Neural Flashcards
What occurs when the pressure in the brain presses on the blood vessels? What happens when that pressure continues to rise as blood flow is further impeded?
causes blood flow to the brain to slow causing cerebral hypoxa and ischemia
brain may herniate and blood flow ceases all together
What is a primary brain injury? Examples? What is a secondary injury/ Examples?
Primary injury: consequence of direct contact to head/brain during the instant of initial injury
Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal injury
Secondary injury: damage that evolves over ensuing days and hours after the initial injury
Cerebral edema, ischemia, or chemical changes associated with the trauma
What are signs of a fracture at the base of the skull? (basal fracture)
Bleeding from nose pharynx or ears
Battle sign: ecchymosis behind the ear
Halo sign: indicates a CSF leak. Ring of fluid around the blood stain from drainage
Raccoon eyes: bruising into the tissue around the eyes
What are manifestations of increased ICP?
Altered level of consciousness, restlessness, irritability
Pupillary abnormalities (a fixed dilated pupil is ominous)
Cranial nerve dysfunction
Sudden onset of neurological deficits and neurological changes; changes in senses, movement, and reflexes
Posturing such as decorticate or decerebrate
Cushing triad – late sign (hypertension, bradycardia, irregular slow RR)
Headache, NV
Seizures
What are the 3 signs of late ICP with Cushing’s triad?
hypertension
bradycardia,
irregular slow RR)
What are manifestations of a concussion or mild traumatic brain injury? What is post-concussion syndrome?
Change in neurologic function (H/A, dizzy, difficulty concentrating)
No identified brain damage if imaging done
Usually resolves within 72 hrs.
Persistent cognitive and physical manifestations
What are manifestations of a cerebral contusion?
Brain is bruised
Forceful injury resulting in bruising of a part of the brain
Can present with decreased LOC,vomiting, confusion
More severe than a concussion
Unconsciousness possible
May lie motionless, faint pulse, shallow breathing, pale skin
Bladder and bowel incontinence
Presents similar to shock (low BP)
Varying outcomes
What is a diffuse axonal brain injury?
Widespread shearing injury of axons
Usually from a severe forceful rotational force
Imaging will not reveal the injury
Results in coma
What is a intracranial hemorrhage?
Collection of blood in the epidural, subdural, or intracerebral space
Chronic subdural or subacute bleeding; the manifestations are delayed for weeks to mont
What is an epidural hematoma? Manifestations? Is it an emergency? Treatment?
Blood collection in the space between the skull and the dura, usually a result from an impact to thetemple area
Client may have a brief loss of consciousness with return of lucid state; then, as hematoma expands, increased ICP will often suddenly reduce LOC
An emergency since arterial bleeding will rapidly expand!
Treatment includes measures to reduce ICP, remove the clot, and stop bleeding
Burr holes or craniotomy, IV mannitol, or 3% N/S
Client will need monitoring and support of vital body functions and respiratory support
What is a subdural hematoma? Who are they commonly seen in? What are manifestations of an acute subdural hematoma? Subacute? Chronic?
Collection of blood between the dura and the brain
Common in elderly, especially with use of anticoagulants
Bleeding is from bridging veins that tear easily in elderly clients
Acute: symptoms develop over 24 to 48 hours
Changes in LOC, pupillary signs, hemiparesis, confusion, ataxia
Subacute: symptoms develop over 48 hours to 2 weeks
Requires immediate craniotomy for drainage and control of ICP
Develops over weeks to months
Causative injury may be minor and forgotten
Clinical signs and symptoms may fluctuate
Severe HA, intermittent; alternating focal neurologic signs; personality changes; mental deterioration; focal seizures
Treatment is evacuation of the clot
What is an intracerebral hemorrhage? Causes? Most common cause? Treatment?
Hemorrhage occurs into the substance of the brain
May be due to trauma or a nontraumatic cause
HTN, aneurysm, tumors, bleeding disorders, anticoagulant therapy
Most common cause is chronic hypertension
Treatment
Supportive care
Control of ICP
Administration of fluids, electrolytes, and antihypertensive medications
Craniotomy or craniectomy to remove clot and control hemorrhage unless area is inaccessible
What should always be assumed with any traumatic brain injury? Treatment for increased ICP includes what measures? What are the supportive measures?
cervical spine injury until ruled out
Adequate oxygenation
Elevating HOB
Maintaining normal blood volume
Drain CSF if needed
Mannitol IV or 3% N/S IV
Hyperventilation with ventilator
Ventilator
Seizure prevention
Fluids and electrolyte maintenance
Nutritional support
Management of pain and anxiety
What is the priority assessment with a brain injury? What other 2 primary assessment should be monitored regularly?
