Exam 3 Flashcards
Normal Neurologic Changes with Aging
Loss of brain mass
Decreased dendrite connections
Decreased cerebral blood flow/oxygenation
Do not need as much sleep
Decreased thermoregulation
Fine motor skills decrease, tremors increase
Level of Consciousness
MOST ACCURATE AND RELIABLE INDICATOR OF NEUROLOGICAL STATUS
Alert
Responsive and oriented and alert, open eyes spontaneously
Disorientation
Cannot follow simple commands, flat affect
Incoherent
Disconnected thought and speech
Unrelated thoughts that don’t make sense
Lethargic
Delayed response to stimulation
Drowsy, but easily awakened
Stupor
When patient wakes up only with vigorous or painful stimulation
Coma
A prolonged state of unconsciousness, unable to arouse
Altered Level of Consciousness
Caused by neurological issues, drugs, metabolism
Initial S/S include restlessness and anxiety, progresses to no response to voice or command
Pupils sluggish and progress to fixed and dilated
Posturing
Indicates a deterioration of condition
Decorticate
Abnormal flexion and extension
Decerebrate
Abnormal extension
Flaccid
No motor response in any extremities
Altered LOC Treatment
Suction, assess lungs, give oxygen, position lateral/side-lying or semi-prone
Padded side rails, avoid restraints
Lumbar Puncture
Putting a hollow needle into the subarachnoid space
Sterile procedure performed at bedside in order to examine the CSF
Have patient lay on their side with knee and head flexed
Contraindications include increased ICP
Normal Cerebrospinal Fluid
Normal clear, colorless
WBC: 0-5 cells/microliters
RBCs: 0
Glucose: 50-75 mg/dL
Protein: 15-45 mg/dL
Abnormal Cerebrospinal Fluid
Cloudy indicates infection
Yellow indicates bilirubin
Pink indicates hemorrhage
Brown/orange indicates elevated protein levels or RBC breakdown
Monro-Kellie Hypothesis
A change in volume of one of the contents in the brain leads to a decrease in another, or else intracranial pressure will increase
Early Recognition of Increased Intracranial Pressure
Decreased cerebral perfusion
Change in level of consciousness, irritability, diplopia, nausea, headache, sluggish pupils
Complications of Increased Intracranial Pressure
Supratentorial shift
Herniation
Later Signs of Increased Intracranial Pressure
Increased systolic blood pressure, bradycardia, deepening irregular respirations
Increased temperature
Posturing, vomiting, hiccups, chocken corneal disk
Diagnostic Tests for Increased Intracranial Pressure
CT scan, MRI
Treatment of Increased Intracranial Pressure
Craniotomy, craniectomy, drainage, internal monitoring
Mannitol, corticosteroids, anticonvulsants, barbiturates, paralyzing agents
Craniotomy
Removing a bone flap from the skull which is eventually replaced
Craniectomy
Bone flap is removed and not replaced
Nursing Interventions for Increased Intracranial Pressure
VS with Neuro checks q1h/prn
Reduce venous volume by elevating HOB, neck in neutral position, avoid hip flexion, restrict fluids
Maintain patent airway
Maintain body temperature
Avoid exercise
Space nursing procedures
Seizure precautions should be instituted
Intracranial Surgery
Supratentorial, infratentorial, transsphenoidal
Burr holes
Cranioplasty
Repair of a cranial defect using a plastic or metal plate
Craniotomy Nursing Interventions
Maintain airway, assess frequently, look for signs of increased ICP, seizure precautions
Medications include phenytoin and phenytoin sodium
Align head in neutral position, HOB 30 degrees
Avoid coughing, sneezing, or nose blowing
Transsphenoidal Pre-Op
Sinus culture, corticosteroids, no nose blowing or coughing, no sucking through a straw
Transsphenoidal Post-Op
Check VS, visual acuity, keep HOB elevated
Provide good oral care due to breathing through the mouth, check for bleeding/CSF leakage
Complications of Transsphenoidal Surgery
Transient diabetes insipidus
CSF leakage
Visual disturbances, post-op meningitis
Pneumocephalus
Syndrome of Inappropriate Antidiuretic Hormone
Seizure
Abnormal electrical activity of brain cells
Can be caused by structural, metabolic, or idiopathic origin
Epilepsy
Recurrent episodes of seizures
Aura
Some kind of sensory change before a seizure occurs
Postictal Period
Rest period after a seizure, varies in time frame
Patient feels groggy and disoriented, common to experience headache, muscle aches
Status Epilepticus
Multiple seizures without a postictal period
Most often caused by sudden withdrawal of anti-seizure medications
Tonic-Clonic Seizures
