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HURST > Neuro > Flashcards

Neuro Flashcards

1
Q

Neuro Assessment

A
  • Know location, how long symptoms have persisted, when they started, and how severe
  • Did anything relieve the symptoms?
  • General appearance and behavior (slurred speech / drooping face)
  • Mental Status
    • awareness of surroundings and alertness
    • orientation to person, place, and time
    • memory (short and long term)
  • LOC - most sensitive indicator of neuro status / may be first sign that there’s a problem
  • Glasgow Coma Scale
  • Pupillary Changes (normal is 2-6mm)
    • PERRLA
  • hand grips / leg lifts / pushing strength of feet
    • strength / follows commands
  • Babinski reflex
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2
Q

Glasgow Coma Scale

A

13-15 is best score

1) Eye Opening
- 4 - spontaneous
- 3 - verbal command
- 2 - to pain
- 1 - no response

2) Motor Response
- 6 - verbal command
- 5 - localized pain
- 4 - flexed / withdraws
- 3 - flexes abnormally
- 2 - extends abnormally
- 1 - no response

3) Verbal Response
- 5 - oriented / talks
- 4 - disoriented / talks
- 3 - inappropriate words
- 2 - incomprehensible sounds
- 1 - no response

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3
Q

PERRLA

A

pupils equal, round, reactive to light, and accommodation

normal pupil size is 2-6 mm

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4
Q

Babinski reflex

A

normal in an infant up to 1 year (goes away when they walk)
abnormal in adult

Babinski - toes fan
Plantar - toes curl

If an adult has babinski reflex, then there’s severe problem with CNS that’s affecting upper motor neuron

Possible Causes: tumor or lesion on brain or spinal cord, meningitis, multiple sclerosis, Lou Gehrig’s disease

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5
Q

Deep Tendon Reflex Scale

A 
0 = no response (absent)
1+ = present, sluggish or diminished (hypoactive)
2+ = active or expected response (normal)
3+ = more brisk than expected; slightly hyperactive but not necessarily pathological 
4+ = brisk, hyperactive w intermittent or transient clonus
  • ankle clonus = abnormal reflex movements of foot induced by sudden dorsiflexion

normal reflex documented as 2+ / 4+

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6
Q

Lumbar Puncture

What’s it used for and how are they positioned?

A

Used to:

 - obtain CSF to analyze for blood, infection, and even tumor cells
 - Measure pressure readings with a manometer and reduce CSF pressure
 - administer drugs intrathecally (into spinal canal)

Client positioned propped up over bedside table w head down while arching their back or in fetal position.

inspect surrounding skin at puncture site for any infection

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7
Q

CSF should be…

A

clear and colorless

look just like water

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8
Q

Lumbar Puncture Post-Procedure

A

lie flat or prone for 4-8 hours

increase fluids to replace lost spinal fluid and reduce risk of complications
- most common complication = headache

pain of headache increases when client sits up and decreases when they lie down

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9
Q

How do we treat a headache caused by a lumbar puncture?

A

they need to lie flat

bed rest, fluids, pain meds, blood patch

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10
Q

Lumbar Puncture Complications

A

brain herniation - if pt has increased ICP, lumbar puncture is CONTRAINDICATED
- needle insertion creates low pressure which makes brain suck downwards (fatal)

infection - if bacteria gets in puncture site, it infects CSF and meningitis can occur
- no punctures near lesions

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11
Q

Early S/sx of Increased ICP

A

change in LOC (coma or as subtle as change in attention span)
speech may become slurred or slowed
delay in response to verbal suggestion (slow response to commands)
increase in drowsiness
restlessness with no apparent reason
confusion

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12
Q

Late S/sx of Increased ICP

A
  • Marked change in LOC progressing to stupor, then coma
  • VS changes
    - Cushing’s Triad = immediate intervention to prevent further brain ischemia and restore perfusion
  • Slow, full, bounding pulse
  • Irregular respirations
    - change in pattern such as Cheyne Stokes or ataxic respirations
  • Decerebrate and decorticate posturing
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13
Q

Cushing’s Triad

A

systolic HTN w widening pulse pressure

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14
Q

Decerebrate Posturing

A

present with all 4 extremities in riged extension / WORST

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15
Q

Decorticate Posturing

A

present with arms flexed inward and bent in toward body and legs are extended

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16
Q

Miscellaneous S/sx of Increased ICP

A

headaches (anytime head injury pt complains of headache = think ICP is increasing

change in pupils and pupil response
- in profound coma = pupils will be fixed and dilated

projectile vomiting can occur bc vomiting center in brain is being stimulated
- if this happens, assume ICP is up

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17
Q

Complications of increased ICP

A

Brain herniation - obstructs blood flow leading to brain death

DI and SIADH

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18
Q

Treatment for increased ICP

A

Goal = relieve increased ICP

 - reduce cerebral edema
 - reduce amount of CSF
 - reduce amount of blood volume in brain

Maintain Cerebral Perfusion:
- oxygenation - decreased O2 and increased CO2 causes vasodilation in brain which
increases ICP
- don’t want hypotension or bradycardia
- isotonic saline and inotropic agents (dobutamine and norepinephrine)
- inotropic agents are emergency meds and not given long term
- keep temp below 100.4 (hypothalamus not working = cooling blanket)
- hypothermia used to treat cerebral edema by decreasing metabolic demands of brain
- antipyretics (anti-fever)
- HOB elevated
- keep head midline so jugular veins can drain
- when turning, if ICP doesn’t go back down after 15 min, turn back
- avoid restraints, bowel/bladder distention, hip flexion, valsalva, isometrics, no sneezing, no nose blowing
- limit suctioning and coughing
- space interventions so they can rest
- monitor Glasgow coma scale and VS for Cushing’s Triad
- Barbiturate-induced coma to decrease cerebral metabolism (phenobarbital, thiopental, propofol)
- Osmotic diuretics (mannitol) - pull fluid from brain cells and filter through kidneys
- Hypertonic saline (3%) - pulls fluid from brain
- steroids (dexamethasone) - when tumor is cause
- fluid restriction (less volume = less pressure)

*** increased volume = increased CO = increased brain perfusion

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19
Q

If Glasgow coma score is below ____ think _____.

