Page 244 - Critical Care Nursing Demystified

Chapter 5 CARE OF THE PATIENT WITH NEUROLOGICAL NEEDS 229

Other Responses

Blink Reflex and Corneal Response

Normal blinking is frequent, bilateral, and involuntary, averaging 15 to 20 per
minute. To assist in determining brainstem function, this response is tested by
passing a wisp of cotton either from the side of each eye toward the sclera or
over the lower conjunctiva of each eye to cause blinking. There is no blink
response in the unconscious patient.

Signs of Meningeal Irritation

It is important to mention signs of meningeal irritation that the patient might
be experiencing such as nuchal rigidity, fever, resistance to neck flexion, head-
ache, and photophobia. Two specific signs of meningeal irritation that the nurse
should become familiar with are
Brudzinski’s sign – involuntary flexion of the hips when the patient’s neck is
flexed toward the chest.
Kernig’s sign – pain in the neck is evident when the thigh is flexed onto the 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.
abdomen and the leg is extended at the knee.

Auscultation

Neurological examination relies heavily on frequent, accurate vital sign assess-
ments. Slight trends can signal worsening degrees of neurological impairment.
Auscultation includes assessment of respirations, temperature, pulse, blood
pressure, and bruits.

Respirations
A patient may have difficulty maintaining a patent airway as a result of increas-
ing intracranial pressure, a partially obstructed airway, a high cervical spinal
cord injury, a decreasing level of consciousness, or progressive diaphragmatic
paralysis. Respiratory distress can range from the crescendo- decrescendo pat-
tern of Cheyne-Stokes respirations interspersed with periods of apnea, to
hypoventilation and respiratory acidosis or hyperventilation, which can lead to
respiratory alkalosis. Assess for status of lung sounds, provide for adequate gas
exchange, monitor gas exchange levels, avoid aspiration difficulties, and pro-
mote a patent airway.