ACUTE AND INTERMEDIATE PHASE NURSING IN TBI: NEUROLOGICAL AND OTHER ROUTINE NURSING INTERVENTIONS: ASSESSING VITAL NEUROLOGICAL SIGNS

Assessing Vital Neurological Signs frequently and looking for deviation trends (stability, deterioration, or improvement)

  • Perform an initial baseline assessment and frequent subsequent assessments:
    • Every 5 - 15 minutes for unstable patients
    • Every 2 - 4 hours after patient is well stabilized
      Onset of cerebral herniation and new intracranial hemorrhage are the major life threatening problems associated with acute deterioration

  • Include the following in the neurological assessment:
    • Level of consciousness
      • Orientation to time, place, and person is assessed in patients who can respond verbally
      • Glasgow Coma Score is used in patients who are comatose
    • Cognition
      • Assess by asking simple questions, e.g., "show me 2 fingers", in patients who can respond verbally
      • Glasgow Coma Score is used in patients who are comatose
    • Brain stem function
      • Pupil assessment for any change in size or reaction; e.g.
        • 1 pupil becomes dilated and progressively nonreactive to light as a result of transtentorial herniation or a focal lesion
        • an oval or ovoid pupil is usually an early sign of transtentorial herniation.
        The automated pupillometer is more accurate and reliable than the manual examination in measuring pupil size and reactivity (Meeker, et al 2005)
    • Other assessment; e.g.
      • Absent corneal and gag reflexes usually indicate a poor prognosis
      • Absent corneal reflex should be treated with special protective eye care and lubrication
      • Grimacing in response to the insertion of a cotton-tipped applicator, in one nostril and then the other, can indicate a facial nerve deficit
      • Absent gag reflex may indicate a high risk for aspiration pneumonia
      • Eyes can be checked for doll's eye reflex
    • Motor function
      • Asymmetrical spontaneous movement and lateralization (e.g. hemiparesis and hemiplegia) suggest a focal mass lesion on the side of the brain opposite the side of motor weakness
        • Decortication and decerebration are seen in comatose patients following TBI
        • Bilateral or unilateral flaccidity may be seen in spinal injuries
    • Other assessments
      • Abrasions or contusions on the face and scalp
      • Ecchymosis on the mastoid bone (Battle's sign)
      • Periorbital ecchymosis (raccoon's eyes)
      • Conjunctival hemorrhage
      • Clear or bloody drainage from ear, nose, or postnasal area
      • Nuchal rigidity of the neck
      • Elevated ICP and shape of P1, P2, and P3 components

Based on information in Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing, 4th ed., Philadelphia: Lippincott, 1997 and in Chin PA, et al. Rehabilitation Nursing Practice, N.Y.: McGraw-Hill, 1998, except for information where other papers are cited.