Self-Directed Learning Module for Pediatric Neuro Vital Sign Assessment

Developed by: Katrina Verschoor, Clinical Nurse Educator, 3A Neurosciences Edited by: Dr. Angela Price and Dr. Kati Wambara

September 2002 Last Up-dated: March 2004

Table of Contents

Module Objectives ...... 2

Introduction to Pediatric Neuro Vital Sign Assessment ...... 5

Patients At Risk ...... 6

Section One: Obtaining a History for the NVS Assessment...... 8 The Purpose of the Neuro Assessment...... 8 Obtaining a History...... 9 Tools Required for a Standard NVS Assessment...... 11

Section Two: Assessing Mental Status using the Modified Glasgow Coma Scale ...... 12 Level of Consciousness ...... 13 Eye opening/Arousal...... 14 Best Verbal Response/Awareness ...... 15 Best Motor Response...... 19 Localization ...... 20 Decorticate Posturing (abnormal flexion)...... 21 Decerebrate Posturing (abnormal extension)...... 22 Infant Reflexes ...... 25 Total GCS Score ...... 27

Section Three: Assessing Extraocular Eye Movement and the Pupils...... 26 Denver Developmental Test ...... 32 Assessment of Cranial Nerves ...... 34

Section Four: Assessing Strength and the Ability to Move...... 36 Pronator Drift ...... 35

Section Five: Assessing Color, Sensation and Warmth of Extremities and Bladder Function ...... 39 Summary of Physical Effects of Immobilization ...... 41

Section Six: Vital Sign Assessment ...... 47 Blood Pressure...... 47 Cerebral Edema...... 49 Autoregulation...... 52 Metabolic Regulation...... 52 CSF Regulation ...... 52 When the Regulatory System Fails...... 53 Respirations ...... 53 Oxygen Saturation ...... 55 Pulse ...... 55 Temperature ...... 56 Nursing Interventions for Increased ICP...... 58 Mannitol Quick Reference Guide ...... 60

Section Seven: Assessing Pain...... 61 Standard Pain Scales Used at C&W ...... 64

Section Eight: Assessing Affect...... 67

Section Nine: Monitoring Weight and Head Circumference ...... 71

Summary: The Patient with a Head Injury ...... 73

Appendices: Study Guide Answer Key (Provided by unit CNE on request) References 2

Module Objectives

1.0 The nurse will be able to define each area of a neuro vital sign assessment for the pediatric patient.

1.1 The nurse will be familiar with all components of the neurological assessment and have a clear understanding of the relevance of each area in a complete clinical assessment. 1.2 The nurse will know how to grade responses on the modified Glasgow Coma Scale appropriately. 1.3 The nurse will know how to determine the appropriate NVS record sheet based on the actual and/or the developmental age of the child.

2.0 The nurse will be able to identify the differences between a spinal neuro vital sign assessment and a standard neuro vital sign assessment.

2.1 The nurse will be able to identify the four main components of a spinal neurological assessment. 2.2 The nurse will be able to identify and use supporting clinical knowledge and Nursing Policy and Procedure to carry out a spinal neuro vital sign assessment.

3.0 The nurse will be familiar with basic neuro-anatomy in order to complete an accurate neuro vital sign assessment.

3.1 The nurse will understand the basic functions of the cranial nerves (CNs), how to test nerve integrity, and specify how alterations in function may present in clinical situations. 3.2 The nurse will understand the basic functions of the spinal nerves and how alterations in function may present in clinical situations.

4.0 The nurse will be able to identify trends in assessments and be able to intervene appropriately in the clinical setting.

4.1 The nurse will understand the importance of and demonstrate the practice of visual hand-over according to the guidelines provided. 4.2 The nurse will be familiar with the location and administration guidelines for Mannitol. 3 4.3 The nurse will be able to calculate and administer Mannitol according to C&W protocol. 4.4 The nurse will have a basic understanding of how and why Mannitol is used and which patient’s are at risk for increased intracranial pressure. 4.5 The nurse will be able to determine the need for increased vigilance based on assessment findings and carry this practice out as needed. 4.6 The nurse will understand why practice guidelines do not support decreasing the frequency of neuro vital sign assessments, or omitting any component of the NVS assessment, without a written physician’s order. 4.7 The nurse will support the principles of Family Centered Care by including the primary caregiver, when appropriate, to assist in the neuro vital sign assessment and in interpreting highly subjective data obtained from the assessment.

5.0 The nurse will be familiar with the three main pain scales used in the pediatric population.

5.1 The nurse will understand the rationale for routine pain assessments in determining the neurological status of the patient. 5.2 The nurse will be able to determine the appropriate pain scale for each patient based on the actual and/or developmental age of the child. 5.3 The nurse will understand the implications of intractable/worsening pain and know when to communicate assessment findings to the physician.

6.0 The nurse will understand the relevance of assessing the patient’s general behaviour and affect and record scores appropriately.

6.1 The nurse will support the principles of Family Centered Care by including the primary caregiver in assessing the child’s affect throughout a shift. 6.2 The nurse will understand the potential relevance associated with changes in behaviour and affect when determining the neurological status of the patient.

7.0 The nurse will follow C&W’s standards for documentation when recording all assessment findings, including information provided from the family and/or primary caregiver, and any contextual data that may provide information relevant to the patient’s condition. 4

7.1 The nurse will be competent in accurately recording any additional assessment information in the Nurse’s Notes section of the chart, providing context, when appropriate. 7.2 The nurse will be familiar with documentation guidelines for C&W and will review as needed.

8.0 The Pediatric Neuroscience Nurse at C&W will review the Self-Directed Learning Module for Pediatric Neuro Vital Sign Assessment on a yearly basis and as needed.

8.1 The nurse will develop and maintain his/her skill in NVS assessment.

5 Introduction to Pediatric Neuro Vital Sign Assessment

Although nursing assessment of neurological status is a routine part of care for

patients with suspected and known neurological problems, accurate assessments of

infants and children can be challenging. In addition to the skill required to

understand and recognise the differences between neurological assessments of

adults and children, the pediatric neuroscience nurse must learn to gather data

appropriately, interpret the findings accurately, assimilate the information and

implement appropriate nursing interventions in a clinical crisis. This module is designed to assist the pediatric nurse with completing a neurological assessment on

children of all ages and at varying stages of development, as well as acquire

knowledge and skill with appropriate clinical interventions.

The prerequisites required for becoming proficient at pediatric neurological

assessments are a clear understanding of normal growth and development and the

pathophysiological processes that may put a patient at risk for injury associated with altered neurological status. To assist with the learning process, some

principles of normal growth and development and pathophysiological processes will

be covered in this module.

This module is designed to be reviewed on a yearly basis in order to increase

and/or reinforce the nurse’s knowledge and skill in the area of pediatric NVS

assessment. It is the individual nurse’s responsibility to ensure that a yearly review

is completed and that all areas of their practice are within set standards.

Reflective questions are included in each section to enhance learning and reference

materials are listed for those who choose to do a more in-depth study. A post-test

is provided at the end of the module and should be submitted to the Clinical Nurse

Educator when complete.

6 Patients at Risk

The C&W Neurosciences unit provides care to many children with varying degrees of injury and illness that require close neurological monitoring. The pediatric nurse must be able to identify those patients who require neurological assessment and those who are potentially at risk for neurological complications associated with medical treatments, disease processes or sustained injuries. The following are examples of children who are at risk for or who may be experiencing neurological injury:

Accidental or non-accidental trauma victims:

o Cranial or spinal cord injuries such as fractures, concussion or

hemorrhage etc.

o Shaken-Baby Syndrome

o Near-drowning or other hypoxic injuries

o Birth trauma

o Orthopedic injuries (Fat Embolism, & Compartment Syndrome)

Children with CNS and generalised infections:

o Meningitis

o Encephalitis (herpes, chicken-pox etc.)

o Sepsis

o Patients at risk for infection r/t surgical or diagnostic procedures

involving the CNS (laminectomy, rhizotomy, lumbar puncture, craniotomy,

external ventricular drain [EVD] and shunt insertion etc.)

o Brain and spinal abscesses

Children with the following disease processes:

o Cancer (brain or spinal cord tumors [or as a result of radiation or

chemotherapy])

o Epilepsy and Epileptic Syndromes 7 o Diabetes (prolonged hypoglycemia or diabetic ketoacidosis [DKA])

o Ischemic or hemorrhagic stroke (i.e. Moya-Moya)

o Guillian Barre (spinal NVSs only as no increased ICP)

o Multiple Sclerosis (spinal NVSs only as no increased ICP)

o Inflammatory Bowel Disease, Crohn’s and Colitis (rare)

o Neurodegenerative diseases / Metabolic Diseases

o CNS Lupus

o Electrolyte Imbalances (SIADH, Diabetes Insipidus, Diabetes Mellitus,

eating disorders etc.)

o Poisoning (lead, carbon monoxide etc.)

o Drug toxicities (Baclofen, Valium, Ativan, illegal drugs etc.)

Children with congenital anomalies

o Spina Bifida (meningomyelocele)

o Hydrocephalus or intraventricular hemmorhage (shunt malfunction /

shunt infection)

o Arterial-Venous Malformation (AVM) or aneurysm (leading to

hemorrhagic stroke)

o Various Syndromes effecting cognition and /or mental and physical

development

Reflective Questions:

1.0 What are the clinical differences between a closed head injury and an open

cranial fracture? What are the risks associated with both?

2.0 Can you think of some ‘non-neurological’ conditions that can progress to a

neurological crisis and why?

References and Resources to Enhance Learning:

Fisher M.D. Pediatric traumatic brain injury. Critical Care Nursing Quarterly.

1997; 20 (1): 36-51.

Winch, A.E. & Ouverson. Nursing intervention for thromboembolic

complications of chronic ulcerative colitis in children. MCN. 1992; Vol.

17. 86-90.

Section One: Obtaining a History for the Neurological Assessment

This section will focus on:

The purpose of the neuro assessment

Obtaining a history for the pediatric neurological assessment

The Purpose of the Neuro Assessment:

As in all areas of nursing, assessment is the basis for developing an appropriate

individualized care plan and formulating nursing diagnoses to guide interventions.

An accurate, complete initial neuro assessment is paramount in determining the

severity of injury or insult and, over time, identifying trends that could signify a crisis. Ultimately, the prevention of further injury is the basis of the neuro

assessment in the at-risk population. Although there can be some degree of

subjectivity and discrepancy between recorders, there are ways to decrease

variations in recording, thus enhancing the ability to identify subtle downward

trends early and increase positive patient outcomes. For this reason, it is essential

that the nurse taking over care of the patient on neuro observation does a 9 complete NVS assessment and critically compares the findings with that of the previous nurse noting any changes and determining the relevance of the variations.

For those children who are difficult to assess or who have fluctuating responses to

stimuli, the nurse is encouraged to do a visual hand-over to observe and discuss the variations and difficulties experienced in the assessment process (specific guidelines will be discussed later). Ultimately, observing responses and distinguishing what is normal from what is abnormal is key in the neuro assessment.

The main components of the neurological exam include:

obtaining a history

assessment of mental status / higher cortical function (level of consciousness,

orientation, speech and language, memory)

assessment of motor function

assessment of sensory function

assessment of brainstem function (cranial nerve function and vital sign

assessment)

assessment of cerebellar function (balance and coordination)

assessment of spinal cord function

We will now discuss each component of the pediatric neurological exam in detail.

