management of patients with neurologic dysfunction Flashcards
terminology
akinetic mutism
unresponsiveness to the enivronment
patient makes no movement or sound but sometimes opens the eyes
terminology
altered level of consciousness
when a patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness
terminology
brain death
irreversible loss of all functions of the entire brain, including the brain stem
terminology
coma
prolonged state of unconsciousness
can be medically induced
terminology
decerebration
an abnormal body posture associated with severe brain injury, characterized by extreme extension of the upper and lower extremities
terminology
decortication
an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extention of the lower extremities
terminology
locked-in syndrome
condition resulting from lesion in the pons in which patient lacks all distal motor activity (paralysis) but cognition is intact
terminology
persistent vegetive state
condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function
terminology
status epilepticus
episode in which the patient experiences multiple seizures with no recovery time in between
what are some possible causes of altered LOC
- neurologic (damaged nerves)
- toxicologic (drugs)
- metabolic (lack of O2 or lack of sugar)
what are some clinical manifestations of altered LOC
- not responding well
- confused
- pupil changes
- eye opening changes
- verbal/motor response off (GCS)
describe the assessment for altered LOC
- LOC (GCS)
- evaluate mental status
- cranial nerve function
- pattern of respiration
- eyes (pupils and corneal reflex)
- facial symmetry
- reflexes (respond to noxious stimuli?/deep tendon/pathologic)
- abnormal posturing
name some diagnostics for altered LOC
- LOC – with GCS – eye opening, verbal response, and motor response
- CT
- MRI
- EEG
- SPECT
- PET
- Lab tests – Blood glucose, Electrolytes, Serum ammonia, ABG’s, ETOH, Toxicology, LFTs, PT/INR, PTT
what is the first priority for medical management of neurological dysfunction
obtain and maintain airway
name some other shit included in the medical management of neurologic dysfunction
- circulatory status (BP and HR monitored to measure for adequate pefrusion to brain and body)
- IV for fluids and meds
- nutritonal support - feeding tube or gastrostomy
- DNR status
- other med management includes pharmacologic therapy and prevention of other complications
what are some nursing interventions for neurologic dysfunction
- maintaining airway
- protecting patient
- managing nutritional needs
- providing mouth care
- maintaining skin and joint integrity
- preserving corneal integrity
- maintaining body temp
- preventing urinary retention
- promoting bowel function
- meeting family needs
- monitor and manage complications
what are the three components that are in a state of equilibrium in the brain
- brain tissue
- blood
- CSF
describe the monro-kellie hypothesis
- sum of volumes of brain, CSF, and intracranial blood is constant
- limited space for expansion within the skull
- an increase in any one of the components causes a change in the volume of others
whats the most common cause of increased ICP
head trauma
what are some secondary effects of increased ICP
- brain tumors
- subarachnoid hemorrhage
- toxic or viral encephalopathies
describe increased ICP
- decreased cerebral perfusion
- stimulates edema
- causes herniation (dire and frequently fatal event)
increased ICP may reduce cerebral blood flow (CBF) which leads to…
- ischemia and cell death
- slow bounding pulse
- resp irregularities
increased partial pressure and arterial CO2 causes…
vasodilation -> increased CBF and IICP
decreased partial pressure arterial CO2 causes…
vasoconstriction -> limits blood flow to brain
define cerebral edema
an abnormal accumulation of water or fluid in the intracellular space, extracellular space or both d/t an increase in volume in brain tissue
whats this gonna cause? -> change in LOC and seizures
describe the compensatory mechanisms of the brain
autoregulation -> brains ability to change the diameter of its blood vessels to maintain constant CBF during alterations in systemic blood pressure
when does cushings response occur
occurs when CBF decreases significantly
increased BP, widening pulse pressure, and cardiac slowing
autoregulation failure
describe cushings triad
- bradycardia
- hypertension
- bradypnea
what are some clinical manifestations of increased intracranial pressure
- changes in LOC
- abnormal resp and vasomotor responses
- restlessness
- confusion
- increased drowsiness
- stuporous, reacting only to loud or painful stimuli
- decortication or decerebration
what are some complications of IICP
- brainstem herniation
- diabetes insipidous
- SIADH
what is the goal when treating increased ICP
- decreasing cerebral edema
- lowering volume CSF
- decreasing cerebral blood volume
what can be used to treat increased ICP
- osmotic diuretics (mannitol)
- restricting fluids
- draining CSF (peritoneal shunt)
- controlling fever (tylenol)
- maintaining BP and oxygenation
- reducing cellular metabolic demands
what are some nursing interventions for increased ICP
- maintaining patent airway
- adequate breathing pattern
- optimize cerebral tissue perfusion
- maintain negative fluid balance
- preventing infection
- monitor and manage potential complications
whats a craniotomy
opening skull
whats a craniectomy
removing skull
whats a cranioplasty
replacing skull
define seizures
episodes of abnormal motor, sensory, autonomic, or psychic activity
