2.9 Neurological, Sensory-Motor Flashcards
Describe the following reflexes and their significance
REFLEXS CORNEAL
CN V & VII
When the cornea is touched there should be a brainstem reflex leading to blinking or bilateral eyes and tearing
Absence means something is affecting the nerves such as a tumor, brain stem CVA or brain death
Describe the following reflexes and their significance
OCULOCEPHALIC “DOLL’S EYES”
Positive reflex: when the head is turned the eyes should turn with opposite
Negative reflex: when the head is turned the eyes become fixed straight ahead
Describe the following reflexes and their significance
OCULOVESTIBULAR “COLD CALORICS”
When ice cold water is used to irrigate the EAR. The brainstem reflex should trigger the eyes to look toward the direction of the irrigated ear
Absence of the reflex indicate brain death
Describe the following reflexes and their significance
GAG
CN IX & X
There should be contraction of posterior pharynx muscles when stimulated
Absence can mean over sedation or brain death
Describe the following reflexes and their significance
BABINSKI
Planter response to movement of a hard object up the bottom of the food. Normal response is curling of all toes inward (negative Babinski)
Dorsiflexion or fanning of the toes indicates presence of Babinski (abnormal) and can indicate spinal cord or brain injury. (positive Babinski)
This is a primitive response in infants and can also occur with ETOH intoxication or seizure activity
Neuro assessment abnormal findings and their significance
RESPIRATORY CONSIDERATIONS
Damage to pons/medulla leads to inability to regulate breathing patterns based on oxygen and carbon dioxide. As a result, you have irregular patterns of breathing depending on the area of injury
Excessive yawning or sighing: first sign of deterioration
Cheyne-stokes: altered deep and rapid breathing with periods of apnea
Hyperventilation: 40 breaths/min or higher
Apneustic: long inhalation and long exhalation
Ataxic/Apneic: uncoordinated or irregular breathing, pt no longer responding to carbon dioxide
What is the Glasgow Coma Scale
Measure a person’s level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body
3 PARTS
Components of the Glasgow Coma Scale
EYE OPENING
Eye Opening: Spontaneously 4 To sound 3 To pain/pressure 2 No response 1
Components of the Glasgow Coma Scale
VERBAL RESPONSES
Verbal responses: Oriented 5 Confused 4 Single words 3 Incomprehensible sounds 2 No response 1
Components of the Glasgow Coma Scale
BEST MOTOR RESPONSE
Best motor response: Obeys commands 6 Localizes pain 5 Flexion-withdrawal 4 Abnormal flexion (decorticate) 3 Abnormal extension (decerebrate) 2 No response (flaccid) 1
What does a GCS of 3 mean?
Could mean patient is dead
OR
Severe neurological injury
Describe the following head injury
BLUNT
No break in skin:
Acceleration (hit in head with bat)
Deceleration (fall)
Acceleration/decelerations (combination of two), Rotation, usually not good outcome, (brain rotating within skull, MVA, shaking baby)
Describe the following head injury
PENETRATING
Break in skin: gunshot, knives, metal object, rocks/objects of nature.
NI:
Never pull out object, secure and held in place
Control bleeding
High infection risk
Domestic: CPS, APS
Describe the following head injury
COUP-CONTRECOOUP
Acceleration and Deceleration head injury
ie: MVA with the head being forced forward and then back with anterior and posterior injury. Think “whiplash”
Pathophysiology and assessment finding of the following hematomas
EPIDURAL
Focal (localized) injury
Hematoma/Hemorrhage
Epidural:
Blood in space between the skull and dura mater, typically from an arterial bleed. Common with skull fractures
Findings:
Loss of consciousness then regain consciousness
ICP
Emergent surgical
Pathophysiology and assessment finding of the following hematomas
SUBDURAL
Focal (localized) injury
Hematoma/Hemorrhage
Subdural:
Blood in space between dura and arachnoid typically from a venous bleeding
Findings: Acute: s/s during time of injury or few days later Pupil changes HA Resp changes Chronic: s/s can be weeks to months Fall is common Mimic dementia Slow changes to complete loss of consciousness
Pathophysiology and assessment finding of the following hematomas
INTRACEREBRAL
Focal (localized) injury
Hematoma/Hemorrhage
Intracerebral:
Blood deep in brain tissue, most common with contusions, penetrating trauma, depressed skull fractures
Findings: HA Vomiting Seizures Reduced level of consciousness Hemiparesis Surgical need Drain placed
Identify the complication of a traumatic brain injury
HERNIATION
Herniation Syndrome:
Shifting of the brain tissue into another part of the brain due to blood or edema.
