Stephanie Banfield. 1. Frontal Lobe Controls: Behaviour Emotions Organisation Personality Planning Problem solving Arteries: ACA, MCA. 5.

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3 1. Frontal Lobe Controls: Behaviour Emotions Organisation Personality Planning Problem solving Arteries: ACA, MCA 2. Parietal Lobe Controls: Judgement of shape,size,texture, and weight The sensation of pressure and touch Understanding of spoken/written language Arteries: ACA, MCA 3. Occipital Lobe Controls: Colour recognition Shape recognition Arteries: PCA Cerebellum Controls: Balance Muscle co-ordination Posture maintenance Arteries: Basilar PICA, AICA, SCA ACA = Anterior Cerebral Artery MCA = Middle Cerebral Artery PCA = Posterior Cerebral Artery PICA = Posterior Inferior Cerebellar Artery AICA = Anterior Inferior Cerebellar Artery SCA = Superior Cerebellar Artery Brainstem Controls: Alertness Blood pressure Digestion Breathing Heart rate Arteries: Vertebral Basilar 6. Hippocampus Controls: Object recognition Stores meaning of words or places Arteries: PCA 7. Temporal lobe Controls: Smell Identification Sound Identification Short-term Memory Hearing Arteries: MCA, PCA

4 Speech centres Broca; control the muscles of the larynx, pharynx and mouth that enable us to speak Wernicke s area, injury here may result in receptive dysphasia.

5 Contra-lateral Control

6 Blood Supply to the Brain

7 Stroke and Aetiology interruption of the blood supply to the brain, caused by a blocked or burst blood vessel cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. (World Health Organisation 2010) Cerebral infarction/ischaemic 81% Intracerebral haemorrhage 13% Subarachnoid haemorrhage 6% Risk of recurrence within 5 years 30-40% (Stroke Association 2010)

8 Stroke What do you do if you think your patient is having a stroke?

9 Lacunar Stroke

10 Ischemic stroke (Thrombo/embolic stroke) hypercholesterolemia hypertension Atrial fibrillation Ischaemic heart disease/angina Peripheral vascular disease Diabetes

11 Previous stroke/tia Smoking Increased alcohol intake Poor diet/obesity Increased ageatherosclerosis Oral Contraceptive Pill Drug misuse

12 Haemorrhagic Stroke Chronic high blood pressure. Amphetamine. Amyloid angiopathy Arterial Venous malformation (AVM), inflammation of blood vessels (vasculitis), bleeding disorders, anticoagulants,

13 Intracerebral and subarachnoid haemorrhage

14 Subdural haemorrhage and small vessel disease

Subdural Haematoma A subdural hematoma (American spelling) or subdural haematoma (British spelling), also known as a subdural haemorrhage (SDH), is a type of haematoma, usually associated with

15 Subdural Haematoma A subdural hematoma (American spelling) or subdural haematoma (British spelling), also known as a subdural haemorrhage (SDH), is a type of haematoma, usually associated with traumatic brain injury. Blood gathers between the dura mater, and the brain. Usually resulting from tears in bridging veins which cross the subdural space, subdural hemorrhages may cause an increase in intracranial pressure (ICP), which can cause compression of and damage to delicate brain tissue. Subdural hematomas are often lifethreatening when acute. Chronic subdural hematomas, however, have a better prognosis if properly managed.

16 Raised Intracranial Pressure Early Signs Later Signs Agitation Vomiting Headache Dilated pupils Increased systolic blood pressure Bradicardia Abnormal respiratory pattern

17 Causes and Treatment Causes Treatment Oedema Steroids Haemorrhage Manitol Tumour Hyperventilation Encephalopathy Hemicraniectomy

18 Hemicraniectomy

19 Neurological Assessment AVPU what does this mean? Blood sugar Pupils Then move onto GCS and full neuro assessment

20 Neurological assessment Why perform a neurological assessment? The reasons to perform a neurological assessment include: 1. Identify the presence of nervous system dysfunction 2. Detect life-threatening situations 3. Establish a neurological baseline for the patient 4. Compare data to previous assessments to determine change, trends and necessary interventions 5. Determine the effects of nervous system dysfunction on activities of daily living and independent function 6. Provide a database upon which nursing interventions will be implemented.

