front. Fixed eyes would be positive and is bad. Oculovestibular reflexes tested by caloric testing Spay ice water in their ear. Eyes should turn away from the ear that is being squirted with water. Table 21-6 has diagnostic tests for neurologic disorders pg 480 – 484. Good reference for any testing we discuss in these 4 chapters
PHYSICAL ASSESSMENT Vital signs: Rise in systolic pressure and a widening pulse pressure may indicate an intracranial pressure (ICP) increase ICP increase also possibly slow, bounding pulse, irregular and labored breathing Mental function and level of consciousness: Glasgow Coma Scale (table 21-7) FOUR (Full Outline of UnResponsiveness) Newer, used for comatose or intubated patients who can’t speak Score 0-4 in four categories: eye, motor, brainstem, respiratory
NEUROLOGIC AND NEUROMUSCULAR STATUS Orbital pressure Pinch the trapezius Mandible pressure Sternal rub: Purposefully withdrawing from the stimulus or an attempt to push it away Nonpurposeful response – Posturing Failure to respond at all Decorticate (flexor) posturing – cortex injury/ better Decerebrate (extensor) posturing – brainstem injury
FIGURE 21-10: DECORTICATE POSTURING
FIGURE 21-10: DECEREBRATE POSTURING
PHYSICAL ASSESSMENT Pupillary reactions – test brainstem Controlled by cranial nerves II & III Direct reflex – eye with the light CONSTRICTS!!! Consensual reflex – opposite pupil CONSTRICTS!!! Pupils that remain fixed and dilated = brain damage One pupil that remains fixed and dilated = increased ICP Table 21-8 has good pupil info “Neuro” check (LATE RESPONSE) Vital signs, level of consciousness (LOC), pupil reaction, and motor function Can be ordered q 15 min to q 8hrs
SAFETY ALERT PG 488 If changes in data indicate a rise in ICP or a decrease in LOC, it is important to alert the charge nurse and physician. This is even more important when possible intracranial bleeding is suspected as it may indicate an emergency situation.
NURSING DIAGNOSES Ineffective breathing Impaired mobility Self-care deficit Dysphagia Incontinence Bladder program Bowel program Pain Confusion Aphasia Sexual dysfunction Psychosocial concerns Ineffective family coping (Also refer to Table 21-9.)
INEFFECTIVE BREATHING Monitor the adequacy of respiratory effort and promote patent airway and chest expansion.
- Fall '19