Grand mal
Most common, bilateral movement of extremities, whole body is involved
Tonic is stiffening, clonic is jerking of extremities
Associated with an aura, postictal period, loss of consciousness, incontinence, biting of tongue
Absence Seizures
Petit Mal
More frequent during childhood and adolescence
No aura, no postictal period, does not last very long, no loss of consciousness
Sit upright and have a blank stare, might lose muscle tone
Modifiable Risk Factors for Cerebrovascular Disorders
Hypertension Cardiovascular disease Elevated cholesterol or hematocrit Obesity Diabetes Oral contraceptive use Smoking and drug and alcohol use
Transient Ischemic Attack
Temporary focal loss of neurologic function caused by ischemia
Preventive Treatment and Secondary Prevention of TIA
Healthy diet, exercise, prevention of periodontal disease Carotid endarterectomy Anticoagulant therapy Antiplatelet therapy "Statins" Antihypertensive medications
Carotid Endarterectomy
Usually performed to remove atherosclerotic plaque that has significantly reduced the lumen of the artery
Symptoms in carotid disease are caused by a significant reduction in cerebral blood flow
Nursing Management of Carotid Endarterectomy
Assess pain and treat
Neuro checks every hour (cough/gag reflex, visual fields, motor/sensory integrity)
Assess patency of carotid artery by palpating temporal artery
VS hourly
Continuous EKG monitoring
Dressing check, HOB elevated, TCDB
Antiplatelet therapy
Watch for These After Carotid Endarterectomy
Hemiplegia/hemiparesis, pupil irregularity, aphasia
Difficulty breathing, stridor, tracheal deviation
Excessive bleeding from drains
Dysrhythmias, hypotension, hypertension
Cranial nerve injuries
Stroke
Sudden loss of function resulting from a disruption of the blood supply to a part of the brain
Ischemic (80-85%)
Hemorrhagic (15-20%)
Thrombotic Stroke
Cerebral thrombosis is a narrowing of the artery by fatty deposits called plaque
Plaque can cause a clot to form, which blocks the passage of blood through the artery
Embolic Stroke
An embolus is a blood clot or other debris circulating in the blood
When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood
Hemorrhagic Stroke
A burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak
Severe headache, early and sudden changes in LOC, vomiting
If blood flow to the brain is totally interrupted…
Neurologic metabolism altered in 30 seconds
Metabolism stops in 2 minutes
Cellular death occurs in 5 mintues
If adequate blood flow can be restored in less than 3 hours…
Less brain damage = less function loss
Area around dying cells are ischemic cells (penumbra)–target for reperfusion
Use of thrombolytics
Manifestations of Ischemic Stroke
Symptoms depend on the location and size of the affected area
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of balance or coordination
Sudden, severe headache
Perceptual disturbances
Medical Management of Acute Phase of Stroke
NIHSS assessment tool
Thrombolytic therapy
Elevate HOB
Maintain airway and ventilation
Continuous hemodynamic monitoring and neurologic assessment
Nursing Management of Acute Phase of Stroke
Ongoing, frequent monitoring of all systems, including VS and neurological assessment (LOC, motor symptoms, speech, eye symptoms)
Monitor for potential complications, including musculoskeletal problems, swallowing difficulties, respiratory problems, and s/s of increased ICP and meningeal irritation
Nursing Management After a Stroke
Focus on patient function, self-care ability, coping, and education regarding needs to facilitate rehabilitation
Medical Management of Hemorrhagic Stroke
Control hypertension
CT scan, cerebral angiography, lumbar puncture
Supportive care
Bed rest with sedation
Oxygen
Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further breathing
Nursing Management of a Hemorrhagic Stroke
Complete and ongoing neurological assessment
Monitor respiratory status and oxygenation
Patients with intracerebral or subarachnoid hemorrhage should be monitored in the ICU
Monitor fluid balance
Collaborative Problems and Potential Complications of Stroke
Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia
Myoclonic Seizures
Characterized by muscle jerking, no aura or postictal phase, no loss of consciousness
Diagnosis of Epilepsy/Seizures
Blood tests
CT/MRI
EEG
Medications for Epilepsy
Valium
Phenobarbital
Dilantin
ADLs with Epilepsy/Seizures
Avoid driving for a specific period of time, avoid operating machinery or swimming
