the aphasic patient.
4. Discuss three nursing interventions used to decrease intracranial pressure.
- The authors have completed disclosure forms and report no relationships relevant to the content of this article.
Evaluation of neurological status and level of consciousness is an essential part of nursing at the critical care level. Regardless of diagnosis, patients can experience neurological deficits and changes in mental status based on their current condition, medication regime or acute changes in their overall condition. The recognition of a change in mental status can make a significant impact on a patient's prognosis. Early identification of neurological deterioration is vital to preventing secondary brain injury.1,2
The physical assessment can reveal numerous clinical indications that can influence patient care and medical management. This article will summarize the neurological assessment of the critical care patient, which may consist of those with known neurological diagnoses and patients that have a normal baseline assessment. After reviewing this article, the professional nurse will be able to perform both basic and advanced neurological assessment skills, identify acute neurologic decompensation, describe the obstacles to communication in the aphasic patient and discuss postoperative management for the neurosurgical patient.
Acute Subdural Hematoma
A 62-year-old female was admitted to the neuro ICU with an acute subdural hematoma following an unwitnessed fall at home. The patient arrived to the ICU awake and alert, registering a Glasgow Coma Scale score of 15. The patient reported frequent falls at home, and often felt dizzy or complained of muscle weakness. Neurosurgical physicians have been consulted to evaluate the patient but have not advised surgery at this time. A repeat CT scan is ordered the following morning to reevaluate the hematoma. The critical care nurses will perform an hourly neurological assessment and observe for changes in condition.
Hours after admission, the patient becomes lethargic, arousing only to tactile stimuli and complains of a headache. The patient drifts off to sleep easily, and her breathing pattern becomes rapid and shallow. The nurse alerts the physician, who arrives at the bedside. Upon assessment, the pupillary response to light has become sluggish, and the patient is experiencing episodes of bradycardia. Systolic blood pressure increases, and is managed using intravenous antihypertensive medication.
The patient is transported to radiology and a repeat CT scan of the head confirms the subdural hematoma has increased in size from the initial scan. Left untreated, the cerebral edema may cause downward herniation of the brain stem and cause irreversible brain damage or death. The physician will perform an emergency craniotomy and evacuation of the hematoma to relieve increasing intracranial pressure.
The physician updates the family on the patient's condition and potentially poor prognosis. The primary nurse alerts the chaplaincy service to provide support for the family as the patient is prepared for emergent surgical intervention.
In order to evaluate level of consciousness, most healthcare facilities utilize the Glascow Coma Scale (GCS). The GCS is considered the most sensitive indicator of a lapse in neurological functioning and is often to earliest sign of acute change in intracranial pressure.3 Translating the motor response, verbal abilities and alertness findings to a numerical score minimizes the subjective aspect of the physical assessment. Nurses in all levels of care should be familiar with the GCS and consistently incorporate it into the neurological assessment, regardless of diagnosis.
The neurological assessment should begin with alertness and arousability. A patient who is "alert" engages in appropriate conversation and follows both simple and complex commands, implying an intact limbic and reticular activating system. A patient who is simply "awake" will demonstrate a lack of interaction and appropriate behavior. These patients will open their eyes spontaneously but fail to follow commands or verbally communicate. Lethargy is a progressively decreased state of consciousness, describing a patient who requires additional verbal or tactile stimuli to be awakened.
Decreased Pain Response
In patients with advanced levels of a decreased consciousness, producing painful stimuli should begin with the least intrusive measures. Simple and gentle techniques such as shaking the patients shoulder to awaken them or pinching the subcutaneous tissue on the hand or arm might provide enough stimulation to observe a response. Additional noxious stimuli can be produced by rubbing the knuckles along the sternum or by using a hard object to provide nail bed pressure. When performing this assessment, it is important to make both the patient and family members aware of the rationale behind painful stimulation, as it can be upsetting for others to witness.
Level of consciousness is often relayed in terms of GCS, but because it can vary tremendously, it is best communicated among healthcare professionals when supplemented with narrative describing specifics behaviors or deficits. In the case study described earlier, a change in the patient's level of consciousness initially triggered the nurse to alert the physician and initiated the physician's decision to perform life-saving surgery. Because communication is an essential component to the neurological assessment, both the oncoming and outgoing nurse should perform a simultaneous exam at change of shift.
