Neurovascular Assessment

Adult Nursing NCLEX Review Neurological System Neurovascular Assessment

#1 Neurological assessment is level of consciousness. If the LOC changes, there is a problem!

Shine a light and pupils constrict. Remove the light and pupils dilate. PERRLA = pupils equal, round, reactive to light and accommodation. Size of pupils 2-6 mm. Pupillary reaction is mainly assessing CN III.

Minimum score = 3 (Severe neurological impairment). Maximum score = 15 (fully alert client). < 8 = Unconscious client.

Decorticate posturing is a reflex pose that causes the legs to become rigid and straight, while the arms flex upward and hold tensely to the chest (core of the body). DECORTICATE THE ARMS TO THE COR. posturing causes extremities to extend and hold rigid. Decerebrate has many “E”s so thing “arms EXTEND.” Decerebrate posturing = SEVERE brain damage.

The pressure inside the skull increases, leading compression of brain. Commonly occurs in clients with traumatic brain injury

Coughing, Sneezing, Suctioning, Agitation, valsalva Maneuver (bearing down), Vomiting, Avoid fever; ↑ brain oxygen needs., Avoid Rectal thermometers, Lumbar punctures (lead lead to brain herniation), Prevent shivering

Bradycardia, Cheyne-Stokes breathing, Increased pulse pressure. Cushing Triad: 190/50= wide pulse pressure (Pulse pressure = 190-50=140). HR 50 = bradycardia. RR 9= abnormal breathing.

Midline position of the head. Placing HOB 15-30 degrees. Prevent flexion of the neck and flexion of the hips. Keep PaCO2 between 30-35 mm Hg. Elevated PaCO2 causes vasoconstriction ⇒⇑ICP. Maintain normal ICP 5 to 15 mm Hg. ICP monitor is inserted in lateral ventricle. Maintain a cerebral perfusion pressure 60 to 100 mm Hg

Mannitol will remove water from the brain and take it to the vessels.
Mannitol will cause kidneys to make more urine
Major side effect: Pulmonary edema. Monitor for lungs for crackles. Remember Mannitol takes fluid from the brain and takes it to the vessels. Vessels take fluid to the heart/lungs.

Mean Arterial Pressure (MAP) = (2(DBP) + SBP)/3
Example: 120/70
(2(70) + 120)/3 =87
Cerebral Perfusion Pressure = MAP – ICP
Example if ICP is 12 and MAP 87
CPP = 87 – 12 = 75

ICP Symptoms again

Vision changes (blurred vision or diplopia). This is due to papillledema (swelling of the optic nerve).
Changes in LOC
Cheyne Stokes respirations
Headache
Pupil changes
Abnormal posturing.
Seizures
Vitals: Increased BP with widenining pulse pressure, bradycardia, and decreased respirations. This is Cushing’s triad.
In children: bulging fontanels, high-pitched cry, and irritability

Treatment

Assess neuro status
Prevent overhydration
HOB 15 to 30 degrees.
Keep head midline
Antiseizure medications
Steroids to decrease inflammation
Mannitol (watch for heart failure/pulmonary edema)
Avoid narcotics or medications that depress breathing.

Oculocephalic reflex. The absence or abnormal response of the Doll’s eyes reflex can be indicative of neurological dysfunction, especially in the brainstem. If the eyes do not move in the opposite direction when the head is turned, it may suggest impairment in the brainstem, potentially due to injury or pathology.