Exam 2 neuro Flashcards
what is the goal of neuro problems?
prevent further injury
achieve goal by understanding foundations of neuro function so that disfunction is easily identified
what are the neuro problems?
- traumatic brain injury (TBI): inter-cranial pressure monitoring
- cerebrovascular accident (CVA/stroke): tissue plasminogen activator (TPA) and cerebral aneurysm
- seizures
- spinal cord injuries
- Guillain-barre
what is an open TBI?
Basilar skull fracture
(Visible on the external skull)
KEY FINDING
Clear or blood-tinged drainage from the eyes, ears, nose that is positive for glucose = Cerebrospinal Fluid (CSF)
what is a closed TBI?
Concussion
Clinical findings: brief loss of consciousness, headache, retrograde amnesia (memory loss of events immediately prior to injury)
Contusion
(more emergent)
Described as:
Coup- affecting one area of the brain due to impact
Contrecoup- affecting the area opposite of coup
Together- Coup-Contrecoup
Typically affecting the frontal and occipital lobes
what are the different areas of the brain?
frontal lobe
temporal lobe
brainstem
cerebellum
occipital lobe
pariental lobe
motor control (premotor cortex), problem solving (prefrontal area), and speech production (Broca’s area)
frontal lobe
auditory processing (hearing), language comprehension (Wernicke’s area), memory/info retrieval
temporal lobe
involuntary responses
brainstem
balance and coordination
cerebellum
sight (visual cortex) and visual reception and visual interpretation
occipital lobe
touch perception (somatosensory cortex) and body orientation and sensory discrimination.
pariental lobe
what are the 3 types of cerebral hematomas?
- Epidural hematoma- rapid accumulation of blood in the epidural space.
-Rapid increase in ICP leading to death
-Intermittent loss of consciousness and waking. - Subdural hematoma
-Often resolve but may need intervention depending on the lobe involved - intracerebral hematoma
what is the treatment for cerebral hematomas?
The treatment of brain hematomas depends on the severity of the bleed, the location of the bleed, and presentation of the patient condition.
What do you need to monitor for increased ICP?
early s/s:
agitation
restlessness/irritability
change in LOC
decreased mental status
sudden vomiting
without nausea
late s/s:
seizures
posturing (decorticate and decerebrate)
Cushing triad
what are the late deadly signs of increased ICP?
lungs: irreg. respirations and Cheyne strokes respirations
neck: nuchal rigidity (stiff neck)
brainstem affected:
-eyes: pupils (fixed and dilated, unequal) 8mm (normal = 2-6mm)
-foot: babinski reflex (toes fan out when stimulated = BAD)
seizures and coma
abnormal posturing: decorticate and decerebrate
focus on recognizing the _________ in ICP and _________ interventions.
changes
proper
what does ICPS stand for?
I- Immobilize C spine. Log roll patient
C- CO2 low: lower CO2 means lower ICP. CO2 dilates vessels and will increase ICP.
P- Positioning: 30-35 degrees (semi-fowlers), no flexing/bending, no coughing, sneezing, etc
S- Suctioning: 10 seconds or less, infrequent, hyperventilate patient
what are the interventions for hematomas?
Airway, breathing, circulation – vital signs w/ O2 sat
Stabilize cervical spine(Position client with HOB 30-45 degrees elevation)
Intubate (GCS <8) or if gag reflex impaired or absent
Control external bleeding
Maintain normothermia
what is important to know for prevention of 2nd injury, concussion and contusions, and skull fx in hematomas?
Prevent secondary injury:
by treating cerebral edema and increased ICP
Concussion and contusion:
monitor and manage ICP
Skull fractures:
If CSF leak, prophylactic antibiotics
Surgery –elevate depressed bones, remove fragments; craniectomy and cranioplasty
what needs to be managed with hematomas?
Manage intracranial pressure monitoring system and ICP: Manage nausea and vomiting Minimize environmental stimulation
Manage eye problems- prevent corneal damage
Manage hyperthermia (goal 36-37 deg C/96.8-98.6 F): Cooling blanket, etc
Manage CSF leak – rhinorrhea or otorrhea – notify HCP
Teach client not to sneeze or blow nose
No NGT or perform NT suctioning – if basilar skullfracture r/f meningitis
Implement seizure precautions and prophylaxis
Manage headache
Prevent VTE, skin breakdown
A nurses assesses the GCS of a patient who is resting with eyes closed. When the nurse speaks to the patient, they open their eyes. What eye opening score would you give this patient?
