EXAM 4 Flashcards
What are the two major nervous systems?
The Central Nervous System and The Peripheral Nervous System.
The Peripheral Nervous System has two further divided systems, what are they and what do they do?
The autonomic system and the somatic system. They work together to control cognition, mobility, and sensory perception.
What is the CNS composed of and what does each composition do?
Brain:which directs the regulation and function of the nervous system and other body systems. Spinal Cord: which initiates reflex activity and transmits impulses to and from the brain.
What does the posterior and anterior part of the spinal nerves do?
Posterior: carries sensory information (sensory perception) to the cord.
Anterior: transmits motor impulses (mobility) to the muscles of the body.
The ANS is divided in to what two other categories?
Sympathetic (fight or flight) and Parasympathetic (rest and digest)
What are the key parts o a NEURO assessment?
Appearance Speech Affect Motor function Medical History ADL performance Family Medial History Patients Memory (especially recent memory) Mental Status (orientation) Establish baseline Compare left and right sides, and upper and lower extremities. LOC Cranial nerves PERRLA Glasgow Coma Scale The Cardinal Fields of Gaze
What does a decrease in mental status of an older adult often mean? What are important assessments to make?
An infectious process. ( Most commonly a UTI)
Also can mean hyper or hypoglycemia and hypoxia.
Spo2/ FSBS/ Asses for s/sx of infection I.E.: fever/ sputum production/ urine with sediment or odor/ red or draining wounds.
What is the Glasgow coma scale, what are the three assessment categories and what are the ranges of the scores?
used reliably to help describe the patient’s level of consciousness.
Eye opening, Motor response, and verbal response.
Score ranges from 3(coma) 15(best/normal).
What is the 1st category of GCS?
Eye opening: Spontaneous 4 Sound 3 Pain 2 Never 1
2nd category of GCS?
Motor response: Obeyed commands 6 Localized pain 5 Normal flextion (withdraw) 4 Abnormal flextion 3 Extension 2 None 1
3rd category of GCS
Verbal response: Orientated 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
What are signs of altered cognition?
headache; restlessness, irritability, or unusual quietness; slurred speech; and a change in the level of orientation.
What is decerebrate and decorticate posturing?
Decerebrate: outward flextion (more severe)
Decorticate: inward
What is decerebrate or decorticate posturing and pinpoint or dilated nonreactive pupils a late sign of? And what is each associated with?
Neurologic deterioration Decerebrate is usually associated with dysfunction in the brainstem area. Decorticate is seen in the patient with lesions that interrupt the corticospinal pathways.
What is one of the first priorities in head trauma or multiple injuries?
Rule out cervical spine fracture.
What are nervous system changes r/t aging?
Slower processing time. Recent memory loss. Decreased sensory perception of touch. Chang in perception of pain. Change in sleep patterns. Altered balance and coordination. Increased risk for infection.
What are interventions for Slower
processing time and its rationale?
Provide sufficient time for the affected older adult to respond to questions and/or direction. Allowing adequate time for processing helps differentiate normal findings from neurologic deterioration.
What are interventions for recent memory loss and its rationale?
Reinforce teaching by repetition, using written teaching, and employing memory aids like electronic alarms or applications for electronic devices that provide recurrent alerts. Greatest loss of brain weight is in the white matter of the frontal lobe. Intellect is not impaired, but the learning process is slowed. Repetition helps the patient learn new information and recall it when needed.
What are nursing interventions for decreased sensory perception of touch and its rationale?
Remind the patient to look where his or her feet are placed when walking. Instruct the patient to wear shoes that provide good support when walking. If the patient is unable, change his or her position frequently (every hour) while he or she is in the bed or chair.Decreased sensory perception may cause the patient to fall.
What are nursing interventions for change in perception of pain and its rationale.
Ask the patient to describe the
nature and specific characteristics of pain Monitor additional assessment
variables to detect possible health
problems. Accurate and complete nursing
assessment ensures that the interventions
will be appropriate for the older adult.
What are nursing interventions for changes in sleep patterns and its rationale?
Ascertain sleep patterns and
preferences. Ask if sleep pattern
interferes with ADLs.
Adjust the patient’s daily schedule
to his or her sleep pattern and
preference as much as possible (e.g.,
evening versus morning bath). Older adults require as much as
younger adults. It is more common for
older adults to fall asleep early and arise early. Assess sleep habits.
