ok...neuro nurses...need insight please!

gwenith, BSN, RN · May 19, 2004

I am moving this thread to the neuro forum.

Lots of hints for newbies there.

Mostly you also need to know the difference between alertness and awareness and be mindful that you can have one without the other.

Pupils are not commonly, the first change seen in raised ICP

Nurse to minimise ICP change and secondary head injury

NeuroICURN · May 21, 2004

Hi TNNURSE!!!

That's great that you're thinking of moving to a neuro ICU! I love it!! It's definately a place that you have to have sharp assessment skills.....and a warped sense of humor helps a lot! (See the "you know you're a neuro nurse if" board! LOL)

Anyway, I'd love to write you more and answer your questions now, but I could go on for days. Unfortunately, I'm pooped and I have my 3rd (and last) 12 hour day to do tomorrow! So, I'll write ya perhaps tomorrow or the next day!

Take care!

Elenaster · May 21, 2004

Good questions and I'm excited for you. May I ask what your current nursing background contains? You may be able to draw from past experiences and build on those skills when you move to the Neuro ICU.

If you haven't previously worked as an ICU nurse, I would assume that you would get at least 6 weeks of orientation, which more than anything will help you become familiar with your unit, patient population, and co-workers.

As far as drugs go, you've already mentioned two biggies - Dilantin and Decadron. IV Dilantin is incompatible with pretty much everything except MIVF's and you need to check levels to make sure they're therapeutic. Decadron raises blood glucose levels and may require BG monitoring in non-diabetic patients, or even worse, insulin gtts (AAACCCCKKKKK). Another commonly used drug is Nimodipine, which is a calcium channel blocker used to dilate cerebral vessels for patients at risk for or in vasospasm. In some patients it drops their BP, but others seem unaffected by it. Also Mannitol is an osmotic diuretic used to decrease cerebral edema. If your unit gets a lot of ischemic events, you should probably investigate TpA protocols at your hospital. The main thing to remember is TpA=huge risk for hemorrhage.

Other than that, propofol and ativan are your best friends :)

Know your Glascow Coma Scale backwards and forwards. It won't be long until you're referring to patient's by their score (i.e., Mr. Smith is a 9 today but he was a 5 yesterday). Also know nursing interventions to help reduce ICP, triple H therapy for vasospasm, and what physiologic symptoms preclude impending brain death.

Let's see....other practical tips:

1. Unless your patient is in a coma, paralyzed and sedated OR totally with it and ready to go to the floor, DO NOT TRUST HIM. Neuro patients are a crafty bunch, and unless you enjoy calling cranky doctors to put your drain back in, or like doing the required paperwork when your patient falls out of bed, I recommend utilizing restraints and watching your patient like a hawk.

2. Neuro patients are crazy and can't help it. You will likely be insulted, spit on, screamed at, threatened, cussed out, etc. If you're the sensitive type, don't let them get to you. I'm sure most of them would be embarrassed if they were actually cognizant of their behavior. A good sense of humor is key.

3. The patient's families are even crazier and can help it. Hopefully your unit will have strict visiting policies and it is your job to enforce them. I've found that very rarely are family members of any help at all to your patients while they're in the ICU. You'll see what I mean the first time a well-meaning family member awakens your newly sleeping patient after he hasn't slept for 2 or 3 days. The main problem is the families are usually so freaked out and exhausted that they have real difficultly focusing on anything but their own needs. I tell them to eat, sleep, and get some rest because they really need to be well for their loved one after they are discharged from the ICU.

4. Most neurosurgeons are big babies with huge egos and God complexes. Ignore them unless you need orders or something. Do not let them hurt your feelings and keep in mind that most of their tantrums have nothing to do with you.

Well, I think I've said enough. Good luck with your transition!

NeuroICURN · May 22, 2004

Other than that, propofol and ativan are your best friends :)

OMG Elenaster...I couldn't have said it better myself! My favorite type of patient is one that's tubed and on propofol!!! :chuckle Is it wrong to feel that way??? LOL

Let's see....other practical tips:
1. Unless your patient is in a coma, paralyzed and sedated OR totally with it and ready to go to the floor, DO NOT TRUST HIM. Neuro patients are a crafty bunch, and unless you enjoy calling cranky doctors to put your drain back in, or like doing the required paperwork when your patient falls out of bed, I recommend utilizing restraints and watching your patient like a hawk.
2. Neuro patients are crazy and can't help it. You will likely be insulted, spit on, screamed at, threatened, cussed out, etc. If you're the sensitive type, don't let them get to you. I'm sure most of them would be embarrassed if they were actually cognizant of their behavior. A good sense of humor is key.
3. The patient's families are even crazier and can help it. Hopefully your unit will have strict visiting policies and it is your job to enforce them. I've found that very rarely are family members of any help at all to your patients while they're in the ICU. You'll see what I mean the first time a well-meaning family member awakens your newly sleeping patient after he hasn't slept for 2 or 3 days. The main problem is the families are usually so freaked out and exhausted that they have real difficultly focusing on anything but their own needs. I tell them to eat, sleep, and get some rest because they really need to be well for their loved one after they are discharged from the ICU.
4. Most neurosurgeons are big babies with huge egos and God complexes. Ignore them unless you need orders or something. Do not let them hurt your feelings and keep in mind that most of their tantrums have nothing to do with you.