Obtaining a History:

An important part of a nurse’s daily assessment includes understanding the history

of the illness or injury. Typically, detailed history notes are provided in the chart

by the admitting or consulting physicians, which should be clearly communicated

onto the nursing kardex. As well, the nurse needs to obtain a history of patient 10 status over the past 12 hours in order to get a clear picture of any changes in

patient status.

In the pediatric population the initial history is usually obtained from the primary caregiver and the shift history is obtained from both the nurse and the primary caregiver. Histories can also be obtained from older children; however, data

should be verified with either a parent or primary caregiver to ensure

accuracy. It is important to understand that some patients with neurological

conditions, such as frontal lobe dysfunction, may appear to give clear historical

information, however, this information is often incorrect.

When beginning the daily neurological examination of the patient, the nurse should

do the following:

Read the kardex and/or chart history.

Discuss the status of the patient with the nurse from the previous shift.

Observe the patient prior to providing any hands-on nursing care. Observe for

spontaneous movements, behaviour, symmetry of movement, demeanor, affect,

speech patterns, and other normal or abnormal developmental characteristics

etc. Make note of initial observations in the Nurse’s Notes (i.e. ‘Received

patient awake and alert, playing cards with mom in bed…’ etc.).

Initiate a discussion with the primary caregiver about the events of the past 12

hours. This may also lead to a discussion about what led to the admission. Ask

questions specifically related to the signs and symptoms of the illness or injury,

onset, severity, duration, frequency, progression, remission of symptoms,

treatments, aggravating and alleviating factors etc. (i.e. “Have you noticed

anything different about your child over the past shift?…explain to me what you

have noticed that is different”) 11 Let the primary caregiver know the plan for the shift (i.e. frequency of NVS

assessments, specific tests or treatments etc.) and the reason assessments are

important, especially during the night.

Indicate when you are ready to start your NVS assessment.

Complete a visual hand-over with the nurse from the previous shift, including

doing a NVS assessment, when indicated.

The standard recommended guidelines for visual hand-over reports on 3A are as

follows:

If the patient is on q2h, or more frequent NVS assessments.

If the patient is receiving either 1:1 or 2:1 nursing care.

If the patient is difficult to assess due to age, injury or other factors.

If the patient is showing a decrease in GCS scores, or other neurologic

indicators, that could indicate a potential deterioration (i.e. the child is felt to

be becoming less stable).

If the child is going to have a NVS assessment done by a nurse other than the

primary nurse for that shift. It is always best that the same nurse do all of the

assessments throughout the shift, whenever possible, as there is much less of a

chance of missing subtle trends early.

A visual handover may be performed between staff at any time and for any

reason and is always encouraged. Current data suggests that a visual handover

can enhance the learning experiences of novice nurses as well as significantly

enhance team discussions regarding patient specific concerns (which ultimately

makes a positive impact on patient outcomes).

Tools Required for a Standard NVS Assessment:

Penlight or ophthalmoscope light 12 Stethoscope

Thermometer

BP cuff and machine

NVS record and pen

Reflective Questions:

1.0 How do you think reading the patient’s history and understanding the disease

process will enhance your ability to complete a neurological assessment and

interpret the data effectively?

2.0 How do you think discussing the patient’s status with the primary caregiver

will enhance your assessment? In what situations do you think it may hinder

your assessment?

References and Resources to Enhance Learning:

Maher, L. Better history, shorter exam. Patient Care. 2000; 3: 161-174

Section Two: Assessing Mental Status Using the Modified Glasgow Coma Scale

This section will focus on:

The definition of mental status, consciousness, awareness and arousal

Assessing the mental status of the verbal and preverbal pediatric patient

Review what the Glasgow Coma Scale is and why we use a Modified Glasgow

Coma Scale in the pediatric population.

The mental status assessment consists of evaluating the patient’s level of consciousness (LOC); which involves eye opening, best verbal response and best 13 motor response. These three areas, collectively, are referred to as the Glasgow

Coma Scale (GCS). Each response is given a numeric value, moving from the best response (highest score) to the worst response (lowest score). The highest GCS score is 15 (healthy and alert) and the lowest possible score is 3 (dead). The GCS was originally developed to be used in emergency situations to determine the level of injury sustained and the potential outcome of the injury. In serial assessments of the at-risk patient, the GCS is used as part of a more holistic assessment to determine any improvement or deterioration in function. In reviewing the areas to be assessed, the importance of first determining the patient’s developmental level

(or the ‘norm’ for that patient) and becoming familiar with modified ways of assessing mental status becomes clear. Always start the assessment by ensuring you have determined the patient’s developmental age and have matched that to the appropriate NVS assessment record (verbal or preverbal). To assist you in determining a child’s developmental age, ask the parents or primary caregiver questions directed at the patient’s pre-injury abilities (i.e. How does your child normally communicate? How does your child mobilize? How does your child indicate they are hungry? Have you ever been told what level your child functions at? Is your child’s development considered normal?..etc.)

Level of Consciousness (LOC):

Consciousness (awareness of self and the environment, as well as responding appropriately to the environment) is a sensitive indicator of cortical function and is poorly assessed by using the GCS. Subtle changes in LOC, detected by serial assessments, however, are often the first indicators of neurological improvement or deterioration and MAY NOT always be reflected in the GCS score. When assessing LOC always apply stimuli in a strict sequence (from mildest to most severe), to ensure the response is the patient’s ‘best response’. 14 The three areas to be assessed when measuring LOC are:

1. Eye Opening / Arousal:

Eye opening indicates the patient’s degree of arousal and is recorded in the ‘Eye

Opening” portion of the NVS record. Arousal refers to the state of being awake.

Arousal is the lowest level of consciousness and does not indicate awareness.

Arousal indicates that the reticular activating system, which consists of the brainstem, thalamus and hypothalamus, are intact and coordinating with the cortex.

Decreased consciousness can result from injury to either the brainstem or one or

both hemispheres.

When assessing eye opening, the nurse must be sensitive to how much of a stimulus

is required to produce eye opening. Because ease of eliciting an eye opening

response can fluctuate with the sleep/wake cycle, it can be difficult to determine

if the degree of stimulus required to produce a response is normal or abnormal for

the individual patient. This is why the nurse should have a clear understanding of

what is normal for each child prior to starting the assessment. It is also essential

to remember that all assessments should start only once maximal arousal has

been obtained. For example, at 0200 hrs, the patient should be woken, noting how

much stimuli is required in order to get the child to stay awake (is the amount of

stimuli required considered normal or abnormal for the patient and time of day?

Document this in the Nurse’s Notes). If the child is able to wake easily and

maintain wakefulness, this is considered a ‘spontaneous’ response. GCS scores

should never drop solely because of the time of day and the sleep cycles.

Note: Incomplete eye closure (as seen in some facial nerve palsies) should NOT be

confused for spontaneous eye opening. As well, eye opening does not have to be

bilateral or full to be considered spontaneous. If at all possible, apply painful

stimuli to sites other than the supraorbital area to elicit an eye opening response,

as this can cause reflex closure of the eye. If the eyes are swollen shut, mark ‘S’ in 15 the ‘none’ section and make a note in the Nurse’s Notes to explain why an eye

opening response could not obtained. In these situations, you will not be able to

total the GCS score.

2. Best Verbal Response / Awareness:

Awareness comes about when the RAS coordinates with other areas of the

cerebral cortex (gray matter) effectively, allowing for appropriate interpretation

of environmental stimuli. The way to assess the degree of awareness is to assess

vocalizations in the preverbal child and verbalization in the verbal child. For

example, in the verbal child, awareness is recorded in terms of orientation to

person, place and time, appropriate use of words for age, and intact short-term

and long-term memory. Early neurological deterioration may first appear as loss

of orientation. Typically a patient will lose orientation to time (short-term memory), then place (slightly longer-term memory), and then person (long- term memory).

The best way to assess the degree of orientation is to engage the patient in

appropriate conversation for age.

Questions to ask to assess orientation are (appropriateness is dependant on age):

What is the date today? (month/day/year) If the child does not know,

orientate them and check for recall at the end of your assessment and

again at the beginning of your next assessment.

What time is it?

Where are you?

What is your name?

Questions to ask to assess recognition and recall are:

Who is the person sitting next to you?

Hold up a familiar toy and ask “What is this?” or “What noise does this

animal make?” 16 What is your address? Phone number?

When is your birthday?

Do you have any brothers? Sisters? A dog? A cat? Any pets? What are

their names?

What is your favorite food?

What grade are you in?

Questions to test long-term memory are:

Who was your teacher last year?

What did you eat for dinner last night?

What is your favorite movie? Who was your favorite character in the

movie?

Questions to test short-term memory are:

What movie are you watching?

Give the child a word to remember at the beginning of the assessment

and ask him to recall it at the end of your assessment, such as

“Remember the word hamburger”

When doing assessments it is important to test all three areas of orientation plus

recognition and recall (short and long term memory). If a child is not sufficiently

oriented to all three spheres, they are considered ‘confused’ (i.e. a patient can’t be

half-oriented and half-confused, although age and developmental factors play a

significant role in determining appropriate responses).

To assess awareness in the infant or preverbal child, the nurse must be aware of

normal developmental indicators of awareness. Typically awareness of the

environment is indicated by appropriate interest and interaction with the

immediate surroundings. Infants show awareness of self by crying when hungry,

frightened or wet. The infant should be assessed for appropriate cooing, babbling 17 and crying to determine the child’s state of awareness. For example, a healthy baby will cry when hungry but be easily settled with nourishment. Young infants will

demonstrate appropriate rooting reflexes, cry when hungry and suck appropriately.

Older infants will ‘make strange’, cry appropriately when frightened and be easily

settled by a parent or when the frightening stimulus is removed. Deteriorations in

awareness may present as either a lack of interest and decreased interaction with

the environment, or an irritable, inconsolable cry that often does not respond

consistently to comfort measures. With decreasing awareness, the child may

become very lethargic and only cry or moan in response to a painful stimulus.

To assess awareness in the infant the nurse should consider the following:

Is the baby easily wakened?

What noises does the baby make when woken? When a mild stimulus is

applied?

Does the baby coo, babble or cry at ‘typically’ appropriate times?

What noises does the baby make when playing or being interactive. Does

the baby appear interested, attentive or smile easily?

What does the baby’s cry sound like? Is it high pitched or inconsolable?

Is it considered lethargic, or robust and ‘typical’ for age?

At what times does the baby cry? Do the times coincide with the need

for food or to be changed? or is a pattern lacking?

What interventions cause the baby to stop crying? Are the interventions

considered ‘typical’ for the baby?

How does the baby interact with the parent? Does the baby seem to

recognize and seek the mother when hungry or upset? Does the baby

settle easily with the parent/ primary caregiver?

The score given to the responses obtained in this section should be further

supported with specific details about the baby’s behaviour in the Nurse’s Notes. 18 This is the best way for the nurse to ensure clarity of communication and fully support the conclusions drawn from the data obtained in the assessment.

To assess awareness in the verbal or nonverbal, developmentally delayed child the nurse should consider the following:

What is the child’s typical best response? Note this on the NVS sheet

next to the highest score and mark this as ‘normal for child’. Clearly

document in your Nurse’s Notes whom you obtained this information from

and any other data to support the classification. Also record the child’s

best response in the kardex and the NCP for easy reference.

What is the child’s ‘typical’ way of communicating awareness? Does the

child smile? Track? Make specific vocalizations or have a specific

vocabulary that helps connote a specific meaning? What are they?

Is the child using his typical means of communicating appropriately?

At what times does the child cry? What interventions are helpful in

comforting the child? Is this consistent with the child’s ‘normal’

behaviour?