Promote a healthy lifestyle
Wear a medical alert bracelet
Nursing Interventions during a Seizure
Never leave alone
Lower to floor and remove objects from area
Support and protect the head, turn to side if possible
Loosen clothing around the neck
Do not restrain the patient or pry open the jaw
Patient Education for Epilepsy
Good oral hygiene–Dilantin can cause gingival hyperplasia
Avoid alcohol because it lowers the seizure threshold and interacts with antiseizure medication
For women, seizures may increase during menstruation and antiseizure medications may make birth control less effective
Primary Headache
No organic cause identified
Migraines, cluster headaches, cranial arteritis
Secondary Headache
Symptom associated with another organic cause
Brain tumor, aneurysm
Migraine Headache
Unknown cause, Vascular type
Prodrome phase, aura phase, headache phase, recovery phase
Cluster Headache
Named for a pattern of headaches
Caused by histamine or serotonin release
One-sided burning, sharp and steady pain, presents with watering of the eyes and nasal stuffiness
Tends to be more common in men
Steroids and opioids usually prescribed
Headaches
Assess pain, stressors, anxiety
Can be caused by tyramine *(aged cheeses and cured meats), nitrates (cured meats), glutamates (Chinese food), vinegar, chocolate, yogurt, alcohol, caffeine
Tension headaches should not be given opioids
Primary Injury–Head Trauma
Head is directly injured
Acceleration-Deceleration
Coup-Countrecoup
Secondary Injury–Head Trauma
Occurs after the primary injury
Epidural Hemorrhage
Life-threatening, arterial bleed
Subdural Hemorrhage
Needs to be monitored, venous blood loss, not as fast as epidural
Positive Glucose in Drainage
Indicates cerebrospinal fluid
Signs/Symptoms of Head Trauma
Headache Nausea/Vomiting Abnormal sensations Loss of consciousness Bleeding from ears or nose Abnormal pupil size/reaction Battle's Sign (discoloration behind ear; basilar fracture) Raccoon eyes (basilar fracture)
Nursing Interventions for Head Trauma
Stabilize cervical spine
Give mannitol, Dexamethasone
Monitor signs of bleeding
Control temperature
Epidural Hematoma
Treatment is Burr holes
Post-Op: report CSF leak immediately, give quiet non-stimulating environment, check Neuro and VS frequently
Neurologic Level of Spinal Cord Injury
Refers to lowest level at which sensory and motor function are intact
Spinal Cord Trauma Complications
Loss of sensory/motor function
Areflexia (all neurological activity below area of injury is gone)
Neurogenic shock (ANS not working, all vital organs are affected due to decreased BP)
Hyperreflexia (abnormal CV response to stimulation that leads to high blood pressure)
Venous thrombosis
Autonomic Dysreflexia
Medical emergency that can lead to seizures, stroke, and death
Caused by noxious stimuli below the spinal cord injury
Severe bradycardia, HTN, diaphoresis, dilated pupils, severe headache
Sit patient upright to lower BP
Brain Tumor Causes
Mostly unknown but linked to radiation
S/S of Brain Tumors
Caused by inflammation and compression
IICP, cerebral edema, headache, vision changes, cognitive changes, new onset seizure, focal neurologic signs, hyrocephalus
Altered pituitary function with hormonal effects
Primary Brain Tumor
Originates from cells within the brain; rarely metastasizes
Gliomas: projecting tumors, difficult to remove
Meningiomas: encapsulated, slow growing, benign, compression
Acoustic Neuromas: grow slowly, loss of hearing, tinnitus, vertigo, benign
Secondary Brain Tumor
Originate outside of the brain, twice as common as primary
Lung, breast, lower GI, pancreas, kidney, and skin
Diagnosis and Treatment of Brain Tumors
Dx: CT, EEG, CSF analysis
Surgery: craniotomy/craniectomy
Radiation, chemotherapy
Corticosteroids to relieve headaches
Mannitol, anti-seizure medications
Nursing Interventions for Brain Tumors
Assess LOC and headaches
Position upright to alleviate IICP
Aspiration precautions
Seizure precautions, do not stop anti-seizure medications
DVT precautions
Pathophysiology of Parkinsonism
Chronic, progressive, degenerative disease
Onset at age 60, genetically linked, associated with exposure to different environmental factors
No cure, damage to dopamine producing cells
Can be drug-induced (anti-psychotics)
Characteristic Features of Parkinsonism
Bradykinesia (slowed movements)
Rigidity (resistance to passive movement, leads to poor balance and shuffling gait, mask-like appearance)