excessive electrical excitation
what are the three seizure types
- generalized (covers entire brain)
- focal (originates in one side of brain)
- unknown (does not fit in either)
all convulsions are seizures but…
not all seizures are convulsions
what can provoke a seizure
anxiety, fear, tumor, alcohol, electrolye imbalances (sodium or calcium)
describe the pathophysiology of seizures
Underlying cause is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain
These cells emit abnormal, recurring, uncontrolled electrical discharges
- Loss of consciousness
- Excessive movement
- Loss of muscle tone or movement
- Disturbance of behavior, mood, sensation, and perception
what are some causes of seizures
- cerebrovascular disease
- hypoxemia
- febrile (childhood)
- head injury
- HTN
- CNS infections
- metabolic and toxic conditions (not enough sugar/O2)
- brain tumor
- drug and ETOH withdrawal (SIWA scale)
- allergies
clinical manifestations depend on the location of discharging neurons. these manifestations may be…
- May range from simple to prolonged convulsive movement with loss of consciousness
- May experience unpleasant sights, sound, odors, or tastes
- generalized: both hemispheres of the brain
- focal: both motor and nonmotor symptoms
describe generalized seizures
are a type of seizurethat impairs consciousness and distorts the electrical activity of the whole or a larger portion of the brain (which can be seen, for example, on electroencephalography, EEG)
- BIL hemispheres involved
- intense rigidity of entire body
- alternating muscle relaxation and contraction
- tonic-clonic seizures
- tongue often chewed
- incontintent of urine and feces
hat happens after 1-2 minutes of a generalized seizure
- movement subsides
- relaxes and lies in deep coma breathing noisily
- postictal state (lethargy, difficult to arouse, longer seizure = longer postictal state)
describe focal seizures
affect initially only one hemisphere of the brain - You might be aware of what is going on around you in afocal seizure, or you might not. Different areas of the brain (lobes) are responsible for controlling all of our movements
- no natural classification
- may be impairment of… consiousness or awareness, dyscognitive features, localization, progression of ictal events
oh no! someones having a seizure right in front of you, whatre you gonna do about this shit
- seizure pads
- lower them to the ground
- lay them on their side
- protect head and airway
- benzos then loading dose of antiseizure meds
- careful with suctioning bc they will bite right through there
what should you note when when someone is having a seizure
- what happened right b4
- exactly what time it started
- what happened exactly with the seizure
- did they harm themselves?
- exactly what time they stopped
describe the assessment of a seizure
- type of seizure
- frequency/severity
- precipitating factors
what diagnostics are used for seizures
- EEG (major diagnostic tool)
- CT/MRI (to r/o lesions)
- PET/SPECT (measure cerebral blood flow)
- complete seizure profile and history
whats included in complete seizure profile and history
- includes baseline neurological exam
- description of seizure activity
- lab studies (ABG, CBC, BMP, glucose, drug tox)
describe nursing management of seizures
identify precipitating activities
activities during seizure
- Maintain airway
- Use jaw-thrust
- DO NOT attempt to open the airway with your fingers or an oral airway
- Keep suction available
- Prevent injury
- Observe seizure activity
- Document seizure activity
- Administer appropriate anticonvulsant
- Privacy
- Loosen clothing
activities after seizure
- Prevent complications
- Positioning
- Maintain seizure precautions
- Medicate as ordered
- No oral temperatures
- Patent IV access
- Bed in lowest position
- O2 and Suction at bedside
- Positioning during seizure
describe epilepsy
A group of syndromes characterized by unprovoked, recurring seizures
classified by specific patterns
- age of onset
- family hx
- seizure type
primary (idiopathic)
secondary (epilepsy is a sx)
what are some risk factors for epilepsy
- Genetic
- Birth trauma
- Asphyxia neonatorum
- Head injuries
- Hormonal
- Infections
- Toxicities
- Fever
- Circulatory problems
- Metabolic disorders
- Drug/Alcohol intoxication
what are some clinical manifestations of epilepsy
- dysfunction ranges from mild to incapacitating
- loss of consciousness
- not associated with intellectual levels
what are some gerontologic considerations of epilepsy
- High incidence of new onset seizures
- CV disease is the leading cause
- Head injuries
- Dementia
- Infection
- Alcoholism
- Aging
- Medication interactions
name some antiepileptic drugs
- phenytoin
- ethosuximide
what should not be given with antiepileptics
contraceptives
describe phenytoin
- most common
- given as loading dose then maintenance dose
- check levels frequently
- high risk for hyperplasia gingivitis (gums grow over teeth and bleeding gums)
- given oral or IV (phlebitis common)
what is ethosuximide used for
absent seizures
what deugs are first line for active seizures
benzodiazepines and barbiturates
- diazepam/lorazepam
- phenobarbital
what are some adverse effects of antiepileptics
- allergies
- idiosyncratic
- acute toxicity
- chronic toxicity (can destroy bone marrow = anemia, infection, bleeding)
- dose related
- takes weeks to months to get therapeutic effect
- gerontologic considerations - toxic effects of long term use is osteoporosis
