Exam 2 Neurological Disorders Flashcards
Physical Assessment of Neurological System includes (5)
1) Level of Consciousness
2) Motor Function
3) Sensation
4) Reflexes
5) Vitals
What do we use to assess LOC?
Range =
Best Score =
Glasgow Coma Scale
- Eyes opening
- Motor response
- Verbal response
3-15
15
Levels of Motor Function 0 = \+1 = \+2 = \+3 = \+4 = \+5 =
0 = no movement \+1 = slight movement \+2 = can raise extremity; but not lift it \+3 = can raise extremity; not against resistance \+4 = full ROM, less strength then normal \+5 = full ROM, full strength
Sensation
- Can they differentiate between?
Soft vs Sharp
Reflexes
- Babinski =
- Protective reflexes =
- extension of big toe
- brain stem
Vitals
- Cushings triad indicates =
Symptoms (3)
What should you do?
= herniation in progress
- Bradycardia, Bradypnea, Widened pulse pressure (wide gap btw systolic and diastolic)
- Call provider!
Normal Findings
1) GCS =
2) AO x ___
3) +__ strength in arms/legs bilaterally
4) Sensation ____ and ____
1) 15
2) x4
3) +5
4) Intake and Equal
Abnormal Findings
1) GCS =
2) AO =
3) +___ strength in arms bilaterally, +___ strength in legs bilaterally
4) Sensation =
1) 13
2) awake, alert, and oriented to person and place
3) +4, +5
4) cannot differentiate btw sharp vs. dull sensation
Spina Bifida =
Results in (3)
= Birth defect where neural tube fails to close as a fetus
1) Spina Bifida Occulta
2) Meningocele
3) Meninomyelocele
Causes of Spina Bifida
Unknown causes
Associated with lack of folic acid
Spina Bifida S/S
1) _____ ___ abnormalities
2) _____ near buttocks
3) H______
1) Neural tube abnormalities
2) Dimpling near buttocks
3) Hydrocephalus
Diagnosis of Spina Bifida when and with what?
Prenatally with Ultrasound
Spina Bifida Interventions
1) Prevention =
2) ____ control
3) ____ prep
Foods high in folic acid =
1) folic acid for child bearing age
2) Infection
3) Surgical
= dark leafy green vegetables, most fruits, potatoes, US grains are enriched with FA
Hydrocephalus =
= Enlargement of the ventricles due to increase in CSF
Cause of Hydrocephalus =
Due to (2)
Enlarged ventricles ->
= too much, or too little absorption of CSF
- head trauma, tumors/masses
- push out on brain -> enlarged head/fontanels
Hydrocephalus S/S
1) H____
2) ____, _____ eyes
3) _____ fontanels
4) ____ head circumference
5) _____ scalp veins
6) V______
7) _____ at later stages (unable to walk straight)
1) headache
2) Bulging, Sunsetting
3) Bulging
4) Increased
5) Dilated
6) Vomiting
7) Ataxia
Hydrocephalus Solution* =
- monitor for ____/____
- _____/____ is an emergency bc it may indicate?
- Temporary of Permanent?
VP shunt*
- malfunction/infection
- headache/fever, may indicate kinks, infection
- permanent (life long)
Hydrocephalus Nursing Interventions
1) ___ prep for vp shunt
2) Monitor head _____
3) Monitor for ___ activity
4) Careful _____ changes
5) Keep baby _____
1) Surgical prep
2) circumference
3) seizure
4) Position
5) calm
Cerebral Palsy =
Affects which muscles?
Non-progressive, permanent disability that affects movement and speech
Affects both voluntary and involuntary muscles
Cerebral Palsy Types
1) Not always associated with _______ ->
2) MRCP =
1) mental retardation -> fully cognitive but unable to speak/move properly
2) Mental Retardation Cerebral Palsy
Cerebral Palsy Diagnosis
- Often diagnosed when?
- May occur later in life after what?
