CNS assessment Flashcards
Glasgow coma scale
Eye-none, to pain, to voice, spontaneous
Verbal-None, no words only sounds, words but not coherent, disoriented conversation, Normal conversation
Motor-None, decerebrate, decorticate, withdraws to pain, localized pain, normal
Add together. mild-13-15 mod-9-12 severe- 3-8 less than 8 is a problem
aphasia/dysphasia dysarthria Anisocoria diplopia dysphagia papilledema aptaxia ataxia hemiplegia nystagmus
aphasia/dysphasia- cerebral cortex- cant understand language
dysarthria-mm of speech- cerebral of CN
Anisocoria-unequal pupils optic nerve
diplopia-seeing double II, IV, VI
dysphagia-IX, X brainstem
papilledema-optic disc swelling-II
apraxia-cerebral cortex- difficulty moving
ataxia-Cerebellum
hemiplegia-Motor cortex paralysis of one side
nystagmus-Cerebellum, brainstem, vestibular rapid pupil movement from side to side,
head injury
Scalp, skull, Brain
Head injury Laceration Skull fracture Head trauma Contusion Hemorrhage Epidural hematoma subdural hematoma intracerebral hematoma
Laceration-cut with lots of blood
Skull fracture- Bone fx
Head trauma-Concussion or traumatic brain injury
Contusion/hemorrhage-bruising, bleeding in brain
Epidural hematoma- Tear in art in brain
subdural hematoma- broken blood vessles below duramater
intracerebral hematoma -bleeding in cerebrum
What are the manifestions of head injuries
Altered LOC Headache Nausea vom Seizures Increases ICP possible hyperthermia if hypothal is damaged
Basilar skull fractures
Liner fraction involving base of skull tear in duramater-leakage of CSF
Rhinorrhea, otorrhea
battles sign- posturicular ecchymosis
racoon eyes-periorbital ecchymosis
tx for head injuries
CT-most effective Emergency tx Surgery-Craniectomy, craniotomy tx cerebral edema manage ICP
Head emergency initial
CAB if unresponsive, ABC if responsive assume neck injury with head injury stabilize cervical spine Apply 02 non-rebreather Establish IV with 2 large bore cath Intubate if less than 8 control bleeding with sterile pressure dressing Remove patients clothing
Head emergency ongoing
Maintain normothermia using blankets
monitor vitals and Aand O GCS and pupil size and reactivity
If gag reflex is impaired expect intubation
assess rhinorrhea otorrhea snd scalp wounds
give fluids cautiously to prevent fluid overload and increasing ICP
What is the monroe kelly doctrine
If volume in 1 component goes up the volume in the other must go down to maintain ICP.
Numbers for stuff in the brain
what is normal pressure and when do we treat
how do we measure
CSF-10 percent Blood-12 percent brain-75 percent 5-15 tx at 20 Pressure transducer
What is CPP how to calculate what is normal and what is MAP and how to calculate
CPP- cerebral perfusion pressure- it is how much blood is getting to the brain
PP=MAP-ICP
normal-60-100 less than 50 is ischemia and less than 30 is incompatible with life
Mean arterial pressure- amount of blood during one cardiac cycle
MAP=(DBPx2)+SBP/3
normal is 70-100
6 things Damaged brain tissue can cause
Hypercapnia, acidosis, impaired auto-regulation, Hypertn and cerebral vasodilation, brain hernia
Vasogenic edema
and three things that cause it
Leakage of lg molecules from capillaries intosurrounding extracellular space
Brain tumorrs, abcess, toxins
Cytotoxic edema and 3 things that cause it and one thing about it
Disruption in the integrity of the cell membrane causes fluids to shift into the the cells
Cerebral hypoxia, destructive lesions or trauma BBB intact
Cytotoxic edema and 3 things that cause it and one thing about it
Disruption in the integrity of the cell membrane causes fluids to shift into the the cells
Cerebral hypoxia, destructive lesions or trauma BBB intact
interstital edema and three things that cause it
Build up of fluid in the brains ventricles-Hydrocephalus
too much CSF, obstruction of flow or reabsorption issue
Manifestations of ICP 10
Change in level of consciousness-Number one maybe irritability or sleepy
Change in vitals- Cushings and change in temp
Ocular- unilat pupils, slow, not reactive to light, can’t move eye up, eyelip pitosis, papolledema,
decrease in motor function-Posturing and hemiparesis or plagia