As mentioned previously, supporting documentation in the Nurse’s Notes is essential in justifying the conclusions drawn from the NVS assessment. It is also essential for other nurse’s to have as much detailed information about the developmentally delayed child as possible in order to continue doing accurate assessments, especially at times when parents are not available for consultation.

This data will also increase the ability of the nurse to identify downward trends as early as possible. Unfortunately, developmental delay can be as unique and varied as each patient, and can often cause difficulties in the assessment process. Severe developmental delay can challenge the nurse’s ability to accurately obtain pertinent information and draw meaningful conclusions from it. The best way to cope with 19 these challenges is to get parental input prior to and throughout the assessment

process, and develop patient specific ways of testing for the presence of pre- injury skill.

Dysphasia (impairment of speech resulting from a brain lesion) and Aphasia

(absence or impairment of the ability to communicate by speech, writing or

signing due to disfunction of brain centers) are two focal neurological signs that

DO NOT reflect decreased level of consciousness. If, however, a patient suddenly exhibits a decreased ability to communicate, this DOES reflect neurological decline (i.e. sudden stroke). Dysphasia or aphasia are the result of lesions or injury to the speech centers in the dominant hemisphere or the result of a post-fossa craniotomy (post-fossa mutism / cerebellar mutism). Dysphasia, aphasia and mutism should be documented in the flowsheet by writing ‘NN’ or ‘NCP’ and further documentation should be provided in the specified nursing record. In these cases,

LOC can not be assessed using the ‘best verbal response’ section of the GCS and,

therefore, the GCS can not be totalled. However, if the child is able to

communicate awareness in all spheres by other means, such as writing, nodding

appropriately, or use of a communication board, for example, this should be noted

as a ‘best response’ for that child and all areas of orientation should examined. The

RN should write ‘NN’ in the ‘best response’ box and fully describe the questions

asked and how the patient responded in the Nurse’s Notes.

When assessing best verbal response, the nurse should assess for facial symmetry,

clarity and co-ordination of speech, tongue movements and acuity of hearing. This

provides a gross assessment of CNs #5, 7, 8, 9, 10, and 12 (refer to pg. 32).

3. Best Motor Response:

Assessment of best motor response is the third piece of information required to

determine LOC using the GCS and can only be assessed if the child’s motor system 20 is intact. By initiating a command and eliciting a response, the nurse can

determine the child’s level of alertness, awareness and motor function. The

neurologically intact older child should understand and obey verbal commands such

as ‘wiggle your toes or fingers’, ‘squeeze my hand’ or ‘push my hand away’. It is

important to remember to differentiate between intentional squeezing and reflex squeezing by having the child release on command and / or by eliciting a repeated response. A response

should be elicited from all limbs and the ‘best response’ recorded. It is important to

remember that this section is testing cortical and motor function. A response, even if it is only from one side, indicates appropriate cortical processing and, therefore, should be recorded as the ‘best response’. Any asymmetry will need to be fully explained in the

Nurse’s Notes and reported to a physician. For children with spinal cord injuries or

those who are ‘locked in’ due to brainstem strokes etc., the best motor response

may be eye blinking to command, opening and closing the mouth to command, or

looking in a specified direction on command. To simply mark ‘no response’ would give

a falsely low GCS rating. When assessing best motor response, the nurse should

focus on the integrity of CN #11, which controls the movement of the shoulders.

Localization to pain:

This refers to a purposeful attempt to remove a painful or ‘annoying’ stimulus and

is elicited by applying a painful stimulus above the level of the clavicle. Localization

is assessed in older children, as infants are too immature to localize (infants

respond to touch or pain with a withdrawal response).

To obtain a localization response the stimulus should be applied either to the trapezius muscle (innervated by CN#11) or the supraorbital region (innervated by a

branch of CN#5) only. (Note: Never use supraorbital pressure on children with

head injuries, frontal craniotomies, facial surgeries or facial fractures

because of the possibilities of underlying fractures or an unstable cranium).

With supraorbital pressure the hand should move above the level of the clavical to be considered localization. With a trapezius squeeze, the hand should move across 21 the midline and above the clavicle to be considered localization. A true

‘Localization’ response is marked when the patient can touch the hand of the

assessor in an attempt to remove the painful stimulus. If a weak response is

obtained, the nurse should mark ‘NN’ in the ‘localization’ section, and write

‘attempts to localize’ in the nurse’s notes. If localization cannot be elicited, then

the nurse should assess the upper limbs for a withdrawal response from pain by

applying a peripheral stimulus, such as nail bed pressure. The nurse must be aware

that in order to get an appropriate lower limb response, light peripheral

stimulation, such as stroking the plantar surface of the foot, should be avoided as

it is difficult to assess the difference between withdrawal flexion and a reflex

arc. The best way to by-pass a spinal reflex is to apply firm, continuous pressure to

the toes or Achilles tendon. It is important to note here that assessment of the

periphery of children under one year of age should include trying to elicit a positive

Babinski reflex (dorsiflexion of the big toe and fanning of the remaining toes in

response to plantar stimulation). This reflex is normal up to one year of age,

however, if present in older children, is a sign of cortical-spinal tract injury or dysfunction. Older children who are neurologically intact should exhibit plantar flexion of all the toes when the bottom of the foot is stroked (negative Babinski reflex).

Decorticate posturing (abnormal flexion):

This is an abnormal motor response that can be witnessed either unilaterally or

bilaterally in response to a noxious stimulus. Decorticate posturing presents as a

consistent flexion of the elbow, movement of the arms toward the midline,

pronation of the forearm, clenching of the fists, extension of the legs, and plantar

flexion. Typically this can be differentiated from localization because the

movements are slower and do not always correspond with the location of the

stimulus. Decortication is an indication of damage to the cerebral hemispheres at 22 the level of the outer cortex (gray matter/ outer layer of the brain). The gray

matter is primarily responsible for conscious thought, reasoning and behaviour.

There are also large masses of gray matter located deep inside each hemisphere

called the basal ganglia. A part of the basal ganglia called the internal capsule

contains white matter (myelinated sensory and motor nerves and connecting pathways) that connects the cerebral cortex to the brainstem and spinal cord.

Decortication typically represents damage at the level of the cortex and / or the

basal ganglia. The patient will flex the arms away from the noxious stimuli and extend the feet into the noxious stimuli.

Decerebrate posturing (abnormal extension):

This is an abnormal motor response that can be witnessed bilaterally or

unilaterally, with decorticate posturing on the opposite side, in response to a

stimulus. Decerebrate posturing can also be witnessed intermittently and is seen in

brainstem compression resulting in transtentorial herniation. Decerebrate

posturing presents as a sustained spinal hyperextension, clenching of the teeth,

extension of the arm at the elbow, adduction, and hyperpronation of the arms,

extension of the legs, and plantar flexion. Decerebrate posturing is a sign of

severe, deep hemispheric damage, affecting the more primitive areas of the brain

such as the brain stem (midbrain area). The patient will extend all limbs into the

noxious stimuli. Decerebrate posturing signifies massive cerebral injury and has a

serious prognosis associated with it.

Review the following diagrams of abnormal flexion and extension:

Assessment of ‘best motor response’ in the infant differs somewhat than that of an older child. For infants, the nurse should first assess for spontaneous, age appropriate movement. This might mean assessing for appropriate reflexes and developmental milestones such as those listed below:

Referenced from: McGee, S & Burkett, K.W. Identifying common pediatric neurosurgical conditions in the primary care

setting. Nursing Clinics of North America. 2000; Vol. 35. No. 1. 61-85.

Referenced from: Kozier, B., Erb, G. and Olivieri, R. Fundamentals of Nursing; Concepts, Process and Practice. 4th ed. 1991.

Addison-Wesley. New York. p. 603. 26 Younger infants can be assessed for the rooting, grasp, Babinski and Moro

reflexes and older infants can be assessed for the ability to grasp toys and

bottles, or reach for a parent in a meaningful manner. The second and third best

responses, ‘withdrawal to touch’ and ‘withdrawal to pain’, must be differentiated

from abnormal flexion (decorticate posturing) by observing the entire body when applying a localized stimulus. Withdrawal to touch typically only involves the limb

being stimulated and there is no accompanying lower extremity extension or

plantar flexion.

It is important to remember that assessment of movement alone, without an

assessment of awareness (LOC) will not provide any early indications of

neurological deterioration. This is why it is essential to check all areas,

including pupil size, at each assessment.

Referenced from: Barker, E. Neuroscience Nursing. 1994. Mosby. St. Louis. p.303.

27 4. Total GCS Score:

Once the three sections of the GCS have been assessed fully and each response

given a numeric equivalent, a total GCS score can be obtained. As mentioned

previously, slight changes may not always be reflected in the GCS as the record is

a ‘gross’ scale, therefore, slight changes, whether reflected in the total score or

not, must be reported as they can indicate neurological decline. Contextual

information pertaining to the NVS assessment should be noted in the Nurse’s

Notes and provided to the physician as well. Remember that the normal sleep/wake

cycle should not be reflected in an increasing and decreasing GCS score (i.e. sleep does not = coma). The amount of stimulation required to arouse the patient should be noted and used as part of the overall assessment, however, once the child is awake, the nurse should assess for continued spontaneous eye blinking. If present, this is considered a ‘spontaneous’ response. At no time should a NVS assessment be omitted or the assumption made that a child is ‘sleeping’. It is impossible to differentiate between normal sleep and neurological deterioration without doing a complete NVS assessment.

Reflective Questions:

1.0 What aspects of the patient’s history will be important to know when

assessing the mental status of the older verbal child?

2.0 When assessing memory, what must the nurse know about the patient’s

history in order to determine accurateness of the response? Who can the

nurse utilize in assessing accuracy?

28 References and Resources to Enhance Learning:

Larson, G.Y., Vernon, D.D., Dean, JM. Evaluation of the comatose child. In:

M.C. Rogers, ed. Textbook of Pediatric Intensive Care. Williams &

Wilkins. Baltimore 1996: 735-745.

Section Three: Assessing Extraocular Eye Movement (EOM) and the Pupils

This section will focus on:

How to assess the pupils of infants and children

Normal and abnormal pupillary reactions

The cranial nerves involved in assessment of the eyes

Pupil assessment and EOM assessment is a critical component of the NVS

assessment because it gives clear information regarding cranial nerve function and

changes in intracranial pressure (ICP). During an eye exam, the nurse assesses CNs

#2,3,4 and 6. Anatomically, the areas of the brainstem that control arousal are adjacent to the area of the brain that control pupils, therefore assessing both together, provides the nurse with more comprehensive data and assists in detecting changes. For this reason, at no time should the eye assessment be

omitted from the NVS assessment!

The pupillary light reflex is a combination of afferent (sensory) input from the

optic nerve (CN#2) and the efferent (motor) response from the oculomotor nerve

(CN#3). Pupils are normally 2-6 mm in size and constrict briskly to light. A 1mm

variation in resting pupil sizes is considered normal. The Oculomotor nerve (CN#3)

is responsible for eye opening, eyelid and eyeball movement including pupil

constriction and dilation. The Trochlear nerve (CN#4) is responsible for turning

the eyeball downward and medially, and the Abducens (CN#6) and Trochlear (CN

#4) together, are responsible for turning the eye laterally. All three nerves 29 together allow the eyes to move in the nine cardinal directions (i.e. up, up-right, right, down-right, down, down-left, left, up-left and front).

