Cranial Nerve	Assessment
I: Olfactory	Not routinely tested
II: Optic	Visual acuity: read or see printed material, count fingers, see light
III: Oculomotor	Extraocular movements (EOMs) Pupil assessment: constriction/dilation
IV: Trochlear	Extraocular movement
V: Trigeminal	Corneal reflex Facial sensation
VI: Abducens	Extraocular movements
VII: Facial	Speech musculature Taste (not routinely tested) Raise eyebrows, smile
VIII: Vestibulocochlear	Hearing
IX: Glossopharyngeal	Swallowing, gag reflex
X: Vagus	Speech musculature
XI: Spinal accessory	Shoulder shrug
XII: Hypoglossal	Speech musculature

Table 34-2 MUSCLE STRENGTH GRADING

0	No detectable movement
1	Flicker of muscle movement
2	Joint movement with gravity eliminated
3	Moves against gravity, not resistance
4	Moves weakly against resistance
5	Full strength against resistance

Table 34-3 BRAINSTEM INTEGRITY TESTS

Test	Description
Doll’s eyes (oculocephalic reflex)	Present when eyes move in the direction opposite that in which the head is moving (found with an intact brainstem but damaged cerebral cortex)
Caloric testing (oculovestibular reflex)	Present when eyes move toward the ear stimulated with cold water (found with an intact brainstem but damaged cerebral hemispheres; with a brainstem lesion, caloric reflex will be absent or ocular movement will be disconjugate)
Apnea test	Allowing carbon dioxide to build up to stimulate the respiratory system in order to determine whether or not patients will breathe on their own
Brainstem reflexes	Pupils Gag Cough Corneal

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Ineffective airway clearance

2. Impaired gas exchange

3. Decreased cardiac output

4. Ineffective tissue perfusion: cerebral

5. Pain

6. Anxiety/fear

7. Impaired verbal communication

8. Risk for injury

9. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood products/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

1. Continuously monitor and treat as indicated

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

3. If positive 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) Perinatal problems may affect neurologic status

2) Babinski’s reflex is normal up to 2 years of age

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

4) Large occiput causes flexion of neck when in supine position

5) Ligamentous and muscular laxity of spine predisposes child to spinal cord injury (SCI) without radiographic abnormality (SCIWORA)

b. “Pearls”

1) Assess tone by noting resting position of the infant

2) Meningeal irritation may present as a sharp, shrill cry, with irritability and loss of appetite in infants

3) Adaptation of the GCS for infants and children (see Appendix C)

4) History that indicates possible abnormalities: delay or regression in developmental milestones, unusual behavior for age, clumsiness or progressive weakness, learning or school difficulties

5) Consider maltreatment in unusual situations

2. Geriatric

a. Aging related

1) Gradual slowing of the conscious and reflex reaction time

2) Impairment of fine discrimination abilities

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

4) Altered drug response and tolerance

5) Cortical atrophy stretches subdural bridging veins and increases the risk of subdural hematoma (SDH)

6) Consider abuse or neglect in unusual situations

b. “Pearls”

1) Use stronger stimuli and allow more time to respond

2) Use sharper contrasts with sensory stimuli

II. SPECIFIC TRAUMATIC NEUROLOGIC INJURIES

A. Increased Intracranial Pressure

Increased intracranial pressure (ICP) is a reflection of three relatively fixed volumes: (1) brain, (2) cerebrospinal fluid, and (3) blood. As the level of any one of these increases, the levels of the other two components decrease to provide compensation and keep the ICP within normal limits, despite increasing pathologic processes. As a result, the brain will demonstrate only slight increases in pressure despite a wide range of volume expansion. However, as the disorder progresses, compensatory mechanisms are depleted, resulting in a rapid increase in ICP even though there may only be a small concurrent increase in volume. This produces a shift of the brain tissue with eventual herniation of the brain through the tentorial opening that results in pressure on the brainstem and produces a clinical picture of altered level of consciousness as well as pupillary, motor, and vital sign changes. As ICP rises, cerebral perfusion pressure (CPP) decreases, leading to cerebral ischemia and the potential for hypoxia with secondary insult. Cerebral ischemia can lead to increased concentrations of carbon dioxide and decreased concentrations of oxygen in cerebral vessels. Carbon dioxide causes vasodilation of blood vessels that further contributes to the problem. Underlying causes of an increase in ICP include conditions that (1) increase brain volume, (2) increase cerebral blood volume, or (3) increase cerebrospinal fluid volume. CPP is the blood pressure gradient needed to perfuse the brain and is normally in the range of 70 to 100 mm Hg. It reflects a balance between the incoming blood (MAP) and the opposing pressure existing in the brain (ICP) and is determined by the following equation: MAP – ICP = CPP. Either a decrease in the MAP or an increase in the ICP can lead to insufficient CPP (Table 34-4).

Table 34-4 INSUFFICIENT CEREBRAL PERFUSION PRESSURE

Mean Arterial Pressure	Intracranial Pressure	Cerebral Perfusion Pressure
Unchanged	Increased (↑ in intracranial volume)	Insufficient to perfuse brain
Decreased (hypovolemic or distributive shock)	Unchanged	Insufficient to perfuse brain