Shifting shears/tears the vasculature causing decreased brain perfusion and ultimately brainstem compression and herniation
Supratentorial (3 types):
Cingulate: highest up in brain, increased ICP
Central: compression of midbrain, rapid decline of level of consciousness or coma
Uncal/lateral: pressing brain centrally, CNIII trapped, pupil dilation, decreased level of consciousness, respiratory arrest
Infratentorial:
Upward or downward displacement through foramen magnum altering vital functioning. May have altered respirations, fixed pupils, posturing, eventually resp or cardiac arrest
Identify the complication of a traumatic brain injury
BRAIN DEATH
Non reversable loss of brain function Must maintain normothermia Absent of all reflexes No depressant drug/ETOH poisoning Institutional policy may include EEG, brain flow study, apnea test Notify Gift of Life
Identify the complication of a traumatic brain injury
SIADH
Posterior pituitary can alter release of ADH
SIADH: syndrome of inappropriate antidiuretic hormone)
TOO much ADH causing retention of water
Urine: low volume, very concentrated, high specific gravity
Serum: low serum osmolality
Treatment:
Restrict fluid
Slowly replace Na+
Identify the complication of a traumatic brain injury
DIABETES INSIPIDUS
Posterior pituitary can alter release of ADH
Diabetes Insipidus:
Insufficient ADH causing diuresis
Urine: increased urine output, low specific gravity
Serum: increased serum osmolality
Treatment:
Fluid replacement
Reduce Na+
Replace ADH with vasopressin
Identify the complication of a traumatic brain injury
HYPERTHERMIA
Impaired function of the hypothalamus altered temperature regulations (as long as infection has been ruled out). Increased temperature means increased cerebral metabolic rate and increased ICP. Antipyretics will not help. Use of ice packs and cooling blankets.
Identify conditions that predispose a patient to increased intracranial pressure (IICP)
Hydrocephalus Bleeding in the brain Swelling of the brain Aneurysms Brain/head injury High blood pressure Stroke Infections: meningitis, encephalitis
Identify the signs and symptoms of IICP
Early s/s:
Decreased level of consciousness
HA
N/V
Late s/s:
Pupil changes
Posturing
Cushing’s Triad
Explain why a sudden rise in IICP is such a catastrophic situation
.
Describe type of intracranial monitoring
EPIDURAL PROBE
Probe is placed between skull and dura mater
No drain
Can monitor ICP numbers
Describe type of intracranial monitoring
SUBARACHNOID SCREW
Fiber optic catheter placement allows the sensor to record from inside the subdural space
No drain
Can monitor ICP numbers
Describe type of intracranial monitoring
INTRAVENTRICULAR CATHETER
IVC is used to connect the ventricles of the brain to an external ventricular drainage device (EVD) system. typically inserted into the right lateral ventricle as not to interfere with language
Describe purpose and priority nursing interventions for patient with a ventriculostomy
IVC is used to connect the ventricles of the brain to an external ventricular drainage device (EVD) system. typically inserted into the right lateral ventricle as not to interfere with language
NI:
Dependent drainage of CSF
Closely monitor output
Risk for infection, keep system sterile
Must level transducer at the tragus of the ear (per physicians order)
Monitor ICP and CPP (cerebral profusion pressure) readings
Describe nursing care and interventions that prevents IICP in the critically ill patient
Maintain dressings, drains, special precautions for bone flap removal Close monitoring of vitals and ICP Reduce infection risk (VAP, antibiotics) Frequent neuro checks HOB up min 30 degrees Low stimulation Seizure precautions Family teaching Pain control