The first part of the eye assessment involves having the patient open their eyes

and assessing for symmetry of eye opening. Next look at the size, shape, and

midline position of the pupils by asking the child to look directly at you. This will

also assist in assessing the patient’s cortical function (ability to understand and obey commands) and ability to accommodate (focus). For infants, hold a brightly colored toy in front of you or put your face directly in front of the child.

Encourage eye contact and tracking in all directions with all age groups. If a patient is accommodating appropriately, the pupils should constrict equally.

It is important to note that an early sign of third cranial nerve compression

caused by transtentorial herniation may be a slight change in the shape of the

pupil from round to oval or small pupils that react sluggishly to light. This can

progress to nonreactive, bilaterally dilated or asymmetrically dilated pupils

that are predictive of a poor prognosis.

Check for double vision or other difficulties by asking older children if they have

been experiencing any changes in their visual acuity. Ask the child to count the number of fingers you are holding up or have them read words from a book or

describe what they see on the television etc. Ask the child if they see a shadow or

a double overlap. For younger children, assess for difficulties with coordinating

reaching and grasping in the appropriate direction. Remember that infants typically

start to develop their ability to focus at approximately 1-2 months of age and

begin to developed basic hand-eye co-ordination (such as reaching for a rattle), at

approximately 4 months of age.

30 Take a moment to review the following chart to familiarize yourself with common pupillary changes and their pathological indicators as well as the Denver

Developmental Test, which reflects major milestones for each age group.

Referenced from: Barker, E. Neuroscience Nursing. 1994. Mosby. St. Louis.

p. 68-69 32

Referenced from: Whaley, L.F. & Wong, D.L. Essentials of Pediatric Nursing.

1989. Mosby. St. Louis. 3rd ed. p.1086.

33 The next step in the assessment includes checking for pupillary reaction to light.

Assessments are often easier in a dimly lit room using a strong pinpoint light such as an opthalmoscope. Start by approaching the eye from the side to avoid the accommodation reflex. Next, bring the light in from the side of one eye. Watch for brisk pupil constriction in the first eye, as well as a consensual constriction of the opposite pupil. Repeat the process from the opposite side. If the child is blind in one eye, assess for constriction of the blind pupil when the light is shone into the opposite eye. There will not be any pupillary response in either eye if the light is shone directly into the blind eye. Note: pupils can also be checked in children with cortical blindness, as the second and third cranial nerves are intact.

Pupil reactions are marked as ‘Brisk’, ‘Sluggish’ or ‘Fixed’. The ‘+’ and ‘-‘ symbols can also be used to note slight variations in either direction. Avoid continually shining a sharp light into the pupils over and over as this can cause bleaching of the retina.

At times it can be extremely difficult to assess the pupils of younger children who are uncooperative and do not understand directions. At these times it may be necessary to do the assessment while an infant is relaxed such as when feeding, or by making the assessment into a game by allowing the child to use the flashlight under the blankets while playing ‘tent’, for example. It is also impossible to assess the pupils of children whose eyes are swollen shut. It is important to remember to never pry swollen eyes open as this can cause further injury to the child. Always provide contextual/supporting documentation in the Nurse’s Notes when any part of the assessment cannot be performed.

Review the following chart to familiarize yourself with cranial nerve function and assessment techniques:

Referenced from: Whaley, L.F. & Wong, D.L. Essentials of Pediatric Nursing. 1989.

Mosby. St. Louis. 3rd ed. p. 168.

It is important to note that some findings that are abnormal in adults are normal in children. For example, young infants may have an asymmetric blink and a disconjugate gaze. Infants may also exhibit a few beats of nystagmus and have irregular movements of the tongue on protrusion and at rest. Strabismus may also 35 appear between the ages of three and six years. Although strabismus is not normal, it reflects a muscle problem and not a cranial nerve problem. Although these findings may be normal in certain age groups, they should still be clearly documented and reported in order to rule out anything pathophysiological.

It is important to remember; that in most cases abnormal findings in pupil size, shape and reactivity are indications of increasing intracranial pressure or focal signs of cerebral dysfunction and must be reported STAT.

Reflective Questions:

1.0 How would you modify your NVS assessment for children whose eyes are

swollen shut? How would you ensure accurateness and completeness of your

assessment? (consider the location and function of the brainstem in

conjunction with the location of the cranial nerve pathways when thinking

about this question).

2.0 In what situations would it be essential to know what treatments and/or

examinations the patient has received in order to interpret your assessment

findings accurately?

References and Resources to Enhance Learning:

Lerner, Alan.J. The little black book of neurology. 3rd ed. Drug effects on the pupils. pg. 358-359. Mosby. 1995. O’Hanlon-Nichols, T. Neurologic assessment: the basics of a comprehensive examination. American Journal of Nursing. 1999. Vol.99, No. 6. 44-50.

Section Four: Assessing Strength and the Ability to Move

This section will focus on:

Determining the difference between degrees of strength

Tests that can be used to accurately determine strength

Testing strength and the ability to move assesses components of spinal nerve function, muscle strength and coordination, and cognitive function. Injury to any of these areas can cause changes in muscle mass, muscle strength, muscle tone, posture, or produce abnormal movements.

Ataxia, for example, is reflective of cerebellar (balance and coordination center) dysfunction and, therefore, should be assessed for frequently. Damage to the cerebellum is characterised by symptoms involving skeletal muscles. Ataxia may present as an inability to touch the end of the nose with the finger due to the loss of co-ordination of movement and sense of body position. Another sign of ataxia is a change in the speech pattern due the lack of co-ordination of speech muscles.

Cerebellar damage may also result in gait disturbance, in which the patient may stagger or is not able to co-ordinate normal walking movements. The patient will appear to be experiencing dizziness, however, the nurse must be sure not to make this erroneous assumption. Younger children may have difficulty coordinating crawling and may stop trying to mobilize. Cerebellar injury may also cause nausea and vomiting. To determine if the nausea and vomiting is related to cerebellar injury and not true dizziness, the nurse should assess the patient’s ability to coordinate movements, as described above to rule out cerebellar injury as the primary cause. Assessments should also include looking for paralysis and paresis, hypertonia, hypotonia, atonia, dystonias, posturing, spacticity and rigidity. When assessing strength, it is important to do a bilateral comparison of all limbs as well as assess co-ordination for sitting, standing, crawling and walking. Begin the 37 assessment by having the older patient squeeze your right and left fingers at the

same time. Also have the patient push your hands away with their feet. Next, apply

resistance to the tops of the hands and feet, and have the patient dorsiflex

against your resistance, noting any variations in strength. Next, assess how the patient sits, rolls, crawls or walks. For the infant, resistance can be assessed by noting the effectiveness of the grasp and the ability to perform spontaneous

movements against gravity. Strength can also be assessed in the infant by noting

the force in which they withdraw from noxious stimuli, turn themselves, and crawl

or play with toys. If an older patient has no ability to move against forced

resistance but has some spontaneous weak movements against gravity, this is

considered a ‘weak’ response. ‘Trace’ movements are described as minimal

contractions in response to a stimulus but with no purposeful movement against

gravity. ‘Absent’ refers to complete flaccidity.

Pronator Drift can only be assessed in the older, cooperative child. In assessing

for drift, the nurse is looking for weakness on one or both sides, and signs of

cerebellar injury. To assess drift, have the child stand or sit in front of you with

their eyes closed, palms up and arms directly out in front at shoulder level. Have

the child stand like this for approximately 20-30 seconds. As you look at the child

check to see if one arm pronates and drifts downward; this indicates muscle

weakness on that side. Also assess if both arms pronate and drift downward; this

indicates bilateral muscle weakness. If you assess that one or both arms move

upward, this could indicate cerebellar injury. Any abnormal findings should be

documented on the NVS record as ‘Rt’, ‘Lt’ or ‘NN’ and a clear description provided

in the Nurse’s Notes. Drift should always be reported to the physician if it has not

been previously documented.

38 The strength scale most commonly used amongst Health Care Teams is called the

‘Strength Grading Scale’. This scale grades each response on a scale of zero to five.

Referenced from: Barker, E. Neuroscience Nursing. 1994. Mosby. St. Louis. p. 63.

Use of ‘Weak’, ‘Moderate’ and ‘Strong’ should NOT be used in charting as it is subjective and is a poor descriptor of patient status.

Strength, as with muscle bulk, must take into account the age, sex and fitness level of the patient. For example, a frail, bed bound patient may have muscle weakness due to severe deconditioning and not to intrinsic neurological disease. Interpretation must also consider the expected strength of the muscle group being tested. The quadriceps group, for example, should be much more powerful then the Biceps.

There is a 0 to 5 rating scale for muscle strength: 0/5 No movement Barest flicker of movement of the muscle, though not enough to 1/5 move the structure to which it’s attached. Voluntary movement which is not sufficient to overcome the force of 2/5 gravity. For example, the patient would be able to slide their hand across a table but not lift it from the surface. Voluntary movement capable of overcoming gravity, but not any 3/5 applied resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied. 4/5 Voluntary movement capable of overcoming “some” resistance 5/5 Normal strength ‘+’ and ‘-‘ can be added to these values, providing further gradations of strength. Thus, a patient who can overcome “moderate but not full resistance” might be graded 4+ or 5- . This is quite subjective, and therefore should be supported 39 further with detailed description in the chart. To preserve inter-rater reliability, a visual handover report is always recommended between staff members.

To ensure that assessments between two different nurse’s are as reliable as possible, a visual handover, including a joint NVS assessment, will help decrease subjectivity when recording fine variations in strength.

Reflective Questions:

1.0 What challenges may present when there are a number of different nurses

performing an assessment? What are some ways that the challenges can be

minimized?

2.0 When assessing muscle strength it is important to remember that some

alterations can be related to either brain dysfunction, nerve dysfunction

and/or muscle injury. How would you determine the direct cause of

alterations in strength?

3.0 Which types of conditions/surgeries would indicate a need for assessment

of ataxia and interventions to protect the patient from injury associated

with ataxia?

Section Five: Assessing Colour, Sensation and Warmth (CSW) of Extremities

and Bladder Function

This section will focus on:

How to assess peripheral perfusion accurately.

Causes for alterations in peripheral integrity.

Signs of peripheral compromise

40 CSW:

Assessment of peripheral circulation is included in the NVS assessment for a number of reasons. Firstly, it is an essential part of a Spinal Neuro Vital Sign

(SNVS) assessment when there is a potential for tissue swelling, tumor growth or other pathophysiological conditions to compress the spinal nerves. Secondly, neurologically compromised children are at high risk for developing peripheral complications associated with immobility, secondary to their specific disease process or injury. For example, a child with CP is at higher risk of peripheral tissue injury not only because the co-ordination of movements away from injury is compromised but also because they have decreased active muscle contraction to facilitate venous return of blood to the heart. This can cause venous stasis, edema and secondary tissue injury in dependent areas. Also, altered sensation in the periphery may be a sign of peripheral neuropathy, compressed or injured spinal nerves or early signs of disease processes such as Guillian Barre Syndrome.

Referenced from: Whaley, L.F. & Wong, D.L. Essentials of Pediatric Nursing. 1989. Mosby. St. Loius. 3rd ed. p. 1016.

Although CSW is part of a SNVS assessment, it is to be included in all NVS assessments. Peripheral assessments can be incorporated into the assessment of limb strength and co-ordination by actively looking at each limb and completing several simple visual exams.

First, assess the temperature of the extremities by feeling both limbs simultaneously. When arterial circulation (oxygenated blood entering the limb) is compromised, the extremity will become pale, mottled and cool to the touch. When 42 venous circulation (deoxygenated blood returning to the heart and lungs) is compromised, blood will pool and the limb will become cyanotic and cool.

