Nursing Issues

Nursing Issues

Paula Snyder

The performance of a thorough neurologic history and physical examination is of paramount importance and will enable the neuroscience team to diagnose the patient with neurologic disease rapidly and will expedite definitive treatment.

An accurate history may be difficult to obtain because of the patient’s neurologic status. Family members or a significant other may need to be called on for the patient’s history. Old charts and records may also need to be consulted. A detailed history should include the chief complaint, a history of the present illness, and a past medical history. A chief complaint includes a brief statement or response to the question, What brought you to the hospital today? A history of the present illness includes a description of the signs and symptoms, onset, location, severity, duration, frequency, and aggravating and/or alleviating factors. The past medical history should include the patient’s medical and medication history, substance use and abuse, sexual history, and family and social history.

The neurologic history should include assessment of pain, headaches, seizures, and changes in eating or sleeping patterns. It should attempt to derive answers to the following:

It is important to ascertain the mechanism of injury in trauma patients. Acceleration-deceleration, rotation, flexion-extension, and axial loading may cause specific brain or spinal cord injuries. These injuries may include coup/contrecoup brain injury, diffuse axonal injury, and spinal injuries. “Down” times and extrication times are also important. When did the trauma occur? How long was it before medical assistance was given? Discerning the patient’s hypoxia or hypotension at the scene of the injury may give clues to its severity or long-term prognosis. Finding out if there was vomit at the scene, for example, or if the patient had gurgling respirations can alert you to whether or not the patient has been predisposed to respiratory complications such as aspiration pneumonia.

The mental status exam is a brief assessment to test higher levels of cortical function. Asking simple questions regarding persons, places, time, and reason assesses orientation and attention. Is the patient able to answer questions during the interview, or is he or she distracted, needing to be redirected frequently? Assessment of remote and recent memory is tested with such questions as, What did you have for breakfast? and, Where did you grow up? or by asking the patient to recall three words told to him or her earlier in the exam. Have the patient name objects, such as a pen, paper clip, and comb, and their function or purpose. Have the patient read, write, and copy figures. Test abstract reasoning and judgment by asking the relationship between word pairs (cat-dog, comb-brush, hot-cold) or the meaning of a saying or proverb (e.g., “A stitch in time saves nine”). Refer the patient for neuropsychological evaluation if deficits are present.

Pupillary response is a function of the autonomic nervous system via cranial nerve (CN) III. Parasympathetic and sympathetic control causes the pupils to constrict and dilate. Before beginning the pupil exam, dim the room lights to prevent missing a minimal reaction.

The following steps are followed in a pupillary assessment:

Motor assessment includes a general assessment of

• Symmetry
  
• Muscle bulk
  
• Atrophy
  
• Tone: spasticity, rigidity, and flaccidity
  
• Strength
  
• Reflexes

Vital signs should be documented at least hourly. Careful attention should be paid to trends or gradual changes in vital signs and neurologic responses. These changes may not be noticeable on an hourly basis, but they are significant over time. A decrease in GCS of 2 points is significant and should be reported to the attending physician, as it may signal increasing intracranial pressure (ICP) or tissue hypoxia. Other hourly observations should include pupillary responses, extraocular movements, focused motor and sensory exam, strict intake and output, blood pressure, heart rate and rhythm, temperature, central venous pressure, and pulmonary artery pressures when available.

Changes in vital signs are often late; earlier signs of neurologic deterioration are increasing headaches, agitation, nausea/vomiting, and a sense of impending doom. You may also see cranial nerve changes, such as facial drooping or asymmetry, dysconjugate gaze, and pupillary changes. There may be increasing pronator drift, muscle weakness, and posturing. Brainstem reflexes (gag, cough, and corneal reflexes) should be noted upon initial assessment and during interim assessments, every 4 hours or more often as indicated. Seizure may also indicate neurologic deterioration. Acute changes in LOC may be a sign of silent seizure and should be evaluated by electroencephalogram (EEG).

Hypotension associated with head injury is usually a sign of a terminal event. In the NICU patient with signs of life, it is probably attributable to another cause, and it should be evaluated aggressively. In trauma patients, it may be caused by bleeding in the chest, abdomen, or pelvis, or associated with blood loss in long bone fractures, or it may be a result of spinal cord injury (SCI). Hypotension in high SCI is usually accompanied by bradycardia. Hypertension not associated with increased ICP may be caused by pain, fear, and anxiety. The patient may also have a known or unknown history of hypertension.

Respiratory changes may not be as evident in the NICU patient, who often comes to the unit already intubated on mechanical ventilation. Changes can still be observed, though. Respirations may become rapid and deep, as in central neurogenic hyperventilation. This type of hyperventilation serves to lower ICP by lowering partial pressure of CO₂ (PCO₂), thus causing cerebral vasoconstriction, but it may worsen tissue hypoxia. Cheyne-Stokes respirations may precede cerebral herniation. Agonal respirations often occur when death is imminent. Rapid respirations may result from hypoxemia. Inadequate oxygenation of the brain will result in secondary brain injury in the NICU patient. Respiratory monitoring should include continuous assessment of oxygenation status to prevent hypoxemia. The routine O₂ titration order “keep SpO₂ [pulse oxygenation saturation] greater than 97%” will not ensure optimum brain tissue oxygenation. SpO₂ and partial pressure of oxygen in arterial blood (PaO₂) should be correlated with arterial blood gases.

It is better to get a computed tomography (CT) scan than to guess whether or not a patient is deteriorating or just waxing and waning. Generally speaking, if the patient does not look as good postop as he or she did preop, you probably need to rule out postop bleeding. Do not just chalk up a change in neurologic status to the patient’s being “sensitive” to anesthesia. Subdurals do reaccumulate, epidurals do rebleed, and hematomas can develop in postop hematoma cavities. There may be delayed bleeding in trauma or stroke patients. Be aware and report changes to the physician promptly.

Recruit the patient’s family members. Make them your allies. Teach them the basics of patient care, and involve them in their loved one’s daily routine. When the patient has a neurologic disease or injury, he or she is probably going to need family assistance for activities of daily living, at least on a short-term basis, if not for the long term. Teaching family members early will help in their transition to caregivers. An added benefit is that they will not be calling you to the bedside constantly because they are anxious about every gurgle or alarm. Families are often the best alternative to restraint use in agitated patients. However, you must first observe the interaction between the family members and the patient. Do they have a soothing effect on the patient? Are they responsible and attentive to the patient? If they are, you may be able to reduce restraint use while improving the patient’s comfort level.

Family members need some distraction when their loved one is in the hospital. After the patient has passed the critical phase of his or her NICU stay, it is a good time to ask the family to begin compiling a “memory book” for the patient. It should include clearly labeled photos of family members, friends, pets, home, cars, and anything else of importance to the patient. This will help the patient remember and/or relearn who was in his or her life and what his or her life was like.

It is important to mobilize the patient as soon as possible. Sit the patient up in bed as soon as you can get an okay from the physician. Let the patient dangle his or her legs from the bed. The longer a person lies on his or her back, the harder it will be to move him or her. Use elastic support hose, and change positions slowly to help prevent orthostatic hypotension. Abdominal binders may also be helpful in SCI patients. Involve physical therapists as soon as the patient has passed the initial critical phase of his or her hospitalization. In the meantime, turn the patient frequently (every 2 hours or more frequently). If the patient is on prolonged bed rest, suggest some form of rotational therapy bed.