Speech & Vocal Deficits
There are numerous psychosocial factors that can impact a patient's ability to formulate or utilize appropriate words. A language barrier, flat affect and neurological impairment are some of the many conditions that prevent normal communication. Patients may be unable to properly verbalize orientation to self, person and time when asked to do so. Further action must be taken by the professional nurse to determine if the absence of appropriate speech is due to a benign factor or true neurological deficit.
Aphasia is a clinical indicator of damage to the brain that affects the ability to produce and understand speech. Typically, patients who experience speech deficits have hypoperfusion to Broca's area, which contains motor neurons that control speech.4 Deficits of this nature can be extremely challenging for a patient, as communication becomes difficult and frustrating despite other neurologic functions remaining intact.
The nurse performing the neurological assessment should remain mindful of the aphasic patient's limitations, allowing adequate time for answering questions and providing prompting of words or pictures in order to initiate a response. By providing prompts, the patient is likely to formulate a verbal response by repeating or when given choices. For example, the nurse may ask the patient to state the month. The aphasic patient may stutter, uses multiple interjections ("uh" or "um") before formulating a word. Providing a choice of answers ("Is it May or June?") or sounding out the first letter of the correct answer may assist in generating speech. In order to redirect and refocus when a patient becomes discouraged, the nurse may suggest the patient watch the mouth of the person speaking in order to demonstrate formulation of words.
In addition to supporting and assisting the aphasic patient, the nurse should also educate family members of the patient about speech deficits and strategies to improve communication. In the event the patient has speech deficits or other types of language limitations, a more reliable indictor of a true neurological assessment may be the ability to follow commands or the presence of purposeful movement.
Brain Stem Reflexes
As the patient described shows signs of decompensation in terms of her mental status, other clinical indicators begin to manifest. A change in normal responses of the
cranial nerves suggests the brain stem has begun to become affected, likely from the increasing size of the hematoma or generalized cerebral edema. A lack of response in any single reflex is a sign of neurologic impairment, as the intact brain stem will provide protective reflexes without the individual being conscious. The assessment of brain stem reflexes is often performed by a physician, but can be completed relatively quickly during the nursing assessment.
In a normal individual, pupil size and shape will be round and symmetrical and respond equally to light. The patient with brain stem compression may display unequal pupil size, a sluggish reaction or absent reaction to light. In a neurologically intact individual, the pupil will constrict immediately when exposed to light. Pupil size may also be affected by medications such as narcotics, benzodiazepines and atropine. It is necessary to be mindful of these side effects, as they should be incorporated into the neurological assessment. A difference in size or reaction to light is indicative of impaired neurological function and should be reported to a physician.
The corneal response is often evaluated in congruence with the pupillary assessment, as the intact patient will be inclined to blink upon foreign contact with the eye. The corneal reflex in patients with decreased responsiveness can be stimulated by stroking the lashes of the eye, or using gauze to gently make contact with the cornea and assess for blinking or movement of the eye.
The cough and gag reflexes are vital indicators to a threatening decompensation of brain stem reflexes. Patients who fail to produce a cough or gag reflex when the oral cavity is stimulated are unable to provide airway protection, which may be accompanied by a poor inspiratory effort.5 These patients will generally require immediate intubation, as the patient is unable to protect their airway from foreign body or body fluid aspiration. In the event advanced airway placement is not immediately available, the patient should receive bag-valve mask support to ensure adequate ventilation is taking place.
The lack of the pupillary, corneal and cough/gag reflexes during the neurological assessment are clinically significant findings that will require immediate surgical or medical intervention. The assessment of additional cranial nerve reflexes by nursing personnel is generally not required, unless expressly desired by the physician or during the brain death examination. Additional cranial reflexes may be examined by the nurse as well but are generally carried out by a physician.
Motor reflexes can be a significant part of the neurological assessment, especially in patients who are nonverbal or orally intubated. The nurse will begin evaluating motor reflexes with gentle tactile stimuli, progressively increasing to noxious stimuli as needed.
In the absence of following commands, a localized response is seen when the patient demonstrates purposeful movement toward the source of pain. Withdrawal involves moving only against gravity or laterally in response to pain. A lack of response may be related to high pain tolerance, the use of sedation or analgesic medications and the presence of neuromuscular blockade. A lack of motor response will prompt the nurse to deliver additional noxious stimuli, such as nail bed pressure and sternal rub.