Assess for pink nail beds with a capillary refill less than or equal to3 seconds.

Press the nail beds (or the tips of the digits) until they blanch, and release quickly while counting the length of time it takes for the nail beds to become pink again.

Peripheral pulses can be assessed on the dorsal aspect of the foot (dorsalis pedis) and behind the ankle (posterior tibial) bilaterally, and at the wrist (radial) and brachial area, when assessing the arms and hands. A Doppler device may also be used when pulses are difficult to obtain manually. Pulse volume should also be assessed, watching for bounding, weak or thready pulses.

The sensation experience will be difficult to assess in the preverbal child as co- operation and an interactive discussion is most often required to get accurate data.

In the older child you may simply ask if the limb feels like ‘pins and needles’ or

‘tingly’ or if the child can feel you touching the limb. You may ask the child to differentiate between warm and cold sensations or soft and hard. It is important to clarify with a child if he/she reports that his limbs feel ‘numb’ as ‘numb’ can often be confused with ‘weak’. It is important to know what the baseline is for each child in these situations.

Note: When assessing the lower limbs of the comatose child, developmentally delayed child or infant, it is easy to mistake a spinal reflex arc for movement provoked by sensation. Remember that reflexes of the lower limbs can be elicited, even in children with spinal cord injury who have little or no peripheral sensation.

When assessing the periphery, start at the most distal end and move centrally. If alterations are evident, it is important to note at what level the altered sensation begins and ends. More in-depth assessments, which include the use of a tuning fork 43 and various tactile objects, are typically reserved for the physician and are not

generally considered a part of the daily nursing assessment per se.

It is important to remember that CSW assessments on catheterised limbs

(femoral lines, arterial lines etc.) are essential in preventing secondary injury

associated with clot formation, edema, infection, erosion, or extravasation of the cannula, for example.

Bladder Function:

Assessing bladder function is an essential component of both the NVS assessment and the SNVS assessment for a number of reasons. Firstly, loss of bladder control, in a child that is normally continent, can be a significant sign of either spinal nerve

compression or injury (especially in the presence of altered CSW and limb

strength), or cerebral injury (especially in the presence of altered LOC).

Children can also experience a neurogenic bladder, which is caused from damage to

the nerve supply either at the central nervous system level or the level of the

spinal cord. A neurogenic bladder can present in a number of ways, including not

being able to empty the bladder completely, dribble incontinence, loss of sensation

to indicate the bladder is full, frequency and urgency, and involuntary voiding. A

neurogenic bladder can be the result of spinal cord tumors above T12, MS, injury

or lesions in the S2-S4 region, Spina bifida, abdominal surgery involving transection

of the parasympathetic nerves, or post-operative spinal hematoma / nerve

compression.

Urination occurs as a result of voluntary and involuntary nerve impulses. The

sympathetic and parasympathetic nervous systems (components of the autonomic

nervous system) are responsible for co-ordinating the relaxation and contraction

of the bladder wall and the internal and external bladder sphincters. In addition, 44 the spinal cord and cerebral cortex are responsible for transporting, interpreting and initiating voluntary urination.

When the amount of urine in the bladder reaches a certain level, stretch receptors in the bladder wall transmit impulses to the lower portion of the spinal cord. These impulses are carried through sensory nerve tracts to the cortex, the sensory input is interpreted and the need to urinate is consciously registered. Simultaneously,

when a conscious decision to empty the bladder is made, a signal is sent to a nerve

centre in the sacral spinal cord which initiates a parasympathetic reflex

(subconscious) causing contraction of the bladder wall and relaxation of the

internal sphincter. Then the conscious portion of the brain sends impulses to the

external sphincter, the sphincter relaxes and urination takes place on a conscious

level. So, although emptying the bladder is controlled mainly by reflex, it may be

initiated voluntarily (even before the stretch receptors are triggered) and stopped

at will because of cerebral control of the external sphincter and certain pelvic

muscles. If consciousness is altered or the sensory nerve pathways obstructed,

cerebral processing is by-passed, and the bladder stretch receptors initiate the

parasympathetic reflex causing incontinence to occur.

For children who have, or who are at risk for, Diabetes Insipidus (DI) or Syndrome

of Inappropriate Anti-Diuretic Hormone (SIADH) such as patients with head

injuries or encephalitis for example, an accurate Intake and Output record is

essential in tracking and preventing injury associated with fluid and electrolyte

imbalances. The NVS record can reflect when output is either too high or too low

and provide the nurse with indications for closer observation.

Even though assessing continence may seem somewhat redundant or tedious, it can,

in fact, provide very important details about consciousness, cognition and spinal

nerve integrity. It is important to remember that an early sign of neurological

deterioration is confusion, which may present as loss of either bladder or 45 bowel control in a previously continent child and is to be reported to a

physician.

Lack of urinary control is normal for children under the age of 2 years because the neurons to the external sphincter are not fully developed. Regressive behaviour, such as incontinence in the toilet-trained toddler, is also considered likely especially when the child is sick or stressed, but still should be documented appropriately in the Nurse’s Notes and reported clearly to a physician.

For children who have sustained an injury to the spinal cord or who are at risk for spinal cord compromise, SNVS, including assessment of peripheral CWS, bladder control and vital signs are essential in detecting spinal nerve compression.

Also, in Guillian Barre Syndrome, bladder and bowel changes are most often expected due to the disruption of the sensory and motor neurons of the autonomic nervous system.

Refer to the following picture to help determine the clinical manifestations of nerve compression at various vertebral levels:

Reflective Questions:

1.0 In what ways can you ensure clear communication between yourself and the

primary caregiver in terms of stressing the importance of reporting

incontinence? (never assume parents will report everything!)

References and Resources to Enhance Learning:

Prendergast, V. & Sullivan, C. Acute spinal cord injury: nursing considerations

for the first 72 hours. Critical Care Nursing Clinics of North America.

2000:Vol. 12, No. 4. 499-508.

Section Six: Vital Sign Assessment

This section will focus on:

Components of vital sign assessments

Pathophysiological reasons for alterations in vital signs in the neurologically

compromised patient.

Pulse, respiration, blood pressure and temperature (regulated by the autonomic

nervous system) provide information regarding the adequacy of circulation to the

brain and the periphery. Such autonomic activity is most intensely disturbed in

cases of deep coma, brain stem lesions and brainstem or transtentorial herniation.

Assessment of the vital signs can also provide general information regarding the

integrity of the Vagus nerve (CN#10).

Approximately 75% of adult cases of late stage cerebral decompensation exhibit

Cushing’s Reflex, which is the combination of an increase in systolic blood pressure,

a widening pulse pressure and a decrease in the pulse. In children, this reflex is

fairly uncommon, and if it does occur, is a very late sign. Therefore, any changes in respirations, pulse, blood pressure or temperature are important to note during serial assessments. The tendency will be for the blood pressure to increase as the HR falls in cases of increased ICP.

Blood Pressure:

Obtaining an accurate blood pressure reading is essential with all general

assessments as well as the NVS assessment. Blood pressure changes can signify

increasing ICP, pain and anxiety (which can be associated with rising ICP) as well as fluid overload or dehydration (complications of DI and SIADH, for example).

In the neurologically at-risk patient, if cerebral edema increases, or available intracranial space is minimized due to increasing lesions or bleeds, cerebral blood 48 supply will become compromised. If ICP rises above the mean arterial BP, cerebral profusion will be cut off completely. At this point, swift intervention is required in order to stop complete brainstem compression, herniation and death.

Blood pressure should always be graphed on the NVS record in order to be able to visualize slight changes.

Familiarity with normal blood pressures for different age groups is essential in determining variations that could prove to be significant.

Review the following chart of normal vital sign parameters for the pediatric patient:

Compiled from: Whaley, L.F. & Wong, D.L. Essentials of Pediatric Nursing. 1989. Mosby. St. Louis. 3rd ed. Ghajar, J. Traumatic brain injury. The Lancet. 2000. Vol. 356. 923-929.

49 Cerebral Edema: (* This section taken directly from Specht D.M. Cerebral edema: bring the brain back down

to size. Nursing CE Handbook. March, 1998.) Cerebral edema is brain swelling that, because the skull is a confined space, can

lead to ischemia, herniation and death. The most widely accepted explanation of

cerebral volume dynamics is the Monro-Kellie doctrine, which states that the brain

is part of a closed system encased in a solid mass of bone (limited room for

expansion of contents). The three components are:

Brain [80-85% of contents]

CSF [8-12% of contents]

Blood [3-10% of contents]

The total volume of the cranial cavity is consistently 1700-1900 ml in the adult patient, but varies significantly in the first two years of life. Once the fontanelles and cranial sutures close the volume becomes relatively stable.

To maintain a steady state, an increase in the mass or volume of one of the cranial components must be balanced by an equal decrease in one or both of the others.

Although there are different types of cerebral edema, it is important to recognize that clinically, they all present the same. 50

The following algorithm illustrates the cyclic nature of events associated with increasing cerebral edema:

The brain uses three types of compensation to maintain a stable state. They are:

Cerebral pressure regulation (commonly called autoregulation)

Metabolic regulation

CSF regulation

52 Autoregulation:

This mechanism maintains constant cerebral perfusion despite changes in systemic

arterial pressure. When systemic pressure rises, cerebral arterioles constrict to

keep the amount of blood entering the brain at a steady rate. When arterial

pressure decreases, the cerebral arterioles dilate to increase blood flow to the

brain. It is important to note that neonates, do not have autoregulation, therefore,

will exhibit a concurrent rise in BP as cerebral perfusion pressure (CPP) rises.

Metabolic Regulation:

Changes in oxygen (02) and carbon dioxide (C02) levels affect cerebral blood vessels as well. Low 02 and high C02 levels trigger vasodilation. Hyperthermia is

another cause of vasodilation. Increasing metabolic activity raises cerebral blood

flow, leading to higher use of 02 and glucose. Waste products accumulate faster

and blood flow is increased and maintained to help eliminate them, despite the

simultaneous increase in ICP.

CSF Regualtion:

The brain also regulates the production and reabsorption of CSF. Decreased

production or increased reabsorption decreases ICP. This compensatory response

could be triggered, for example, when a slow-growing tumor increases the mass of

brain tissue in the skull. However, a quickly evolving increase in the mass, such as a

subdural hematoma, poses a tougher problem for the brain’s compensatory

mechanisms to handle. The brain can’t compensate fast enough for a fast growing

mass, so ICP can rise acutely. During compensation CSF will also tend to pool in

areas of lower pressure, such as the spinal cord, as pressure increases.

CSF is produced in the choroid plexuses, which are spongy semipermeable

membranes within the ventricles. CSF is formed as an ultrfiltrate of plasma. When

CSF pressure is less than the mean arterial pressure, CSF production is normal. 53 Because the membrane is semipermeable, if CSF pressure is equal to or greater

than the mean arterial blood pressure, CSF production slows or stops. As ICP

increases CSF is pushed into the dural sheath surrounding the optic nerve causing

venous congestion and papilledema.

When the Regulatory System Fails:

Unfortunately, regulatory mechanisms have limits. When these compensatory

mechanisms fail to control increasing ICP, decompensation occurs.

Unchecked, increasing ICP leads to hypoxia and cell death. Hypoxic brain cells don’t

regulate metabolic processes effectively, waste products accumulate, C02

increases, and acidosis develops. To respond to the build-up of C02 and acidosis,

the reflex vasodilation increases cerebral blood flow. In a compromised brain,

increased blood flow causes a further increase in ICP, and the vicious cycle

continues. Unless the cycle is broken, the patient will die.