Describe nursing implications and rationale for use of medication for head injury patient
DIURETICS:
MANNITOL
FUROSEMIDE
Diuretics: in attempt to lower ICP
Mannitol: hyperosmotic
Furosemide: loop diuretic (enhances Mannitol)
Nursing:
Strict I/O
Monitor for fluid overload
Monitor for dehydration
Describe nursing implications and rationale for use of medication for head injury patient ANTICONVULSANTS: PHENYTOIN DIAZEPAM LEVETIRACETAM LORAZEPAM
Anticonvulsants: to reduce the likelihood of seizures
Phenytoin: anticonvulsant
Levetiracetam: anticonvulsant
Diazepam: benzo, antianxiety, anticonvulsant, sedative/hypnotic, muscle relaxant
Lorazepam: benzo, antianxiety, sedative/hypnotic, analgesic adjunct
Nursing:
Monitor for SI
Rash
Vitals: resp, BP
Describe nursing implications and rationale for use of medication for head injury patient B/P MEDS: LABETALOL HYDRALAZINE NOREPINEPHRINE
BP meds to maintain MAP (70-110 norm) within parameters
Labetalol: beta blocker, antianginal, antihypertension
Hydralazine: vasodilator, antihypertensive
Norepinephrine: vasopressor, produces vasoconstriction
Nursing:
Monitor BP
I/O
Monitor for fluid overload
Describe nursing implications and rationale for use of medication for head injury patient SEDATIVE/HYPNOTICS: PROPOFOL MIDAZOLAM DEXMEDETOMIDINE
Sedative/hypnotics: to reduce stimulation, muscle contraction and overall cerebral O2 demand
Propofol: anesthetic, short 1/2 life, may decrease BP, MUST be mechanically intubated
Midazolam: benzo, antianxiety, anticonvulsant, sedative/hypnotic, CNS depression, amnesia
Dexmedetomidine: sedative/hypnotic, ICU sedation, may decrease BP and HR
Nursing:
Monitor HR and BP
SI
Describe nursing implications and rationale for use of medication for head injury patient
STEROIDS
Steroids: to reduce cerebral edema
**NOT indicated in TBI, only with tumors
Dexamethasone: anti-inflammatory
Nursing:
Check blood sugar
I/O
Check edema
Describe nursing implications and rationale for use of medication for head injury patient
HORMONES
VASOPRESSIN
Hormones: for treatment of diabetes and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
Vasopressin: replacement hormone, antidiuretic, vasopressor, reduce urine output and increase urine osmolality
Nursing:
I/O
Monitor BP, HR
Describe nursing implications and rationale for use of medication for head injury patient
GI MEDS:
FAMOTIDINE
PANTOPRAZOLE
GI prophylaxis: to reduce likelihood of ulcers due to the reduce gut motility and stress on the body
Famotidine: antiulcer, histamine antagonist
Pantoprazole: antiulcer, proton pump inhibitor
Nursing:
Monitor for blood in stool, emesis, gastric aspiration
Describe nursing implications and rationale for use of medication for head injury patient
ANTIPSYCHOTIC:
PHENOTHIAZINE
CHLORPROMAZINE
Antipsychotic: with alternate use for hiccups or shivering. Alters dopamine in CSN
Chlorpromazine: phenothiazines, antiemetic, antipsychotic
Nursing:
Monitor fluid intake
Bowel function
BP
Describe nursing implications and rationale for use of medication for head injury patient
NEUROMUSCULAR BLOCKING AGENT:
VECURONIUM
Neuromuscular blocking agent: to provide paralysis in the event of uncontrolled seizures or need for induced hypothermia
Vecuronium: IV fusion
Nursing:
Monitor HR, BP
Peripheral nerve stimulator may be used to determine level of blockade induced. Determines level of paralyze of patient
Four impulse are delivered to sites of ulnar, facial or tibial nerves:
0:4 too much paralytic
2-3:4 adequate paralysis
4:4 paralysis is insufficient
Identify priority assessments for barbiturate coma and neuromuscular blocking agents in pt with IICP
.