Other stimuli may occur throughout the head-to-toe assessment, such as during endotracheal suctioning, phlebotomy and hygiene care. It is important to understand the neurological assessment is not a singular event, but an ongoing and evolving evaluation. It is the responsibility of the professional nurse to recognize abnormal findings or changes in mentation in any patient and report them immediately.
Other medical states can contribute to an "abnormal" neurological exam. Physiological or disease processes, medication administration or certain clinical states can all affect the neurological assessment. However, they are challenging to the professional nurse as these patients are often a threat to their own safety or the safety of others. It is the responsibility of the nurse to evaluate the situation and perform the actions within their scope of practice to maintain patient safety while collaborating and communicating with the physician.
Alternative techniques to control behavior are the preferred method of restraint in patients with neurological conditions. Though they may be indicated by the physician, the utilization of narcotics or benzodiazepines will alter the true neurological assessment and may mask other acute changes in clinical presentation.
The patient returns to the ICU postoperatively following a craniotomy, evacuation of hematoma and insertion of a ventriculostomy catheter. In the immediate postoperative period, the critical care nurse will perform hourly neurological exams and note expected and abnormal findings. The nurse will document the presence of cranial reflexes, response to pain and ICP level. The physician will also order a repeat CT scan of the head following surgery, and other scans may follow based on the clinical presentation.
The physician may chose to use a short-acting method of sedation, such as propofol, which can be quickly excreted and provide a true neurological exam in a shorter period of the time. The nurse may also be required to titrate medication infusions to ensure the patient's safety and maintain a normal ICP. Propofol has a rapid onset that occurs in approximately 30 seconds and is typically eliminated in 30-60 minutes, providing a window for a neurological assessment in the absence of sedatives while minimizing the time for potential adverse effects.6
In the event a patient should require a continuous infusion of sedation and analgesia for longer than a 24-hour period, a sedation interruption should be performed in which either the nurse or physician perform a clinical exam in the absence of medication. The nurse should be mindful discontinuation of sedation can cause severe agitation and increased intracranial pressure, and pose a threat to patient safety. When using continuous sedation, the primary nurse should be aware of the policy guidelines established by the healthcare facility.
Following surgical intervention, it is at the discretion of the physician to utilize a drainage device for postoperative intracranial pressure (ICP) management. External interventions include decreasing the auditory and focal stimuli of the room, providing comfort measures and increased the head of bed angle. Family education is also a critical intervention, as the nurse may need to request that they not change the position of the patient and that verbal and tactile stimuli be kept minimal to reduce elevation in ICP.
The findings reported based on the neurological assessment will dictate the care and further interventions of the patient. The primary nurse will be the "eyes and ears" of the neurosurgical team as this nurse will be performing the most frequent assessment. It is critical to have good communication with the covering physician regarding the current clinical presentation and to alert the physician immediately in the event of worsening signs or symptoms.
Two days after surgery, the ICP levels have stabilized and the physician asks the nurse to wean the sedation and analgesia infusions and evaluate the patient for extubation. Shortly after, the patient remains intubated but begins to become more awake and responds well to verbal reassurance when agitated. The patient has a Glasgow score of 11 and meets the appropriate parameters for extubation. The patient is extubated without difficulty and is placed on nasal cannula. The physician removes the ventriculostomy at the beside and places a dry dressing at the insertion site, with is monitored by the primary nurse for potential CSF leakage.
The patient remains stable, and although noted to have difficulty formulating words is able to follow simple and complex commands. Knowing the residual expressive aphasia is an expected finding, the nurse suggests a speech pathology and physical therapy consult to assess functional rehabilitation.
The patient continues to require assistance with activities of daily living, but is demonstrating improvement on a daily basis. The physical and occupational therapists recommend an acute rehabilitation facility where the patient will receive assistance in transitioning back to baseline activity. She will continue to see the neurosurgeon on an outpatient basis to evaluate her progress.
The patient has a strong likelihood of returning to her baseline level of functioning. The positive outcomes she has had are due to the collaborative efforts of the surgical, nursing and rehabilitation team. It is evident that each individual plays a role in the diagnosis, treatment and management of her primary injury. As the primary bedside caregiver, the registered nurse is a vital component in the overall patient outcome based on the expert neurological assessment.
To view the Course Outline and take the test online, click here.
For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.
References for this article can be accessed here.
Andrea McGinsey is a staff nurse in the surgical ICU and Anna Kirk is a clinical specialist in the surgical ICU, both at Albert Einstein Medical Center, Philadelphia.