- in first year of life d/t hypoxia at birth or in utero
- a hypoxic event
Cerebral Palsy S/S (3)
1) Spastic (stiff)
2) Dyskinetic (involuntary)
3) Ataxic (shaky)
Spastic sx in Cerebral Palsy
1) ____ - reflexia
2) ____ tonia
3) ____ spasticity
4) ___ walking
5) S_____
6) Continues to have =
1) Hyper-reflexia
2) Hypertonia (increased muscle tone)
3) Muscle spasticity
4) Toe walking
5) Scissoring
6) Neonatal reflexes
Dyskinetic sx in Cerebral Palsy
1) ____ movement
2) Trouble ______
1) Writhing
2) Speaking
Ataxia =
= uncoordinated movements
Is there a cure for Cerebral Palsy?
Teaching =
Teach patients NO cure,
= Encourage participation with classmates
Cerebral Palsy Multidisciplinary Interventions (3)
1) Phyiscal Therapy
2) Occupational Therapy
3) Early Intervention
Head Injury =
Causes (6)
= Mild to total brain injury
- Automobile accidents, bicycle, skiing, hockey, football, abusive head trauma (shaking baby syndrome)
S/S of Head Injury
1) H_____
2) V_____
3) B_____
4) H_____
5) D______
6) L______
7) Level of ______
1) History
2) Vomiting
3) Bruises
4) Headache
5) Dizziness
6) Lacerations
7) Consciousness
Nursing Interventions for Head Injury
1) ______ scale
2) Prep for CT vs MRI?
3) ______ management
4) Concussion _____ + ___ -__
5) Educate about?
1) Concussion
2) CT = quick, but lots of radiation; used if child has certain qualifications vs. MRI = longer, but no radiation
3) Emergency
4) Teaching + follow-up
- full cognitive rest - no phones/computers, videogames, hw, reading
- play simple board games
5) Head safety
Seizure =
_____ movements
Time of abnormal electrical discharge in the brain
Involuntary
Epilepsy =
chronic illness with recurrent, unprovoked seizures due to an abnormality in the brain
Causes of Seizures
1) _____ link
2) I______
3) I______
4) Id______
5) F_____ (____ seizures)
1) Genetic
2) Injury
3) Infection
4) Idiopathic
5) Fever (Febrile seizures)
Signs and Symptoms of Seizures (8)
1) Focal
2) Generalized
3) Status Epilepticus
4) Simple Febrile
5) Tonic
6) Clonic
7) Postictal period
8) Simple Febrile
Focal =
- Affects the _____ side
= On one side of the brain
- Opposite
Generalized =
- Causes _____ and _____ abnormalities
- ___ LOC
= generalized misfiring of electrical activity
- symmetric, bilateral
- +
Status Epilepticus =
- _____ without?
- Risks increased for _____, ____ damage, and _____
= prolonged, continuous seizure of more than 5 minutes
- Intermittent, without return to consciousness in between
- hypoxia, neurological damage, death
Simple Febrile =
- Occurs commonly during age _____-_____
- Lasts no more than ____ minutes
- Only ___ per 24 period
Generalized tonic clonic with postictal period
- 6 months - 6 years
- 15 min
- 1
Tonic
- ___consciousness
- Muscle _______
- S______
- Unconsciousness
- Muscle contraction
- Stiffness
Clonic
- Alternating ______ and ______
- Rhythmic ______
- contraction and relaxation
- jerking
Postictal period =
decreased LOC - not completely back to baseline, responsive to name but not talking
Nursing interventions for Seizures
- S_____ !