vomiting without nausea
HS that is constant
stiff neck cant bend down
Positive babinsky
seizure
coma
Pupil 3
1 dilated- CN111 8mm
Bilat dilated and fixed BAD sign
Pinpoint- pons damage or drugs
Decorticate
flexed arms, wrists, fingers with adduction in upper ext
extension internal rotation and plantar flex in lower
problem with cervical spine or cerebral hemisphere
decerebrate
all four extremities with rigid extension. Adduction in upper arms over pronation in arms, flexed hands, plantar flexed feet
Ventriculostomy
Gold standard for measuring ICP. Cath insertion into lateral vent, and connected to external transducer
you can measure pressure, remove a sample of CSF or give drugs
Diagnostic for IICP
CT-Number one! MRI PET EEG cerebral angiography, ICP and brain tissue oxygen measurement Dopler and ekoked potentail studies. subarachnoid screw NO LUMBAR PUNCTURE
Breathing with IICP Cheyne stokes Central neurogenic hypervent Apneutic CLuster Ataxic
Cheyne stokes-BL hem metabolic dysfunction- cycles of hypervent and apnea
Central neurogenic hypervent-Regular rapid breathing lower mid and uper pons
Apneutic-mid brain lower pons prolonged inspirations with pause with expirratory pause
CLuster-medulla/pons cluster breaths with irregular pause
Ataxic -Reticular- irregular- deep mixed with shallow/pauses/slow
Mannitol 7 things
Mannitol- IV no PO
Plasma extension and osmotic
measure Is and OS need cath for accuracy in unconscious
can cause metabolic acidosis, hypok
BBW bronchospasms
CI in renal or increased osmolality
can cause edema/heart fail because of fluid overload
Drugs for IICP 10
Mannitol Hypertonic saline Corticosteroids H2 receptor antag to prevent bleeds and ulcers Antiseizure meds Antipyretics Sedatives, analgesics, barbituates stool softeners
Name some things that increase ICP 5
Fever, agitation, shivering, pain, seizures
Why are we worried about airway with IICP
Secretions may cause tongue to slip to back of throat
what do we look at for mental status
general appearance and behavior, cognition-AandO, memory, judgement, problem solve, mood and affect
YOU NEED TO DO CRANIAL NERVES
how to assess Motor 5
Strength, tone, coordination, symmetry, balance
How to assess sensory
Touch, pain, temp, vibration, position, cortical-graphesthesia and stereognosis
How to test reflexes 5
Babinski-toes up or down you brush up on foot and across
brudinski-pull head up and knees go up
kernigs0 cant straighten leg when hip is flexed to 90
clonus
dolls eye
most common risk for a stroke 4 more to know
HTN
Alcohol, apnea, metabolic syndrome, BCP
Heart conditions to cause a stroke
A fib, valve, congenital defects, History of TIA
Ischemic stroke def and 2 kinds
Clot stops blood flow to brain
Thrombotic-Injury and formation of blood clot causes narrowing of blood vessle most common from HTN and DM and athero
Embolic- Embolism travels from some place else and occludes art=Infaraction and edema usually from A FIB
Hemmorrhagic stroke
Bleeding and swelling from bleeding usually from aneurysm HTN and age
Intracerebral hemorrhage
Bleeding into brain from rupture of a vessle
Suddent onset, Poor prog,
htn most common cause, usually during activity,
Subarachnoid hemmorhage
Intracranial bleeding into cerebrospinal fluid
rupture of aneurysm, trauma, drugs, fall,
Cerebral aneurysm
Vasospasms, in cirle of willis, silet killer, loss of conscousness or not survivors often have significant complications
R manifestations of a stroke 7
Paralysis of L side, L side neglect, spatial perception neglect, Minimize problems, Impulsive, impaired judgment, Impaired time concepts,
L side manifestations of a stroke 9
Paralysis of R side, R side neglect, impaired speech and language, slow cautious movements, aware of def, depression, impaired comprehension, aphagias,
S/s of motor effected by stroke
Apraxia, akensia, hypo/hyper reflexia, mobility, swallowing, gag, self-care, elemination issuesm, flaccidicy and spasticity
Affect after stroke
Exaggerated emotional response depression frustration
Tx for stroke 4
ABC, neuro checks, TX of edema, Prevent further injury,
Ischemic stroke tx
Tpa-breakdown clot, 3-4 hours after onset, cant for hem!
