Neuro checks, ICP and stroke

The neuro check

• Check orientation to person, place, time and situation, and compare it with the client's baseline.
• Sedatives, pain medicines and paralyzing drugs can cloud the exam: note what the client has had.
• Compare the two sides of the face and body; they should match.
• Strength: 0 (no contraction) to 5; lower grades aren't tested against resistance.
• Expected pupils: equal, round, reactive to light and accommodation.
• Report at once: a change in mental status or pupil response, a facial droop, slurred or absent speech, sudden weakness on one side.

Glasgow Coma Scale

Scores: Eye opening, verbal response and motor response. On its own, 8 or less isn't a diagnosis of coma.

Rising intracranial pressure

Act early: Act on the early change in consciousness; don't wait for the late signs.

Lowering the pressure

• Head of the bed at about 30 degrees, neck neutral; check perfusion.
• A quiet room, less stimulation. Prevent straining with stool softeners.
• Meningitis: low sodium from water retention can raise the pressure further, so watch the sodium.
• Mannitol may be ordered. Untreated rising pressure can push the brain out of place, which can be fatal.
• Keep the neck midline, avoid sudden neck or hip bending, space out care, sedate cautiously.

ICP monitoring

• Intraventricular catheter: the most accurate; it can also drain cerebrospinal fluid.
• Subdural bolt: placed quickly. Epidural sensor: least invasive, but can't drain fluid.
• Adults: normal resting pressure commonly about 5 to 15 mmHg; treatment thresholds differ.
• High pressure: drain fluid through the catheter, adjust the ventilator, or IV medicines.
• Watch for bleeding, infection, and signs of brain injury or herniation.

Head injury

• Signs: loss of consciousness, headache, blurred vision, unequal pupils, nausea and vomiting, clear fluid from the nose or ears.
• Subdural hematomas are common in older adults after falls. Symptoms can appear right away, or hours or days later.
• Get help right away: marked sleepiness, odd behavior or speech, a severe headache or stiff neck, a seizure, unequal pupils, a weak arm or leg, any loss of consciousness, vomiting more than once.
• Assume the spine is injured too: keep the head in line with the spine. Possible skull fracture: don't press on the wound or remove debris.
• Don't remove a helmet if a serious head injury is suspected. Teach no alcohol or street drugs for 48 hours.

Meningitis

• Severe headache, stiff neck, high fever, sudden confusion, sensitivity to light and sound, vomiting, a rash of tiny spots.
• Kernig's: pain when the knee is straightened. Brudzinski's: hips and knees bend when the neck is flexed. Only a minority show them.
• Spinal fluid: normal is clear and colorless; pink suggests bleeding, cloudy suggests infection.
• Broad-spectrum IV antibiotics promptly, not waiting for a scan or lumbar puncture. Dexamethasone (community-acquired bacterial) helps prevent hearing loss.
• Suspected meningococcal or Hib: droplet precautions until 24 hours of effective therapy; pneumococcal: standard.
• Close contacts of meningococcal disease get preventive rifampin, ciprofloxacin or ceftriaxone.

Ischemic or hemorrhagic stroke

TIA: Stroke symptoms that fully resolve: a warning of a coming stroke. Teach clients and families to get help for any stroke sign, even one that fades.

Thrombolysis (ischemic stroke)

• Guidelines: alteplase or tenecteplase within 4.5 hours if eligible, plus selected imaging-based later cases; the label's 3 hours is narrower.
• The stroke team assesses eligibility. Not with bleeding in the brain, active internal bleeding, a bleeding disorder, brain or spinal surgery or serious head injury in the last 3 months, or severe uncontrolled hypertension. An INR over 1.7 is just one exclusion.
• Clotting tests like the INR are drawn, but don't hold thrombolysis for them unless anticoagulant use or a bleeding disorder is suspected.
• Alteplase: 0.9 mg/kg, max 90 mg; a tenth as a one-minute bolus, the rest over an hour. Control blood pressure closely during and after.
• No aspirin within 24 hours after thrombolysis, and only after follow-up imaging. Bleeding precautions.

BE FAST

Then: Stroke team. CT without contrast first, to rule out bleeding; check glucose too, since low or high sugar can mimic stroke.

Stroke nursing care

• Right-sided stroke: spatial awareness, judgment, impulse control. Left-sided: speech, language, analytic thinking.
• Acute phase: airway first, watch for seizures, frequent vital signs and neuro checks.
• Trained swallow screen before any food, fluid or oral medicine. Coughing while eating can signal aspiration.
• Dysphagia: as close to 90 degrees as tolerated, per the swallowing plan. Thicken liquids exactly as prescribed.
• Visual field loss: approach and place items on the intact side; teach scanning. Never lift by the weak arm.