[raindrop]

Can you guys tell I have a Neuro test coming up that is either going to make or break me???

1) If you are assesing a comatose Pt, who is a 1 on the Glasgow chart for Eye response, do you open the lid and check the pupil response or not? If yes, is this how u would chart it....Glasgow Eye 1, pupils Pearl...or...if they don't react...Glasgow eye 1, pupils not PERLA? Or maybe u don't even open the eye?

2) How do u chart that u did a Glasgow? Do u write out each test, i.e., Eye 2, Speech 2, Motor 2. Hmmm.

3) What Pt's absolutely can't have a spinal tap?

4) If someone comes into the ER with a suspected neck and/or spinal cord injury, and they have a brace on, the HOB is to be up 30 degrees, right? The only time they are to be flat is if they aren't stabilized, but if they are, the HOB should be up, for both types of injuries?

[NurseyBaby'05]

Originally Posted by raindrop

Can you guys tell I have a Neuro test coming up that is either going to make or break me???

1) If you are assesing a comatose Pt, who is a 1 on the Glasgow chart for Eye response, do you open the lid and check the pupil response or not? If yes, is this how u would chart it....Glasgow Eye 1, pupils Pearl...or...if they don't react...Glasgow eye 1, pupils not PERLA? Or maybe u don't even open the eye?

2) How do u chart that u did a Glasgow? Do u write out each test, i.e., Eye 2, Speech 2, Motor 2. Hmmm.

3) What Pt's absolutely can't have a spinal tap?

4) If someone comes into the ER with a suspected neck and/or spinal cord injury, and they have a brace on, the HOB is to be up 30 degrees, right? The only time they are to be flat is if they aren't stabilized, but if they are, the HOB should be up, for both types of injuries?

Hey Rain-

We just got done with ours, so let me see if I retained anything.

1-chart left and right eye instead of one and two. Indicate pupil size and perrla + or - and note specifics. Definitely open they eye.

2-Not sure what instructor is after on Glasgow. Usually there is a form broken into categories where you can score each individually. I would get clarification from the instructor or fellow classmates on that one.

3-Any pt. who is at risk for increased ICP. In particular, intercrainial bleeders.

4-Right on about HOB being up 30 degrees. Also, keep posture aligned and head in neutral position. Don't have arms and legs flexed too far. All of these things increase ICP.

So, how did I do?

[raindrop]

Originally Posted by NurseyBaby'05

Hey Rain-

We just got done with ours, so let me see if I retained anything.

1-chart left and right eye instead of one and two. Indicate pupil size and perrla + or - and note specifics. Definitely open they eye.

2-Not sure what instructor is after on Glasgow. Usually there is a form broken into categories where you can score each individually. I would get clarification from the instructor or fellow classmates on that one.

3-Any pt. who is at risk for increased ICP. In particular, intercrainial bleeders.

4-Right on about HOB being up 30 degrees. Also, keep posture aligned and head in neutral position. Don't have arms and legs flexed too far. All of these things increase ICP.

So, how did I do?

It makes sense!

Now, about the spinal tap being restricted with anyone who has ICP, that would incude anyone who has had a stroke, been in a MVA, etc, etc? It seems (to me) that if one is at risk for getting IICP, you would WANT to get rid of some by a ST, otherwise it will just keep building up. That's what I don't get.

[NurseyBaby'05]

Yes! You're absolutely correct about wanting to rid the pt. of excess fluid in skull. Now,to monitor ICP, drain fluid if need be, collect a CSF sample and administer meds (be sure they're preservative free) they do a vertriculostomy. It is a form of invasive monitoring that also has a closed CSF drainage system attached. As far as CVA patients go, they are not usually at risk for increased ICP. I'm still digging for the "why" for not doing the lunbar puncture for a patient, but I figured I'd put this up for now.

[NurseyBaby'05]

Now don't quote me on this, but see if this makes sense to you. I think where they are going with nixing the lumbar puncture on these patients has to do with the pressure within the spinal column. I couldn't find in my notes where she said to never do a lumbar puncture on pts with increased ICP, but here's what a I found in my critical care book:

Reduction of ICP by CSF drainage: Accomplished only by using intraventricular or ventriculostomy systems. To prevent herniation when draining CSF, drainage collection bags must be maintained at the level of the tragus of the ear or higher, thereby preventing excessive CSF flow caused by higher-to-lower pressure gradient.

I'm pretty sure she mentioned herniation in her lecture when she was on her soapbox about not doing the lumbar puncture. It makes sense to me.

