Exam #4 (Chp 41-45) Flashcards
What are the 2 major nervous systems?
Central Nervous System
Peripheral Nervous System
Peripheral Nervous System is divided into two systems, What are they? What do they do?
Somatic and Automatic
They work together to control cognition, mobility, and sensory perception.
What is the Central Nervous System composed of? And what do they do?
The CNS is composed of the:
Brain- directs regulation and function of the nervous system and other boys systems
Spinal cord- initiates reflex activity and transmits impulses to and from the brain.
What is the Peripheral Nervous System composed of?
12 pairs of cranial nerves
31 pairs of spinal nerves
Autonomic Nervous System (ANS)
What does the posterior and anterior parts of the spinal nerves do?
Posterior- carries sensory information to the spinal cord (sensory perception- touch, feel, smell, etc)
Anterior- transmits motor impulses (mobility) to the muscles of the body.
The ANS is subdivided into which categories?
Sympathetic - fight or flight
Parasympathetic - rest and digest
What do Neuroglia cells do?
Provide protection, structure, and nutrition to neurons
They are part of the blood-drain barrier and help regulate CSF.
What are the key components of a neurological assessment:
Assess appearance, speech, affect and motor function Medical Hx / Family Hx ADL performance Pt's Memory (especially recent memory) Mental Status (including orientation) Establish baseline data Compare R and L sides, and Upper / Lower extremities Determine LOC Cranial Nerves Assess PERRLA Glasgow Coma Scale Cardinal Fields of Gaze (6 fields of gaze)
What are the components of Sensory perception?
PAIN
Superficial and Deep sensation
Light touch
Proprioception- ability to sense stimuli arising within the body regarding position, motion, and equilibrium
What does a decrease in mental status of the older adult often mean? And what are important assessments to make?
An INFECTIOUS process
Most common site of infection is an UTI.
can also mean hypo or hyper glycemia or hypoxia.
Key early sign of infection is altered LOC.
Assess SpO2, and finger stick blood sugar, signs of infection: fever, sputum production, urine with sediment or odor, red or draining wounds.
When are Neuro-Checks completed? What are the 2 rapid neuro assessment tools?
Admit to health care facility on an emergent basis, on-going patient assessment, and in event of a sudden change of neurological status.
Rapid assessment tools: Glasgow Coma Scale and PERRLA
What is the Glasgow Coma Scale? What are the 3 assessment categories? And the Ranges of the scores?
Measures neurological functioning- to determine LOC.
Assessment categories are:
Eye Opening
Motor Response
Verbal Response
Score ranges from 3 (worse-coma) to 15 (normal)
A decrease by 2 points is clinically significant and contact PCP immediately.
What is the first category of the GCS?
Eye Opening- assess awake and alertness Spontaneous 4 Sound 3 Pain 2 Never 1
What is the 2nd category of GCS?
Motor Response
Obeys Commands 6 Localizes Pain 5 Normal Flexion (withdrawal) 4 Abnormal Flexion 3 Extension 2 None 1
What is the 3rd category of GCS?
Verbal Response- whether or not they are oriented
Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
What are signs of altered cognition?
HA Restlessness Irritability Unusual quietness Slurred Speech Changes in level of orientation
What is decerebrate and decorticate posturing? And what are each associated with?
Decerebrate posturing is outward Flexion (more severe)- associated with dysfunction of the brainstem area
Decorticate posturing is inward Flexion- associated with interruptions of the corticospinal pathways
What is decerebrate or decorticate posturing and pinpoint or dilated nonreactive pupils, a LATE sign of?
They are a late sign of Neurologic deterioration.
What is one of the first priorities in head trauma or multiple injuries?
Rule out cervical spine fracture.
Assess C-Spine!!!
What is ALERT?
Awake and Oriented
What is Lethargic?
Drowsy but easily awakened
What is stuporous?
One who is arouse with only vigorous or painful stimulation.
What is comatose?
Patient who is unconscious and unable to arouse.
What are Nervous System changes related to AGING?
Slower Processing TIME Recent MEMORY loss Decreased Sensory perception to TOUCH Change in perception of PAIN Change in SLEEP patterns Altered BALANCE and COORDINATION Increased risk for INFECTION
What are quality improvement measures to promote adequate sleep?
