NCLEX > Nervous System > Flashcards
Nervous System Flashcards
Adrenaline
Fight or flight
Noradrenaline
Concentration
Concentration
Pleasure
GABA
Calming
Acetylcholine
Learning
Serotonin
Calming & Sleep
Histamine
Immunity
Occipital
Vision
Temporal
Memory, understanding language
Parietal
Perception, math, spelling, logic
Frontal
Thinking, planning, organization, problem solving, emotions, behavioral control, personality
Cerebellum
Balance
Medulla
HR, BP, reflexes (swallowing, vomiting)
Broca’s Area
Expressive language
Wernicke’s Area
Receptive Language
Meninges
Connective tissue covering the CNS
Cerebrospinal Fluid
Clear, odorless liquid found in your brain and spinal cord
Hypotonia
Dec muscle tone
Hypertonia
Inc muscle tone
Paresis
Weakness in muscles
Paralysis
Inability to move muscles
Hyperkinesia
Tremors
Dyskinesia
Spams, involuntary movements, Tardive Dyskinesia
Hypokinesia
Slow movements
Ataxia
Poor muscle control causes clumsy voluntary movements
Dyspraxia
Partial inability to preform purposeful or skilled motor acts
Apraxia
Complete inability to preform purposeful or skilled motor acts
Dysphasia
Difficulty swallowing
Aphagia
Inability to swallow
I. Olfactory
Smell
II. Optic
Vision
III. Oculomotor
Pupil constriction
IV. Trochlear
Downward movement of eyes
V. Trigeminal
Jaw movement, sensation of face and neck
VI. Abducens
Lateral movement of eyes
VII. Facial
Facial movement, taste on anterior 2/3 of tongue
VIII. Vestibulocochlear
Hearing and balance
IX. Glossopharyngeal
Swallowing, taste on posterior 1/3 tongue
X. Vagus
Swallowing, speaking
XI. Spinal / Accessory
Flexion and rotation of head
XII. Hypoglossal
Tongue movements
GCS
Eye response 1-4
Verbal response 1-5
Motor response 1-6
Less then eight = intubate
Decorticate
Damage to the midbrain
* Arms shape like C’s
* Arms pulled in towards center
Clenched fists
Decerebrate
Damage to deep brain structure pons
* Extension of hands outwards
* Arms and legs straight out
* Toes pointed downwards
* Neck and head arched back
Cerebral Perfusion
What
· Blood flow to the brain
· Blood pressure in the body is what sends blood up to the brain
· We MUST have a high enough BP to get blood to the brain…..
○ or it will not have oxygen!
○ and brain cells will start to die!
MAP > 60! (for adults)
Intracranial Pressure
What
○ The pressure inside of the skull
○ Normal = 5-15
○ Monro-Kellie hypothesis
○ The skull is a rigid container filled with: blood, brain, and CSF. If one of those three increases, another must decrease.
○ Works against BP…. pushing blood away from the
brain!
○ High ICP = Less blood to the brain
Increased Intracranial Pressure
Side Effects
○ Headache
○ Vomiting
○ Inc systolic BP
○ Dec HR
○ Speech slurred
○ Decerebrate & decorticate
Causes
○ Cerebral edema
○ Hemorrhage
○ Tumor growth
○ Excess CSF
Herniation
What
* Protrusion of an organ through a natural opening in a covering, muscle, or bone
* There is SO much pressure, that the brain tissue pushes through the skull
Hydrocephalus
What
* Increased accumulation of cerebrospinal fluid
* Increases ICP
Causes
* Tumor
* Hemorrhage
* Infection
Congenital
Seizure
What
○ Seizures are not a disease in themselves
○ They are a symptom of an underlying disorder
§ Increased ICP
§ Infection in the brain
§ Injury to the brain
§ Drug abuse
§ Hyper- or hypoglycemia
§ Hyponatremia
§ Medications
Epilepsy
§ “A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.”