My gawd....I think we were seperated at birth! :roll You really do have to have a SERIOUSLY warped sense of humor to enjoy neuro!!!

P.S. I keep swearing that if I hear another family stand over the pt's bed and do the "family neuro assessment" (you know..."mom, open your eyes, wiggle your toes, etc") I may have to cut my wrists!!! :rolleyes:

NeuroP · May 22, 2004

I am not a nurse, but I have a strong science background (Skeletal Forensics). I was a neuro patient, as recent as April 2004. I had a type 2 meningioma adjacent to the right parietal lobe. As a result, I am now fascinated by neuroscience and have thouroughly enjoyed reading all of your posts.

Let me mention also that neuro nurses are some of the greatest people that I have ever met. Being a neuro patient is terrifying, and my nurses were always there for me.

I recall so many of the things mentioned in this post. As the doctors weaned me from Decadron, my steroid psychosis began to subside, and I began to realize what a crazy reality I had inhabited. I also felt a sense of shame for the manner in which I had behaved. I didn't cuss or insult anyone, but I did become very paranoid and hypersensitive. I cried at the slightest inconvenience. I was also prone to yelling, hysterical laughing, and visual and auditory hallucinations. I swore that the nurses were trying to kill me. It feels so comforting to know that I am not a horrible person and that this was out of my control. I am coming to terms with this now.

I am so happy to be alive. Thanks, nurses.

gwenith, BSN, RN · May 22, 2004

Thank-you for your sensitive post. So many come on this board and berate us for our dark humour not realising that it is borne from compassion in a difficult and trying situation. As a nurse your empathy screams for the patient whose thoughts are now "broken chains" and whose reality is a terrifying mix of emotions and monsters but at the same time you cannot but laugh to relieve this.

I think the hardest thing about neuro nursing is telling the family "we don't know". The uncertainty of outcome is horrendous.

Even here odd circumstances can make us smile such as the story of the teenager who was admitted with a ?anoxic event (not enough oxygen to the brain) the parents had been told that we were uncertain of the outcome and his mother then went into a tirade to the lad about "How could you do this to me?" It was at that moment we knew all would be well as he extended his middle finger in an ancient gesture. The laughter comes but not at anyone but through simple relief.

Thank-you for understanding this I am glad you have recovered and I wish you well for the future. (((((((((((hugs)))))))))))

Elenaster · May 24, 2004

OMG Elenaster...I couldn't have said it better myself! My favorite type of patient is one that's tubed and on propofol!!! :chuckle Is it wrong to feel that way??? LOL

Don't forget an orphan as well

My gawd....I think we were seperated at birth! :roll You really do have to have a SERIOUSLY warped sense of humor to enjoy neuro!!!
P.S. I keep swearing that if I hear another family stand over the pt's bed and do the "family neuro assessment" (you know..."mom, open your eyes, wiggle your toes, etc") I may have to cut my wrists!!!

I know exactly what you're talking about! We had this one patient in our unit for 8 weeks because our most arrogant neurosurgeon thought it was a good idea to extract a brain stem tumor from an 86-year-old. The surgery took more than 20 hours and, big shocker, the pt was a rag doll after they got done. Anyhow, the family was clueless and they came to every freaking visiting time and talked to her in this high-pitched sing-song voice that had every nurse in our unit running for the door. They'd chase after us almost daily, claiming that they were sure she moved her foot or something when they asked her to. Yeeeahhhhh....right, I'll be sure and tell Dr. Almighty when he rounds the next time. :rolleyes:

Elenaster · May 24, 2004

I am not a nurse, but I have a strong science background (Skeletal Forensics). I was a neuro patient, as recent as April 2004. I had a type 2 meningioma adjacent to the right parietal lobe. As a result, I am now fascinated by neuroscience and have thouroughly enjoyed reading all of your posts.
Let me mention also that neuro nurses are some of the greatest people that I have ever met. Being a neuro patient is terrifying, and my nurses were always there for me.
I recall so many of the things mentioned in this post. As the doctors weaned me from Decadron, my steroid psychosis began to subside, and I began to realize what a crazy reality I had inhabited. I also felt a sense of shame for the manner in which I had behaved. I didn't cuss or insult anyone, but I did become very paranoid and hypersensitive. I cried at the slightest inconvenience. I was also prone to yelling, hysterical laughing, and visual and auditory hallucinations. I swore that the nurses were trying to kill me. It feels so comforting to know that I am not a horrible person and that this was out of my control. I am coming to terms with this now.
I am so happy to be alive. Thanks, nurses.

