NU2ICU Neurology

NU2ICU V3 logoNeurology

As a nurse you’ll have practiced obtaining patients Glascow Coma Score (GCS) many times before but in ICU when your patient can be effected by profound sedation due to drugs (like diprivan (Propofol®), dexmedetomidine (Precedex®), ketamine, morphine or fentanyl etc) deterioration is sometimes harder to detect

The GCS process, which is now over 40 years old, measures the following functions:

Eye Opening (E)

  • 4 = spontaneous
  • 3 = to voice (dont confuse sleep with sedation)
  • 2 = to pain (trapezius pinch not finger nail squeeze or sternal rub)
  • 1 = none

Verbal Response (V)

  • 5 = normal conversation
  • 4 = disoriented conversation
  • 3 = words, but not coherent
  • 2 = no words, only sounds
  • 1 = none
  • T = intubated (in ICU)

Motor Response (M)

  • 6 = normal
  • 5 = localized to pain
  • 4 = withdraws to pain
  • 3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bend and held on the chest)
  • 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backwards)
  • 1 = none

As clinicians we use this scale to rate the best eye opening response, the best verbal response, and the best motor response an individual makes. The final GCS score or grade is the sum of these numbers

So what do you do in ICU when your patient is sedated?

Every hour record their level of sedation according to your hospitals scoring tool IE RASS.  At a minimum of every 4 hours (minimum) you should complete a full GCS assessment, if we are doing good nursing the patient should rouse briefly when stimulated showing enough information to develop a trend in their GCS – remember you can assess verbal response when a patient is ventilated by asking yes / no questions and watching for nods and shakes of the head.  To determine a base line try asking if they are in their own house currently, if they say no they are aware enough to assess disorientation / confusion.  And remember if they didn’t speak english (or your ICU’s native language) before they went on a ventilator they probably still don’t, so language barriers must be taken into account

Many ICUs now enforce a sedation hold in the morning during medical rounds to facilitate even greater accuracy of neuro assessment, as a new ICU nurse please be aware this is a time for hyper vigilance of your patient, and even those who look completely sedated can suddenly spring to life and those hands are quick, very quick.   Reaching for invasive lines, endotracheal tubes, catheters or just trying to suddenly sit up, the sedation hold is a high risk period that you should discuss with your Team Leader or senior nurses before you participate in the process

During your patients handover a GCS assessment should be performed with both the staff taking or giving handover and you taking part. this allows you to see what they see, removing any vagaries from the handover – you may assess the pupils as slowly reactive and left 3+, right 4+, where as the next staff may see the same pupils as simply equal and reactive size 4+.  If there is a discrepancy involve your T/L and at any time your concerned about changes to what you see

 

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Neurology

Its important to note comparative handover assessments are also essential with other aspects of nursing care, things like ‘ostomy stomas, long ago I was handed over one was pink, moist and raised but when I first saw it during my bedside assessment (after the other staff had gone home) it was dusky, dry and sunken – this opened a real can of worms about when this obviously not rapid deterioration occurred.   I promised myself never to get caught again and practice dual assessments for anything that may be hidden by sedation, position or sheets!

Every hour you should assess your RASS (or similar – like Ramsay Scoring, S.A.S. etc).  Every hour means every hour – don’t take shortcuts.   Your unit should list or enforce an average target sedation level for patients.  Deeper sedation for only for those who it is deemed necessary – active cooling post Out Of Hospital Cardiac Arrest (OOHCA), traumatic brain injury etc

Targeting a RASS of -1 to -3 usually enables spontaneous breathing and more accurate GCS assessment with the added benefit of greatly decreased weaning time when extubation is planned

Score Classification (RASS)

+4

Combative Overtly combative or violent; immediate danger to staff
+3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
+2 Agitated Frequent nonpurposeful movement or patient–ventilator dyssynchrony
+1 Restless Anxious or apprehensive but movements not aggressive or vigorous
0 Alert and calm Spontaneously pays attention to caregiver
-1 Drowsy Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice
-2 Light sedation Briefly (less than 10 seconds) awakens with eye contact to voice
-3 Moderate sedation Any movement (but no eye contact) to voice
-4 Deep sedation No response to voice, but any movement to physical stimulation
-5 Unrousable No response to voice or physical stimulation

If your ICU specialises in Neurosurgical practices you may be required to look after invasive Intracranial Pressure (ICP) monitoring, Jugular Venous Bulb Oximetry etc and drainage devices

This area of ICU nursing is as big a step for the care nurse as looking after an Intra Aortic Balloon Pump or Swan-Ganz Catheter and as such moves us well beyond the concept of this website.   Any ICU that delivers these care modalities should have a robust in-house training system for you to participate in so ask for access to this information even at your initial interview

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REFERENCES

Human Anatomy & Physiology 9th Edition 2011 by E N Marieb

Oh’s Intensive Care Manual 7th Edition 2014 by Andrew Bersten, Neil Soni

The ICU Book 4th Edition 2015 by Paul L Marino