Neuro Flashcards
What does the GCS measure
measures LOC in a client who has altered LOC or potential of altered LOC
- Eye opening
- Motor response
- verbal response
What is the normal pupil size
2-6mm
What is the normal score for the GCS
13-15
What does PERRLA stand for
Pupil Equal Reactive Round Light Accomodation
Assessment of reflexes name one
Babinski Reflex
Is it normal for a babinski reflex in an infant one year or less
Yes
Is it normal for a babinski reflex in an adult or infant over 1 year
NO
What reflex is normal for an adult or infant over 1
Plantar Reflex
Someone who has a tumor or lesion on spinal cord, MS or Lou Gehrig’s disease what type of reflex do you expect to see
Babinkski (severe problem in the CNS)
In a CT test, what do you need and what should you tell client
A signed consent because of dye
Keep Head still
No Talking
In a MRI do we use a dye or ratiation, magnet
Not usually, doesn’t have to use dye
No radiation
Yes to magnet
Which is better MRI or CT
MRI, Picks up on problems earlier
Someone with a pacemaker can they use a MRI
No
Is fillings ok in teeth ok
YEs it is fine
What type of client can’t tolerate this
Clostraphobic clients
In an MRI can they talk
Yes
What is a cerebral angiography
X ray of cerebral circulation from femoral artery using dye
Do we need a consent for an angiography
Yes
What do we make sure as a nurse pre cerebral angiography
Tell patient to be well hydrated, void
Check peripheral pulses,make sure groin is prepped
Check for BUN and Creatinine because dye will be excreted through kidneys
Hold metformin, monitor output
Check for allergies to iodine/shellfish
Explain that they will have a warmth in face and a metallic taste
What do we make sure as a nurse post-cerebral angiography
Tell client to bed rest 4-6 hours
Watch femoral site for bleeding
Watch for embolus (arm, heart, lung, kidneys
With a cerebral angiography what are we concerned about in terms of embolus
If the embolus goes to brain, we will see a change in LOC, one-sided weakness, paralysis, motor/sensory deficits
What does an Electroencephalopgraphy (EEG)do?
- diagnose seizure disorders
- evaluates types of seizures occuring
- evaluates LOC and dementia
- electric activity in the brain,
- diagnose sleep disorders narcolepsy, cerebral infarct, brain tumors, or abscess
- Screening for COMA
What nursing considerations should occur pre-EEG
- Hold sedatives, because we are measuring electric activity and it would give us a false reading
- No caffeine
- Not NPO (drops BS)
What could the client be asked to be positioned during an EEG
- first lying down quiety
- then hyperventilate to assess brain circulation
- for an unconscious, pain stimuli to see what happends to brain activity
What is the site used for a lumbar puncture
Lumbar Subarachnoid space
What is the purpose of a lumbar puncture
- To obtain and analyze spinal fluid
- To measure pressure using a manometer
- To administer drugs intrathecally (brain, spinal cord)
What position should the client be for a lumbar puncture
Propped to bedside table, head toward chest
Lyying fetal position chin to chest
What position should the client be post-lumbar puncture
Flat for 2-3 hours
Increase fluids to replace lost spinal fluid
Watch for headache- inceases when sitting up and decreases when lying down
How is the headache post lumbar treated
Bed rest
Fluids
Pain meds
Blood patch
What are some complications/ lifethreatening complications from lumbar puncture
- Headache
- Brain Herniation contraindicated with ICP
- Meningitis
If someone has a change in LOC Slurred/slowed speech delay in verbal response increased drowsiness Restless confusion What are these signs
Early signs of Increased ICP
If someone has a change in LOC and is progressing to stupor then coma
They have a change in vital signs; cushings triad and are posturing what are these signs of?
Late signs of Increased ICP
What are cushings triad
- systolic htn with a widening pulse pressure
- Slow full bounding pulse
- Irregular Resps
What is posturing
It’s a response to painful or noxious stimuli and indicates a compromise to motor response in brain
If a patient’s arms are flexed inwards and bent toward the body and the legs are extended what does this indicate
Decorticate posturing
If a patient has all four extremities are rigid extension
Decerebrate posturing
Which client is more serious, decorticate or decerebrate
Decerebrate
Can a client have both decorticate and decerebrate
Yes
What should we be concerned about if a client is rigid and tight
Burning more calories