§ No other underlying disorder
Treatment
§ Anticonvulsants
§ Rapid acting - lorazepam
§ Long acting - phenytoin
* Very important to monitor for therapeutic levels
* Never stop taking suddenly (can cause a seizure)
Nursing Considerations
* Stay with client
* Note time, duration, characteristics of seizure
* Remove harmful objects in clients area
* Cushing clients head
* Looser restrictive clothing
* Assis client to side-lying position
Seizure Precautions
* Oxygen & suction equipment
* Side-lying position with pillow under head
* Padded side rails
* All 4 side rails raised
* Bed in lowest position
Tonic clonic
Phases of tonic (muscle stiffening/rigidity) and clonic (rhythmic jerking) spasm, immediate loss of consciousness
Myoclonic Seizure
Sudden, brief, shock-like contractions of a muscle/group of muscles in extremities
Atonic Seizure
Abrupt loss of muscle tone for a few seconds, then confusion, can result in falls/injury
Absence Seizure
Loss of consciousness, staring off into space
Complex Seizure
Impaired consciousness ranging from confusion to syncope and/or non-responsiveness
Simple Seizure
No loss of consciousness, may experience twitching, sensory changes, or autonomic symptoms
Traumatic Brain Injury (TBI)
What
* Alteration in brain function caused by an external source
Fractures
* Open
* Closed
Bleeds
* Epidural
* Subdural
* Intracerebral
Contusion
* Coup
Contrecoup
Skull Fractures
What
* Open fracture → torn dura
* Closed fracture → dura is intact
Basilar skull fracture
* Battle’s sign → Bruising over the mastoid
process
* Raccoon eyes → Periorbital bruising
Cerebrospinal rhinorrhea
* Test drainage for CSF
○ Halo test
○ Glucose
NEVER INSERT A NG TUBE IN A CLIENT WITH A BASILAR SKULL FRACTURE
Spinal Cord Injury
What
* Damage to the spinal cord causes permanent changes in strength, sensation, and other body functions below the site of the injury
* Symptoms depend on location of the injury
* The higher the injury - the more function that is lost
Injuries at and above T6:
* Monitor for autonomic dysreflexia
Autonomic dysreflexia
Syndrome characterized by
* Sudden severe hypertension
* Bradycardia
* Headache
* Nasal stuffiness
* Flushing
* Sweating
* Blurred vision
* Anxiety
Triggers
* Dehydration
* Anxiety
* Fecal impaction
* Full bladder
* Blister
* UTI
* Pressure ulcer
* Broken bone
* Restrictive clothing
Treatment
* Sit the client up to lower their BP
* Antihypertensives
○ Hydralazine
* Find the cause and treat
○ Full bladder? Catheter
○ Constipated? Remove impaction
○ Pressure injury? Reposition
○ Painful stimuli? Remove stimuli
○ Cold room? Change the temperature
Stroke
What is a stroke?
* “A disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death and a leading cause of disability in the United States. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts”
* There is a lack of oxygen to the brain and that causes damage!
Lack of oxygen can be
* Hemorrhagic
* Ischemic
○ Embolic
○ Thrombotic
Hemorrhagic stroke
* A vessel ruptures and bleeds into the brain
* As the blood accumulates, there is increased pressure on the brain
* The rupture can be caused by a weakened vessel, such as in an aneurysm
* “Worst headache of my life”
Ischemic stroke
* Blood flow to the brain is blocked by a blood clot
○ Thrombotic - a blood clot (thrombus) in an
artery going to the brain. Onset in a stepwise
fashion.
○ Embolic - a clot that’s formed elsewhere (usually in the heart or neck arteries), travels in the bloodstream, and clogs a blood vessel in or leading to the brain. Sudden onset!
* There is a loss of blood circulating to this area of the brain
* The lack of blood leads to a lack of oxygen, causing ischemia and damage
Assessment
* Warning signs:
○ Balance
§ Dizzy → loss of balance
○ Eyes
§ Blurry vision
§ Abnormal pupil response
§ Hemianopia
○ Facial droop
§ Unilateral
○ Arms
§ Arm drift or weakness
○ Speech
§ Aphasia
§ Dysphagia
§ Altered LOC/Confusion
Meningitis
What
* Inflammation of the spinal cord or brain
* Usually caused by a virus or bacteria
○ Rarely caused by fungi or parasites
* Bacterial Meningitis is more dangerous compared to viral
Assessment
* Nuchal rigidity
* Photophobia
* Kernig’s sign
* Brudzinski’s sign
Kernig’s Sign
With the client placed supine and the hip flexed, the knee cannot be completely extended due to pain.
