Top Tips for New Neuro Nurses

New neuro nurses, this guide is for you! There are so many things to remember and new processes to learn. I’m laying it all out for you so you can be prepared for your new adventure.

Top Tips For New Neuro Nurses

You are going to be working with the most critically ill patients. You are going to need the keenest eye for detail and calm demeanor. More than that, you’ll also need the ability to react fast to anything that changes.

These are my best tips for anyone that is a new neuro nurse. I wish I had these tips when I first started.

If you prefer video you can see my video on New Neuro Nurse Tips instead.

1. Know The TOP Disease Processes Landing Patients in a Neuro Unit

Who are you going to take care of? It’s important to know why someone is in the neuro unit so you can give them the best care.

The top disease processes that land people in the neuro unit include:

• Ischemic stroke
• Subarachnoid hemorrhage
• Intraventricular hemorrhage
• Intracerebral hemorrhage
• Subdural hematoma
• Hydrocephalus

There are a lot more that are very important but these are the most important ones to know like the back of your hand.

2. Know Your Patient’s Sodium Level

Just like you would know your cardiac patient’s potassium level – you must know your patient’s sodium level.

It is important that you remember both the brain and the kidneys play a role in water regulation, and therefore a problem with either can lead to problems with sodium levels in the blood.

When the sodium level is too low, cells swell. (“Oh, hell the cell is swelled!”)

What does swelling mean? They get bigger. That’s a HUGE problem if you’ve got a neurologically compromised patient who may already have too much pressure in their brain because of the injury itself… add on to that the cells in the brain begin to swell!? It’s often too much.

This is especially dangerous when the levels drop quickly. Chronic versus acute hyponatremia is important to know. Did your patient come in with a Na level of 131, or have they been like that for months and are hyponatremic at home?

When the level is too high (hypernatremia), it can cause problems as well. You’ll find though that we’re more often worried about it being too low. When the sodium is too high, the water rushes out of the cells and causes them to shrink.

Sometimes, in neurocritical care, we actually drive up the sodium level intentionally to decrease the intracranial pressure! But we must do so carefully because when levels get too high this can also cause cerebral edema (the very problem we’re often trying to correct!). And, if the cells shrinking is severe enough, it can actually cause the rupture of veins in the brain and cause intracerebral hemorrhage (source).

3. Get A Good Baseline Neuro Assessment

Don’t just get a report on your patient and let the off-going nurse take off right away. Do a quick neuro exam with the off-going nurse so you can ensure you’re on the same page as far as neuro deficits are concerned.

Getting a baseline is crucial because neuro changes are often subtle. It can be really tough to quantify or gauge the change if you didn’t get a good idea of their neuro status at the beginning of the shift.

As you’re getting this baseline assessment down, please pay particular attention to their level of consciousness and orientation. We can tend to get lost in the long checklist of a neuro assessment, but it’s also really important to step back and quantify the big picture before us.

You need a definitive answer to these questions:

• How much stimulation does it require to get them to wake up? Meaning, will they open their eyes and look at you with just verbal stimulation… do you have to tap their shoulder… shake their shoulder… or even use painful stimuli (like a trap pinch) to wake them?
• Can they follow commands with all 4 extremities readily?
• Do they fall asleep during the assessment or easily lose focus?
• Are they truly oriented? (Make sure you ask a direct person/place/time/situation question)

So, if it’s six hours into your shift and they don’t seem like they’re responding as they had been you can mentally take yourself back to your very first assessment at the beginning of the shift.

Ask yourself these questions again and try to quantify the changes.

• Does it require the same amount of stimulation as it did earlier to elicit the same response?
• Has their ability to follow commands as readily as before deteriorated?
• Are they able to consistently answer orientation questions?

4. Make Sure The Patient REALLY Knows Their Orientation Questions

Alright, here’s a neuro pet peeve of mine: When a nurse asks identical orientation questions every hour for the entire shift. Patients often memorize the right answers after 1-2 neuro checks so you really don’t know if their neuro status has deteriorated.

Change up your questions.

Maybe first thing in the morning you ask:

• Can you tell me your name?
• What year is it?
• Where are you right now?
• Do you know where you are?

And later you ask:

• Is your name John? (Knowing it’s not John, then giving them a few options with the right one mixed in)
• What holiday did we just celebrate?
• Are you at home right now?
• Do you remember what happened the other day and why you’re here with me right now?

You must ask straight forward orientation questions, even if it feels silly. If it’s too awkward for you, consider prefacing with, “Ok, humor me here! I’m going to ask you some really important questions that may seem obvious but your ability to answer them really tells me how your brain is doing in a way that these machines and monitors can’t.” Then throughout the day, you can say, “Pop quiz time!” when you need to ask them again.

5. Practice Describing Neuro Changes To Your Preceptor

I know, this sounds silly but bear with me.

Quantifying changes is crucial, but learning this isn’t intuitive. We may see these changes in front of us, but giving words to what we observe is much more challenging.

Not: “The patient is sleepier and I’m concerned.”

Rather: “Earlier the patient readily responded to verbal stimuli whenever I entered the room. However, now, I have to turn on all of the bright overhead lights in the room, speak loudly, and shake his shoulder for him to open his eyes and focus on me. He falls back asleep within a minute.”

The neurointensivists, neurologists, and neurosurgeons are relying on our ability to not only notice when things are changing, but also our ability to clearly explain what’s going on so they can make the appropriate medical decision.

Providers can’t just drop what they’re doing and come to the bedside to assess the patient themselves every time you call with a change. Often, neurosurgeons are scrubbed into surgery! So when you have a patient who has changed in their neuro assessments, even if you don’t have to call the provider, practice describing what you’re seeing to your preceptor.

Therefore, describe what’s going on, compare that to your previous findings, and quantify whenever you can so they fully understand the change

The more comfortable you can become with all of the neuro-related terms, the better. You’ll trust yourself more, as will the providers you work with.

Explore Further

Here are some more resources about neuro nursing you should check out next.

• Neuro ICU Nurse – What You Need to Know
• Neuro Nurse Tips for Newbies, Podcast Episode Part 1
• Neuro Nurse Tips for Newbies, Podcast Episode Part 2
• Neuro Nurse Tips for Newbies, Podcast Episode Part 3