NICU pt with brain bleed...assessment??

[RNmom2RJC]

I'm new to this website and was wondering if some of you seasoned nurses had experience with pt's with brain bleeds. A recent pt i had presented with apnea, he was full term. His ct showed tentorial subdural hematoma, left middle cranial faucet subarachnoid hemorrhage at the base of the brain, intracranial hemorrhage with subdural hematoma and left sided subarachnoid hemorrhage, parenchymal involvement couldn't be excluded. The night before we shipped him to a higher level 3 he went apneic about 30 times within 10 hours with sats dropping a few times to the low 60's. All apneia's required stimulation for the pt to breathe again, when he did breathe his sats were 100. My question to anyone who knows is what should my frequent assessments have been besides the usual, i did checks for pupillary dilation and head circ. I am new to the nursing world and this was my first time with a pt. presenting this way. Any suggestions for next time or things i should have been looking for? The baby was a shoulder distocia that was 10 lbs. Looking forward to your feedback!

Michelle

[TiffyRN, BSN, PhD]

I am not the most experienced here, I'm sure some of the others will have better advice. However, I thought of a couple of things; perhaps checking the infant's fontanels for any increasing fullness as this could indicate rising intracranial pressure. Also, checking hematocrit regularly. Often a bleed can initially be detected by a fall in hematocrit. Other than that and what you did, I can't think of anything else. At our facility we don't usually check infant's pupils, for one thing, they are generally very uncooperative so I admire your skill at accomplishing that!

Brain bleeds are not so common in term infants. Most bleeds we see are preemies are are from immature germinal matrix. The infant you describe sounded like he had trauma. Both term infants I remember with large bleeds turned out to have clotting disorders when all the tests came back (Von Willenbrands, not sure on the spelling). One of those infants had a bleed that sounded much like the one you described and there was no trauma. Apnea is a common sign of brain bleeds and can sometimes be seizures

[dawngloves, BSN, RN]

I'm with you Tiffany. I've never assesed a neonates pupils. Never even heard it mentioned. Everything else, HC, H/H, fontanels is what we do.

[Gompers, BSN, RN]

We do neuro checks (including pupil reaction) on babies with severe neurological problems (uncontrollable seizures, severe asphyxia, recent neuro surgery). If the baby is post-op from a neuro procudure, it's every 1-2 hours for that first shift, otherwise the checks are every 4 hours or so.

I've never done them specifically because a baby had a bad IVH or other brain bleed, though.

[RNmom2RJC]

Thanks for all of your responses. It was an interesting case for me as I had not had a full term brain bleed pt. :)