Brudzinski’s Sign
With the client placed supine, passive flexion of the neck causes involuntary flexion of the knee and hips.
Treatment
* Steroids
* Analgesics
* Antibiotics - only if bacterial!!
* Isolation precautions
○ Viral - standard
○ Bacterial - Droplet
§ Considered a Medical Emergency
§ Bacterial meningitis is VERY contagious
* Prevention
○ Hib vaccine
§ Those who are immunized have protection against Hib meningitis
○ Meningococcal conjugate or MenACWY vaccines
○ Recommended for anyone living in close proximity to others
Encephalitis
What
* Inflammation of the brain tissue
* Due to a viral infection
○ HSV most common
* Causes edema and necrosis
* Meninges are also inflamed
Multiple Sclerosis
What
* Autoimmune disorder
* CNS inflammation
* Damages and degrades the myelin sheath surrounding neurons
○ Demyelination
Signs and Symptoms
* Tingling & numbness
* Weakness
* Optic neuritis
* Dysdiadochokinesia: inability to preform rapid, alternating movements
* Ataxia: poor muscle control
* Nystagmus: involuntary, rapid, repetitive eye movement
* Intentional tremor
* Scanning speech
* Hypotonia: dec muscle tone
* Epilepsy, seizures
* Spasticity (muscle, bladder)
Interventions
* No cure
* Corticosteroids
○ Decrease inflammation
Plasmapheresis
Guillain-Barré
What
* Antibody and cell mediated immunologic reaction precipitated by a viral or bacterial illness
* Immune system switches to attacking the nerves and de-myelinates peripheral nerves
* Causes ascending weakness and paralysis
* If ascends to the diaphragm can cause respiratory arrest
Assessment Findings
* Recent illness or infection
○ Ask about a GI bug…. Campylobacter jejuni is responsible for many GBS cases!
* Weakness or tingling in the lower extremities
* Increases in severity and moves up symmetrically
* As severity increases
○ Paralysis
○ Absent reflexes
○ Loss of muscle tone
○ Respiratory distress - requires intubation or trach
* Peaks in about 2 weeks
* Slow recovery
Treatment
* Client will gradually recover as antibodies clear
* Plasmapheresis
○ Filter blood and remove antibodies attacking the nerves
○ Helps symptoms
* Immunoglobulin therapy
Stops the antibodies that are attacking the myelin sheath
Neuropathy
What
* “Weakness, numbness, and pain from nerve damage”
* There has been injury to the peripheral nerve
○ Injuries
○ Infections
○ Toxin exposure
○ Diabetes
* Pain is often described as “pins and needles”, numbness, or weakness
Botulism
What
* Botulinum toxin released by Clostridium botulinum
○ Found in soil and dust
○ Can contaminate honey
§ Children under 1 year old should never have honey
* Inhibits acetylcholine release at the junction between peripheral nerves and muscles
* This causes life-threatening flaccid paralysis
Treatment
* Antitoxin
Assessment Findings
* Blurry vision
* Difficulty breathing
* Respiratory failure
* Symmetric, descending flaccid paralysis
Myasthenia Gravis
What
* Autoimmune disorder
* Communication between nerves and muscles destroyed
Diagnosis
* Tensilon Test
Assessment
* Weak muscles
* Ptosis
* Drooping eyelid
Interventions
* Cholinesterase inhibitors
* Corticosteroids
Immunosuppressants
Parkinson’s Disease
What
* Progressive nervous system disorder
* Caused by degeneration of dopamine neurons
Assessment findings
* Tremor
○ Usually starts on one side
* Rigidity
* Hypophonia
* Mask-like faces
* Akinesia: loss or impairment in power of voluntary movement
○ Bradykinesia
○ Dyskinesia
* Stooped posture
* Difficulty balancing
* Orthostatic hypotension
Symptoms
* Tremor
* Rigidity
* Akinesia: absence of movement
* Ataxia: Poor muscle control
Interventions
* Fall risk
* No cure
* Therapy
○ PT
○ OT
○ SLP
* Carbidopa-levodopa
Increase dopamine in the brain
