Page 238 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 223

Opisthotonus – Spasm where the head and heels are bent backward and the
body is bowed forward. Seen in severe meningitis, tetanus, epilepsy, and
rabies. See Figure 5–3D.
Flaccid – Absolutely no response at all to painful stimuli. Such a nonreaction
can be caused by extensive brainstem dysfunction.
Pupillary function and eye movement – The critical care nurse must assess
the patient’s pupillary size, shape, and degree of reaction to light while
equally comparing both pupils. Pupillary changes occurring during the
nurse’s examination could indicate increasing pressure and compression on
the oculomotor nerve, which happens with increased intracranial pressure.
The nurse should check papillary size and reaction to light accommodation,
EOMs, oculocephalic reflexes, and oculovestibular reflexes. The latter two
reflexes are usually done by the neurologist in a patient who has severe brain
damage and survival is questionable.

Normal Pupils

A normal pupil is round in shape. Each pupil should be of equal size and react Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
briskly to light by constricting to protect the eye. A narrow-beamed light should
be used and directed into each eye from the outer canthus of the eye and
observed for the response of constriction. Also observe for a consensual response
or pupillary constriction in one eye that occurs as a result of the light beam
being shone into the other eye. Consensual response is necessary to rule out
optic nerve dysfunction (see Figure 5–4).
A pupil that is suddenly bigger than the other and more sluggish to light along
with vital sign changes could indicate an increase in intracranial pressure.

NURSING ALERT
The term for unequal pupil size is Anisocoria. Changes that occur in pupil size can
result from the instillation of eye medications, which can cause large, dilated pupils.
Constricted pupils can occur from narcotic overuse. Also, a nurse should recognize
that on rare occasions a patient could have a prosthetic eye, in which case the size,

shape, and reaction to light of the artificial eye will remain stationary and never
change. To spare embarrassment on the part of the nurse, please determine if your
patient does indeed have a fake eye. Having had other eye surgery such as an iridec-
tomy will also affect pupillary size, shape, and reaction to light. Shining a light into
a blind eye will not produce a direct light response in that eye, nor will it produce a
consensual response in the other eye.