Cranial Nerves	Assessment
Eye Signs/Movement
CN II: Optic	Visual acuity (CN II)
CN III: Oculomotor	Visual fields (central, peripheral, temporal) (CN III, CN IV, and CN VI)
CN IV: Trochlear	Extraocular movements (CN III, CN IV, and CN VI)
CN VI: Abducens
Speech Musculature
CN VII: Facial	Lips (CN VII): “me, me, me”
CN IX: Glossopharyngeal	Palate (CN IX and X): “ga-ga, ka-ka”
CN X: Vagus
CN XII: Hypoglossal	Tongue (CN XII): “la, la, la”
Protective Reflexes
CN IX: Glossopharyngeal	Gag/swallow (CN IX and X)
CN X: Vagus
CN V: Trigeminal	Corneal (CN V and VII)
CN VII: Facial
Other
CN I: Olfactory	Smell (CN I): rarely tested
CN V: Trigeminal	Sensory response to cotton wisp over forehead, cheek, and chin (CN V)
CN VII: Facial	Facial movement and expression (pucker, raise brow, smile) (CN VII)
CN VIII: Vestibulocochlear	Hearing (CN VIII)
CN XI: Accessory	Head turning, shoulder shrugging (CN XI)

CN, Cranial nerve.

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Risk for ineffective airway clearance

2. Impaired gas exchange

3. Decreased cardiac output

4. Ineffective tissue perfusion: cerebral

5. Acute/chronic pain

6. Anxiety/fear

7. Impaired verbal communication

8. Risk for injury

9. Deficient knowledge

10. Noncompliance

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) Children have a higher metabolic rate and lack of kidney reserves because of immaturity

2) The Babinski reflex is normal up to age 2 years

3) Fontanelle closure: anterior fontanelle closes between 9 and 18 months of age; posterior fontanelle closes by 2 months of age

4) Infants have flexion posture normally; floppy extended posture is abnormal

5) Infants may not have tonic-clonic seizures but may posture with neck hyperextension and stiffened extremities (opisthotonos positioning)

b. “Pearls”

1) Avoid restraining the child as much as possible

2) Monitor respiratory status carefully during lumbar puncture positioning

3) Assess muscle tone by noting resting position of the child

4) Meningeal irritation may manifest as sharp, shrill cry, irritability, and loss of appetite in infants

5) Use pediatric GCS for children aged 2 to 5 years (see Appendix C)

6) History of developmental delays, unusual behavior for age, clumsiness or progressive weakness, or learning difficulties may be indicative of neurologic abnormalities

2. Geriatric

a. Aging related

1) Approximately 75% of people older than 65 years have some degree of impaired cognitive function

2) Gradual slowing of the conscious and reflex reaction time

3) Impairment of fine discrimination abilities

4) Decreased corneal sensitivity, slower visual reflexes, decreased visual acuity and depth perception, decreased upward gaze, and smaller pupils

5) Diminished hearing abilities

6) Altered drug tolerance and response

b. “Pearls”

1) Use stronger stimuli, and allow more time to respond

2) Use sharper contrasts for testing sensory stimuli

3) Ensure a protected environment

4) Face patient directly, and use lower and louder voice tones

5) Ask one question at a time, and avoid other stimulation while patient answers

II. SPECIFIC NEUROLOGIC EMERGENCIES

A. Headaches

Four percent of emergency department visits are for patients experiencing headaches. The primary goal is to identify the small percentage of patients whose headache may indicate a life-threatening condition. Headache occurs when there is traction, pressure, displacement, inflammation, or dilation of pain receptors (nociceptors) in the brain or surrounding tissues. A primary headache is one for which no organic cause can be consistently identified (e.g., migraines, tension type, or cluster). Approximately 50% of all persons with headaches suffer from migraines (Table 21-2).