Provide usual bedtime routines.
Decrease noise and light at night. Age-related changes include more time
in bed spent awake before falling asleep,
reduced sleep time, daytime napping,
and changes in circadian rhythm
leading to “early to bed and early to Rise.”
What are nursing interventions for altered balance and decreased coordination and its rationale?
Instruct the patient to move slowly when changing positions. If needed, advise the patient to hold on to handrails when ambulating. Assess the need for an ambulatory aid, such as a cane. The patient may fall if moving too quickly. Assistive and adaptive aids provide support and prevent falls.
What are nursing interventions for increased risk for infection and its rationale?
Monitor carefully for infection. Older adults often have structural deterioration of microglia, the cells responsible for cell-mediated immune response in the central nervous system (CNS).
What does PERRLA mean? And what cranial nerve is this testing?
Pupils Equal Round Reactive to Light Accommodation Cranial nerve III Oculomotor (pupil constriction)
What is pronator drift?
If there is a cerebral or
brainstem reason for muscle weakness, the arm on the weak side will
start to fall, or “drift,” with the palm pronating (turning inward).
What is a Babinski’s sign? An what does a POSITIVE one mean and what could is be caused from?
a dorsiflexion of
the great toe and fanning of the other toes, is abnormal in anyone older
than 2 years and represents the presence of central nervous system
(CNS) disease. POSITIVE (abnormal) which is “up going” of the toes. It can mean drug and alcohol
intoxication, after a seizure, or in patients with multiple sclerosis or liver disease.
What can hyperactive reflexes mean?
Hyperactive reflexes indicate possible upper motor neuron disease,
tetanus, or hypocalcemia.
What can hypoactive reflexes mean?
Hypoactive reflexes may result from lower
motor neuron disease (damage to the spinal cord), disease of the
neuromuscular junction, muscle disease, or health problems such as
diabetes mellitus, hypothyroidism, or hypokalemia.
What does FAST stand for and what is it used fro?
Face (symmetrical/ smile/ stick out tong)
Arms (raise both equally)
Speech (slurred?/ can they make a sentence? Recognition and recall)
Time (window of time for intervention/ orientation x3)
Time is brain cells.
A tool used to recognize a stroke.
The three steps to stroke recognition?
Ask the person to smile or stick out their tong.
Ask the person to make a complete sentence.
Ask the person to raise both arms.
What are the components of the brain? What happens if there is damage or changes to these components?
Cerebral Spinal Fluid 10% Intravascular Blood 12% Brain Tissue 78% Skull ICP
What factors can influence ICP?
What is normal ICP range?
Arterial pressure
Venous pressure
Intraabdominal and intrathoracic pressure
Posture
Temperature
Blood gases (CO2 levels)
• Cushing’s Triad increase pulse pressure (BP),decrease pulse, irregular respirations
10-15mm/Hg Elevated if greater than 20mm/Hg
What is normal Cerebral Perfusion pressure?
Normal is 60-100mm Hg.
Less than 55mm Hg is associated with ischemia death.
What factors can affect cerebral blood vessels?
Increase in CO2=vessel dilation=increased ICP.
Decrease in O2=edema=increased ICP
Hydrogen ion concentration= anaerobic metabolism: Acidosis= decrease in oxygen and Alkalosis= increased CO2
What can cause Increased Intracranial Pressuer?
LIFE THREATNING. Increase in any of the following: Brain tissue/Blood/CFS and increased cerebral edema(caused by hypoxia)
What is a migraine? What is used to describe it? What are the symptoms?
Migraine: A migraine headache is a common clinical syndrome characterized by
recurrent episodic attacks of head pain that serve no protective purpose.
Migraine headache pain is usually described as throbbing and unilateral.
Migraine can be accompanied by associated symptoms such as nausea or
sensitivity to light, sound, or head movement. At risk for Stroke and epilepsy. Most common in women.
What is a generalized seizure?
Generalized:may occur in adults and involve both cerebral hemispheres. The tonic-clonic seizure lasting 2 to 5 minutes
begins with a tonic phase that causes stiffening or rigidity of the muscles,
particularly of the arms and legs.
What are the risks for seizures?
metabolic disorders Acute alcohol withdraw Electrolyte imbalance Heart disease High fever Stroke Substance abuse
What are precautions with seizures?
Oxygen Suction equipment Airway IV access Side rails up and padded.