Tremor (pill-rolling characteristic, may go away while sleeping but flare up with stress)
Other Characteristics of Parkinsonism
Dysphagia, drooling
Postural instability, stooped over posture
Depression, dementia
Dysphonia
Diagnosis of Parkinson’s Disease
H&P is used
Requires 2 S/S to diagnose
Diagnosis confirmed with positive response to Levodopa
Treatment for Parkinson’s Disease
LEVODOPA
Drug holidays may be necessary due to disabling side-effects
Physical therapy to help maintain ADLs
Surgery: ablation to portion of brain responsible for rigidity and tremors; deep brain stimulation
Nursing Interventions for Parkinson’s Disease
Mobility (learn how to walk erect, ROM to prevent contractures, frequent rest periods)
Nutrition (risk of choking/aspiration, give appetizing meals, easy to chew and swallow)
Elimination (promote fiber and fluids and stool softeneners)
Teach to keep active, take medications, and take small bites
Huntington’s Disease
Chronic, progressive, degenerative disease
Premature death of cells in the basal ganglia, cortex, and cerebellum
Genetically-inherited, 50% chance of child having it if parent has it
S/S of Huntington’s Disease
Chorea (abnormal, excessive, involuntary movements)
Facial movements (involves speech, chewing, swallowing; problems with aspiration and malnutrition)
Gait deterioration
Mental deterioration
Loss of bowel and bladder control
Treatment for Huntington’s
Palliative treatment to control symptoms
Tetrabenazine is the only approved medication
Thiothixene HCL and Haloperidol are also used to block dopamine receptors
Nursing Interventions for Huntington’s
Safe environment
Emotional support
High-calorie diet (4,000-5,000 calories/day)
Genetic counseling
Pathophysiology of ALS
Loss of upper and lower motor neurons; degenerate in the brain and spinal cord
Death is within 2-6 years of diagnosis
Males affected more than females, occurs between ages of 40-70
No known cause or cure
S/S of ALS
Weakness, difficulty speaking/swallowing, muscle wasting
Eventually muscle paralysis, respiratory failure
Nursing Interventions for ALS
Exercise to decrease spasticity
Support cognitive/emotional functions
Diversional activities
Human companionship
Advanced care planning
Anticipatory grieving
Meningitis
Inflammation of the membranes and the fluid space surrounding the brain and spinal cord
Manifestations of Meningitis
Headache, fever, changes in LOC, behavioral changes, nuchal rigidity, positive Kernig’s sign, positive Brudzinki’s sign, and photophobia
Diagnosis of Meningitis
Blood cultures, H&P, urine cultures
CT scan
Lumbar puncture (decreased glucose, increased protein and WBCs, cloudy appearance)
Medical Management of Meningitis
Prevention by vaccination
Early administration of high doses of appropriate IV antibiotics for bacterial meningitis
Dexamethasone (treat inflammation)
Treatment for dehydration, shock, and seizures
Anti-epileptic medications
Droplet precautions
Nursing Management of Meningitis
Frequent or continual assessment, including VS and LOC
Protect patient from injury r/t seizure activity or altered LOC
Monitor daily weight, serum electrolytes, urine volume, specific gravity, osmolality
Infection control precautions
Supportive care
Autoimmune Neurologic Disorders
Multiple sclerosis
Myasthenia gravis
Guillain-Barre Syndrome
Multiple Sclerosis
A progressive immune-related demyelination disease of the CNS
Frequently relapsing and remitting
Clinical Manifestations of Multiple Sclerosis
Vary and have different patterns
Exacerbations and recurrences of symptoms including fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain, and visual disturbances (diplopia)
Medical Management of Multiple Sclerosis
CT scan
Disease-modifying therapies; interferon B-1a and interferon B-1b, glatiramer acetate, and IV methylprednisolone
Symptom management of muscle spasms, ataxia, fatigue, bowel and bladder control
Major Goals for the Patient with Multiple Sclerosis
Promotion of physical mobility Avoidance of injury Achievement of bowel and bladder continence Promotion of speech and swallowing mechanisms Improvement of cognitive function Development of coping strengths Improved home maintenance Adaptation to sexual function
Myasthenia Gravis
Autoimmune disorder affecting the myoneural junction
Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses
Manifestation of Myasthenia Gravis
Motor disorder
Initially symptoms involve ocular muscles, diplopia and ptosis