Now, wouldn't the same principal apply with the lumbar puncture? It's well below the ventricle of the brain and if there's a lot of pressure (intracranial bleed for example) on the brain tissue above the ventricle, it could force the cerebral tissue into the space against the mid brain (aka CNS control center)as a result from a vacuumlike suction from the pressure being released from below. This would result in a herniation (central, I want to say).

Sorry, if this wasn't too organized. I was trying to think "aloud" on paper. I definitely think this is where they are going with regard to not wanting to do a lumbar puncture on these patients.

When is your test? I'm actually shadowing on a Neuro floor tomorrow and I definitely want to ask this. I'll have a for sure answer tomorrow. Good luck on your test too!

[Elenaster]

Originally Posted by NurseyBaby'05

Now, wouldn't the same principal apply with the lumbar puncture? It's well below the ventricle of the brain and if there's a lot of pressure (intracranial bleed for example) on the brain tissue above the ventricle, it could force the cerebral tissue into the space against the mid brain (aka CNS control center)as a result from a vacuumlike suction from the pressure being released from below. This would result in a herniation (central, I want to say).

Good thinking NurseyBaby - that's why we make sure the EVD is leveled properly every hour and with any movement of the patient. Also you wouldn't want to LP a patient with a suspected or confirmed spinal cord injury because it's very important to maintain alignment until the spine has been surgically fixated.

To answer your question about charting Glasgow, you do it like this:

GCS=15 (E=4, V=5, M=6) or whatever your assessment reveals.

[NurseyBaby'05]

Awesome! Thank you! I was fortuante to get clarification when I shadowed today on a Neuro unit. BTW, I loved it!

[candyndel]

The Coma scale is a crude measurement and is only one small part of the neuro assessment. It is very important to assess pupillary response to light (are u really checking accomodation on all your pts... i know not this comatose one...if not, dont write PERLA), so yes open the lids and show them the light!!
EVM... yes yes yes!!

No to your longboard question. You can raise the HOB 30 only once they are off the longboard. If they are on a longboard, c collar and CID (as with suspected spinal injury) they have to stay flat (the longboard in about 6 ft long). but if u suspect increased ICP and want the HOB up, you will have to put them in reverse Trendelenberg (sp?) until the longboard is cleared. You should only worry about infants lying flat on a board...

Originally Posted by raindrop

Can you guys tell I have a Neuro test coming up that is either going to make or break me???

1) If you are assesing a comatose Pt, who is a 1 on the Glasgow chart for Eye response, do you open the lid and check the pupil response or not? If yes, is this how u would chart it....Glasgow Eye 1, pupils Pearl...or...if they don't react...Glasgow eye 1, pupils not PERLA? Or maybe u don't even open the eye?

2) How do u chart that u did a Glasgow? Do u write out each test, i.e., Eye 2, Speech 2, Motor 2. Hmmm.

3) What Pt's absolutely can't have a spinal tap?

4) If someone comes into the ER with a suspected neck and/or spinal cord injury, and they have a brace on, the HOB is to be up 30 degrees, right? The only time they are to be flat is if they aren't stabilized, but if they are, the HOB should be up, for both types of injuries?

[raindrop]

Thanks a million you guys! Your responses were clear and simple - just what I needed.

My test is ttttttttt-tomorrow. I'm sooooo scared.

The Neuro test tomorrow is the first half. It is going to cover Meningitis, IICP, Cerebral edema, migraines, seizures and possible a few A&P Q's. My instructors tend to hit "initial" signs& symtoms of a disease, "late" s/s of a disease, nursing measures for these people, and of course, pharmacology. Yea me. I'm so scared b/c we only have 2 test left after this one, and being that I'm not doing so well in school right now (thanks to the Renal test), this test could either REALLY drop me, or REALLY bring me up. Stressful!

I'll keep ya's posted.

[NurseyBaby'05]

I'm so glad we were able to help. I definitely know how you feel though. Our renal is on the final and the instructor is the one who did the cardiac test that the class did abyssmally as a whole. (Me included.) A lot of her "best" answers seem to be her own personal preferences as a nurse rather than because of patho, nursing process, etc. **Sigh! ** Oh, well! I'll suck it up and be ready to move on to my mentorship.

Some important A&P to go over is which part of the brain controls a particular human behavior or function. Left lobe vs. rt. lobe and how would you tread these patients. A lot of this affects how you care for these patients. For example, a patient with right brain damage is more likely to have problems with impulse control and spatial-perceptual defecits. Safety would be a huge issue with these patients with regard to care. Also, this may not occur to us b/c were able to function, but these people often need to be reminded where their feet are. (Like, "No! don't stand yet! Your feet haven't reached the floor!") Please let us knwo how you did!

Sending good test wishes!