You can listen to Episode 013 here.

NEURO NURSE TIPS FOR NEWBIES

Neuro Nurse Tips, Part 1: When to Worry, Disease Processes

Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, documentation for nurses, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.

Download the Episode 013 Neuro Nurse Tips for Newbies, Part 1 Show Notes or view them below.

This episode discusses neuro nurse tips with the main questions newbies to neuro have: if neuro changes are subtle, when do I worry? We also discuss common neuro disease processes including ischemic and hemorrhagic stroke, subarachnoid hemorrhage, intraventricular hemorrhage, and more.

Increased intracranial pressure

  • Monroe-Kellie Hypothesis – you’ve got to know this!
  • Brain + CSF + blood = components
  • If any one of those three increases, the other two must decreases/compensate, or increased ICP will result
  • Untreated cerebral edema will result in herniation, and subsequent brain death
  • You cannot get brain cells back; when they die, they die
    • Literally, time is brain
    • Early intervention is KEY

Airway

  • Typically, neuro patients are not intubated due to low oxygen levels
    • They are intubated for brain problems, not lung problems
  • The brain controls breathing
  • If there has been a neurological injury and/or edema, and there is pressure on the brainstem, their breathing will change
  • The brain is not able to tell the body to breathe properly and/or protect the airway (deal with normal oral secretions, keep the airway open) due to injury
    • This can result in aspiration pneumonia easily, as they may have a diminished or absent cough reflex
  • They may have a normal ABG and PaO2, but are working hard to breathe or simply not breathing enough
    • No alarms are going off… they just don’t look right
    • You do not want to wait until this is an emergency, this should be proactively dealt with
  • Their oxygen saturation may be okay, but that doesn’t mean their brain is actually getting enough oxygen
  • You cannot rely on the monitor, you must rely on your assessment

Blood pressure management

  • Increased BP can increase ICP
  • There is a delicate balance between ensuring there’s enough blood pressure to perfuse the brain, but not so much that it’s creating additional pressure
  • Know your blood pressure parameters – verify the order, the physician’s note, and the monitor to ensure all match up
  • Neuro exams can change with high and low BP’s
    • In ischemic strokes, higher blood pressure (even as high as 180-220 systolic) to ensure collateral circulation can perfuse to the vulnerable areas of the brain

Neuro assessment

  • It’s not just checking the pupils and following commands
  • Enables you to detect changes early, way before vital sign changes occur
  • Changes in the neuro assessment tell you if there are changes occurring in their brain
  • You must know your baseline assessment so you know if things change
  • Changes will occur in the neuro assessment FIRST, not vitals
  • Look at changes and trends in the assessment, you must continually compare
  • Important to be able to communicate findings to other nurses and providers – they are relying on you to let them know about the patient’s presentation when they’re not there
  • ALWAYS complete your first neuro assessment with the off-going nurse
  • Continual, consistent, routine assessment will be the difference of catching changes early and not
  • Must know how much stimuli it takes to elicit the same response and if that’s changed

What can impact your assessment

  • Sedation
    • You must pause your sedation for every neuro assessment to get an accurate neuro assessment
    • Use the least amount of sedation as medically appropriate
    • Typically, severely neurologically impaired patients do not require sedation because their injury is so profound
    • For awake, non-intubated patients, delicate balance between pain management and impairing the assessment with pain meds
      • No exact science for what’s too much and what’s not enough
      • Patient’s are different and dynamic
    • It’s up to the nurse to identify the change and communicate to the provider early to enable them to make the best decision possible for the patient before additional deterioration occurs
  • Fever

Ischemic stroke

  • When stroke is suspected, a CT will be done first to look for blood
  • MD’s decide if patient is eligible for tPA or another intervention
  • Monitor for hemorrhagic conversion, especially with larger areas of infarction
    • Closely monitor if patient is on asa and/or subcut heparin and has a larger infarction
  • Know where the stroke was and the size; age matters so if someone is older their brain atrophies and they have more room to swell
  • Peak swelling occurs 72 hours after the injury
  • Think of the brain like real estate
    • If a small bomb goes off in Manhattan, it does a lot of damage
      • Think brainstem
    • If a large bomb goes off in field in Montana, it may do less damage even though it’s larger
      • Think cerebellum
  • Permissive hypertension – we may let the BP run high to maintain perfusion to the penumbra

Hemorrhagic stroke

  • BP control is crucial – typically systolic less than 140
  • Know if they’re on blood thinners – make sure coag studies are done, as they may need to be reversed
  • Assessments are the same as ischemic
  • High risk for seizures – may be on an antiepileptic
  • The brain will slowly absorb the blood over time (weeks – months)
  • Follow up CT’s may be done to see if the bleeding has subsided
  • Surgery does not reverse damage that’s been done – important to educator

Subarachnoid hemorrhage

  • When blood is in the subarachnoid space
  • Typically in the ICU for roughly 2 weeks because of the many very serious complications that can result
  • Most common cause is trauma, fall… then aneurysms (most aneurysm ruptures don’t make it to the hospital)
  • First 24 hours is…
    • 1. Why did they have it?
      • CTA is typically done to identify this
    • 2. Fix the cause
      • If it was an aneurysm, go to surgery for clipping/repair
  • Cerebral edema is essential to monitor
  • Vasospasms – the blood in the subarachnoid space acts as an irritant to the outside of major blood vessels within that space and causes them to clamp down
    • Subsequent ischemic strokes can result

Intraventricular hemorrhage

  • You create and reabsorb cerebrospinal fluid in this ventricular space
  • You can get a hemorrhage in this space – which is bad new bears
  • That blood can sit in this space and start to clot
  • You are constantly creating and reabsorbing spinal fluid, however in this instance, the blood prevents this reabsorption from occurring, therefore increased pressure results
  • Hydrocephalus/ventriculomegaly results because of the increased pressure (basically the ventricles just get bigger because more and more fluid is building up)
  • May need an extraventricular drain inserted to relieve this pressure because we can’t tell the body to stop making cerebrospinal fluid
    • This is a device that a neurosurgeon inserts, but the nurse manages
  • Intraventricular tPA may be necessary to break up that blood that clotted

Resources:

FreshRN Podcast specifically related to neuro:

NRSNG Podcast Episodes specifically related to neuro:

Neuro-specific blog posts:

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