After completing the chapter, you will be able to accomplish the following:

1. Apply a two-piece cervical collar.
2. Implement seizure precautions and seizure management.
3. Care for patient with a halo external fixation device (halo traction).
4. Care for a patient with an external ventriculostomy device.
5. Care for a patient with a fiberoptic intracranial catheter.

• Assessment
• Clinical Decision Making/Clinical Judgment
• Intracranial Regulation
• Safety
• Sensory Perception

• aura
• cerebral perfusion pressure (CPP)
• coma
• decerebrate
• decorticate
• intracranial compliance
• intracranial pressure (ICP)
• level of consciousness (LOC)
• seizure
• ventriculostomy

Many patients experience injury to the head, neck, or spinal column. In addition, numerous disorders, such as infections and tumors, can affect the brain and spinal cord, interfering with neurologic function. Specialized devices may be used to monitor and control intracranial pressure (ICP). Meticulous care is needed after injury or trauma to ensure that further injury does not occur. This chapter covers skills to assist the nurse in providing neurologic care.

Behavioral scales are used to standardize observations for the objective and accurate assessment of level of consciousness (LOC) (degree of wakefulness or ability to be aroused) and monitor changes related to neurologic injury and coma (Hickey & Strayer, 2020). Fundamentals Review 17-1 provides descriptions of terms used to describe levels of consciousness. The Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness (FOUR) score are examples of two tools used to assess LOC. The GCS is used as a rapid evaluation of the status of acutely ill patients at risk of acute brain damage (Derbyshire & Hill, 2018). The FOUR score coma scale is an assessment tool for adult and pediatric patients with severe neurologic impairment (Hickey & Strayer, 2020). It includes information not assessed by the GCS, including measurement of brainstem reflexes; determination of eye opening, blinking, and tracking; a broad spectrum of motor responses; and the presence of abnormal breath rhythms and a respiratory drive, providing a more comprehensive neurologic assessment (Jalali & Rezaei, 2014; Zappa et al., 2020). The FOUR score tool does not include an assessment of verbal response and may be more useful for assessing critically ill patients with depressed level of consciousness or those who have undergone intubation (Almojuela et al., 2018; Iyer et al., 2009; Sadaka et al., 2012). Fundamentals Review 17-2 reviews a brief neurologic exam. Refer to Fundamentals Review 17-3 and Fundamentals Review 17-4 for the GCS and the FOUR Score assessment tools. Refer to Chapter 3 for a review of other components of a neurologic assessment.

1. Check the fit and placement of the collar. The center of the collar should line up with the center of the patient's neck. Center the front of the collar over the patient's chin, ensuring that the chin area fits snugly in the recess of the collar. Be sure that the front half of the collar overlaps the back half. Check to see that at least one finger can be inserted between collar and patient's neck. Check the skin under the cervical collar for any signs of skin breakdown. Have a second person immobilize the cervical spine. Remove the top half of the collar and cleanse the skin under the collar. Assess the skin for signs of irritation and/or breakdown. If not contraindicated, place the patient in the reverse Trendelenburg position to see if this helps. After replacing the collar, assess the tightness of the cervical collar; at least one finger should slide under the collar.
2. Patient and family/caregiver education should include not only important information related to epilepsy and patient care, but encouragement and support for the patient and family/caregiver as well. Provide the following in discussions with Yuka and her mothers: Provide education regarding prescribed medications, including administration, potential side effects, and the importance of not running out of medication (El-Radhi, 2015). Yuka and her mothers should be encouraged to keep a seizure diary (El-Radhi, 2015). Suggest that Yuka and her mothers have periodic “seizure drills” to practice what every family member/caregiver should do if Yuka has a seizure (Epilepsy Foundation, 2014b, 2020). Provide information regarding the actions to take if Yuka has a seizure. Encourage supervision during bathing, swimming, ambulation, or other potentially hazardous activities (Kyle & Carman, 2021). Encourage regular sleep and avoidance of fatigue (El-Radhi, 2015; Kyle & Carman, 2021; Smith et al., 2015). Emergency assistance should be obtained for multiple or prolonged (>5 minutes in duration) seizures; if Yuka has trouble breathing or waking after a seizure; if Yuka has one seizure soon after the first one; or if Yuka is injured during the seizure (CDC, 2020b). Provide information about support groups for Yuka, her mothers and families dealing with a diagnosis of epilepsy. Inform Yuka and her mothers that Yuka should wear a medical alert bracelet.
3. Include the following in discussions with the patient and her family/caregiver: Explain what a ventriculostomy is, the rationale for placing it, and how it helps with the patient's care. Answer any questions they may have regarding the equipment. When positioning and turning the patient, be aware of the location of the ventriculostomy and attached tubing. Ensure that the tubing is not kinked or obstructed by the activity. After positioning the patient, reassess the height of the system to ensure that the location of the stopcock remains at the appropriate reference point: the tragus of the ear, the outer canthus of the patient's eye, or the patient's external auditory canal (AACN, 2017). Turn and position the patient in proper body alignment, avoiding angulation of body parts. Avoid extreme hip flexion or flexion of the upper legs, which can increase intraabdominal pressure, leading to increased ICP. Maintain the neck in a neutral position at all times to avoid neck vein compression, which can interfere with venous return (Hickey & Strayer, 2020). Keep the head of the bed elevated at 30 degrees to promote venous return from the brain, depending on prescribed interventions and facility procedure (AACN, 2017; Hickey & Strayer, 2020). Bathing, turning, and other routine care often have a cumulative effect to increase ICP when performed in succession. Allow rest periods between procedures and carefully assess the patient's response to interventions (Hickey & Strayer, 2020).