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

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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.

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
  • Cerebral perfusion 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
    • Helpful article, go to the end for the part on collateral circulation

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
  • Managing aggressively in neuro patients is essential
  • If your patient is newly lethargic, check their temp!

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:

• Blog post: How to Assess an Unconscious Neuro Patient Like a Neuro ICU Nurse
• Video:How to Asses an Unconscious Neuro Patient Like a Neuro ICU Nurse

FreshRN Podcast specifically related to neuro:

• Neuro Nurse Tips for Newbies, Part 2: Disease Processes
• Neuro Nurse Tips for Newbies, Part 3: Meds, Monitoring, Diagnostics, and Surgeries

Neuro-specific blog posts:

• Nursing Considerations for 3 Neuro ICU Meds
• How to Assess an Unconscious Neuro Patient Like a Neuro ICU Nurse
• Why is My Stroke Patient NPO?
• Nursing Blood Pressure Management in Stroke Patients
• Nursing Priorities for Ischemic Stroke Patients