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

by | Jan 9, 2018 | Podcasts, Neuro Nursing | 0 comments

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Who You’ll Hear

Kati Kleber, MSN RN– Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center.

Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.

What You’ll Learn:

  • Increased intracranial pressure
  • Airway
  • Blood pressure
  • Neuro assessment
  • Impacts on assessment
  • Strokes
  • Hemorrhage

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

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.

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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


  • 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

Neuro Nurse Tips: 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


FreshRN Podcast specifically related to neuro:

Neuro-specific blog posts:

Picture of Kati Kleber, founder of FRESHRN

Hi, I’m Kati.

Kati Kleber, MSN RN is a nurse educator, author, national speaker, host of the FreshRN® Podcast, and owner of FreshRN® – an online platform created to educate, encourage, and motivate newly licensed nurses in innovative ways.

Connect with her on YouTube, Pinterest, TikTok, Instagram, and Facebook, and sign-up for her free email newsletter for new nurses.


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