Noise meters-
reduce noise, decrease lighting, and prioritize/cluster care during hours of sleep.
What does PERRLA mean?
Pupils Equal Round Reactive to Light and Accommodation
Cranial Nerve 3- oculomotor nerve
Complete test in dim lighting
What is Babinski’s signs?
Dorsal Flexion of the great toes and fanning of the other toes
Abnormal in anyone over the age of 2, and is a sign of CNS disease.
Positive Babinski’s - aka Upgoing
Negative Babinski’s - aka Down going
Can occur with drug and alcohol intoxication or after a seizure or in puts with MS or liver disease.
What does hyperactive reflexes mean?
indicate possible upper motor neuron disease, tetanus, or hypocalcemia.
What can hypo active reflexes mean?
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 is FAST?
tool use to recognize a stroke
F- facial symmetry, smile, stick out tongue
A- Arms: can the pt raise both arms equally?
S- Speech: is it slurred? Can the client make a sentence? – Used for recognition and recall
T- Time: get help now, Small window of time for intervention. Or AAO assessment.
Time is brain cells!!
What are the 3 steps to stroke recognition?
Step 1: ask the person to smile and stick out their tongue
Step 2: Ask the pt to make a complete sentence
Step 3: Ask the pt to raise both arms.
Get Help
What is a cerebral angiography used for?
A cerebral angiography is used to detect blockages in the arteries or veins in the brain, head, or neck.
Completed with contrast dye, assess allergies to iodine.
Diagnostic gold standard.
What are precautions taken for iodine or osmolar contrast agents?
Informed Consent is needed.
Assess allergies, especially to iodine
Cautioned in renal disease, diabetic nephropathy, HF, dehydration, old age, drug interactions such as NSAIDs or metformin, previously administered contrast within 72 hours.
Assess kidney function prior to contrast use.
What is a Lumbar Puncture?
A Lumbar puncture requires insertion of a spinal needle into teh subarachnoid space between the 3rd and 5th lumbar vertebrae.
LP is uses to obtain 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, or inject selected drugs.
Not recommended for severe ICP.
Pt will be in fetal side-lying position to separate the vertebrae
Discomfort may be felt- shooting or tingling sensation.
Instruct pt to NOT MOVE.
3-5 tubes of CSF are collected.
Post procedure: lay flat or prone for 4-8 hours and may experience a HA, if it doesn’t go away after medication- notify the physician. Increase fluid intake. Maintain bed rest. Check LP site for leakage.
What are normal Cerebral Spinal Fluid findings? (CSF)
Less than 20cm H20 of pressure
Clear and colorless
0-5 small lymphocytes/mm3 is normal
15-45mg/dL of protein is normal, up to 70 in older adults
Albumin/Globulin ration 8:1
Glucose 50-75mg/dL or 60-70 percent of blood glucose level is normal
What is an EEG used for?
An Electroencephalography records the electrical activity of the cerebral hemispheres.
Make sure the hair is clean and free of products.
Avoid the use of stimulants and sedatives within 12-24 hours of procedure.
Do not FAST, can cause hypoglycemia
Ensure quiet room with sign to ensure people know.
What is an EMG used for?
An Electromyography (EMG) is used to identify nerve and muscle disorders and spinal cord disease.
Especially used for Multiple Sclerosis and Mysthasia Gravis
What is the frontal lobe responsible for?
The frontal lobe is responsible for decisions, thinking, emotions, personality, and Broca’s- ability to speak.
What is the Parietal Lobe responsible for?
The Parietal lobe is responsible for:
Touch
Feel
Pain.
What is the Temporal lobe responsible for?
The temporal lobe is responsible for: Hearing Smell Short term memory Wernicke's- the ability to understand language
What is the Occipital Lobe responsible for?
The occipital lobe is responsible for:
The ability to see (vision)
What is the Limbic lobe for?
The Limbic lobe is responsible for:
Emotional and visceral patterns of survival
Learning and memory
What is the Medulla responsible for?
The medulla is responsible for:
Cardiac-slowing center
Respiratory center
Cranial nerves 9-12
What is the Circle of Willis?
The circle of Willis is a ring at the base of the brain where the anterior, middle, and posterior cerebral arteries are joined together.