Thank you for sharing this with us. Despite my irreverance and warped sense of humor, I really do try to stay aware of what it must be like to be a patient in that bed, scared, confused and unable to articulate myself.

I always enjoy hearing stories from patients that make it through and have meaningful recoveries. One of things that attracted me to Neuroscience nursing in the first place was the ability to witness miracles. Thank you again for sharing your story, and I hope that you've had your last trip to the ICU as a patient.

NeuroICURN · May 24, 2004

I am not a nurse, but I have a strong science background (Skeletal Forensics). I was a neuro patient, as recent as April 2004. I had a type 2 meningioma adjacent to the right parietal lobe. As a result, I am now fascinated by neuroscience and have thouroughly enjoyed reading all of your posts.
Let me mention also that neuro nurses are some of the greatest people that I have ever met. Being a neuro patient is terrifying, and my nurses were always there for me.
I recall so many of the things mentioned in this post. As the doctors weaned me from Decadron, my steroid psychosis began to subside, and I began to realize what a crazy reality I had inhabited. I also felt a sense of shame for the manner in which I had behaved. I didn't cuss or insult anyone, but I did become very paranoid and hypersensitive. I cried at the slightest inconvenience. I was also prone to yelling, hysterical laughing, and visual and auditory hallucinations. I swore that the nurses were trying to kill me. It feels so comforting to know that I am not a horrible person and that this was out of my control. I am coming to terms with this now.
I am so happy to be alive. Thanks, nurses.

WOW! What an amazing story...and thank you for being courageous enough to share it with us! It's soooo nice to hear about the ones that have a good outcome and then share it with us.

I think Elenaster and Gwenith really hit the nail on the head when they said that neuro is one of those places where if you don't laugh sometimes, you'd break down and cry. I can't imagine how scary it would be to be in that bed and not be able to communicate my needs, or scream or even move! I too, always keep that thought with me when dealing with my patient and try to deal with them in the most sensitive, caring ways that I am able.

As for being embarassed about how you behaved....please try not to (I know this is easier said than done). I always tell my patients, when they become aware of their behavior (usually because a family member tells them :angryfire not the staff), that we understand that if they were able to, they would not have acted like that and that they weren't the first and certainly won't be the last! We can tell the difference between a person that is being difficult, just to be difficult and a person that is like that because of the injury to the brain.

Thank you again for sharing your story...it makes all the long days worthwhile for us!

Keysnurse2008 · May 28, 2004

hmm....ok judging from the warped sense of humor here.....I think I have found my niche.I have had neuro pts before(er with chi) and also on a m/s floor......dont you love it when you leave them alone for one single minute...only to return and find they have dumped all the nurse serversdsgs (apx900$ worth) into their bsc.....and they hand you the room telephone that is dripping with some unidentified liquid and for some reason no longer works.

I have a pretty broad nsg background(13-14years)....with eveerything from er,m/s ortho,urology etc......but I am looking for an area where I can learn something new.....and neuro is somewhere I have NOT done yet.Ok.....educate me.....what is triple h therapy...is Haldol one of the h's(lol)?????

NeuroICURN · May 30, 2004

Ok.....educate me.....what is triple h therapy...is Haldol one of the h's(lol)?????

Triple H therapy is part of the standard care for patient's that have had a subarachnoid hemmorhage from an aneurysm rupture and then had a repair....either clipping or coiling.

The H's are: Hypertension, Hypervolemia and Hemodilution. So, essentially what they are attempting to do is to keep the vessels in the brain open so that they can't go into vasospasm, which is a HUGE, HUGE risk in these patients. Also used to prevent spasm is Nimodipine (a calcium channel blocker).

Any neuro ICU nurse will tell you that these can be some of the busiest and most trying patients that you will have! You have to have a dead-on accurate neuro assessment to really pick up the first signs of spasm in your patient....and often times, it's something as slight as a new pronator drift...not even a decrease in l.o.c.!

Once they do start to spasm...well that's a whole other ball of wax! Now that's a busy day!!! :uhoh3:

P.S. Some days you wish that Haldol was part of that Triple H therapy! :chuckle