Table 21-2 PRIMARY HEADACHE SYMPTOM CLUSTERS AND DIAGNOSTIC CRITERIA

Type	Most Common Symptom Cluster	International Headache Diagnosis Criteria^*
*Migraine* Without aura With aura Complicated	*Without Aura (Most Common)* Recurring, attacks lasting 4 to 72 hr Unilateral location Pulsating quality Moderate to severe intensity Aggravated by physical activity Associated with nausea, photophobia, and phonophobia	*Without Aura* Five or more attacks with: 4- to 72-hr duration in adults and 2- to 48-hr duration in children less than 15 yr old (with unsuccessful or no treatment) At least two attacks that are unilateral, pulsating, moderate/severe (inhibits daily activity), aggravated by physical activity At least one attack with nausea, vomiting, photophobia, and phonophobia
	*With Aura* Recurring, localized to cerebral cortex or brainstem Most commonly develops over 5 to 20 min and lasts less than 60 min Headache, nausea, and/or photophobia may follow aura symptoms directly or patient may have symptom-free interval that lasts less than 1 hr Headache may last 4 to 72 hr or may not occur	*With Aura* At least two attacks following an aura Aura with three of four of the following: 1. One or more completely reversible aura symptom with focal cerebral cortical or brainstem dysfunction 2. One or more aura symptom over more than 4 min or two developing or more symptoms in succession 3. No aura symptom lasting longer than 60 min (if more than one aura symptom present, add time for each one) 4. Headache follows aura with less than 60 min aura/symptom-free interval
	*Complicated* Severe neurologic deficit outlasting headache Hemiplegic (result of severe vasospasm) Basilar (most common in young women 15 to 25 yr old, visual aura may occur) Vertebrobasilar symptoms: dysarthria (slurred speech), facial/tongue numbness, dysphagia (swallowing difficulty); difficulty chewing; visual field deficits; one-sided sensory loss; vertigo or dizziness; staggering gait; incoordination; paresthesias; occipital headache within 30 min; may have stupor and confusion; may last hours Dysphoric (migraine with confusion)	*Ophthalmoplegic* At least two attacks of headache with paresis of cranial nerve II, IV, or VI *Retinal* At least two attacks with: Fully reversible monocular scotoma or blindness lasting more than 60 min Headache follows (or before) visual symptoms, with symptom-free interval less than 60 min
*Cluster*	Burning, severe, and sharp Excruciating and exquisite pain Tearing and nasal congestion on one side with lid edema, red eye, sweating, and pallor Rarely seen during an attack, but patient may rub or hit the affected side, pace, and be frantic Periorbital (80%) and temporal locations Usually no aura (reported in 14%) Strictly unilateral, changes sides in 10% to 15% of patients Photophobia and phonophobia common during active period Lasts less than 1 hr in 54% of patients Cluster frequency: one to eight/day, typically 60 to 90 min after falling asleep, 15- to 180-min duration, last weeks to months and may recur for months to years later (may be seasonal-spring and fall) May be precipitated by alcohol, histamine or nitroglycerin	At least five attacks with: 1. Severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 min (untreated); attacks may be less severe, frequent and shorter during part of the time course but no less than half the time 2. Accompanied by one or more: ipsilateral conjunctival injection or lacrimation, ipsilateral nasal congestion or rhinorrhea, ipsilateral eyelid edema, ipsilateral forehead and facial sweating, ipsilateral miosis or ptosis, sense of restlessness or agitation Frequency of one every other day to eight/day Note: probable cluster headache fulfills all but one of the foregoing criteria
*Tension type* Episodic Chronic	Dull, nonpulsating Usually starts at the occiput and moves around bilaterally to the frontal area in a tight band of pressure May last up to 7 days Recurrent, usually in same location Rarely associated with nausea or vomiting No photophobia, phonophobia, or aura May have tight and tender posterior and cervical muscles May be associated with depression, premenstrual syndrome, fibromyalgia, or other somatization disorders	*Episodic* At least 10 headache episodes with: Headache duration 30 min to 7 days At least two of the following: 1. Pressing/tight, nonpulsating quality 2. Mild/moderate (inhibits but does not prohibit activity) 3. Bilateral location 4. No aggravation by physical activity No nausea or vomiting (may have decreased appetite) No occurrence of photophobia AND phonophobia (only one) Number of days with such headache less than 180/yr (less than 15/mo) *Chronic* Same criteria except frequency greater 15 days/mo (more than 180 days/yr) for greater 6 months