Question: the most common cause of changes in the older patient's mental state is: A. Infection B. Sedatives C. Hypoxia D. Electrolyte imbalance
A. Infection– UTI is most common in the Elderly.
Question: A 27 yr old male suffered a frontal lobe infarction secondary to a car crash. What is the appropriate intervention?
A. Enable the bed alarm safety system
B. Place all items in front of the patient
C. Use a picture board with communication
D. Instruct to use the call light prior to getting out of bed.
A. Enable the bed alarm safety system– the frontal lobe is responsible for decisions/comprehension, thinking, emotions/mood, ability to speak.
What is the normal ICP range?
The normal Intracranial Pressure range is 10-15.
Considered ELEVATED if greater than 20 sustained.
What factors can influence ICP?
Arterial / Venous Pressure (BP)
Intrabdominal and intrathoracic pressure (coughing, sneezing, straining)
Posture- lay down to decrease ICP
Temperature
Blood gases (increased CO2 or decreased O2)
Cushing’s triad: increased pulse pressure (BP), decreased pulse, and irregular respirations
What are the components of the Brain?
The components of the brain include:
Cerebral spinal fluid- 10 percent
Intravascular blood- 12 percent
Brain tissue- 78 percent
Also includes the skull
Changes in any one component results in Increased intracranial Pressure
What is cerebral blood flow?
The amount of blood in milliliters passing through 100 grams of brain tissue in 1 minute.
The normal cerebral blood flow is approx. 50mL per 100 grams of brain tissue.
What is normal cerebral perfusion pressure?
The normal cerebral perfusion pressure is:
70-100 mmHg
Less than 55 mmHg is associated with ischemia and neuronal 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 = decreased O2, Alkalosis = increased CO2
What can cause increased intracranial pressure?
Increased ICP is life threatening and can result in brain death
An increase in any of the three components (brain tissue, blood, or CSF) can result in increased ICP.
Increased cerebral edema (caused by hypoxia) can also result in increased ICP.
What is the pathophysiology of ICP?
Insult to the brain - tissue edema - does not = ICP - Compression of the ventricles - Compression of the blood vessels - decreased cerebral blood flow - decreased O2 with death of brain cells - edema build up around the necrotic tissue - increased ICP with compression of brain stem and respiratory center - accumulation of O2 - vasodilation - increased ICP resulting from increased blood volume - DEATH.
What is a migraine headache?
Recurrent episodic attacks of head pain, lasting 4-72 hours.
Throbbing and unilateral
Accompanied by nausea and sensitivity to light, sound, and movement.
At greater risk for stroke and epilepsy.
Most common in women.
What are factors that can trigger a migraine attack?
Alcohol caffeine Aged Cheese foods with tyramine chocolate foods with yeast MSG Nitrates Nuts Artificial sweeteners Smoked fish Stress Fatigue Anger Conflict Missed meals/hypoglycemia Smoking/tobacco Traveling Sleep problems
What are common medications that trigger migraines?
Cimetidine (Tagamet)
Estrogen
Nitroglycerin
Nifedipine (Procardia)
What are medications used to treat migraines?
Acetaminophen, NSAIDs, Ergotamine, Beta Blockers (Propanolol, timolol) CCBs (verapamil) Triptans (activate Serotonin receptors), midrin, Antiepileptic drugs (depakote, topamax)
Tristan’s, Ergotamines, and Midrin can cause a rebound HA aka medication overdose HA
Tylenol and Motrin are used for mild migraines
CCBs, BBs, ergotamine, triptans, Midrin are used for severe migrianes
NSAIDs, AEDs,CCBs and BBs are used for preventative therapy drugs.
What are the 3 categories of Migraines?
Migraines with an Aura (classic migraine)
Migraine without an Aura (common migraine)
Atypical Migraine
What are assessment findings for a Migraine with an Aura? (Classic Migraine) And the phases?
Phase One: Prodrome Phase-
Aura develops over minutes, up to one hour
Pain followed by: Visual disturbance/Flashing lights /Lines or spots/Shimmering/zigzag lines
Numbness, tingling, Acute confusion, Aphasia- difficulty speaking , Vertigo, Unilateral weakness, Drowsiness
Phase Two:
HA accompanied by N/V
Pain beginning in the temple, throbbing in 1 hour
Phase Three:
Pain changes from throbbing to dull
HA/N/V last 4-72 hours
Older pt may have aura without pain- aka Visual migraine
What are assessment findings for a migraine without an Aura? (Common Migraine)
Pain is aggravated by performing routine physical activities, unilateral and pulsating
One of these symptoms are present:
N/V
Photophobia
Phonophobia
HA lasts 4-72 hours, often occurs in the early morning during periods of stress, premenstrual tension, or fluid retention
What are assessment findings for an Atypical Migraine? And the types?