ABCDs (priority assessment)
Assess airway, breathing, circulation to ensure oxygenated blood is feeding the brain
Brain injury or death occurs within 3 to 5 minutes of hypoxia
Changes in LOC using the GCS provide the earliest indication of neurologic deterioration
Cranial nerve function
Eye blink response, tongue and shoulder movement
Assess pupils for size, equality, and reaction to light
Bilateral sensory and motor response
What are nursing interventios with head injuries?
Maintain c-spine precautions until cleared by x-ray or clinically
Report presence of CSF from the nose or ears to the provider
Monitor fluid, electrolytes, and osmolality to detect changes in sodium regulation (DI or SIADH)
Provide adequate fluids to maintain cerebral perfusion pressure
When giving large amounts of IVF, monitor for fluid overload and cerebral edema
Maintain safety and seizure precautions
Assess/monitor respiratory status, cranial nerve function, and bilateral sensory and motor responses
Support the client’s family- coping can be difficult
If brain death occurs, support the family when deciding whether to donate organs
What are the 3 cardinal signs of brain death?
coma
absence of brain stem reflexes
apnea
What is a spinal cord injury? What can be the result of a C-spine injury? T1 or below injury? C4 or above injury?
Involve the loss of motor function, sensory function, reflexes, and control of elimination
Level of injury dictates the consequence
C-spine injuries can result in quadriplegia
T1 or below injuries can result in paraplegia
C4 or above injuries can result in impaired ventilation d/t involvement of phrenic nerve
What is primary and secondary SCI?
Primary injury is the result of the initial trauma and usually permanent
Secondary injury resulting from SCI include edema and hemorrhage
What constitutes the autonomic nervous system? What can occur with injury to the SC from above T6?
Sympathetic chain of nerves is mainlyadjacent to the thoracic spinal cord
Spinal injuries above T-6 can result in neurogenic shock from sympathetic chain injury
What is spinal shock? What is the cause? Manifestations? How long can the loss last?
A sudden, but temporary loss of all reflexes and autonomic function below the level of spinal injury
The loss of reflexes, motor and sensation are all directly related to the spinal cord injury not the sympathetic nervous system
Muscular flaccidity and lack of sensation and absent deep tendon reflexes
Loss of sensation below the spinal cord injury level
Paralytic ileus from the loss of autonomic function
Loss of reflexes can last days to weeks, then become hyper-reflexic
What is neurogenic shock? Manifestations? Timeframe? Treatment?
Sudden loss of communication within the sympathetic nervous system with a SCI
Blood pressure & heart rate decrease, and cardiac output decreases
Venous pooling occurs due to peripheral vasodilation
Paralyzed portions of the body do not perspire because sympathetic activity is damaged- watch for early detection of fever
Can occur within 24 hours of injury and can last for several weeks
Keeping the mean arterial pressure at least 85 mm Hg can prevent further damage
Administer IV isotonic fluids (N/S or L/R)
Norepinephrine IV may be required
What are nursing actions when treating neurogenic or spinal shock?
Spinal shock and neurogenic shock often occur together following a SCI
Stabilize the spinal cord with proper positioning/ immobilizing
Monitor/assess: VS, temp, respiratory status, I&O, neuro status, muscle strength and tone, sensation, GI/GU function, and dependent edema
Treat with appropriate medications (vasopressors such as norepinephrine or atropine to increase HR) and IV fluids
Monitor for skin breakdown and ulcer formation
Client is at greater risk for venous thromboembolism (VTE)
Monitor for manifestations such as leg swelling, areas of warmth and/or tenderness
Administer anticoagulants as prescribed for DVT prophylaxis
What is a common complication of SCI? Cause?
orthostatic hypotension
Caused by an interruption in functioning of the autonomic nervous system and pooling of blood in lower extremities when in an upright position
*Change positioning slowly
*Use a reclining wheelchair
*Use thigh-high hose or elastic wraps to increase venous return that may extend all the way up the client’s leg and include the abdomen
What are nursing care actions relating to muscle strength and tone? What type occurs with acute injury? What about later stages? What is the risk in later stages? Treatment?
