Page 240 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 225

NURSING ALERT

Normal pupillary responses to testing are recorded as PERRLA, which means pupils
equal round and reactive to light accomodation. A change in pupillary size and slug-
gishly reactive to light may indicate increased intracranial pressure. This along with
bradycardia, hypertension, and respiratory changes indicates increased intracranial
pressure is highly suspicious. Call the neurologist stat!

Assessment of Eye Movements (EOMs) or Extraocular Movements

Extraocular movements are intact and coordinated in the conscious patient if
both eyes move together through the full range of eye motions. The nurse
instructs the patient to follow his or her finger (the nurse’s) with the eyes as
the finger is pointed upward, downward, and sideways.

Oculocephalic Reflex or Doll’s Eyes Movements

This response can be observed in the unconscious patient. With the patient’s
eyelids held open, the nurse briskly turns the patient’s head to one side and
observes the eye movements. The eyes should deviate to the opposite direction 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.
from which the head is turned if the doll’s eyes response is present and intact.
Repeat the process by briskly turning the head to the opposite side and observing
the response. The doll’s eye response is absent and indicates brainstem injury
when the eyes with head movement either remain midline, move with the head,
rove about in circles, or move up and down. This is usually done in a patient with
severe brain damage and a positive result can indicate brain death.

NURSING ALERT

Before proceeding with this reflex in the unconscious patient, it is necessary to make

sure that the patient has not suffered a cervical neck injury, which, if provoked
through excessive movement, can cause complete transection of the cord! Make sure
the C-spine x-ray is negative before attempting this.

Oculovestibular Reflex or Cold Caloric Test

This is also a test to evaluate brainstem function and should never be conducted
on a conscious patient. This test involves instilling 20 to 50 cc. of ice water into
the external auditory canal of the ear. Brainstem integrity is confirmed when
there is a normal eye movement response of a rapid rotary nystagmus toward
the irrigated ear. A neurologist usually performs this test in a patient with
severe brain damage . A positive result can indicate brain death.