21 The Glasgow Coma Scale The GCS evaluates three key categories of behaviour that most closely reflect activity in the higher centres of the brain: eye opening, verbal response and motor response (Waterhouse, 2005). These categories enable the MDT to determine whether the patient has cerebral dysfunction. Within each category, each level of response is attributed a numerical value. The lower the value, the greater the neurological deterioration and resulting brain insult. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury. The lowest possible score is 3 which indicates that the patient is completely unresponsive. The aim of the GCS, is to get a firm baseline for comparison. Without this, you will be unable to recognise deterioration in the patient s neurological condition and will not be able to react appropriately.

22 Illustration of GCS

23 Eye Opening The assessment of whether the patient is eye opening shows that the arousal mechanisms in the brain stem are functioning and also demonstrates that the reticular activating system (RAS) has been stimulated. Eye opening spontaneously = 4 This is recorded when the patient is seen to be awake, with their eyes open. The patient should not need to be roused with either speech or touch. Eye opening to verbal command = 3 This should be achieved without touching the patient. Speak to the patient in a normal voice at first, then, if necessary, gradually raise the volume of your voice. They may respond better to a familiar family voice. Eye opening to pain = 2 To avoid distressing the individual, initially simply touch or shake their shoulder. If this illicits no response, deeper stimulus is required. At this stage it is recommended to use peripheral stimulation, as central painful stimulus is likely to make the patient grimace and screw their eyes shut. Apply pressure, using a pen, to the lateral outer aspect of the second or third finger. Pain should be applied gradually and last no more than 10 seconds. Under no circumstances should sternal rubbing or nail-bed pressure be used.

24 Eye Opening No eye opening = 1 This should be recorded when there is no response to a painful stimulus the nurse should be satisfied that adequate stimulation has been applied. Points to note if the patients eyes are closed as a result of swelling, this is recorded as C on the chart. If the patient has been diagnosed as being in a persistent vegetative state, they may still open their eyes and track movement, but they will not be aware of themselves or their environment.

25 Eye Opening Spontaneous Observed before you approach the patient or speak to him To speech Call the patient s name To pain None Apply pressure to the side of the finger (central stimulus to supraorbital nerve will cause grimacing and eye closure) Ensure painful stimuli is adequate

26 Verbal Response This provides the nurse with information about the patient s speech, understanding and functioning areas of the higher, cognitive centres of the brain. It also reflects the patient s ability to express a reply and illustrates whether they are aware of themselves and their environment. Orientated = 5 The patient should be able to tell you who they are, where they are and the current year and month. If ALL three questions are answered correctly, they may be classed as orientated. Confused = 4 If one or more of the questions is answered incorrectly, he patient must be recorded as confused. Typically, a patient who is deteriorating will lose orientation to time, place and person, in that order. Words = 3 Understandable conversation is absent or limited. Patients will offer words, rather than sentences, which make little sense in the context of the question. Often these words will be obscenities.

27 Verbal Response Incomprehensible sounds = 2 Although the patient s response may follow questioning, sounds are more often made in response to a painful stimulus. The patient may only be able to produce moaning, groaning or crying sounds. If the patient has sustained damage to the speech centres in the brain and is alert and awake but unable to talk, it must still be recorded as sounds. No verbal response = 1 The patient is unable to produce any speech or sounds in response to speech or painful stimuli. Points to note: If the patient has a tracheostomy or endotracheal tube, this should be recorded as a T on the chart. If the patient is dysphasic, this should be recorded on the chart as D Cannot get 15 as a score!!

28 Verbal Response Orientated Confused Knows time, place, person should know who he is, where he is and why he is there and know the month, year, season. If patient answers one or more component incorrectly then he must be recorded as confused. Talking in sentences but disorientated to time and place. Inappropriate words Incomprehensible sounds Utters occasional words rather than sentences these are often abusive words elicited by noxious stimuli rather than spontaneous Groans or grunts None If the patient has and ET tube or tracheostomy T is recorded in this section

29 Motor Response This tests the area of the brain which identifies sensory input and translates this into a motor response. The best response is recorded as an indication of the functional state of the brain as a whole. The best possible result is the ability to obey simple commands convincingly. Upper limb response is recorded as these are more reliable than lower limb responses that could be reflexes. How to test arms Extend the index and middle fingers of both your hands and ask the patient to squeeze. The grasp should be firm and equal on both sides. Ask the patient to release their grip, let go some patients with brain injury can show an involuntary grip response when something is placed in the palm of their hand.