Determine baseline and monitor for increased loss of muscle strength
Encourage active ROM and assist if the client lacks all motor function
Flaccid type of paralysis following acute injury
Spastic muscle tone in later stages
If severe, they can develop pressure injuries
Administer muscle relaxants (baclofen and dantrolene) for severe spasticity
Monitor for drowsiness and muscle weakness
What type of injuries can result in a spastic neurogenic bladder? How is it managed for both males and females? What type of injueris can result in a flaccid neurogenic bladder? How is it managed?
upper neuron injuries in the brain
Males use a condom catheter and micturition reflex stimulation (tugging on the pubic hair)
Females use an indwelling urinary catheter d/t unpredictable urine release
lower neuron injuries in the spinal nerves
Males’ and females’ interventions include intermittent catheterization and Crede method (downward pressure placed on the bladder to manually express the urine)
What are nursing actions to maintain skin integrity when dealing with SCI?
Change position every 2 hours, every 1 hour if in wheelchair
Pressure ulcers can develop within 6 hours
Monitor Cervical collars- skin breakdown under chin, on the shoulders, and at the occiput
Use pressure relief devices continuously
What is autonomic dysreflexia? Triggers? Why is it an acute emergency? What types of SCI can result in this complication?
An abnormal, overreaction of the involuntary (autonomic) nervous system to astimulus
The stimulus causes an overreaction by the injured sympathetic systemand an attempt to compensate by the parasympathetic system
Sympathetic stimulation is usually caused by a triggering stimulus in the lower part of the body
Distended bladder
MOST COMMON CAUSE
CHECK PATENCY OF FOLEY CATHETER
Distention or contraction of visceral organs
Such as constipation
Stimulation of the skin by a compressive dressing or a skin infection
because of the resulting extreme hypertension
SC lesion above T6
What are symptoms of autonomic dysreflexia?
Extreme hypertension
Severe pounding headache- Why? What is the risk?
Pallor below the level of SC lesion’s dermatome
Flushing and profuse diaphoresis above the spinal level of lesion
Blurred vision
Restlessness
Nausea
Nasal congestion
Bradycardia
What are nursing action for autonomic dysreflexia?
Place client in sitting position immediately- this is priority!
Notify the healthcareprovider
Determine and treat the cause
Check patency of urinary catheter or insert catheter for distended bladder
Remove fecal impaction
Assess for injury (skin, fractures, infection)
Remove tight clothing
Adjust room temperature and block drafts
Monitor VS
Administer antihypertensives (nitrates or hydralazine)
What is a halo traction/cervical tong? Nursing actions?
Provides traction and or immobilizes the spinal column
Nursing actions
Maintain body alignment and ensure weights hang freely
Monitor skin integrity- assessing under the vest
Provide pin care
Do not use the device to turn or move the client
Good skin care- dry, no powder
Teach vest care- liner should not get wet, liner should be changed periodically
What is a decompressive laminectomy? Nursing actions?
Decompressive laminectomy removes a section of lamina, removes bone fragments, foreign bodies, or hematomas that can place pressure on the cord
Donor bone is often obtained from the iliac crest and is used to fuse the vertebrae together
Paravertebral rods are used to immobilize several vertebral levels
Assess for airway compromise from swelling or hemorrhage with cervical fusions
Assess neurological status and VS every hour the first 4 hrs. post op
What is menigitis? What are the 3 types and common conditions that cause them?
Inflammation/infection of the meninges which cover brain and spinal cord
Types
Bacterial- a contagious infection with ahigh mortality rate
Otitis media, sinusitis can spread to meninges
Viral- the most common form that usually resolves without treatment
Measles, mumps, herpes, West Nile virus
Fungal meningitis is common with AIDS or immunosuppression
Cryptococcus neoformans
What are the 3 vaccines that help to prevent meningitis?
Hemophilus influenzae type b (Hib)
Infants, 4 doses starting at 2 months of age
Pneumococcal polysaccharide vaccine (PPSV)
Also intended to prevent respiratory infections
For adults who are at risk (immunosuppressed or crowded living conditions)
Meningococcal vaccine (MCV4)
Adolescents prior to living in a college dorm or military base
Recommended at age 11 or 12 with a booster at age 16
What are the manifestations of meningitis?
