1 Neuro Assessment for the Non-Neuro Nurse Terry M. Foster, RN, MSN, FAEN, CCRN, CPEN, CEN Critical-Care Clinical Nurse Specialist St. Elizabeth Medical Center Edgewood, Kentucky • Consists of 5 layers – Skin – Connective tissue – Aponeurotic galea – Loose areolar tissue – Pericranium • Highly vascular Scalp Skull • Formed by cranium and facial bones • Maxilla, immovable • Mandible, strong bone • Outer coverings – cranial bones and vertebrae • Inner coverings – Dura mater – Arachnoid membrane – Pia Mater Brain and Cord Coverings
13
Embed
Neuro Assessment for Scalp the Non-Neuro Nurse … · Neuro Assessment for the Non-Neuro Nurse Terry M. Foster, RN, ... Microsoft PowerPoint - Neuro Grand Forks ND [Read-Only] Author:
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Neuro Assessment for the Non-Neuro Nurse
Terry M. Foster, RN, MSN, FAEN, CCRN, CPEN, CEN
Critical-Care Clinical Nurse SpecialistSt. Elizabeth Medical Center
Edgewood, Kentucky
• Consists of 5 layers– Skin
– Connective tissue
– Aponeurotic galea
– Loose areolar tissue
– Pericranium
• Highly vascular
Scalp
Skull
• Formed by cranium and facial bones
• Maxilla, immovable
• Mandible, strong bone
• Outer coverings– cranial bones and
vertebrae
• Inner coverings– Dura mater
– Arachnoid membrane
– Pia Mater
Brain and Cord Coverings
2
Arachnoid Membrane Spider-like
• Not innervated and non vascular
• Forms a real space with the Pia Mater
• CSF circulates beneath the arachnoid membrane in the subarachnoid space
• The Pia mater supports the blood supply to the brain– Forms (with the Ependymal cells of the brain
and the blood vessels) the Choroid Plexus.
– Makes the CSF
Pia Mater - faithful, true
Parietal Lobe
Temporal Lobe
Occipital Lobe
Frontal Lobe
Lobes of the Brain• Frontal Lobe:
– Reasoning, planning, parts of speech and movement (motor cortex), emotions, and problem-solving.
• Parietal Lobe:– Perception of stimuli related to touch, pressure,
temperature and pain
• Temporal:– perception and recognition of auditory stimuli
(hearing) and memory (hippocampus).
• Occipital: – Vision
Functions of the Lobes
3
Neuro Physiology Concepts
Example: Increased Brain Volume
• Mass– Swelling of brain
• Leads to ICP
• Usually manifests as decline in LOC, followed by symptoms/signs on contralateral side
Space occupying mass
Cerebral Blood Flow (CBF)
• Affected by oxygen and carbon dioxide through autoregulation
• O2 = CBF and volume
• CO2 = Dilates cerebral vessels, CBF, blood volume
• CO2 = Vasoconstriction, CBF, blood volume
Measurements of the Brain
• Normal ICP is about 10 mm Hg– ICP > 20 are abnormal
– ICP > 40 severe
• Cerebral Perfusion Pressure– MAP minus ICP = CPP
– Maintain CPP >70 mm Hg
4
Goal: Maintain Cerebral Perfusion Pressure
Cerebral perfusion pressure: MAP - ICP
• Normal CPP– 60-100 mm Hg
• Most significant factor that determines cerebral blood flow– pressure at which brain tissue perfuse
Cranial Nerve Assessment
“On Old Olympic Tower Tops A Finn And German
Viewed Some Hops”
Cranial Nerves
5
Cranial Nerve Function/Assessment
Oculocephalic Reflex
• Doll’s Eyes– Clear C-spine film first– Move (turn) head back and
forth rapidly– Present doll’s eyes: the eyes
move opposite direction of head (good)
– Absent doll’s eyes:(pathological), eyes rotate with the head (fixed) or eyes moving disconjugately
• Lack of response (“fixed globes”) indicative of brain stem failure
Neuro Assessment
• Level of consciousness
• Vital signs
• Sensory/Motor function
• Pupil response
6
Level of Consciousness
• The most important indication of neurological functioning
• Alert & oriented X 3 – person, place, time
• Avoid terms like “semi-conscious” or “semi-comatose”
Vital Signs
• Cushing’s Triad (late sign)– Hypertension
– Widening pulse pressure
– Bradycardia
Sensory/Motor Function(Cerebellular Function)
• “How do they move their arms and legs?
• Extremity movement
• Hand grasps
• Pronator drift?
• Lower extremities
• Gait
Abnormal Posturing
• Decerebrate/extension: Arms at side, clinched fist, rotated outward
• Decorticate/flexion: Arms flexed, rotated inward next to the chest, towards the “core” of the body
• Bilateral? Unilateral?
7
Pupil Function
• Oculomotor nerve (CN III)
• React, React slowly, Fixed
• Later sign in increased ICP
• Is there a glass eye? Cataracts? Implants?
• Altered by many medications– Miotic – constrict (narcotics)