Stephanie Banfield

Stephanie Banfield

1. Frontal Lobe

Controls:

• Behaviour

• Emotions

• Organisation

• Personality

• Planning

• Problem solving

Arteries: ACA, MCA

6. Hippocampus

Controls:

• Object recognition

• Stores meaning of

words or places

Arteries: PCA

3. Occipital Lobe

Controls:

• Colour

recognition

• Shape

recognition

Arteries:

PCA

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

7. Temporal lobe

Controls:

• Smell

Identification

• Sound

Identification

• Short-term

Memory

• Hearing

Arteries: MCA, PCA

4. Cerebellum

Controls:

• Balance

• Muscle

co-ordination

• Posture

maintenance

Arteries: Basilar

PICA, AICA, SCA

5. Brainstem

Controls:

• Alertness

• Blood pressure

• Digestion

• Breathing

• Heart rate

Arteries: Vertebral Basilar

12

34 7

4

5

4

6

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

Stephanie Banfield

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.

Stephanie Banfield

Contra-lateral Control

Stephanie Banfield

Blood Supply to the Brain

Stephanie Banfield

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)

Stephanie Banfield

Stroke

What do you do if you

think your patient

is having a

stroke?

Stephanie Banfield

Lacunar Stroke

Stephanie Banfield

Ischemic stroke (Thrombo/embolic stroke)

• hypercholesterolemia

• hypertension

• Atrial fibrillation

• Ischaemic heart

disease/angina

• Peripheral vascular

disease

• Diabetes

Stephanie Banfield

• Previous stroke/TIA

• Smoking

• Increased alcohol intake

• Poor diet/obesity

• Increased ageatherosclerosis

• Oral Contraceptive Pill

• Drug misuse

Stephanie Banfield

Haemorrhagic Stroke • Chronic high blood

pressure.

• Amphetamine.

• Amyloid angiopathy

• Arterial Venous

malformation (AVM),

• inflammation of blood

vessels (vasculitis),

• bleeding disorders,

• anticoagulants,

Stephanie Banfield

Intracerebral and subarachnoid haemorrhage

Stephanie Banfield

Subdural haemorrhage and small vessel disease

Stephanie Banfield

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 life-threatening when acute. Chronic subdural hematomas, however, have a better prognosis if properly managed.

Stephanie Banfield

Raised Intracranial Pressure Early Signs

• Agitation

• Vomiting

• Headache

• Dilated pupils

Later Signs

• Increased systolic blood pressure

• Bradicardia

• Abnormal respiratory

pattern

Stephanie Banfield

Causes and Treatment Causes

• Oedema

• Haemorrhage

• Tumour

• Encephalopathy

Treatment

• Steroids

• Manitol

• Hyperventilation

• Hemicraniectomy

Stephanie Banfield

Hemicraniectomy

Stephanie Banfield

Neurological Assessment • AVPU – what does this mean?

• Blood sugar

• Pupils

• Then move onto GCS and full neuro

assessment

Stephanie Banfield

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.

Stephanie Banfield

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.

Stephanie Banfield

Illustration of GCS

Stephanie Banfield

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.

Stephanie Banfield

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.

Stephanie Banfield

Eye Opening Spontaneous Observed before you approach the patient or speak to

him

To speech Call the patient’s name

To pain Apply pressure to the side of the finger (central stimulus

to supraorbital nerve will cause grimacing and eye

closure)

None Ensure painful stimuli is adequate

Stephanie Banfield

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.

Stephanie Banfield

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!!

Stephanie Banfield

Verbal Response Orientated 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.

Confused Talking in sentences but disorientated to time and place.

Inappropriate words Utters occasional words rather than sentences – these are

often abusive words elicited by noxious stimuli rather than

spontaneous

Incomprehensible sounds Groans or grunts

None If the patient has and ET tube or tracheostomy ‘T’ is

recorded in this section

Stephanie Banfield

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.

Stephanie Banfield

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.

Stephanie Banfield

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.

Stephanie Banfield

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.

Stephanie Banfield

Motor Response Obeys commands Hold up your arms,– if asking patients to squeeze hands

beware of grasp reflex in unconscious patients

Localises to pain 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

Flexes to pain 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

Stephanie Banfield

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

Stephanie Banfield

How to test limbs Each limb should be assessed separately. The patient should be awake, able to co-

operate 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.

Stephanie Banfield

Grading of motor function Grade each extremity using a motor scale like the one below.

+5 - 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

Stephanie Banfield

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.

Stephanie Banfield

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.

Stephanie Banfield

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 anoxia-

ischaemia or death

Stephanie Banfield

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

Stephanie Banfield

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.

Stephanie Banfield

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

Stephanie Banfield

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)

Stephanie Banfield

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

Stephanie Banfield

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

Stephanie Banfield