Excruciating, constant headache
Nuchal rigidity (stiff neck)
Altered level of consciousness
Positive Kernig sign- thigh flexed on abdomen, can’t fully extend
Positive Brudzinski sign- with neck flexed, flexion of knees and hips is produced
Fever and chills
Nausea and vomiting
Behavioral changes
Photophobia
Hyperactive deep tendon reflexes
Tachycardia
Seizures
Red macular rash (petechiae)
Restlessness, irritability
How is meningitis accurately diagnosed? What does the appearance of spinal fluid indicate? What will labs indicate?
lumbar puncture
Cloudy: bacterial
Clear: viral
Elevated WBC
Elevated protein
Decreased glucose: bacterial
Elevated CSF pressure
What are isolation precaustions for meningits?
Isolate the client as soon as meningitis is suspected!
Droplet precautions
Continue precautions until antibiotics have been administered for 24 hrs. and secretions are no longer infectious.
Those with bacterial meningitis may need precautions continuously. Follow hospital policy.
What are nursing actions when treating meningitis?
Monitor VS and assess for septic shock
Implement fever-reduction measures
Bedrest with HOB at 30°
Monitor for increased ICP. Avoid increasing ICP
Seizure precautions
Provide a calm and quite environment with dim lights
Report meningococcal infections to the public health department
What are meds used with meningitis?
Ceftriaxone or cefotaxime in combination with vancomycin
Given until C&S results are available
Early administration of high doses of appropriate IV antibiotics for bacterial meningitis
Phenytoin
Anticonvulsant if ICP increases or the client has a seizure
Acetaminophen, ibuprofen
Analgesic for HA and/or fever
Prefer nonopioids to avoid masking changes of LOC
Prophylactic antibiotics (ciprofloxacin, rifampin) for those in close contact with the client
What are complications related to meningitis?
Increased ICP
Leads to brain herniation and death
Monitor signs of increased ICP and treat with mannitol
SIADH
Monitor blood and urine labs (serum Na, and urine specific gravity)
Provide interventions such as demeclocycline and restrict fluids
Daily weights
Septic emboli
Can occur in the hands and feet
Lead to gangrene and DIC
What is a brain abscess? Who is at riak? Prevention? Diagnostics?
Collection of infectious material within brain tissue
Risk is increased in immunocompromised clients
Prevent by treating otitis media, mastoiditis, sinusitis, dental infections, and systemic infections promptly
Diagnosis by MRI or CT
CT-guided aspiration is used to identify the causative organisms
What are S/S of a brain abscess? Managment? Nursing care?
Headache that is usually worse in the morning
Fever
Vomiting
Neurologic deficits- weakness, decreasing vision
Signs and symptoms of increased ICP- decreasing LOC and seizures
Control ICP
Drain abscess
Antibiotic therapy
Treat cerebral edema- corticosteroids
Conduct frequent and ongoing neurologic assessment and responses to treatment
Ensure client safety and protect from injury
Provide supportive care
Monitor for neurologic deficits
What is encephalitis? Causes? S/S? Medical management? Nursing care?
Acute, inflammatory process of the brain tissue
Causes
Viral infections
HSV
West Nile
St. Louis
Fungal infections
Headache
Fever
Confusion
Changes in LOC
Vector-borne rash
Flaccid paralysis
Parkinson-like movements
Acyclovir for HSV infection
Amphotericin B and/or other antifungal agent for fungal infection
Control seizures
Control ICP
Frequent and ongoing assessment
Dim lights
Limit noise
PRN pain meds
Use cautiously- may mask neuro symptoms
Monitor intake and output- be alert for presence of renal complications from antiviral therapy
Monitor for seizures
What is MS? Where are the most common locations of damage?
A chronic progressive immune-related demyelination disease of the CNS
Demyelination interrupts the flow of nerve impulses
Plaques can occur on axons
Unable to regenerate and causing irreversible damage
Most common areas include optic nerve, cerebrum, brainstem, cerebellum, and spinal cord
What are S/S of MS?
Fatigue
Weakness
Numbness
Difficulty in coordination
Loss of balance
Pain or paresthesia
Visual disturbances
Difficulty with speech
Muscle spasticity
Bowel and bladder dysfunction
Cognitive dysfunction
Sexual dysfunction
