Nursing Considerations for 3 Neuro ICU Meds

Nursing Considerations for 3 Neuro ICU Meds

This is some quick info on a few very common meds you run into in the neuro intensive care unit. However, please always follow your hospital’s policies and procedures.  This is for informational purposes only and focuses on nursing considerations.. not going in depth on the drug.

Nursing Considerations for 4 Neuro ICU Meds

Propofol or Diprivan

We love this med with all of our neuro hearts. It is given IV as sedation for patients with increased ICP or for patients with seizures. A continuous propofol infusion is one of the options for someone who is having continuous seizures (status epileptics). It is NOT a pain medication. To get this med, they must be intubated or are the process of being intubated

Why we love it: it works quickly and wears off quickly, allowing us to get a quick neuro assessment. You can detect changes quickly, which is essential.

Interesting fact: they were attempting to use it for executions, but the manufacturer refused to supply it for that need

Nursing considerations:

  • You must frequently change the tubing (usually every 12 hours)
  • You must pause it to complete a neuro assessment (usually only a few minutes needed to get the assessment)
  • Work with your dietician to ensure your enteral feeding formula is appropriate. If you are weaning it or increasing it significantly, they may need to change it. Lots of calories!
  • Weight based, make sure an accurate weight is in the chart
  • Watch for hypotension and oversedation
  • If a patient is getting this for status, make sure you know if they want you to pause it for assessments (most likely not) – make sure there’s an order
  • Always flush the line – never pause and leave for a while.. it will clot your line!
  • Titrate to clinical response – don’t just coast. Back off if you need to, increase if you need to.

Mannitol

Mannitol is an osmotic diuretic given to decrease ICP. It doesn’t cross BBB. You increase the plasma osmolality to pull fluid off the brain and out of the body. It increases intravascular volume (pulls fluid into the vessels) and therefore cardiac output.

Interesting fact: it’s actually a sugar alcohol also used in the food industry. It’s a naturally occurring substance found in marine algae and mushrooms.

Nursing considerations:

  • Make sure your serial labs are ordered: q6hr BMPs most likely
  • Holding parameters! Make sure you have an order or know when the MD wants to be notified
    • Serum sodium: typically around greater than 160 (normal = 135-145)
      • You want to drive the sodium up to remove fluid, but not TOO much
    • Serum osmolality: typically greater than 320 (normal = 275-295)
  • Can cause renal failure because of intra-renal vasoconstriction and intravascular volume depletion
  • Increases CO so watch patients with CHF
  • Administer through a filter set or draw up with filter needle
  • If the vial is crystalized, send back to pharmacy to re-warm

Hypertonic Saline (3%)

Used to treat hyponatremia and cerebral edema.

Interesting fact: hyponatremia is the most common electrolyte imbalance

Basically it is salt water. Some docs will use this, some will use mannitol for increased cerebral edema. Evidence is not super awesome about if one is much better than the other.

Nursing considerations

  • Probably will need a line
    • Use judgment.. mild hyponatremia with only one dose.. talk with doc
  • Watch for a rapid increase in sodium. Shouldn’t rise more than 8-12 mmol/L. in 24 hours. Otherwise central pontine myelinolysis can occur.
    • Severe damage of the myelin sheaths of the nerve cells in the brainstem. A BIG deal. They can become paralyzed and die. Extent of damage depends on how many axons get damaged.
  • Watch for fluid overload signs/symptoms
  • Serial sodium labs ordered, q6hrs

Be sure to check out Week 1: Neuro Assessment and Week 2: ICU Time Management.

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!

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Perfecting Your Craft – Week 2, ICU Time Management Tips

Perfecting Your Craft – Week 2, ICU Time Management Tips

Craft beer this week:  Coffee is for Closers, an iced coffee stout by Fullsteam Brewery in Durham, NC.

The ICU is dynamic and things change constantly and quickly. Patient conditions and staffing change significantly in an instant. No two shifts will be the same. However, it is important to know what your routine would be if you are adequately staffed, have an appropriate assignment, and nothing happens that changes your plan (which happens q3years, I know!)

Remember, these are suggestions. Time management is not the same for everyone. Adapt as you see fit. As long as tasks are complete and needs are met, you’re good to go. This is a starting off point.