Status Migrainous:
HA last longer than 72 hours
Migrainous Infarction:
Neurologic symptoms are not completely reversible within 7 days
Ischemic infarct is noted on neuro-imaging
Unclassified:
HA does not fulfill all the criteria to be classified as a migraine
What is the only therapy approved for CHRONIC migraine in adults?
Botox
What are complementary and alternative therapy for migraines?
Yoga Meditation Massage Exercise Biofeedback Acupuncture Herbals Supplements include: vitamin B12, CoQ10, and magnesium
Question: The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods may trigger a migraine? A. Salt B. Sugar C. Tyramine D. Glutamine
C. Tyramine
What are cluster headaches?
Cluster HA are manifested by brief 30 minutes-2 hour, intense unilateral pain that generally occurs in the spring or fall without warning.
Most common chronic short-duration HA with pain lasting less than 4 hours.
More common in men between 20-50 yrs.
Neuroimaging studies indicate cluster headaches are related to an overactive and enlarged hypothalamus.
HAs occur the same time daily for 4-12 wks and remission for 9 months to 1 year.
What are nursing assessments for cluster headaches?
HA usually occurs with Ipsilateral (same side) tearing of the eyes, rhinorrhea (runny nose), Ptosis (drooping eyelid), eyelid edema, facial sweating, and Miosis (constriction of pupils)
Question prescription drugs and OTCs and herbals
Assess recent activity and changes in lifestyle
Explore onset with relationship to emotional and behavioral precipitating factors (bursts of anger, prolonged anticipation, excessive physical activity, excitement)
Identify sleep pattern
Pt often paces, walks, or sits and rocks during an attack
What are nursing interventions for cluster headaches?
Importance of Consistent sleep cycle
Same medications as migraine plus lithium and corticosteroids, OTC civamide, melatonin, and glucosamine.
Wear sunglasses and sit away from Windows during an attack
O2 via mask at 12 L for 15-20 minutes
Surgery recommended for Chronic drug-resistant cluster HA. Last resort- PSR or deep brain stimulation.
What is a generalized seizure?
A generalized seizure may occur in adults and involves both hemispheres. aka tonic-clonic seizure. MOST SEVERE
Lasts 2-5 minutes; starts with
tonic phase: nuchal rigidity, loss of consciousness.
Clonic (rhythmic) phase: jerking of extremities, may bite tongue or incontinent. Fatigue, acute confusion, lethargy (last up to 1 hour after the seizure).
What is pre-ichtal and post-ichtal?
Pre-Ichtal: has an aura before the seizure occurs.
Post-Ichtal: after the seizure is over. A state of extreme exhaustion and lethargy. Pt still at risk for injury.
What is a partial seizure? And what are the classifications of a partial seizure?
A partial seizure is also called a focal or local seizure, occurring in one hemisphere.
Complex Partial: cause loss of consciousness (syncope or blacking out) for 1-3 minutes, automatisms may occur (unaware of environment) and may have loss of memory (amnesia).
Commonly occurs in the temporal lobe- psychomotor seizures.
Simple Partial: Remains conscious, aura involved- Deja vu phenomenon, offensive smell, sudden pain. May have one-sided movement of extremity, unusual sensations, autonomic changes IN HR, skin flushing, and epigastric discomfort.
What are unclassified seizures?
Unclassified or idiopathic seizures account for half of all seizure activity.
Occur for no reason and do not fit into generalized or partial classifications.
What are secondary seizures?
Secondary seizures result from an underlying brain lesson, most commonly a tumor or trauma.
May be caused by: metabolic disorders, acute alcohol withdrawal, electrolyte imbalances- hyperkalemia, water intoxication, hypoglycemia. High fever Stroke Head injury Substance abuse HR disease.
Secondary seizures are NOT considered epilepsy.
These can also be considered risk factors for seizures.
What type of seizure is most common in older adults? And what is commonly associated with seizures in older adults?