Describe the med/surg management of patients with cerebral aneurysm
Out pouching of cerebral artery, most common location is the circle of Willis
If identified before rupture surgical interventions include clipping or coiling
Prevent and treat of ruptured aneurysm:
Vasospasm: use of Ca+ channel blocker
Rebleeding: treat IICP
Describe the post op nursing care of a craniotomy patient
Cranial cavity is surgically opened, tumor/blood clot is excised via the bone flap removal and ultimate replacement of the bone
Post op:
Identify nutritional modifications that are indicated for patients with head injuries
Patients may have swallow inability Tube feedings might be necessary Can increase metabolism Increase potassium intake Reduce carbs (too many carbs can cause CO2 buildup) NO nasal tubes, ONLY oral tubes
Describe post op care of the carotid endarterectomy patient
Surgical intervention to remove atherosclerotic plaque to prevent ischemic stroke (at the carotid artery bifurcation)
Vitals: every hour
HR: cardiac monitor
Resp: monitor airway
Pulse ox: O2
Dressing: to neck
JP drain: check
Cranial nerves: may have abnormality after surgery
HOB: 30 degrees, support head with any movement
Describe pre and post op care for patient with corneal transplants
Lamellar: superficial replacement of cornea
- *Penetrating: full thickness cornea is removed and replaced by donor
- very fine sutures remain in place for 1 year (cornea is avascular and slow healing)
- low risk of corneal rejection d/t avascular nature
NC:
Pain meds
Position on unaffected side with HOB 30 degrees
Administer steroid drops to reduce inflammation
Assess eye patch/dressing for drainage
Teach pt to avoid; coughing, sneezing, vomiting, straining
Sudden sharp pain in eye may indicate hemorrhage
Vision can take up to 12 mo to return
Describe pre and post op care of patients with enucleation
Removal of eye d/t malignancy, infection, glaucoma, intractable pain/trauma
Outpatient
Round implant placed to maintain shape
Pressure dressing 24+ hours
Pt can be up after surgery
NC: Observe for signs of hemorrhage Teach pt about s/s of infection and admin of drops Provide psychological support Irrigation of socket may be required
Long term eye prothesis is placed within 1-2 mo
Describe the effects a head injury has on reproductive health
Patient can experience:
Sexual dysfunction
Changes in hormone levels
Infertility
What is the Cushing’s Triad?
Increased ICP
Increased BP
Decreased HR
Irregular respirations
Progression of IICP (cascade)
Cranial insult/injury= Tissue edema= Increase of ICP= Compression of blood vessels= Decreased cerebral blood flow= Decreased O2 with death of brain cells= Edema around ischemic tissue= Increased ICP with compression of brainstem/respiratory centers= Increase CO2 accumulation= Vasodilation= Increased ICP as result of increased blood volume= Death
8 (…ate) Interventions for ICP and TBI
- Elevate
- HOB min 30 degrees
- avoid hip and neck flexion
- The silence: reduce stimulation, provide block care - Oxygenate
- deliver O2 is appropriate
- blood transfusion: monitor Hgb for anemia (acidosis is NOT good = vasodilation = cerebral edema
- limit suctioning: coughing/vomiting can increase ICP - Intubate
- GCS of <8, notify provider
- protect airway
- optimal ventilation in critical patients - Hyperventilate
- normal pCO2 is 35-45 mmHg
- pCO2 = a potent vasodilator
- hypercapnia (high pCO2) causes: vasodilation = cerebral edema = increased ICP
- hypocapnia (low pCO2) causes: vasoconstriction = increase pH = decreased ICP = ischemia (lack of O2) - Medicate
- BP med to maintain MAP within parameters
- anticonvulsants
- GI prophylaxis
- antipsychotic
- diuretics
- hormones
- steroids - Sedate
- sedatives/hypnotics to reduce stimulation, muscle contraction and overall cerebral O2 demand
- sedation does NOT remove their pain - Refrigerate
- hyperthermia
- hypothermia
- goal normothermia - Evacuate
- surgical intervention
- ventriculostomy
- nursing care post op