A

8 think intubate

20
Q

ICP Monitoring Devices

A

ventricular catheter monitor or subarachnoid screw

- infection risk with this catheter so no loose connections, keep dressing dry

21
Q

Meningitis

A

inflammation of covering of the spinal cord and brain

viral or bacterial infection (resp system transmission)

22
Q

Meningitis S/sx

A 
chills / high fever
severe headache
disorientation that progresses to coma
N/V
nuchal rigidity (stiff neck)
photophobia (light hurts eyes)
seizures
positive Kernig and Brudzinski signs
23
Q

Kernig sign

A

severe stiffness of hamstrings, inability to straighten leg when hips flexed 90 degrees

24
Q

Brudzinski sign

A

severe neck stiffness causes hips and knees to flex when neck is flexed

25
Meningitis Treatment
corticosteroids - decrease inflammation of brain and spinal cord antibiotics analgesics anticonvulsants DROPLET precautions for BACTERIAL meningitis (spread via resp) - very contagious / high mortality rate / immunizations possible VIRAL meningitis transmitted via feces = CONTACT PRECAUTIONS - seen in infants and children
26
What precautions for bacterial meningitis?
DROPLET PRECAUTIONS
27
Precautions for viral meningitis?
CONTACT precautions
28
Closed TBI
brain is injured but skull is not broken, fractured, or penetrated dura is NOT torn
29
Open TBI
brain injury where skull is broken, fractured, or penetrated. Dura is torn in a PENETRATING injury
30
What's most serious skull fracture?
basilar you see bleeding in EENT (eyes, ears, nose, throat) Battle's Sign - bruising over mastoid Raccoon eyes - peri-orbital bruising Cerebrospinal rhinorrhea - leaking spinal fluid from your nose - no blowing nose or stopping flow / we want it to flow freely until it heals * non-depressed skull fractures usually do not require surgery, but depressed skull fractures do
31
How do you tell CSF from other drainage?
positive for glucose and Halo's sign
32
Focal Injuries
contusions - seen w blunt trauma and accel-decel injuries (whiplash) hematomas (epi and subdural) - small hematoma that develops rapidly may be fatal - massive hematoma that develops slowly may allow client to adapt
33
Epidural Hematoma Patho
rupture or laceration of middle meningeal artery (fast bleeder under high pressure) Injury --> loss of consciousness --> recovery period --> bleeding into head --> can't compensate --> neuro changes neuro changes - agitation, confusion, seizures, posturing ** these are the pts that pass out, wake up and may feel fine, pass out again
34
Epidural Hematoma Treatment
Burr holes - remove clot / stop bleeding / control ICP - did they pass out and stay out? - did they pass out, wake up, and pass out again? - did they just see stars? ** this is an emergency
35
Subdural Hematoma
collection of blood between dura and brain usually a venous bleed acute (fast) / subacute (medium) / chronic (slow)
36
Subdural Hematoma Treatment
Chronic - imitates other conditions (drunk) - bleeding & compensating - neuro changes = compensation maxed out Acute or Chronic: immediate craniotomy to remove clot and control ICP
37
Concussion
diffuse brain injury no obvious injury temporary loss of neurologic function with complete recovery will have short period of unconsciousness or may just get dizzy and see spots Bring back to ED if: - difficulty awakening / speaking - confusion - severe headache - vomiting - pulse changes - unequal pupils - one-sided weakness * all of these are signs that ICP is increasing
38
Autonomic Dysreflexia Patho
life-threatening emergency upper spinal cord injury (above T6) exaggerated response to stimuli that are harmless to someone without a spinal cord injury
39
Autonomic Dysreflexia S/sx
``` severe HTN headache bradycardia nasal stuffiness flushing sweating (esp on forehead) blurred vision nausea anxiety ``` * sudden onset * neurological emergency * progresses to HTN stroke if not treated
40
Autonomic Dysreflexia Causes
distended bladder constipation impaction stimuli to skin (pressure, pain, temp)
41
Autonomic Dysreflexia Treatment
FIRST sit client up to lower BP bed bound client in semi-fowlers treat cause (in and out cath, remove impaction (w topical anesthetic), skin pressure, painful stimuli, cold draft, breeze in room) anti-HTN may be required if BP remains elevated after stimulus is removed treach prevention measures
42
CT important thing!
check for iodine or shellfish allergy s/sx of iodine allergy: - N/V, sneezing, itching, hives in first few hrs after CT
43
PET scan
Positron emission tomography useful for diagnosing alzheimers, brain tumors, CVA, parkinsons, mental illness stuff informed consent required they inhale radioactive gas or are injected w it no contact w infants, children, pregnant women for 24 hrs after scan SE: dizziness, lightheadedness, headache
44
Cerebralangiography
check for allergy to iodine and shellfish informed consent monitor BUN / Creatinine / UOP bedrest for 4-6 hrs hold metformin baseline neuro assessment SE: facial flushing, metallic taste Complications: bleeding / embolus to brain (monitor for change in LOC, one sided weakness, paralysis, motor and sensory deficits)
45
EEG
electroencephalography brain scan diagnostic for seizures, sleep disorders, cerebral infarct, brain tumors, abscesses evaluates loss of consciousness and dementia screening for coma / indicator of brain death Hold sedatives and stimulants NOT NPO

HURST (15 decks)

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