What is the management of an acute seizure?
Medication depends on type of seizure
Medication for tonic-clonic seizure activity
may include:
Lorazepam (Ativan)
Diazepam (Valium)
Diastat
IV phenytoin (Dilantin) or fosphenytoin (Cerebyx)
What is a status epilepticus and what is the treatment?
Prolonged seizures that last more than 5 min or repeated seizures over course of 30 min – medical emergency! Establish airway ABGs IV push lorazepam, diazepam Rectal diazepam Loading dose IV phenytoin
What are the two different types of meningitis and the clinical manifestations of each?
General symptom Fever Neurologic symptoms Headache Photophobia Indications of increased ICP Nuchal rigidity Positive Kernig’s, Brudzinski’s signs Decreased mental status Focal neurologic deficits GI symptoms Nausea and vomiting
What lab tests would you perform for for meningitis?
CSF analysis CT scan Blood cultures Counterimmunoelectrophoresis Polymerase chain reaction CBC X-rays to determine presence of infection
What is the drug therapy for meningitis?
Broad-spectrum antibiotic Hyperosmolar agents Anticonvulsants Steroids (controversial) Prophylaxis treatment for those in close contact with meningitis-infected patient
The wife of a patient recently diagnosed with
Alzheimer’s disease asks the nurse if there is a cure for
her husband’s illness.
What is the nurse’s best response?
A. Eating a balanced diet that includes lots of soy products
can prevent Alzheimer’s disease.
B. Cholinesterase inhibitor drugs such as donepezil (Aricept)
can slow the progression of the disease.
C. Removal of neuritic plaques can prevent vascular
degeneration and improve brain cell function.
D. Decreasing the levels of neurotransmitters in the brain can
slow the progression of the disease.
The wife states that her husband is able to perform most of his own
ADLs, and wants to keep her husband safely and independently
functioning in their home as long as possible.
To help her husband maintain safe independence, which action
should the nurse recommend?
A. Ensure that door locks can be easily opened by the patient.
B. Take the patient out into crowds of people as often as possible.
C. Vary times for meals, bedtime, and getting up in the morning.
D. Place outfits on hangers, then allow the patient to choose what to
wear.
At a 6-month follow-up appointment, the wife states that
the patient occasionally has difficulty finding the correct
words to use when he is communicating.
What term does the nurse use to document this
assessment data?
A. Apraxia
B. Aphasia
C. Anomia
D. Agnosia
At an 18-month follow-up appointment, the wife
states that her husband seems depressed most
of the time and has become less talkative over
the past few months.
Which medication could be helpful for this
patient’s symptoms?
A. Sertraline (Zoloft)
B. Amitriptyline (Elavil)
C. Imipramine (Tofranil)
D. Desipramine (Norpramin)
The patient’s wife calls the physician’s office to report that she is
concerned, because the last time her husband took a walk in the
neighborhood where they have lived for 35 years, he got lost and a
neighbor brought him back home.
What measures should the nurse recommend for patient safety?
(Select all that apply.)
A. “Enroll him in the Safe Return program.”
B. “Have him wear an ID bracelet or badge at all times.”
C. “Place him in a geri-chair when you can’t be with him.”
D. “Ask your doctor to prescribe a sedative drug to keep him calm.”
E. “Take him for a walk two or three times a day in different
neighborhoods.”
During the call, the wife states that she must go out of
town for 3 days to care for an elderly cousin, and she is
concerned about her husband’s care.
Which nursing response is appropriate?
A. “Can you return home sooner than 3 days?”
B. “Why are you choosing to care for your cousin instead of
your spouse?”
C. “Your husband only has mild Alzheimer’s disease, so
staying home alone is acceptable.”
D. “There are organizations that may be able to provide an
interim caretaker for your husband.”
What is a Cerebral angiography (arteriography)?
is done to visualize the cerebral
circulation to detect blockages in the arteries or veins in the brain, head,
or neck.
It remains the gold standard for the diagnosis of intracranial
vascular disease and is required for any transcatheter therapy or for
surgical intervention.
What are special precautions taken for iodinated or osmolar contrast agents?
Informed consent Allergies Renal disease(liver failure) Diabetic Nephropathy HF Dehydration Old age NSAIDS/Metformin Contrast w/in 72 hours Kidney function
What is a Computed Tomography (CT)?
