All care that we provide starts with an assessment, and when we are talking about the neonatal brain and creating an environment where the brain can be nurtured and nourished then of course we must start with an assessment, not just of the babies, but of the unit and ourselves.
Before we dive in to the many ways we can assess the brain, let’s step back and talk about why we assess the brain and what does that really tell us?
How do we assess the neonatal brain?
We currently use a variety of tools to assess the neurological function of our babies and there are endless tools that we can employ. From Sarnat to NPASS there are so many tools that evaluate the baby brain. Even as technology progresses, a clinical exam by a skilled bedside nurse is still one of the strongest and most reliable tools in our toolbox.
Using validated tools for specific populations is common in the NICU and are there to guide us and standardize our observations. Some examples of the most common assessment tools that we use to evaluate infant’s neuro state are:
1. Dubowitz – for gestational and neurological assessment
2. Sarnat – for determining the level of encephalopathy and eligibility for therapeutic hypothermia
3. NPASS – for assessing pain and sedation levels
4. Finnegan – for trending infants signs/symptoms of Neonatal Abstinence Syndrome (NAS)
What are the additional tools that we use for neuro-assessment?
There are also exams/testing tools that we utilize routinely that may not seem like neuro-exams, but actually give us important information about the health of the nervous system include:
1. Mandatory newborn screening – to identify metabolic disorders that could injure the brain
2. Mandatory hearing screening before discharge records evoked responses from the auditory center of the brain
3. Lumbar Puncture to assess for infection/inflammation in the CNS
How do we assess brain structure, function and perfusion?
Many of the neuro-assessments we’ve discussed tell us about specific aspects of neurologic functioning or status such as assessing the level pain with NPASS or withdrawal with Finnegan. But what about brain structure, function, and perfusion?
Use of imaging (like MRI, cranial Ultrasound) and bedside monitors ( aEEG, video-EEG, NIRS) are all forms of neuro-assessment!
1. MRI – provides detailed pictures of brain structure, brain maturation, and extent of brain tissue injury
2. aEEG – bedside method for continuous monitoring of brain activity to assess background pattern, sleep wake cycling, and seizure detection
3. NIRS – non-invasive monitoring of tissue oxygenation, measuring brain perfusion
There are a variety of quality improvement and practice improvement projects that could stem from this first Pillar if you just took a look.
- What is your inter-rater reliability on one of the standardized assessment tools I mentioned?
- Is your unit using a standardized state-wide algorithm for treatment based on Finnegan scores?
- Does every infant with HIE get an MRI before discharge?
- What percentage of infants require sedation for MRI?
- What is your temperature ranges for infants who go to the MRI suite?
If you need a little inspiration for your next quality improvement project, check out our Neuro-Nurturing NICU Quick Start Guide and video series!
Blog written by Sarah Bakke
Sarah Bakke, BSN, RNC-NIC
Sarah started her career in a level III NICU in Indiana, and has worked in both level III and IV NICUs over the course of her career. She is currently a staff nurse in the NICU at the Nemours Alfred I. duPont Hospital for Children in Wilmington, DE, and is working towards her MSN as a Pediatric Nurse Practitioner at Drexel University.
She has led a number of neuroprotective initiatives during her time at Nemours including launching a language nutrition program, founding a multidisciplinary NeuroNICU committee, and organizing quality improvement projects. Sarah is passionate about all things NeuroNICU.