Once the maximum level of compensation has been reached, a relatively small

increase of 1-2 mls within the cranial cavity can lead to disproportionate increases

in ICP. A child who is compensating for increasing ICP and who experiences a slight

increase in CO2 (related to such things as a seizure which increases metabolism,

causing an increase in CO2) may experience even a small increase in cerebral blood

volume and decompensate rapidly.

As cerebral pressure increases, there is direct pressure on the brainstem. The

RAS, which controls alertness is effected, resulting in coma and death.

Respirations:

As ICP increases, respirations can be affected. During the early stages of

decompensation, there may be a slowing of the respiratory rate. This slight change may indicate to the nurse that the patient may be experiencing increased ICP as

opposed to merely falling into a deep sleep. This illustrates the need to completely 54 wake the patient for each assessment and determine arousal, awareness,

comprehension and orientation.

As ICP continues to rise, the patient moves into the herniation stage of

decompensation and Cheyne-Stokes breathing occurs. This type of breathing

indicates a lack of perfusion to the cerebral hemispheres and basal ganglia (higher functioning areas and nerve pathways within the brain). Also, in the herniation

phase of decompensation, Central Neurogenic hyperventilation occurs. This type of

breathing is triggered by severe compression of the midbrain and pons. As

pressure rises and herniation worsens, apneustic breathing occurs which indicates

compression to the mid and lower pons and the brainstem. As the patient’s status

worsens and death becomes imminent, cluster and ataxic breathing occurs, which is

the result of compression of the medulla. Eventually, respirations will stop and

death will occur.

When recording respirations, it is important to document both rate and pattern, in order to detect the slightest changes early.

Referenced from: Barker, E. Neuroscience Nursing. 1994. Mosby. St. Louis. p. 305.

55 Oxygen Saturation:

The oxygen saturation level is a supportive and very valuable piece of data that

assists the nurse in quantifying the effectiveness of the respiratory rate and

effort. Oxygen saturation levels are essential to monitor in children who are at high risk of cerebral edema, or cerebral bleeds. Early drops in the saturation level can alarm the nurse that the respiratory effort is changing. Although the saturation monitors can sometimes provide false alarms, it is essential that the nurse thoroughly trouble shoot a machine that appears to be alarming unnecessarily. At no time should a monitor be removed, ignored or turned down without a written Physician’s order.

A saturation level, for normally healthy children, is approximately 97%-100%. Even seemingly mild drops to the mid to low 90’s should be considered relevant and investigated. The nurse should increase her observation and assess for a trend over time. If the patient shows a consistent drop or irregular pattern, report to a physician and implement supportive measures as ordered. Respiratory therapists are also available to assist with children who are having difficulty managing appropriate oxygenation. The nurse should ensure that the head of the bed is elevated, the airway is suctioned (if needed) and the physician, RT, or code team are called, as needed.

Note: Never apply supplemental oxygen to a child who is suspected of having

increased ICP as it can potentiate a build-up of C02. A child with emergent

increased ICP requires assisted ventilation in the ICU.

Pulse:

The pulse rate is also very important to assess during a NVS assessment. Although

the heart rate can provide clues to what is occurring within the cranial vault, these

changes may only occur once the patient has entered the early stages of

decompensation. This helps illustrate the importance of picking up early changes in 56 the neurologically compromised patient as soon as possible. In pediatric nursing,

pulse rates should always be assessed apically, using a stethoscope. The nurse

should never assume that mechanical readings are accurate, and should always

double-check a mechanical reading with an apical assessment.

As mentioned earlier, during the Cushing’s response, the body attempts to

adequately perfuse the brain by increasing the blood pressure. As the volume

within the skull increases, the body struggles to try and get oxygen into increasingly tighter areas. The heart rate and diastolic pressure then drop in

order to allow for the heart to have a longer filling time. At this point a

widening pulse pressure becomes evident and the pulse will be very full and

bounding as the heart struggles to maintain adequate perfusion.

Temperature:

In the pediatric patient, temperatures are routinely done via the axilla and oral routes.

It is important to remember that an increase in temperature can produce

significant physical effects that can further compromise the neurologically fragile

patient. As explained previously, one of the most significant outcomes of an

increased temperature is compensatory vasodilation of the cerebral vessels,

resulting in increased cerebral blood flow and cerebral edema. An increased

temperature can also drastically increase the metabolic needs of the brain. As the

demand for glucose and 02 increases, the body pumps more blood into the tight

cranial vault and the metabolic rate increases.

High temperatures can also put the patient at risk for seizures, which in turn can

trigger the sequelae of cerebral hypoxia, cerebral edema and/or cerebral

hemorrhage.

57 Cerebral bleeds can also cause fluctuations in temperature, and should be suspected if it occurs in a patient who is at risk.

In many cases, as ICP rises, the hypothalamus (the part of the brain responsible for temperature control) has difficulty functioning appropriately. As pressure is exerted in the diencephalon (area in which the hypothalamus is located, just above the brainstem) temperature patterns may fluctuate. In any event, whether there is a sharp increase or a distinct irregular pattern of temperature control, the neuroscience nurse should suspect that the patient’s status may be compromised, and act immediately.

Review the following diagram, which reflects the clinical signs of compensation and decompensation:

58 Nursing Interventions for Increased ICP:

Research into the causes and treatments for increased ICP continues and the effectiveness of some therapies remains controversial. For the most part, however, the therapies that can be implemented on the unit are well accepted.

They are:

Elevating the head of the bed to 45 degrees. By taking advantage of gravity,

this measure encourages venous drainage via the jugular veins. During the early

compensation phase CSF reabsorption increases. As CSF is reabsorbed from the

sagital sinus into the blood stream there will be a greater volume of fluid

entering the jugular veins, therefore, gravity will significantly assist in the

drainage process at this time.

Maintaining the patient’s head in a midline position. Venous drainage from the

jugular veins is impeded if the head is tilted to one side. Use pillows or towel

rolls to keep the head at the midline. If you are concerned that the patient

might vomit and aspirate, turn him/her on their side but keep the head and neck

aligned at the midline. Have suction equipment available.

Maintaining normal body temperature. Elevations in temperature increase the

cerebral metabolic rate and cerebral blood flow, raising ICP. Administer

Acetaminophen, as prescribed, to decrease temperature. Prevent shivering, as

this will increase the metabolic demand and can further increase blood flow to

the brain.

Decreasing environmental stimuli, especially noxious stimuli. Sensing,

interpreting and responding to stimulation requires energy. The brain receives

this energy by increased blood flow to the brain, which raises ICP. When

possible, dim the lights, speak softly, use gentle touch, and space nursing

interventions to limit the rise in ICP. Limit suctioning, for example, to 10

seconds and suction only when necessary. Continually assess the patient for 59 signs of increasing ICP in relation to nursing interventions etc. This may

present as agitation and restlessness, for example. Teach family and friends

how to decrease stimulation during their visit.

Monitoring and maintaining normal electrolyte balance. Patients with cerebral

edema can deteriorate rapidly due to hyponatremia, hypernatremia or

hypoglycemia. Electrolyte and glucose imbalances may increase cerebral edema

and alter LOC. The nurse should ensure that serum electrolytes and glucose are

monitored and the results communicated to the physician in a timely fashion.

The nurse should also ensure that the IV fluids ordered and administered are

appropriate for maintaining electrolyte balance.

Administering osmotic diuretics. In a neurological crisis, Mannitol will be

ordered IV STAT. The nurse should always be prepared, in advance, to

administer Mannitol. An accurate weight and IV access is necessary to deliver

Mannitol. The nurse should be familiar with how to calculate a safe dosage and

be able to program the IV pump for rapid administration. Mannitol reduces

cerebral edema by pulling excess fluid from the extracellular space into the

blood vessels, for drainage. In some cases Mannitol may be ordered with a loop

diuretic such as Lasix, which increases the excretion of water and sodium from

the kidneys. Mannitol may be ordered from 0.25gms/kg – 1.0gm/kg IV over 3-5

minutes. Mannitol is supplied in both 20% and 25% solutions.

Review the following chart for quick calculations of Mannitol:

Reflective Questions:

1.0 Based on the theory of compensation and decompensation, when is a patient

most at risk for rapid deterioration?

2.0 What nursing interventions can assist in detecting rapid deterioration in the

at-risk patient?

61 References and Resources to Enhance Learning:

Pollack-Latham, C.L. Intracranial pressure monitoring Part 1: physiological

principles. Critical Care Nurse. 1988: Vol. 7, No. 5. 40-51.

Humphreys, R.P. Complications of Pediatric Head Injury. Pediatric Neurosurgery. 1991-92; 17: 274-278.

Section Seven: Assessing Pain

This section will focus on:

Why pain assessments are an important component of the Neurological

assessment

The three standard pain scales used at C&W

Pain is a common characteristic of many neurological conditions and in many cases is under reported, inaccurately documented, and under treated. By incorporating a pain assessment into each NVS exam, the nurse can track the patient’s pain experience more comprehensively. Nursing interventions and follow-up pain ratings are also recorded to better meet the needs of the neurologically at-risk patient.

Pain can be associated with the following conditions:

Tissue or supporting structure injury (skull fracture, post-operative pain etc.)

Neuropathic pain (nerve pain such as with Guillian Barre, for example)

Migraine

Increased intracranial pressure

In some children it may be very difficult to determine the difference between pain and other behaviours. It is important to realise, however, that an assumption of pain is always better than an assumption of non-pain, in meeting the patient’s needs. In most cases, the nurse is encouraged to initiate a conversation with the 62 parent or primary care giver about the patient’s behaviour and affect in order to decrease personal bias and get a clear understanding of how current behaviours vary from the norm. Children who are delayed may present with behaviours that

appear out of context and may not be recognised as pain behaviours by a nurse who

is unfamiliar with the child.

In terms of a neurological assessment, not only a pain rating, but also a clear

description of the type and location of the pain is essential to obtain on each

assessment, if possible.

Early morning headaches, sudden onset of pain, pain that is increasing or changing,

and pain that does not respond to analgesia are cause for concern. Also pain that is

localized to or radiating down the neck can be a sign of post fossa pressure

requiring increased vigilance and must be reported to a physician.

Contextual information regarding the patient’s report of pain and the nurse’s assessment of the patient in pain, should always be provided in the Nurse’s

Notes (i.e. Did the patient appear more anxious? Were there any other changes associated with the pain, such as changes in the VSs, vision or ability

to walk? Did the patient vomit etc.?). These are essential pieces of data

required to accurately track any significant changes in patient status and

responsiveness to treatment. Once data has been obtained to suggest a change in

the pain experience, the nurse must look for any other subtle changes or trends

that may indicate a worsening condition. Ataxia, drift, early loss of orientation

[time, place then person], minor confusion [using words appropriately but not

providing accurate data], irritability, combativeness and anxiousness are all

significant coexisting behaviours that signify a deteriorating neurological condition.

The physician must be notified and put on alert that you are concerned about the

potential implications of the assessment findings.

This illustrates the need to be consistent with doing routine pain assessments using the same pain tool each time. 63 Don’t stop assessing for pain because you assume the patient is improving or

that the pain experience is unchanged.

As the child becomes more familiar with the rating process, they will report their

pain more frequently and more accurately. Never assume that patients and/or

parents will independently report pain or minor changes in personality or

orientation. Always question the patient, especially if the patient has not reported any pain. Reassure families that accurate pain assessments are required to detect any changes in the patient’s status.

