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Disclaimer: this is a short and sweet explanation of a nursing assessment of an unconscious neuro patient.  

References are included at the end with supplemental information.  

Always refer to your hospital’s policies and procedures to guide your practice.

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I was a neuro ICU nurse for four years and worked with some amazing neuro ICU nurses, neurologists, neurosurgeons, and physician assistants. Below are some of the tips I’ve learned along the way!

Education for the family is critical

Before you even touch the patient, let’s chat education.

Let the family know about painful stimuli before you perform it. It can be pretty shocking for someone to see this, so please warn people beforehand.

Another thing that’s really important is to educate them about the importance of the frequent neurological assessments. Family members frequently want their unconscious loved one to do as much as possible (squeeze their hand, raise a finger, wiggle toes, etc.). This is a normal desire. They want them to do well.  However, it’s critical that the family allows their loved one to rest between assessments. I’ve just finished bathing, turning, and assessing a patient who needs to rest until I come back in 2 hours to assess them all over again… and before I walk out of the room I start to hear someone scream, “COME ON SWEETIE, SHOW ME HOW YOU CNA SQUEEZE MY HAND!” Please let them know how essential it is for the patient to save their minimal energy for your assessments.

Encourage and educate them about the importance of maximizing rest between assessments because these assessments.  This is essential because when changes in brain occur, they are evident in the assessments, not vital signs.

There are lots of beeps and buzzes in the neuro ICU.  Educate them about monitors, equipment, and when to worry. Some don’t realize that most of the equipment is connected to a monitor at the nurse’s station and will put on their call light with every beep (which would mean A LOT of call lights!).  Some will freak out with each beep, and some will even try to get the beeping to stop by themselves and press buttons they shouldn’t press. Proactively educate.

Unconscious neuro patient assessment tips

Here are some essential neuro ICU assessment tips!

  1. Pause sedation! You must pause sedation for each assessment unless an order tells you not to, otherwise you cannot accurately assess their neurological status
  2. Do your assessment the same way every single time – like your golf swing or how you would shoot a basketball… there should be a very specific routine you go through
  3. Look at CTs and MRIs and compare them to diagnosis
  4. Change in level of consciousness is usually the earliest reliable indication of a change in intercranial pressure (ICP)
  5. Vital signs / pupillary changes are LATE. If you’re just watching vitals and checking pupils, you’re missing something and your intervention will be too late.
  6. Do your first neuro assessment with the off-going nurse to compare
  7. Temperature can profoundly affect your assessment and increase ICP
    • For each degree increase, the normal metabolic demand is increased by 10%. They increase cerebral edema and infarction!
    • Temp changes does not typically signify a change in the neuro injury, but requires prompt intervention
  8. Keeping the head of bed at 30 degrees is ideal, unless contraindicated.  This keeps head midline, promotes venous return, which decreases ICP. However, make sure this isn’t contraindicated in your patient before implementing
  9. Avoid shivering and agitation, as this also increases ICP. Notify the MD if you’re noting either of these, as they’ll likely order something to decrease it.
  10. Don’t try to interpret your assessment in your documentation, just write what you see (so don’t write “seizure”, write what you’ve observed specifically, like “rhythmic twitching”)
  11. Know your acceptable forms of pain:
    • Trap pinch
    • Supraorbital pressure
    • Sternal pressure – not rub
    • Nail bed – can elicit a spinal reflex and be reproduced in a brain dead patient.. I only do this if I’m not getting a response

How to go through your neuro ICU patient assessment

Alright, now that you’ve gone through some basic tips, let’s go through a systematic way to approach assessing an unconscious neuro patient.

  1.  Look at vent – are they breathing over the vent before you stimulate them? What’s their respiratory pattern?
  1. Look at them before you touch them – are they making any movements? (Remember, your sedation is paused at this point.) Is this movement purposeful? Are they going for the ventilator, scratching themselves, picking at bed linen, and so forth? Does their face look symmetrical? Note their hemodynamics before you start getting them all riled up.
  1. Level of consciousness  – this is super important, people!
  • Awake / alert: do I really need to explain 😉
  • Confused: disoriented, agitation, poor memory
  • Lethargic: awakens, but takes some effort and is kind of cloudy when they wake up
  • Obtunded: needs repeated stimulation but falls back asleep
  • Stuperous: minimal movements, pain or vigorous stimulation needed
  • Comatose: no response to anything at all, not even pain
  1. Eyes, eyes baby
  • See if they’ll open them by themselves (“Sir, can you open your eyes for me?”)
    • If they will follow that command, see if you can get them to look in all four quadrants (look up here, down
      here, over here, etc.)
    • Walk from one side of the bed to the other, see if they’ll follow you
  • If cannot open eyes, do so for them and note that
    • Close them frequently for them during the assessment
  • Check pupils for size, shape, level of reactivity (brisk, prompt, sluggish, nonreactive, hippus).
  • Check blink to threat reflex by pretending you’re going to poke them in the eye, but don’t!
  • If blink isn’t present, check corneal reflex by using cotton or saline
  • Oculocephalic reflex/Doll’s Eyes: briskly move head with eyes open. If eyes stay fixed, that indicates loss of brainstem.
    • I always do this one with the doc, I’m not so great at telling this unless it’s painfully obviously
  1. Cough and gag reflex
  • Perform oral care, then touch back of throat with oral care kit and observe
  • Suction patient to elicit cough reflex, note facial response to further assess facial symmetry
  1. Can they follow commands?
  • “Grip my hand, show me two fingers, give me a thumbs up, wiggle your toes”
  • Must be repeatable and consistent
  • Educate family about reflexive movement
  • Assess all 4 extremities for commands
  • If no commands.. must elicit pain
  • See beginning for acceptable forms
  • Use your pain stimuli on each arm
  • Progression from best to worst..
    • Follows commands (yay!)
    • Localized pain: attempts to stop painful stimulus
    • Withdraws from pain: pulls away from stimulus
    • Flexion: flexes arm, note how far (midabdomen, nips), legs will extend
    • Extension: you’ll know this when you see it! Some will extend and then flex, legs will extend
    • No movement/response to pain at all (most ominous)
  • Plantar stroke – we do not want to see their greater toe fan
  • Assess tone!
  • Lift hand and drop.  Rapid drop = coma, slow drop = consciousness
  • Bend knees; put heels on bed and release
    • External rotation and drop = coma
    • Slow extension to bed = consciousness

Video demonstration of the above assessment

As part of a short series of videos, I performed a demo of an unconscious neuro patient on my husband. Here is the video!

More neuro resources

Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!

Enroll in Class

FreshRN Podcast episodes specifically related to neuro:

NRSNG Podcast Episodes specifically related to neuro:

Neuro-specific blog posts:

Book recommendations:

    

References