30 Motor Response Obeys commands = 6 The patient can respond to instructions accurately. It is worth asking the patient to perform several other movement, for example, stick out their tongue, show their teeth or raise their eyebrows. It is a good idea to make the patient obey at least two different commands or at least the same command twice. Localising to pain = 5 This is a response to a central painful stimulus. It involves the higher centres of the brain recognising that something is hurting and trying to remove the source of the pain. A painful stimulus should only be used if the patient is not responding to verbal instructions. To be classified as localisation, the patient must move their hands up to the point of stimulation, bringing their hands up towards the chin, across the midline, in an obvious co-ordinated effort to remove the source of pain. If the patient is already localising, for example, to a nasogastric tube or oxygen mask, then painful stimulus need not be applied.

31 Motor Response Painful stimulus can be: Supra-orbital pressure AVOID in patients who have suspected or known facial fractures and those who have a vagal nerve sensitivity Jaw margin pressure AVOID Sternal Rub AVOID Trapezius squeeze Other methods of painful stimulus are not recommended as they can elicit a peripheral reflex response only. Withdrawal from or flexing to pain = 4 In response to a central painful stimulus, the patient will flex or bend their arms at the elbow towards the source of pain, but will not attempt to remove it.

32 Motor Response Abnormal flexion to pain = 3 Also known as decorticate posturing and is a much slower response to painful stimuli. It can be recognised by the flexing of the upper arms and rotating the wrist. The thumb will often come through the fingers. This is an abnormal response and occurs when there is an interruption in the motor nerve pathway between the cortex of the brain and the brain stem. Extension to pain = 2 Also known as decerebrate posturing. This is a very serious sign, with a poor prognosis. It indicates that there is damage to the brainstem. It is characterised by straightening of the elbow and internal rotation of the shoulder and wrist. Often the legs will also extend, with the toes pointing downwards. No motor response = 1 The patient will not move at all in response to a painful stimulus. This indicates that the patient s brain is incapable of processing any sensory input or motor activity. Ensure that you have applied an adequate amount of stimulus Points to note: Always record the best arm response using a central painful stimulus. You are not testing the spinal response at this stage, you are testing the brain. Spinal reflexes can even occur in patients who have been certified as brainstem dead.

33 Motor Response Obeys commands Localises to pain Flexes to pain Hold up your arms, if asking patients to squeeze hands beware of grasp reflex in unconscious patients Apply painful stimulus to trapezius until a response is observed. If the patient responds by bringing up the hand to the chin or above this is localising Elbow bending is recorded as flexing to pain Abnormal flexion to pain Elbow flexion accompanied by a spastic flexion of the wrist Extension to pain Straightening of the elbow is recorded as extending to pain None Ensure stimulus is adequate

34 Limb assessment Evaluation of the limbs provides the nurse with detail of the geographical distribution of dysfunction and is important when performing a full neurological assessment of the patient. A difference in responsiveness in one limb compared to another indicates focal brain damage. Hemiparesis or hemiplegia usually occurs in the limbs on the opposite side to the lesion (due to the crossing over of nerve fibres in the medulla). However, it may also affect the limbs on the same side as the lesion due to the pressure on the contra lateral hemisphere

35 How to test limbs Each limb should be assessed separately. The patient should be awake, able to cooperate and understand what you are asking them to do. Have the patient flex and extend their arm against your hand, squeeze your fingers, lift their leg while you press down on their thigh, hold her leg straight and lift it against gravity, and flex and extend her foot against your hand. A peripheral stimulus needs to be applied to limbs that you have not seen move. As part of the motor assessment, also check for arm pronation or drift. Have the patient hold her arms out in front of her with her palms facing the ceiling, eyes closed. If you observe pronation a turning inward of the palm or the arm or the arm drifts downward, it means the limb is weak.

36 Grading of motor function Grade each extremity using a motor scale like the one below full ROM, full strength +4 - full ROM, less than normal strength +3 - can raise extremity but not against resistance +2 - can move extremity but not lift it +1 - slight movement 0 - no movement

37 Pupil assessment Pupil reaction is a very important observation and is often the only way to assess the neurological status of the sedated patient. Pupils should be round, equal in size and between 2 and 5mm in diameter. Abnormal shaped pupils may be a sign of brain damage, but they may also be due to a previous eye injury or because of cataracts. Any changes to pupil reaction, shape and size can be a late sign of raised ICP. Sluggish or suddenly dilated, unequal pupils are an indication that the oculomotor cranial nerve is being compressed through the foramen magnum. The patient will need urgent intervention at this stage. Any changes must be reported to the medical team, as this is a medical emergency.