What is the surgery for Strokes
Carotis endarterectomy stent for occluded caroted art
What is FAST
Face-Smile one side droops?
Arms raise arms on side droops?
Speech-Simple sentence
Time-any symptoms call 911
Sx of stroke
Tinnitus, vertigo, HA, Dark blurred vison, Diploplia, ptosis, dysartheria, dysphagia, ataxia, uni/bilat weakness or numbness
c4, c6, t6, L1
c4-Tetra and paralysis of respiratory, C6-tetra with pa in hands and arms, T6 para below chest, L1-Para below waist
ASIA impairment scale for SCI
A-complete no S or M
B-incomplete-S nut no motor
C incomplete-M preserved- MM greater than 3 more than 1/2
D-Incomplete0 M presereved mm greater than 3 in 1/2
E-Normal
incomplete injuries Anterior cord syndrome Brown- conus cauda
Anterior cord syndrome-Damage to anterior spinal cord from compression r/t flextion-motor paralysis, loss of pain and temp sensation below (B)LOI
Brown-Damage to 1/2 of spinal cord commonly cervical-Contralateral (opposite side) - loss of pain/temp sensation BLOI
Ipsilateral (same side) – loss of voluntary motor function
conus-Damage to lowest part of spinal cord-motor weakness and altered sensation, burning sensation in UEs (LEs not as affected)
cauda-Damage to cauda equina-nerve bundle rootmotor function in LEs mb preserved, flaccid, or weak – more mid-moderate backpain
Decrease/loss of sensation in peri area impotence, areflexic B/B
Manifestations in spinal shock
- Occurs shortly after injury (30-60 mins)
- Loss of DTRs, sphincter reflexes
- Loss of sensation, thermoregulation
- Flaccid paralysis BLOI
- Lasts days-weeks
- Often masks postinjury neuro function
Neurogenic shock manifestations
Occurs in injury ABOVE T6. SNS not working right to control vasomotor tone in the blood vessels vasodilation decreased resistance HpTN venous blood pooling less filling of the ventricles bradycardia and hypothermia (warm extremities, cold inside) decreased CO + tissure perfusion death
SX: HpTN Bradycardia Hypothermia d/t blood pooling (warm outside, cold inside) Decreased preload/filling
Discuss the acute care treatment plan of a spinal cord injury (SCI) patient. Acute
Maintain patent airway/adequate ventilation (prehospital)
Prevent further damage via immobilization (prehospital)
Maintain perfusion via fluid replacement, control bleeding (monitor other trauma)
Keep pt warm (can’t regulate temp)
Indwelling catheter to prevent bladder distension
Only real tx = surgery (decompress, help reduce secondary injury, fuse bones) – 24 hours!
Discuss the acute care treatment plan of a spinal cord injury (SCI) patient.
