Ask yourself: Is the airway patent? If so, is the patient able to maintain it? First step: Evaluate ABCs and vital signsĪs with any patient, give top priority to assessing the ABCs-airway, breathing, and circulation. Yet despite the relative brevity of this type of exam, it can yield a significant amount of information. If your patient can’t follow commands, you’ll be able to assess only the pupils, eye opening, motor response, and some of the cranial nerves. If she can, your exam can be more comprehensive and should include evaluation of: The type of neuro exam you conduct depends on whether your patient can follow commands. Once you’ve completed the initial assessment, subsequent assessments can be either basic or more in-depth. Performing it early is crucial because this helps you establish a baseline for later comparison.įor accurate interpretation of assessment findings, nurses on the offgoing and oncoming shifts should evaluate the patient’s neurologic status together during shift changes or care transfers (as well as with the medical team on rounds). It starts the moment you meet the patient. The neuro exam can be conducted quickly and is easy to integrate into your daily assessment. One reason may be that, unlike CT scans and other diagnostic tools, its results come in shades of gray, not black and white. Although it’s still an integral assessment component for critically ill patients, many bedside nurses overlook or underuse it. Subtle changes in findings may indicate the need for further testing.īefore the advent of computed tomography (CT) in the 1970s, the neurologic examination was the main tool used to monitor a patient’s neurologic condition. But once you become proficient in performing this exam, you’ll be able to detect early significant changes in a patient’s condition-in some cases, even before these show up on more advanced diagnostic tests. Author Guidelines and Manuscript SubmissionĪssessing the neurologic status of unconscious or comatose patients can be a challenge because they can’t cooperate actively with your examination.While FDP without deterioration of consciousness has been described due to traumatic subdural and epidural hematomas, we report this unusual constellation as a sign of rising ICP and impeding herniation due to intraparenchymal contusions, highlighting that any pupillary change warrants prompt work-up and intervention.Ĭase report contusion fixed pupil intraparenchymal hemorrhage traumatic brain injury. His pupil became reactive 5 hours after surgery. We performed an emergent right-sided decompressive hemicraniectomy with durotomy and duraplasty. Head computed tomography showed worsening midline shift and interval increase in subfalcine herniation related to increased peri-hematoma edema. Hypertonic saline and mannitol produced no improvement in his pupillary exam. Corneal reflexes were intact bilaterally. His gaze was dysconjugate with impaired vertical excursion and inability to fully abduct to the right side. He described complete loss of vision and could not identify objects or count fingers. The patient was drowsy, arousable to tactile stimuli, answering questions, oriented to place and time, following commands on his right side, maintaining Glasgow Coma Scale of 14 (E4, V5, M6). On hospital day 8, his right pupil became fixed (NPi 0) and dilated (4.8 mm). A 58-year-old man with history of hypertension and diabetes mellitus type II presented after being assaulted, with bifrontal contusions and right frontal intraparenchymal hemorrhage. We describe an exceptional case of a patient with bifrontal contusions who developed worsening edema and a unilaterally FDP while maintaining consciousness and the ability to communicate. Patients with fixed and dilated pupils (FDPs) due to rising intracranial pressure (ICP) typically experience a deterioration in consciousness.
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