The most common type of seizure in older adults is Complex partial seizures.
Seizures in older adults are commonly associated with: HTN, cardiac disease, DM, stroke, dementia, and recent brain injury.
What are some considerations regarding epilepsy women?
Hormone changes from menstrual cycles and oral contraceptives in conjunction with Antiepilectic drugs require MORE frequent monitoring for drug effectiveness.
Teratogenic risks associated with AEDs.
AEDs also contribute to osteoporosis in menopausal women.
What are common seizure precautions? What should NOT be at the bedside, as it can result in injury?
Seizure precautions include: Oxygen Suction Equipment Airway IV access Side rails up and padded or place mattress on floor.
NO padded tongue blade– more likely to chip a tooth or increase risk for aspiration.
What are some Antiepileptic drugs (aka anticonvulsants) used for ACUTE seizure management?
Lorazepam (Ativan)- Monitor ABCs. 4mg over 2 minutes, can give up to 8mg.
Diazepam (Valium)- monitor ABCs.
Diastat (rectual Valium)- monitor ABCs.
IV Phenytoin (Dilantin) or fosphenytoin (Cerebryx)- Monitor GI distress, gingival hyperplasia, anemia, nystagmus. Check CBC and Ca level. Therapeutic range: 10-20; toxic if greater than 30. Give up to 50mg/min. Fosphenytoin is water soluble, causes fewer cardiac complications, compatible with more IV fluids, give at rate 100-150mg/min. Assess labs q6-12 hours after loading dose, then 2 wks after PO dose started.
What are common medications use for LONG-TERM seizure management? And what are some nursing interventions associated with each med?
Carbamazepine (tegretol)- T-C seizure; monitor HA, N/V, blurred vision. CBC. No crush or chew.
Clonazepam (Klonopin)- Absent seizure. Monitor liver function
Divalproex (Depakote)- all seizures; watch N/V, rash, lethargy, anorexia. CBC and liver function.
Lamotrigine (Lamictal)- Partial seizures; Diplopoda (double vision), HA, Dizzy, drowsiness, life-threatening rash when given with valproic acid.
Levetiracetam (Keppra)- adjunct partial seizure; monitor renal function, notify PCP if gait disturbance.
What is self-management education regarding seizures?
Educate the pt and family on:
- understanding the med orders
- Emphasize not to stop AEDs even if seizures stop; d/c can lead to life threatening status epilepticus.
- Balanced diet, rest, stress reduction techniques. Keep seizure diary.
- NO OTCs or herbals without talking to PCP. NO alcohol.
- Wear medic alert bracelet
- Follow ups, lab tests Important
- Social services resources- refer to epilepsy foundation.
- Employment safety- cannot discriminate
- Vocational rehabilitation
What is EBP care for tonic-clonic or partial seizures?
Protect the patient from INJURY. NOTHING in mouth. Turn pt to SIDE LYING position to keep airway clear. LOOSEN tight clothes Maintain PATENT AIRWAY NO restraints RECORD length of seizure
At completion of a seizure, what are some cares to complete?
Assess VS Perform Neuro check Keep patient on side Allow rest DOCUMENT seizure
What is included when documenting a seizure?
How often seizures occur Describe each seizure Did more than one type occur Any observations noted during seizure How long the seizure lasted When the seizure took place Whether the seizure was proceeded by an aura What the pt does after the seizure How long it takes for the pt to return to pre-seizure state
What is status epilepticus? What are common causes of status epilepticus? What are nursing interventions for status epilepticus?
Status epilepticus is a prolonged seizure lasting longer than 5 minutes or repeated seizures over 30 minutes. This is a medical EMERGENCY.
Seizures last longer than 10 minutes can cause DEATH.
Common causes: Sudden withdrawal of AEDs Infection Acute alcohol or drug withdrawal Head trauma Cerebral edema Metabolic disturbances
Interventions:
Establish airway
ABGs
IV push Lorazepam or diazepam; if no line give IM
Rectal diastat
Loading dose of phenytoin- no more than 50mg/min
Question: A client with a history of seizures is placed on seizure precautions. What emergency equipment will teh nurse provide at the bedside? A. Oropharyngeal airway B. O2 C. NG tube D. Suction E. Padded tongue blades
A. Oropharyngeal airway
B. O2
D. Suction