CT scanning is an accurate, quick, easy,
noninvasive, painless, and least-expensive method of diagnosing neurological problems. CT scans
distinguish bone, soft tissue (e.g., the brain, vascular system, and
ventricular system), and fluids such as cerebrospinal fluid (CSF) or
blood. Tumors, infarctions, hemorrhage, hydrocephalus, and bone malformations can also be identified.
Claustrophobic (pre-procedure sedation)
Remove hairpins/wigs/hair pieces.
May feel warm cool sensation with contrast or metallic taste.
What is an MRI and the nursing interventions for it?
Magnetic resonance imaging (MRI or MR) has advantages over CT in the
diagnostic imaging of the brain, spinal cord, and nerve roots. It does not
use ionizing radiation but, instead, relies on magnetic fields. NO METAL. Some tattoos are lead based, so make sure to ask. Ask about metal implants.
What is an LP? And what are some nursing interventions for it?
Lumbar puncture (spinal tap) is the insertion of a spinal needle into the
subarachnoid space between the third and fourth (sometimes the fourth
and fifth) lumbar vertebrae.
A lumbar puncture (LP) is used to:
• Obtain cerebrospinal fluid (CSF) pressure readings with a manometer
• Obtain CSF for analysis
• Check for spinal blockage caused by a spinal cord lesion
• Inject contrast medium or air for diagnostic study
• Inject spinal anesthetics
• Inject selected drugs
Not recommended for SEVERE ICP.
What are normal CSF findings?
Less than 20cm H2O pressure Clear and colorless 0-5 small lymphocytes 15-45mg/dl or proteins (up to 70 in older adults) 8:1 albumin/globulin ratio 50-75 or 60-70% glucose
What ia an EEG and hat are some nursing interventions for it?
Electroencephalography (EEG) records the electrical activity of the
cerebral hemispheres.
Hair is clean w/o hair products.
Avoid sedative or stimulants w/in 12-24 hrs.
Do not fast, can cause hypoglycemia.
Ensure quite room with sign to ensure people know.
What is an EMG?
Electromyography (EMG) is used to identify nerve and muscle disorders
as well as spinal cord disease. Especially used for MS and Mysthasia Gravis.
What is the circle or willis?
It is where all three, anterior,middle, and posterior arteries are joined together.
What is post op for LP?
Pt will be in side-lying fetal position.
Keep pt prone for 4-8hrs.
Encourage fluid.
Check for leakage.
Ask about headache and notify position if persistent with medication.
What are factors tha can trigger a migraine?
Aged cheese or other foods with tyramine
• Caffeine found in beverages such as coffee, tea, cola OR caffeine
withdrawal
• Chocolate
• Foods with yeast such as pastry and fresh breads
• Monosodium glutamate (MSG)
• Nitrates (meats), pickled or fermented foods
• Nuts
• Artificial sweeteners
• Smoked fish
Stress/Fatigue/Anger/Conflict
What are common medications that trigger migraines?
- Cimetidine (Tagamet)
- Estrogens
- Nitroglycerin
- Nifedipine (Procardia, Nifed )
What are Common medications that treat migraines?
Mild: Acetaminophen NSAIDS Severe: Triptan, Midrin and Ergotamine can cause rebound headaches Chronic: Botox Prevention: CCB Beta Blockers NSAIDS Antieptileptic drugs
What are the three categories of Migraines?
Migraine with an aura (classic)
Migraine w/o an aura (common)
Atypical
What are the assessment findings for a migraine with an aura and its phases? (Classic)
1) Prodrome:
• Aura develops over a period of several minutes and lasts no longer
than 1 hour.
• Pain may be preceded by:
Visual disturbances
Flashing lights
Lines or spots
Shimmering or zigzag lights
• A variety of neurologic changes, including:
Numbness, tingling of the lips or tongue
Acute confusional state
Aphasia
Vertigo
Unilateral weakness
Drowsiness
2)• Headache is accompanied by nausea and vomiting.
• Pain usually begins in the temple. It increases in intensity and becomes
throbbing within 1 hour.
3)• Pain changes from throbbing to dull.
• Headache, nausea, and vomiting usually last from 4 to 72 hours. (Older
patients may have aura without pain, known as a visual migraine.)
What are the assessment findings for a migraine w/o an aura? (Common)
• Migraine begins without an aura before the onset of the headache.
• Pain is aggravated by performing routine physical activities.