Assumptions: this is day shift, you have two patients, and a CNA is working with you

Report

  • Maximize this time
    • Look at orders (what needs to be done immediately, sooner, later)
    • Look at meds (make sure none are overdue, look at what is due 0900 and before and if you need to get it from pharmacy/is it very time sensitive)
  • While they’re talking, look at all of your lines
    • What needs to be changed, when?
    • How much is left of your fluids/drips? Do you need to get new ones sooner rather than later?
  • Mentally plan your day
    • When will you change your lines, do you have any procedures/scans/tests?
  • Learn to give and receive report efficiently
    • 30 min is MAX for report
    • Speak concisely when giving report, don’t ask questions until the end when receiving report
    • It’s not a time to catch up with buds – it is precious time
    • When you’re done – LEAVE! Don’t linger!

Consolidate Constantly

  • Complete meds, a turn, assessment, and chart all at once
  • Spending slightly more time in a room and completing more tasks at once is much faster than one task at a time with each patient. You’ll be constantly chasing your tail. It’s better to complete tasks slightly early or slightly late than everything is late.
  • If an MD is rounding and completing an assessment, complete one then as well and save yourself another trip
  • Be proactive with educating patients/families while in the room to cut down on questions/call bells just to answer questions

Stay ahead

  • Move quickly at the beginning to get everything done. Beginning of shifts are busiest between meds and getting that first assessment charted
  • Even if you are ahead or don’t have anything pressing going on, move fast to get these things done. You never know what’s about to happen.

When the chaos ensues…

  • Immediately think: “who needs me most right now?”
    • Stop and breathe. Ask a coworker for help prioritizing if you don’t know.
    • Everyone may try to make you think that what they are worried about/asking about is a priority, but only YOU know the needs of both of your patients. Be unapologetic about this, even if someone is mad. You can’t make everyone happy when patients are unstable/have immediate needs.
    • Delegate to your coworkers the task-oriented things, not the things that require you to provide information about your patient that would take too long to explain

Charting

  • If you are pressed for time, chart the ABNORMAL things only and go back and fill in the “chart this same basic thing on everyone” stuff later. So if their assessment was normal except for their lungs and their peripheral pulses, just chart those things in real time and then go back later. It is really, really easy to forget this stuff.
  • If you don’t have time to chart anything at all, at least chart “reassessment” or at least one thing at that time so you have a time stamp.
  • Learn shortcuts. The faster you can chart, the more efficient you will be. The less time spent charting, the better. This doesn’t mean chart LESS, this means chart more EFFICIENTLY. Focus on less clicks, learn the shortcuts, read the updates or tips and tricks sent out by IT via email.
  • If deemed appropriate, copy and paste your assessment and change what needs to be changed (saves a LOT of time)

Sample morning of time management

  • Before report: print telemetry strips
  • 0645-0700: Report on patient #1, quick intro, and “I’ll be back shortly after I get report on my other patient.. do you need anything before I come back?” Check to see if you need to bring any replacement drips/fluid when you return.
  • 0700-0715: Report on Patient #2
  • 0715-0730: With patient #2, introduce, educate, assess, chart (only a few things.. stuff you would easily forget), give any meds (typically minimal at this time), level your lines check your alarm settings, see if you need to replace any fluids/drips. Before leaving the room, check to see your 0800/0900 meds for patient #1 and get those on your way back to #1’s room. Be quick and efficient.
  • 0730-0800: Back to patient #1 and educate, assess, chart, turn, level lines, check alarms. Once 0800 hits, scan and administer all 0800 and 0900 meds and replace fluids/drips. Before leaving the room, check #2’s chart to see what you need to bring in to that room for 0800/0900.
  • 0800-0830: Back to #2 and medicate, turn, finish charting
  • 0830-0845: At nursing station, interpret/chart tele strips and double check orders/chart to make sure you haven’t forgotten anything

If nothing happens, which is rare, you’ll be done with everything at 0900. It is essential to be as caught up as possible constantly because you never know who is going to be unstable and what’s coming through the door.

What are your ICU time management tips?

Be sure to check out Week 1: Neuro Assessment and Week 3: Neuro ICU meds.

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How to Assess An Unconscious Neuro Patient Like a Neuro ICU Nurse

How to Assess An Unconscious Neuro Patient Like a Neuro ICU Nurse

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.

This post contains affiliate links.

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:

Neuro-specific blog posts:

Book recommendations:

    

References

 

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