These are the three pain scales provided on the NVS record:

Please note that pain can be assessed in the severely injured (semi-comatose), developmentally delayed child and the infant by using scale #1. This scale assists the nurse in detecting pain by assessing the face, legs, activity level, cry and consolability of the child. Each area being assessed is given three options to choose from. When assessing the face, for example, a ‘0’ is given if there is no particular expression or smile. A score of ‘1’ is given if there is an occasional grimace or frown or if the child is withdrawn or disinterested (remember, children in chronic pain often show signs of withdrawal or apathy as opposed to crying). A score of ‘2’ is given if the child has a constant quivering chin, with a clenched jaw. This pain scale will provide a total score of 0-10. Interventions should be based on input from the family as well as interpretation of the quantitative value of the pain assessment. It is important to remember, also, that not all children present the same when in pain and the report of pain is always the degree the patient states it is (what would produce intense pain for one person may not for another). There are many factors 66 that can affect the pain experience as well. Things such as culture, up-bringing,

past experiences and anxiety can all affect the pain experience and should be

taken into consideration.

Pain scale #2 typically works well for children aged 5-12 who are awake and alert.

It is important to discuss the pain scale and get each patient familiar with how the scale is used. By using this pain scale, the nurse may also be able to detect slight changes in cognition when assessing the patient. For example, if a patient suddenly appears to be confused or is unable to appropriately express their pain, this may indicate to the nurse that significant changes have occurred in the patient’s neurological status.

Pain scale #3 is typically used with older children who are able to use abstraction.

Once again, frequent pain assessments as part of the neurological exam can provide clues to the patient’s awareness, orientation and ability to use abstract thought.

This scale is not appropriate for older children who are delayed, severely injured, or who are unable to think abstractly.

Reflective Questions:

1.0 In what ways can pain present as a neurological decline and vice versa?

2.0 How would you determine the difference between pain and neurological

decline in the pediatric patient?

3.0 What pain scale would you use with a developmentally delayed 15-year-old

who has concrete thinking abilities?

67 Section Eight: Assessing Affect

This section will focus on:

Why affect ratings are included in the overall neurological assessment of the

patient.

Ways to decrease subjectivity when recording affect.

The recognition of mood changes and general behaviour changes are essential in detecting early neurological deterioration. By including the affect rating section in the NVS documentation record, the nurse is reminded to take a holistic look at the child, and observe for potentially significant changes in overall behaviour.

Emotions such as anger, hostility, fear and love all guide behaviour and are, for the most part, generated by the limbic system. The limbic system is made up of a number of structures surrounding the brain stem including the hippocampus, thalamuas, hypothalamus, the floor of the lateral ventricles, and components of the first cranial nerve (Olfactory). The hippocampus and portions of the cerebrum are also responsible for memory, which tie assessments of affect, behaviour and memory together. In some clinical studies, stimulation of a certain part of the hypothalamus has induced intense fear, anxiety and rage, and stimulation of other parts of the hypothalamus has induced docility.

The frontal lobe is connected to the limbic system by neural tracts and is responsible for inhibiting and modulating emotions. In cases of cerebral insult or injury, the limbic system and/or the frontal lobe may be affected, causing the patient to express uncontrolled emotional outbursts. The patient may show intense anxiety, fear, rage, and combativeness or simply present with a ‘flat’ affect.

68 Children experiencing an increase in intracranial pressure may exhibit emotional outbursts related to confusion and the inability to accurately interpret their situation. Their responses may be ‘inappropriate’ and they may be irritable or

become withdrawn. An alteration in either direction should be considered a

significant finding and be clearly documented in the Nurse’s Notes and reported to

a physician. It is important to focus on variations from what would be considered

normal for the patient, taking into consideration the specific situation (i.e. most

children should be irritable during painful procedures). For example, some children

may become increasingly more anxious and frightened as intracranial pressure rises. Other children, particularly infants, may change from happy and interactive

to neutral and withdrawn.

It is important to note that the affect ratings, as listed on the NVS record, do not

move from best response to worst response as in the GCS as certain emotional

expressions are considered healthy in specific situations.

Any change in behaviour and affect should prompt the nurse to increase her

vigilance and have a high index of suspicion, especially when the emotion does

not fit the specific situation or when it is not the patient’s normal response.

Parents are essential in assisting the nurse with detecting subtle changes and

providing baseline norms for the child, especially when the child is delayed. By

including the parent or primary caregiver in the assessment and interpretation of the data, subjectivity and bias, on the part of the nurse, can be minimized.

Assessing affect during the night, when the patient is routinely disturbed for NVS

assessments, can be difficult. Even so, although mood changes are expected at

these times, the nurse should not assume that the response obtained is benign.

Take the following case study, for example:

You are taking over the care of a patient named Peter, who is a 15 year old boy

admitted to the unit after being hit in the head with a baseball. His admission diagnosis is r/o concussion. Peter had been drinking beer at the time of the injury. 69 His blood alcohol level is 100mg/dl (0.10). At handover report you are told that

Peter has been neurologically stable. When you first assess Peter you are

unable to assess his pupils because he is belligerent and refuses to let you touch

him. You are able to determine that Peter is oriented to person, place and time and

he is able to follow commands. Given his high blood alcohol level, you are not

surprised at his behaviour. Peter’s mother states that he is typically a very polite

and respectful boy. You decide to increase your assessments to every half-hour as

opposed to every hour, as originally ordered. You notify the physician of your

difficulty with Peter and are told that increasing observations is a prudent plan.

On your next set of observations, you find Peter apparently sleeping quite soundly.

You question whether or not to wake him, knowing he will not be very happy. After

thinking about it for several minutes you decide that omitting this assessment

would be contraindicated because a concussion can cause intracranial swelling and

bleeding.

You try and awaken Peter, but find that he is not waking very easily. You wonder if

this is normal for the patient. You also wonder if the alcohol could be causing a

deep sleep or if Peter is experiencing increased intracranial pressure. Realising

that you have no way of determining what could be causing Peter to be

difficult to wake, you persist. You gently shake him and call his name. Peter’s mother informs you that Peter is typically hard to arouse but is not often grumpy

when woken.

Peter finally wakes up and angrily says ‘leave me alone’ and tries to kick you, then

falls back to sleep. You try and rouse him again and he finally rolls over angrily and

yells ‘listen to me you dumb waitress!’.

The nurse completes her assessment as comprehensively as she can and calls the

physician.

70 This case study demonstrates several points of interest. Firstly, affect can

change for many reasons, including when sleep cycles are disrupted.

However, the nurse should never assume that a patient’s confusion or

reluctance to co-operate is a ‘normal’ response without investigating further.

In this case, the nurse recognises that there are a number of reasons why the

patient is not waking and decides that she must investigate more deeply. She

obtains information from Peter’s mother about what Peter is typically like which

helps her determine ‘normal’ behaviour from ‘abnormal’ behaviour. By being

persistent, the nurse recognises that Peter is having difficulty staying awake.

Peter also appears angry and combative, which is not a normal response for him

when woken. As well, the nurse notes that although Peter’s speech is co-ordinated, he confuses her with a waitress. Although each piece of data that the nurse

collects can be attributed to the consumption of alcohol, the nurse recognises that she does not have the ability to determine the actual cause of the behaviour changes and reports her assessment findings to the physician.

The second point of interest is that the nurse responded to the patient’s condition by increasing her observations. This can be done independent of a written physician’s order and is always encouraged. The nurse also kept the physician informed of her specific concerns. Always remember that it is essential to

inform the physician of your concerns and your assessment findings, especially

when you are expected to obtain meaningful data in the midst of complicating

factors (such as alcohol). Although some parents may resist the nurse waking the

child for assessment overnight, it is essential that the time be taken to explain the

importance of each assessment and reinforce that waking the child is essential.

Section Nine: Monitoring Weight and Head Circumference

This section will focus on:

Why weight is essential to monitor in the neurologically compromised patient.

An accurate weight is essential for many reasons, especially with children who are

neurologically compromised. For example, children with severe brain injuries, often

experience an increase in muscle tone. A sustained increase in tone can

substantially increase the need for extra calories. As well, these children can also

be very diaphoretic and can loose a significant amount of fluid over a 24-hour

period. If the child’s ability to take in adequate amounts of food and fluid is

compromised and they are started on supplemental tube feeds or parenteral

nutrition, it is essential to ensure that the therapy is meeting their energy needs and weight is maintained.

Children who have, or who are at risk for, Diabetes Insipidus (DI) or Syndrome of

Inappropriate Antidiuretic Hormone (SIADH) also require frequent weights as

water loss (DI) and water retention (SIADH) can potentiate physiological and

neurological complications. Children on ACTH (steroid to treat infantile spasms)

must be monitored as the medication significantly stimulates the appetite and

weight gain can be rapid. The blood pressure must also be monitored closely as

hypertension from the medication can be further exacerbated by increased fluid

volume if intake is not controlled.

For most children, an accurate weight is essential in determining appropriate

medication dosages. For example, children on NVS assessments may require anti- 72 epileptic medications or possibly Mannitol if they have a neurological crisis. An

accurate dose calculation is dependent on an accurate weight.

(Refer to the 3a ward specific Policy and Procedure Manual for specific guidelines

for monitoring weights). Note: Injury to CNs #1,5,7,9,or 12 can result in either

the loss of smell, taste, or the ability to manipulate food effectively. This can

present as a disinterest in food and eventual weight loss in long-term patients.

Head Circumference:

Infants whose sutures are open and who are at risk for increased intracranial

pressure should have their head circumference (HC) measured daily. Although the

cranium can accommodate increasing intracranial volume to a certain degree by

expanding the head circumference, eventually, the infant will start to show signs of

increased ICP. The infant’s eyes may ‘sun-set’ (down-gaze with bulging eyes), the

fontanel will become full, bulge and feel taught when sitting (which may improve

when lying flat). Increases in HC should be reported to the physician along with any

other signs that indicate increased ICP.

Summary:

Review the following algorithm for the patient with a head injury. Note how NVS

assessments are incorporated into all levels of nursing care. Ultimately, NVS

assessments direct the nursing process and aim to preserve the neurological function of the patient.

Referenced from: Kozier, B., Erb, G. and Olivieri, R. Fundamentals of Nursing; Concepts, Process and Practice. 4th ed. 1991.

Addison-Wesley. New York.