38 How to test Pupils Explain to the patient what you are about to do. Wash your hands thoroughly. Note as a baseline the shape, size and equality of the pupils. Move a light from the outer aspect of the eye towards the pupil and withdraw it. This should cause the pupil to constrict quickly and redilate. Note the reaction of the untested pupil also the untested pupil will also have a reaction to the light, but less briskly, this is called consensual light reflex. Repeat on the other side. Record unusual eye movements, such as nystagmus or deviation to the side. Briskly reactive pupils are recorded as +, unreactive pupils as - and sluggishly reactive pupils as S. Points to note: If eyes are closed due to gross orbital swelling, this should be marked as C on the chart. A bright pen torch should be used. Minor inequalities in the size of the pupils is normal. The use of eye drops, such as Atropine, can dilate the pupils.

39 Size Appearance Causes Pinpoint Pupil so small it is barely visible Opiate overdose; pontine haemorrhage Small Smaller than average, larger than pinpoint Bright room; opiates; pontine haemorrhage; metabolic coma Midposition Pupil & iris observed, about half of their diameter is iris & half is pupil Seen normally; if unreactive, midbrain damage is indicated Large Pupils are larger than average Dark room; amphetamines; orbital injuries Dilated Pupil & iris observed, but pupil enlarged with iris barely visible Abnormal; terminal stage of sever anoxiaischaemia or death

40 Vital signs Temperature Regulation may be disrupted due to damage to the hypothalamus In the acute phase of brain injury hyperthermia should be treated as it will exacerbate cerebral ischaemia and adversely affect outcome Heart rate ECG changes may occur in the acute stage following cerebral insult as a result of catecholamine release These can include peaked P waves, prolonged QT interval, heightened T waves, ST segment elevation or depression Bradycardia is present in the later stages of raised ICP (compensatory phase Cushing s response) or when there is an associated cervical spine injury. Tachycardia is present in the terminal stage of raised ICP Arrhythmias are seen in posterior fossa lesions or when there is blood in the CSF

41 Vital signs Blood pressure In a normal brain a fall in blood pressure does not cause a drop in cerebral perfusion pressure since autoregulation results in cerebral vasodilation to protect brain tissue. However, following cerebral insult/injury, when autoregulation may be impaired, hypotension may lead to brain ischaemia. Hypotension (systolic BP <90mmHg) has been identified as a predominant factor in secondary brain injury and is related to morbidity and mortality. Hypotension is associated with a rising ICP and is part of the Cushing s response rising BP with a widening pulse pressure, bradycardia and decreasing respirations. This is a late response and may not appear in some patients and is invariably preceded by a drop in GCS.

42 Vital signs Respiration Changes in the respiratory pattern are common following cerebral insult and patients often require advanced respiratory support in the acute stage. Initially an acute rise in ICP will cause slowing of the respiratory rate indicating loss of all cerebral and cerebellar control of breathing, with respiratory function at only brain stem level As ICP continues to rise the rate becomes rapid indicating that the brain stem is affected too. A decreased level of consciousness may compromise respiratory function, therefore observe for potential airway problems Irregular pattern Noisy or snoring respirations Use of accessory muscles Tacypnoea/dyspnoea/apnoea

43 GCS...DONT FORGET Score the patient as you see them no guessing or backdating the results If they do not meet one criteria move down the score to the next one Always start the assessment with the patient as awake as possible (even at 2am)

44 GCS...DONT FORGET If patient looks different to the GCS scoring do a set of obs together at hand over Consistency with using the neuro. Obs is vital to detecting changes in the patients Don t forget to spot other changes like increasing confusion even if the GCS hasn t yet changed

45 GCS...DONT FORGET Patterns of change in GCS Dropping obviously! Fluctuating widely could it represent seizure (sub-clinically) Increasing difficulty in obtaining the same GCS Small changes within the category e.g. confused but worsening confusion, obeys some commands but not others

Neurological assessment

Article 481. Shah S (1999) Neurological assessment. Nursing Standard. 13, 22, 49-56. This article relates to the UKCC Professional Development categories: Care enhancement and Reducing risk. Neurological