Weakness of facial muscles, swallowing and voice impairment (dysphonia), generalized weakness
Medical Management of Myasthenia Gravis
Cholinesterase inhibitor (Mestinon)
Immunomodulating therapy
Plasmapheresis
Thymectomy
Care of the Patient with Myasthenia Gravis
Energy conservation
Strategies to help with ocular manifestations
Prevention and management of complications and avoidance of crisis
Measures to reduce risk of aspiration
Avoidance of stress, infections, vigorous physical activity, high environmental temperatures
Myasthenic Crisis
Result of disease exacerbation or precipitating event, most commonly a respiratory infection
Severe generalized muscle weakness with respiratory and bulbar weakness
Patient may develop respiratory compromise and failure
GIVE CHOLINESTERASE INHIBITOR
Cholinergic Crisis
Caused by overmedication with cholinesterase inhibitors
Severe muscle weakness with respiratory and bulbar weakness
Patient may develop respiratory compromise and failure
GIVE ATROPINE AS ANTIDOTE
Guillain-Barre Syndrome
Autoimmune disorder with acute attack of peripheral nerve myelin
Rapid demyelination may produce respiratory failure and ANS dysfunction with CV instability
Most often follows a viral infection
Management of Myasthenic Crisis
Patient education in signs and symptoms of myasthenic crisis and cholinergic crisis
Ensuring adequate ventilation; intubation and mechanical ventilation may be needed
Measures to ensure airway and respiratory support
ABGS, serum electrolytes, I&O, and daily weight
If patient cannot swallow, NG feeding may be required
Avoid sedatives and tranquilizers
Manifestations of Guillain-Barre Syndrome
Weakness, paralysis, paresthesias, pain, and diminished or absent reflexes starting with lower extremities and progressing upward
Bulbar weakness, cranial nerve symptoms, tachycardia, bradycardia, hypertension, or hypotension
Medical Management of Guillain-Barre
Requires intensive care management with continuous monitoring and respiratory support
Plasmapheresis and IVIG are used to reduce circulating antibodies
Recovery rates vary, but most patients recover completely
Care of the Patient with Guillain-Barre Syndrome
Ongoing assessment with emphasis on early detection of life-threatening complications of respiratory failure, cardiac dysrhythmias, and deep vein thrombosis
Monitor for changes in vital capacity and negative inspiratory force
Assess VS frequently or continuously, including continuous monitoring of ECG
Collaborative Problems/Potential Complications of Guillain-Barre
Respiratory failure Autonomic dysfunction Deep vein thrombosis Pulmonary embolism Urinary retention
Cranial Nerve Disorders
Trigeminal neuralgia
Bells’ palsy
Trigeminal Neuralgia
Condition of the 5th cranial nerve characterized by paroxysms of pain
Most commonly occurs in the 2nd and 3rd branches of this nerve; vascular compression ad pressure is the probable cause
Occurs more in the 50s and 60s and in women and people with MS
Pain can occur with any stimulation such as washing face, brushing teeth, eating, or a draft of air
Patients may avoid eating, neglect hygiene, and may isolate themselves
Medical Management of Trigeminal Neuralgia
Antiseizure medications such as carbamazepine, gabapentin, phenytoin, or baclofen
Surgical treatment such as microvascular decompression of the trigeminal nerve, radiofrequency thermal coagulation, percutaneous balloon microcompression
Nursing Interventions for Trigeminal Neuralgia
Pain prevention and treatment regimen
Avoidance of triggers
Measures to maintain hygiene
Strategies to ensure nutrition
Recognize and provide interventions to address anxiety, depression, and insomnia
Bells’ Palsy
Facial paralysis due to unilateral inflammation of the 7th cranial nerve
Most patients recover completely in 3-5 weeks and this disorder rarely occurs
Manifestations of Bells’ Palsy
Unilateral facial muscle weakness or paralysis with facial distortion, increased lacrimation, painful sensations in the face, may have difficulty with speech and eating
Medical Management of Bells’ Palsy
Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder
Nursing Management of Bells’ Palsy
Provide and reinforce information and reassurance that stroke has not occurred
Protection of the eye from injury; cover eye with shield at night, instruct patient to close eyelid, use of eye ointment and sunglasses
Facial exercises and massage to maintain muscle tone