3
the pt opened eyes to speech
A nurses is assessing the GCS of a patient admitted with a TBI following a motor vehicle accident. When asked where they were, the patient responded his “dorm room” and stated that his dad, who was at the bedside was his roommate. What verbal response score would you give this patient?
4
the pt is speaking with intention, but appears confused
A nurses is assessing the GCS of a patient admitted with a TBI following a motor vehicle accident. When assessing the patient for motor response using the Babinski reflex, the nurse notes that the patient’s toes fan out. What does this indicate about the patient and what score would you give?
3
When the Babinski reflex is tested, the toes should extend or point down normally. A positive Babinski test indicates brain stem involvement
What is the scoring on the Glasgow coma scale (GCS)?
13-15 mild
9-12 moderate
3-8 severe
less than 8 = intubate
anosmotic diuretic, elevates blood plasma osmolality, resulting in enhanced flow of water from tissues, including the brain and cerebrospinal fluid, into interstitial fluid and plasma.
Mannitol
what is important to know about mannitol?
Used to decrease ICP
Must be given IV
Systemic edema may occur due to enhanced flow of fluid AWAY from the brain and INTO interstitial space.
Watch for signs of heart failure as a result
what other meds are used for neuro problems?
Phenytoin- prevents seizures
Steroids- decrease swelling
Phenobarbital- barbiturate to decrease brain activity
what is the #1 risk factor for strokes?
1 risk factor- Hypertension (over 140 systolic)
what are the types of strokes?
ischemia
hemorrhagic
what are the interventions for strokes?
Stroke risk decreases by 50% when blood pressure is controlled.
Nursing intervention:
Pt EDUCATION to be compliant with BP meds
A nurse is caring for a patient who is recovering from a stroke. The nurse notes that the SBP is over 200. What is the best nursing intervention?
Reduce SBP slowly and keep above 170 for first 24-48 hours. This allows the body to normalize rather than having a hypotensive response.
What does BE FAST stand for?
B = balance (loss of balance, HA, dizziness)
E = eyes (sudden loss of vision in 1 or both eyes)
F= face (does the persons face look uneven?)
A= arm (weak)
S= speech difficulty
T = time to call 911
What are the S/S of a stroke?
New and sudden loss of balance or dizziness.
Sudden, SEVERE headache is most often associated with cerebral aneurysm rupture
Sudden loss of vision related to pressure on the occipital lobe
Facial drooping or uneven smile
New and sudden one-sided weakness, most often manifested as unilateral arm drop
Slurred speech or difficulty communicating words appropriately
TIME IS BRAIN
What is important to know about left brain stroke?
language & logic
dysphasia
reading or writing probs
R hemiparesis (1 sided weak)
R side neglect
Note:
Pt safety: consider which side is stronger
Responsible for our verbal abilities
what side is affected in a L brain stroke?
Left brain = Right side affect
what is important to know about a right brain stroke?
reckless & really creative
lack of impulse control
behavior changes
L hemiparesis (1 sided weak)
L side neglect
Note:
Pt safety: strong side AND behavior and impulse control
Can be difficult for families to witness
what side is affected in a R brain stroke?
Right brain = Left side affect
what is important to know with strokes?
Last known well time determines the start of the stroke
Arrival to stroke center/ED = 0 minutes to treatment
A CT scan MUST be done to determine treatment approach
Ischemic or embolic stroke = blocked vessels
tPA is the treatment of choice if started within 60 minutes of arrival to care center
how is tPA given and what does it do?
IV injection
dissolves blood clots and restores blood flow
what is the nursing management for strokes?
Neuro assessment every 1-2 hours, NIH stroke scale
Vital signs including ICP, CPP every 1-2 hours and prn
Respiratory status
I&O, fluid balance, IV fluids,
ECG and cardiac enzymes
Serum electrolytes especially sodium
Bladder and Bowel function
Ability to communicate
what are the interventions for a stroke?