- O____, B____
- Monitoring s____ and ____ signs
- ___ placement
- M_____ as ordered (1)*
- Safety! (stay at bedside, take anything away)
- Oxygen, Blood
- Symptoms (time, on which side, what it looks like), Vital signs
- Medication (rectal diastat*)
Nursing Interventions for Simple Febrile Seizures
- S_____ intervention
- Monitor ______
- Anti______
- Safety
- Frequency
- Antipyretics (motrin, tylenol)
Reyes Syndrome =
= causes confusion, swelling in the brain, and injury to the liver
Reyes Syndrome caused by =
Teaching that the patient may =
Viral Illness + Aspirin -> fat metabolism in liver, kidneys, and brain
= suffer from permanent brain damage
Signs and Symptoms of Reyes Syndrome
- C_____
- _____glycemia
- Increased ______ levels
- V______
- Confusion
- Hypoglycemia
- Ammonia
- Vomiting
Reyes Syndrome Staging
Stage 1 = S____/V_____/T_____
Stage 2 = C_____/_____ babinski/______ to pain
Stage 3-5 = ______ to ______ posturing; then to ____ and _____
Stage 6 = ____ to ____ due to ___
1 = Sleeping, Vomiting, Tachypnea 2 = Confusion/ Positive babinski/ No response to pain 3-5 = decorticate to decerebrate, seizures and death 6 = unable to classify due to meds
Meningitis =
Pathogen invades the =
Most common central nervous system infection
Meninges
Meningitis Causes (2)
- Multiple types of bacteria (life threatening)
- Viral forms are less serious
Signs and Symptoms of Meningitis
- increased _____
- Hyper/hypo______
- S_____ (late sign)
- V____, F____, C_____
- Increased ICP
- Hyper/hypothermia
- Seizures
- Vomiting, Fever, Confusion
Viral Meningitis Symptom =
Photophobia
Nursing Interventions for Meningitis
- _____ Immediately! What type? Even with _____
- B____ test
- Prep for L_____ P_____
- ____ culture
- If throat culture positive (bacteria) give =
- If negative (viral) (2)
- Isolate, Droplet, Suspicion
- Blood
- Lumbar Puncture
- Throat
- Antibiotics STAT! ; however want to start ASAP whether viral or bacterial until test results come back
- best rest, antipyretics
Brain tumors =
= Benign or cancerous mass in the brain
Causes of Brain Tumors =
- ____ most common childhood cancer
= Unknown, may be hereditary
- second
- most common form of solid mass in children
Signs and Symptoms of Brain Tumors
- V____* (red flag?)
- At____
- H______
- S____ (later sign)
- _____ head circumference (in babies)
- Abnormal _____
- Abnormal ____ movements
- Vomiting* (morning vomiting is a red flag, bc pressure changes when position changes)
- Ataxia
- Headaches
- Seizures
- Increased
- Speech
- Eye
Nursing Interventions for Brain Tumors
- ____ prep for either (2)
- C___/R____
- Surgical prep for mass removal or VP shunt
- Chemo/Radiation
Increased Intracranial Pressure =
= Pressure due to a growth, inflammation, or increased CSF in CNS
Causes of increased ICP (4)
- Head ____
- ___ infection
- T_____
- Excess ____
- Head Injury
- CNS infection
- Tumor
- Excess CSF
Signs and Symptoms of Increased ICP (in babies)
1) ______ head circumference
2) ______ sutures
3) B_____, E_____ fontanels
4) _____ _____ (protruded forehead)
5) ____ cry (neuro-cry, very high pitched)
6) S_____
7) H______
8) V____ changes
9) P_______ (in the back of the eye)
10) V______
1) Increased
2) Separated
3) Bulging, enlarged
4) Frontal Bossing
5) Shrill
6) Seizures
7) Headache
8) Visual
9) Papilledema
10) Vomiting
Nursing Interventions for Increased ICP
- HOB =
- Keep child’s head _____
- _____ environmental stimuli
- ______ as ordered
- Prep for __ ____
- elevate 15-30 degrees
- straight
- minimize
- medicate
- VP shunt
Nursing Diagnoses for Neurological Disorders
1) Risk for knowledge _____, I_____
2) ___/____ operative considerations
3) Impaired urinary _____
4) Risk for I____, S_____
5) At risk for a____/f___, impaired co____, mo____ altered ____ state, delayed g___ and d_____, p____
1) deficit, infection
2) Pre/Post
3) elimination
4) injury, seizures
5) anxiety/fear, coping, mobility, mental, growth/development, pain
