NURSE-UN 1243 Adult and Elder Nursing 3 Week #3:Neuro Basics
Glasgow Coma Scale
Higher score = better you are
Physical Assessment
● Vital signs
● Cushing’sTriad - a response to ischemia from rapid brain injury
- Cushing's triad refers to a set of signs that...
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NURSE-UN 1243 Adult and Elder Nursing 3 Week
#3:NeuroB asics
Glasgow Coma Scale
Higher score = better you are
Physical Assessment
● Vital signs
● Cushing’sTriad - a response to ischemia from rapid brain injury
- Cushing's triad refers to a set of signs that are indicative of
increased intracranial pressure (ICP), or increased pressure in
the brain. Cushing's triad consists of bradycardia (also known
as a low heart rate), irregular respirations, and a widened
pulse pressure.
▪ Opposite the 3 symptoms of shock (↓BP, ↑HR, ↑RR)
1. Increase SBP with widening pulse pressure (gap between
systolic and diastolic BP increases)
2. Bradycardia
3. Altered Respirations slowed
● Temperature Regulation
● Injury to or dysfunction of hypothalamus temperature regulation
● Hypothermia
● Hyperthermia
● Pupillary Reactions
● Provides information about location of the lesion
, ● Assess for size, symmetry, shape, and reaction to light
● Head to toe assessment
● Nurses watch the trend over time--3mm at 8am but 2 hrs
later, change in LOC and pupillary size; make sure equally
round and reactive to light
Intracranial Pressure (ICP) ** Normal ICP = 5-15 mm Hg ** ICP
indicators are on exam I.e. “Pt is in for MVA 3 hours ago.
Which of these signs does the nurse expect to find?”
● Early Indicators
● The earliest sign of increasing ICP is a change in LOC (less alert, confusion, slurred
speech)
▪ Hemorrhagic stroke is the most common cause
▪ Make sure you do head to toe assessment RIGHT AWAY in the
morning or as soon as you get the neuro pt!!!
, ▪ Pupil size, vitals, LOC, and temperature are esp important in
neuro--track the changes and check often, like every hour,
get peers as witnesses and chart and escalate to dr, even if
they brush you off!!!
▪ Chart it!-Write who you spoke to, the date and time and what they said
● Papilledema ↑ICP causes swollen optic nerve and visual disturbances, H/A,
nausea
● Slurring of speech
● Delay in response
● Vomiting
● Late Indicators
● Further decrease in LOC
● Cushing’s triad
● Pupil changes
● Altered respiratory patterns
● Posturing
Management of Increased ICP
● ABC’s
o Intubate if glasgows under 8
● IV therapy and vasoactive agents
● Temperature control
● Body positioning fowler's (30-45 degrees)--gravity helps fluid flow
● Maintain ventilation (PaO2 >60 mm Hg)
● Osmotic diuretics increase urine output - mannitol
● Sedatives/paralytics since pt is high risk for seizures
o LOC changes → agitated/combative
o chemical restraint if risk of hurting self or others ***NCLEX--chemical restraint is
last resort
● Barbiturates-sedative
● Provide safe and protective environment
● Protect patient from injury
● Bed low position
● Side rails
● Frequent checks Q 15 Min or hourly
● Reorient
● Create calm environment pt combative/overwhelmed
● Noise kept to minimum
● Dim light at night
● Limit number of visitors at one time
Neurological Problems
Learning outcomes
1) Implement health promotion
practices related to neurological
health alterations identified by
Healthy People 2030 for the adult &
older adult population. Specifically
, related to:
• Stroke : Reduce Stroke Deaths
• Parkinson’s disease
• Normal pressure hydrocephalus (NPH).
2) Demonstrate clinical decision
making based on the integration of
information from multiple
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