NExt
Prevent DVTs (measure calf) Prevent skin breakdown (immobile and lack of sensation) Maintain adequate nutrition/fluid needs (this is usually increased – need lots nutrients to heal) Treat pain (neuropathic)
Discuss the acute care treatment plan of a spinal cord injury (SCI) patient. Long term
PT/OT to manage/prevent contractures
SP for swallow assess
Bladder/bowel training – self cath, retraining, prevent retention/infx
Recognize and manage autonomic hyperreflexia
Psychological support
Pt teaching – rehab goals, expectations of improvement
Long term Complications of SCI
Grief and depression – loss of control, mb function, SI R/T immobility: Pneumonia UTIs Pressure ulcers Sepsis DVTs Mechanical ventilation probs, infx
manifestations of autonomic hyperdysflexia
Injury @ T6 or higher. Exaggerated response from the SNS which is running unopposed by the PNS
Some irritating stimulus below T6 - usually bladder distension, bowel impaction, restrictive clothing, skin breakdown … SNS overreacts but can’t do much bc signals aren’t getting to the brain correctly. Signals ARE getting to SNS/PNS but they’re not working together, so … SNS turns on vasoconstriction severe HTN, HA, bradycardia, diaphoresis (ALOI), piloerection (BLOI) baroreceptors can get signal to the brain and are like OMG HELP! decreases HR in response to HTN but can’t dilate peripheral vessel BLOI
Tx for Autonomic hyperreflexia
Sit pt upright or elevate HOB 45
Identify the cause and help – insert cath or look for kink, resolve impaction, remove clothing
Notify HCP
Monitor and manage BP (vasodilators) if sx continue
If left untx’d M.I., stroke, status epilepticus
Parkinsons disease patho
Chronic, progressive neurodegenerative D/O characterized by a gradual onset of sx r/t depletion of dopamine (affects movement, memory, focus)
- slow movements - bradykinesia
- increased muscle tone – rigidity
- tremor @ rest, gait changes
Exact cause unknown – mb r/t environment, family hx, exposure to toxins, drugs, mb post-neuro problem (hydrocephalus, stroke, NG d/o’s, hypo-PTH, tumor, trauma
- abnormal clumps of Lewy Bodies
Men > women
Manifestations of parkinsons
Tremors (1st sign) -pill rolling Rigidity Akinesia (brady) Postural instability (shuffling gait) Depression, anxiety, apathy, fatigue, pain, urinary retention, constipation, ED, ST memory loss, cogwheel rigidity, lewy body clumps, retropulsion, fenestration, arms flexed, hypokineticdysartharia, loss of smell.
Management for Parkinsons
Deep brain stimulation and ablation
exercise , transplantation of fetal neural tissue
anticohlenergics
Complications for park 4
Halucinations, Immobility issues, orthostatic hypotn, dementia
ASL
Death is usually from respiratory dysfunction
ALS
what is it nursing interventions 7
Loss of motor neurons mod-intense endurance exercises for trunk and limbs facilitate communications decrease aspiration risk Detect respiratory dysfunction decrease pain Risk for fall divert
What is huntingtons disease
Progressive, degenerative brain d/o – genetic
Onset usually 30-50 yo
Deficiency in ACH + GABA excess DP
Manifestations for Huntingtons
- excessive and involuntary movements (chorea0
- chewing, swallowing, gait severely impacted
- severe depression, high r/f suicide
** Coup-contrecoup injury
ccurs when brain moves inside skull d/t high energy or high impact injury mechanisms.
Coup/primary = direct impact of brain on skull
Contrecoup/secondary = second area of damage on opposite side from injury (more severe)
Most common skull fracture location = basilar
- damage to structures that protect the brain @ base of skull leakage of CSF
- only break in very severe trauma
- NO NGT if this is happening
Head injury manifestations
SX = rhinorrhea (CSF leak from nose), otorrhea (CSF leaks from ear), Battle’s Sign (ecchymosis @ cheek bones), Raccoon Eyes (ecchymosis around eyes)
High r/f meningitis
Clinical Manis:
- Altered LOC - HA - N/V - Seizure activity - IICP - Hyperthermia if hypothalamus damaged