Study Guide for Pediatric Neuro Vital Sign Assessment

1. Orthopedic patients are at risk for neurological complications r/t: a. Fluid overload b. Fat Embolism and Compartment Syndrome c. Urinary retention d. Circulatory collapse

2. Patients with Crohn’s disease and Colitis are at risk for neurological complication r/t: a. Skin break-down b. Abdominal pain c. Thromboemboli d. Circulatory collapse

3. The intent of the initial neuro assessment (including the Glasgow Coma Scale) is to determine: a. The severity of the injury, insult, or illness b. Normal behaviours for the child c. Which medications the doctor should order d. The child’s developmental age

4. The purpose of serial neuro assessments is to determine: a. The normal behaviours of the child b. If the child is responding to treatment c. Trends that can signify an improvement or decline in status and prevent further injury to the patient d. Determine if the child is dehydrated

5. When obtaining information from a patient the nurse must be aware of the following: a. Information may be incorrect and should be verified by a parent b. The patient is always right c. The patient can always provide valuable information d. The patient can tell you when they are starting to loose consciousness

6. The nurse would do a visual hand over for which of the following reasons: a. If the child’s fluid balance is negative >150cc in 12 hours b. If the child is anxious c. If the child has a temperature d. If the nurse determines or feels the patient has become less stable or has been difficult to assess

7. Mental status assessments are done by: a. Applying supraorbital pressure b. Using the GCS / modified GCS c. Doing a complete VS assessment d. Asking a psychiatrist to consult

8. Which of the following is not included in the GCS? a. Neurovascular status b. Eye opening c. Best verbal response d. Best motor response

9. GCS responses can be tailored to the developmentally delayed child by recording the child’s ‘best response’ on the NVS record next to the highest score for any of the areas being tested, however, the child’s second third and fourth best responses can not be applied to the varying scores. T or F

10. The verbal or preverbal NVS record should be chosen based on the patient’s post-injury status. T or F

11. Changes in level of consciousness are late indications of increased ICP T or F

12. When applying a stimulus to elicit a response, the nurse should: a. Apply the stimulus very carefully in order to prevent a bruise b. Apply only supraorbital pressure c. Apply the stimuli in sequence, from mildest to most severe until a response is obtained d. Always apply the stimulus to the same area

13. Arousal is assessed by: a. Eliciting an eye opening response b. Applying pressure to the sternum c. Obtaining age appropriate vital signs d. Obtaining an appropriate oxygen saturation level

14. Arousal is controlled solely by the Limbic System T or F

15. The GCS score should drop slightly during normal sleep and wake cycles. T or F

16. Supraorbital pressure is an adequate stimulus to elicit an eye-opening response. T or F

17. If the eyes are swollen shut the nurse should check ‘none’ in the eye-opening category and reflect this with a low GCS score. T or F

18. Orientation is typically lost in which order: a. Person, time, place b. Place, time, person c. Time, person, place d. Time, place, person

19. An infant indicates awareness by: a. Crying when they are hungry, wet or uncomfortable b. Sleeping very soundly when the environment is noisey c. Always remaining calm when a parent is close by d. Ignoring toys that are brightly colored

20. For the child with post-fossa mutism, the nurse should mark ‘NCP’ or ‘NN’ in the ‘Best Verbal Response’ section and provide supporting documentation for which of the following two reasons: a. To show that the patient has a low LOC b. To prevent future nurses from asking the child questions c. To let future nurses know that the mutism does not necessarily indicate a decreased LOC d. To provide a rationale for why this section of the NVS record could not be used to obtain a total GCS score

21. To determine the difference between a reflex and an intentional response the nurse should: a. Elicit a repeated response b. Only apply peripheral stimulation to the hands c. Only apply peripheral stimulation to the feet d. Only consider movements that have been obtained using a central stimulus

22. For children with high spinal cord injuries or brainstem strokes, a best motor response might be: a. Vomiting when suctioned b. A gag reflex c. Eye blinking on command d. Obtaining a negative Babinski reflex

23. Localization can be assessed in all age groups. T or F

24. Supraorbital pressure can be used on all patients to elicit localization. T or F

25. Stimulation to elicit lacalization must be above the level of the clavicle because: a. The sensory input is received by the cranial nerves and therefore can not be mistaken for a spinal reflex b. The sternal rub will cause bruising c. You may get injured if you stand over the patient d. Both b & c

26. When assessing for a withdrawal response from pain the nurse should assess all four limbs: T or F

27. When assessing the periphery, the nurse should look for: a. A negative Babinski reflex in children <1yr b. A positive Babinski reflex in children <1yr c. A positive Babinski reflex in healthy children >1yr d. Never assess for the Babinski reflex

28. Decorticate posturing is an abnormal flexion reflex that occurs with damage to the outer cortex of the brain and/or the basal ganglia. T or F

29. Decerebrate posturing presents as: a. Arms and legs extended, plantar flexion and hyperpronation of the arms b. Flaccid paralysis of the upper body and plantar flexion c. Spinal arching with dorsiflexion d. Arms hyperpronated to the chest, dorsiflexion and extension of the legs

30. Decerebrate posturing may present in all but which of the following conditions: a. Advanced brainstem lesions b. Herniation c. Early onset Diabetic Ketoacidosis (DKA) d. Bilateral forebrain lesions

31. When assessing best motor response, the nurse is also assessing the gross integrity of by checking the strength of shoulder movements: a. CN #1 b. CN#3 c. CN#8 d. CN#11

32. An early sign of increased ICP is posturing. T or F

33. Pupils are normally 2-6 mm in diameter. T or F

34. There are 9 directions of gaze that the nurse should assess for. T or F

35. Horner’s Syndrome can be a sign of increased ICP when there is pressure on the hypothalamus, although it would be difficult to assess in an unconscious person. T or F

36. Argyll-Robertson pupils are irregular in shape, size and do not respond to light and are a sign of: a. Nothing too serious b. Neurosyphilis, viral encephalitis or syringomyelia c. Pregnancy d. Paralysis below T12

37. If you were to swing a flashlight quickly from eye to eye you would expect to see: a. Constriction of both pupils equally b. One pupil to dilate while the other constricts c. Both pupils to dilate after a couple seconds d. None of the above

38. One of the first signs of compression of CN#3 would be a slightly oval shaped pupil that can progress to a dilated and non-reactive pupil. T or F

39. Miosis may be witnessed in children who are experiencing a seizure. T or F

40. When assessing pupils for a light response, the nurse should stand directly in front of the child without waiting for the patient to accommodate. T or F

41. When assessing the pupils, the nurse is looking at everything except: a. Midline position b. Color c. Shape and size d. Consensual constriction of both pupils to light

42. Nystagmus may be considered normal in infancy. T or F

43. When assessing strength the nurse should look for: a. Muscle mass, tone and strength b. Ataxia or abnormal movements c. Posture and the ability of the child to say if they are experiencing any deficits d. All of the above

44. Ataxia may present as all except which of the following: a. Looking dizzy b. Inability to repeatedly touch the end of the nose with the finger c. Headache d. Change in speech pattern

45. If an older child is not able to move against forced resistance without support but is able to move against gravity with support, they are noted to be ‘weak- minus’. T or F

46. Drift is an assessment of cerebellar function. T or F

47. Assessing strength in a 2 month old infant includes: a. Assessing movement against gravity and the force of withdrawal b. Noting if the infant is able to push the blankets off if they are placed loosely over them. c. Noting if the infant is able to kick or push against resistance

d. All of the above

48. Immobility can cause decreased muscle strength resulting in decreased venous return and cardiac output, which can progress to a compromised periphery. T or F

49. Continence and incontinence can not provide information about which of the following: a. Spinal cord integrity b. Circulatory status c. Brain function d. LOC

50. A neurogenic bladder is caused by: a. Decreased LOC b. Damage to the nerve supply at the CNS or spinal cord level c. Having a full bladder d. Being catheterized for less than 7 days

51. The NVS record can reflect when urine output is abnormal and provide the nurse with indications for closer observation. T or F

52. Cushing’s Triad refers to everything except: a. Increased systolic BP b. Increased temperature c. Widening pulse pressure d. Decreased heart rate

53. When recording the BP on the NVS record, the nurse should be sure to graph it for easy visualization of slight changes. T or F

54. Cushing’s triad is a common sign of neurological decline in most children. T or F

55. The Monro-Kellie Doctrine: a. Is an algorithm the doctors follow to track ICP b. Is an oath all Neurosurgeons take when entering into practice c. Explains the physics of hydrogen ions d. Describes the compensation mechanisms of cranial contents to maintain a steady volume and pressure

56. Which of the following are not considered compensation mechanisms; a. Autoregulation b. Acidosis c. Pressure regulation d. CSF regulation

57. Autoregulation means that as the systemic BP increases or decreases the cerebral arterioles constrict or dilate to keep cerebral blood flow at a steady rate.

T or F

58. Metabolic regulation refers to increasing the cerebral blood flow to provide the brain with extra 02 and glucose to meet metabolic demands. T or F

59. CSF regulation refers to either an increase of CSF absorption or a decrease in CSF production. T or F

60. Decompensation occurs when: a. There is a rapid or sudden increase in cranial volume b. When the pulse pressure widens too far and the heart stops c. The regulatory mechanisms fail to manage the increasing ICP d. Both a&c

61. A child who is compensating for increased ICP may decompensate rapidly d/t: a. An increase in cranial volume of 1-2 mls b. A build-up of CO2 r/t decreased 02 , such as with a seizure or when falling asleep c. A tumour that is growing rapidly d. All of the above

62. Cheyne-Stokes breathing refers to breathing with jagged inspirations and expirations seen in stage 4 of decompensation (herniation). T or F

63. Central Neurogenic Hyperventilation occurs prior to decompensation. T or F

64. Apneustic breathing refers to: a. Apnea b. Long pauses between each breath with long periods of breath holding once inspiration is complete c. Sporadic episodes of apnea d. None of the above

65. Cluster and Ataxic breathing may occur just prior to death. T or F

66. To encourage CSF and blood drainage, the most effective position for a patient with increased ICP is; a. Supine with head in the midline b. Prone with the head down 30 degrees c. Supine, HOB up 30-45 degrees with the head in the midline position d. Reverse Trendelenburg

67. Patients who are at risk for increased ICP should have their oxygen saturation levels monitored. T or F

68. The best way to obtain a pulse on a pediatric patient is: a. Only mechanically (sat monitor or BP machine etc.) b. Assessing the Dorsalis Pedis c. Apically, using a stethoscope d. Brachially

69. The heart rate will be faint and feathery during early decompensation. T or F

70. One of the most significant implications of an increased temperature in a compromised patient is: a. They will require Tylenol b. They will need to have blood cultures drawn c. They will need to be isolated d. The temperature will increase the metabolic demands of the brain which will increase cerebral blood flow

71. A child weighing 32 kg is ordered 0.25 gms/kg of 25% Mannitol. How much would you give?

72. A child weighing 40 lbs is ordered 1.0 gm/kg of 20 % Mannitol. How much would you give?

73. Pain can be associated with all but which of the following neurological conditions: a. Very late diabetic neuropathies b. Increased ICP c. Guillian Barre d. Head injuries

74. The nurse is encouraged to use any pain assessment tool, with any patient, at any time. T or F

75. The nurse can omit the pain assessment if the patient generally appears better. T or F

76. The child in pain may have similar S&S as the child with increased ICP. T or F

77. Pain scale #2 is typically used for children aged: a. 3-10 b. 5-8 c. 12-15 d. 5-12

78. Emotions are generated in which area of the brain? a. The Reticular Activating System b. The Limbic System c. The basal ganglia d. The frontal lobe

79. The area of the brain that generates emotional responses is also partially responsible for memory. T or F

80. Emotions are modulated (given a behavioural response) by the frontal lobe. T or F

81. The affect ratings on the NVS record go from best to worst response in all situations. T or F

82. A nurse should not be concerned if a patient expresses agitated behaviour on being woken. T or F

83. What are two very important points to remember when assessing a neurologically at-risk patient who present with compounding issues?

84. It is important to monitor the neurologically compromised patient’s weight because: a. They may have trouble regulating their intake and output d/t damage to the pituitary and the hypothalamus b. They may require more calories because of increased muscle tone c. They may be on steroids such as ACTH which can increase the BP and cause weight gain d. You may have to calculate accurate drug dosages based on the patients current weight e. All of the above

85. Injury to which of the following cranial nerves can result in disinterest in food and an inability to coordinate mastication, resulting in weight loss: a. 1, 5, 7, 9, 12 b. 2, 3, 4, 6 c. 10, 11, 12 d. All of the above

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