• Pain is unilateral and pulsating.
• One of these symptoms is present:
Nausea and/or vomiting
Photophobia (light sensitivity)
Phonophobia (sound sensitivity)
• Headache lasts for 4 to 72 hours.
• Migraine often occurs in the early morning, during periods of stress, or
in those with premenstrual tension or fluid retention.
What are the assessment findings for an Atypical migraine and what are the different types?
• Status migrainous:
Headache lasts longer than 72 hours.
• Migrainous infarction:
Neurologic symptoms are not completely reversible within 7 days.
Ischemic infarct is noted on neuroimaging.
• Unclassified:
Headache does not fulfill all of the criteria to be classified a migraine.
What are complementary measures to take for a migraine?
Yoga Meditation Massage Exercise Biofeedback Vitamin B12 (riboflavin) Coenzyme Q10 Magnesium supplement to maintain normal serum values have a role in migraine prevention. Acupuncture Herbal medication
What are cluster headaches?
Cluster headaches are manifested by brief (30 minutes to 2 hours), intense unilateral pain that generally occurs in the spring and fall without warning. It is classified as the most common chronic short-duration headache with pain lasting less than 4 hours. Typically in Men 20-50 years old.
Neuroimaging studies suggest that cluster headaches are related to an overactive and enlarged hypothalamus. The headaches occur at about the same time of day for about 4 to 12 weeks (hence the term
cluster), followed by a period of remission for 9 months to a year
What’s are nursing assessment for Cluster headaches?
Question the patient about prescribed drugs for both the prevention and
relief of the headache, as well as OTC drugs and herbal preparations he
or she may be taking. . Ask the patient to recall a typical week’s activities and any recent changes in lifestyle. Explore the
relationship of cluster headache onset with emotional and behavioral
precipitating factors such as bursts of anger, prolonged anticipation,
excessive physical activity, and excitement. Ask him or her to identify
bedtimes and waking times to help assess changes in activity or lack of
continuity in the sleep-wake cycle.
The patient often paces, walks, or sits and
rocks during an attack. The headache usually occurs with:
• Ipsilateral (same side) tearing of the eye
• Rhinorrhea (“runny nose”) or congestion
• Ptosis (drooping eyelid)
• Eyelid edema
• Facial sweating
• Miosis (constriction of pupils)
What are nursing interventions for cluster headaches?
Consistent sleep-wake cycle Same medications a migraine PLUSE: Lithium Corticosteroids OTC civamide (a capsaicin isomer), available as a nasal spray Oral melatonin Oral glucosamine Wear sunglasses Sit away from window O2 12L via Mask for 15-20min For CHRONIC resistant to meds SURGERY LAST RESORT.
What is a partial seizure?
Partial: also called focal or local seizures, begin in a part of one
cerebral hemisphere. They are further subdivided into two main classes:
Complex partial seizures: may cause loss of consciousness (syncope), or
“black out,” for 1 to 3 minutes.
Simple partial seizure: remains conscious throughout the episode.
In addition, some
partial seizures can become generalized tonic-clonic, tonic, or clonic
seizures. Partial seizures are most often seen in adults and generally are
less responsive to medical treatment when compared with other types.
What are unclassified seizures?
Unclassified, or idiopathic, seizures account for about half of all
seizure activity. They occur for no known reason and do not fit into the
generalized or partial classifications.
What are secondary seizures?
Secondary seizures result from an underlying
brain lesion, most commonly a tumor or trauma. They may also be
• Metabolic disorders
• Acute alcohol withdrawal
• Electrolyte disturbances (e.g., hyperkalemia, water intoxication,
hypoglycemia)
• Substance abuse
• High fever
• Stroke
• Head injury
Heart Disease
What is status electives? What is the treatment?
Prolonged seizure that lasts more than 5 minutes. Or repeated seizures over a course of 30min. MEDICAL EMERGENCY.
Airway/ABGs/IV push diazepam, lorazepam/loading dose of IV phenytoin.
What cant you administer warfin with?
Phenytoin
What are the symptoms of meningitis?
Fever Headache Photophobia ICP Nuchal rigidity \+ Kernigs/babinski signs Decreased mental status N/V
What are the lab assessments of meningitis?
CSF analysis CT scan Blood cultures Counterimmunoelectrophoresis Polymerase chain reaction CBC X-ray Lumbar puncture
