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
Skull
• Formed by
cranium and facial
bones
• Maxilla, immovable
• Mandible, strong
bone
Scalp
• Consists of 5 layers
–
–
–
–
–
Skin
Connective tissue
Aponeurotic galea
Loose areolar tissue
Pericranium
• Highly vascular
Brain and Cord Coverings
• Outer coverings
– cranial bones and
vertebrae
• Inner coverings
– Dura mater
– Arachnoid
membrane
– Pia Mater
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Arachnoid Membrane
Spider-like
• Not innervated and non
vascular
• Forms a real space with
Pia Mater
• CSF circulates beneath the
arachnoid membrane in the
subarachnoid space
Pia Mater - faithful, true
• 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
the
Lobes of the Brain
Functions of the Lobes
• Frontal Lobe:
Frontal Lobe
– Reasoning, planning, parts of speech and
movement (motor cortex), emotions, and problemsolving.
Parietal Lobe
Occipital Lobe
• Parietal Lobe:
– Perception of stimuli related to touch, pressure,
temperature and pain
• Temporal:
Temporal Lobe
– perception and recognition of auditory stimuli
(hearing) and memory (hippocampus).
• Occipital:
– Vision
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Example: Increased Brain
Volume
Neuro Physiology
Concepts
• 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
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Goal: Maintain Cerebral Perfusion
Pressure
Cerebral perfusion pressure: MAP - ICP
• Normal CPP
Cranial Nerve Assessment
– 60-100 mm Hg
• Most significant factor that determines
cerebral blood flow
– pressure at which brain tissue perfuse
“On Old Olympic Tower
Tops A Finn And German
Viewed Some Hops”
Cranial Nerves
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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
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Level of Consciousness
• The most important indication of
neurological functioning
• Alert & oriented X 3
– person, place, time
Vital Signs
• Cushing’s Triad (late sign)
– Hypertension
– Widening pulse pressure
– Bradycardia
• Avoid terms like “semi-conscious” or
“semi-comatose”
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?
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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)
– Mydriatic – dilate (Atropine, eye drops)
Increased Intracranial Pressure
Increased Intracranial Pressure
(ICP)
• Change or decrease in level of
consciousness
• Vital sign changes
• Decrease or weakness in extremity
movement
• Slurred speech
• Vomiting – especially projectile
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Increased ICP (Con’t)
•
•
•
•
Pupil response slow
Incontinence
Seizures
Progress to:
– Coma
– Respiratory arrest
– Bradycardia
Interventions for Increased ICP
•
•
•
•
Elevate HOB 30 degrees
IV – Normal Saline – slow rate
No Dextrose solutions or D. 50
No Valsalva
• Prepare for Stat CT
Interventions for Increased ICP
•
•
•
•
•
•
Immediate recognition
Time is crucial
ABC’s
Oxygen
Intubation, 100% oxygen
Bagging – don’t hyperventilate
Epidural Hematoma
• Blood above dura
mater
1-Head trauma
2-Loss of conscious
3-Lucid phase (“Really, I
think I’m OK.”)
4-Deteriorate – circling
the drain…
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Surgical Evacuation of
Epidural Hematoma
Epidural Hematoma
Subdural Hematoma
Subdural Hematoma
• Blood under the dura
mater
• Acute, subacute, &
chronic
• Trauma related
• Alcoholics & elderly
• Collection of blood
below dural
meningeal layer and
above the arachnoid
covering
• Tearing of bridging
veins
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Subdural Hematoma
• Older adults and alcoholics at risk
• Acute symptoms observed within 24
to 48 hours
• Sub acute symptoms observed
within 2 days to 2 weeks
• Chronic symptoms observed from 2
week to 3-4 months after injury
Cerebral Concussion
• Most common brain
injury
• May have brief LOC
• Retrograde amnesia
• Perseveration
(repeating statements)
• Nausea, headache
• Post-Concussion
Syndrome
Skull Fracture
Skull Fractures
• Linear
Clinical Manifestations
– Headache
– Possible decreased level of consciousness
• Depressed
– Headache
– Possible decreased level of consciousness
– Possible open fracture
– Palpable depression of skull “bony step-off”
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Battle Sign
• Ecchymosis at mastoid
area
• Later sign of basilar
skull fracture
Racoon Eyes
Coup/Contra Coup Brain Injuries
• Bilateral periorbital
ecchymosis
• Facial, orbital, or skull
fxs
• Early after injury
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Subarachnoid Hemorrhage
• Sudden onset
• “The worse headache
ever.”
• Altered LOC
– Irritable, restless
• N/V
Subarachnoid Hemorrhage
Treatment for Subarachnoid
• Prevent further rebleeding
• Surgery versus observation
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Thank you!
Terry M. Foster, RN
[email protected]
859-301-2159
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