- Administer rt-PA as ordered
- Perform bedside swallow screening
- Support respiratory function
- Elevate HOB 30 degrees
- Place NG tube of feeding tube for nutrition and medication administration
- Implement aspiration precautions - Bleeding precautions for clients receiving thrombolytics or anticoagulants
- Positioning, mobility, ROM
- Manage client with unilateral neglect and visual field cut
9.Obtain PT and OT evaluations early - Aphasia Interventions
- Provide skin care, early mobility, eye care, mouth care Implement
- Prevent constipation
- Hemorrhage precautions (preop) if applicable *risk for rebleed
- monitor for complications
what is important to know about managing a client with unilateral neglect and visual field cut?
inattention to weak or paralyzed side
Neglect syndrome – decreased safety awareness – injury
Encourage to use affected side when performs ADLs
Approach from affected side and sit on affected side
Anchoring (light house strategy) scan affected side
what are the aphasia interventions?
Provide repetitive directions
Break tasks down to one step at a time
Repeat names of objects frequently used
Allow time for patient to comprehend and answer
Speak slowly and calmly with simple words/sentences
Use picture board, communication board or computer technology Consult speech therapy
what are the hemorrhage precautions?
BP control
Bedrest
Dark quiet room, keep calm
Stool softener
No restraints
Increase HOB 30 degrees
what are the teachings for strokes?
- BP control
- Stroke diagnosis
- Activation of EMS
- Warning signs and symptoms stroke
- Client specific and family specific risk factors for Stroke
- Smoking cessation
- Diet needs (high fiber and adequate fluid intake)
- Medications for prevention of stroke
- ”FAST”
what are the spinal cord injuries?
cervical injury (C1-C8)
thoracic injury (T1-T12)
lumbar injury (L1-L5)
Acuity of injury depends on location of the spine
Cervical injury?
Effects all 4 limbs- Quadriplegia (tetraplegia)
Respiratory- Impaired breathing = life threat
thoracic injury?
effects lower limbs (paraplegia)
legs, bladder, bowels
lumbar injury?
effects legs and bladder
what do spinal cord injuries complications lead to?
lead to emergency and life-threatening problems
what is the pharmacology for spinal cord injuries?
neurogenic shock: IV fluids and vasopressors (increase BP)
steroids “-sone”: prednisone and dexamethasone
muscle relaxers
The spinal injury creates a disrupted communication between the sympathetic nervous system and parasympathetic.
what is this Life-threatening emergency?
Autonomic Dysreflexia
what are the nursing interventions for spinal cord injuries?
- notify HCP
- correct the cause:
-bladder assessment (palpate bladder, bladder scanner, check the foley for kinks)
-bowel assessment
-remove “constrictive” clothing
-measure BP - BP meds (AFTER assessment)
what are the seizure precautions?
side rails up
side lying position
seizure pads against the side rails
pillow under head
suction available
bed in low position
curtain for privacy
acute inflammatory demyelinating polyneuropathy
Guillain-Barre syndrome
most cases are preceded by an infection such as campylobacter jejuni enteritis
S/S of Guillain-Barre syndrome?
paresthesia in the hands and feet
symmetrical muscle weakness (usually begins in the legs and ascends)
severe respiratory muscle weakness (necessitating vent support may develop)
absent or depressed deep tendon reflexes
Early signs of respiratory failure are inability to cough and inability to lift head and eyebrows
what is the treatment for Guillain-Barre syndrome?
modalities of disease modifying therapy for GBS are plasma exchange and IV immune globulin (IVIG).
Autonomic dysreflexia?
spinal cord injury at T-6 or higher
triggered by sustained stimuli at T-6 or below from:
restrictive clothing
blister
dehydration
broken bones
fecal impaction
anxiety
pressure areas
full bladder or UTI
*almost any stimulus below T6
The communication between_______ and PNS is disrupted causing vasodilation above the injury and _______________ below.
SNS
Vasoconstriction
what are the 2 biggest probs that arise with neurogenic shock?
hypotension and bradycardia. Vasopressors like epi and norepi are used to improve hemodynamics
what are the causes of neurogenic shock?
spinal cord injury above T5
spinal anesthesia
vasomotor center depression (ex: severe pain, drugs, hypoglycomia)
what increases the risk for a stroke?
HTN increases the risk for stroke because of the constant added pressure of the cerebral vessels. This may cause weakness (hemorrhagic) or there may be plaque build up (ischemic)
what do we want to see with an increased ICP?
We want “dolls eyes” that move with head movement. Indication of intact brain stem.
