Neuro Flashcards
GCS
Eye Opening
Motor Response
Verbal Response
Normal pupil size
2-6mm
Babinski Reflex is normal when?
Child up to 1 year
If they’re walking, it shouldn’t be present
Positive Babinski Reflex
Fanning of the toes when you stroke the bottom of the foot. This means there is a severe problem in the CNS. (Tumor or lesion on the brain or spinal cord, multiple sclerosis, lou gehrig’s dz)
Negative Babinski Reflex
Good thing, should have a plantar reflex/curling of the toes
Ankle clonus
Series of abnormal reflex movements of the foot, induced by sudden dorsiflexion
CT scan
With/without contrast dye
Takes pics in layers
Keep head still, no talking
Do you need to sign a consent for a CT w/ dye?
Yes
Why are MRIs better than CTs
They pick up on the patho earlier
What is used in an MRI
A magnet
No radiation
Sometimes dye, not usually
Do teeth fillings matter for MRIs?
No, they aren’t metal
Old veterans for MRIs
They should get an x-ray first to see if any scrap metal is in their skin
Cerebral angiography
Consent is needed bc dye is used
X-ray of cerebral circulation
Goes through the femoral artery, similar to heart cath
Pre-procedure cerebral angiography
Well hydrated/void/peripheral pulses/groin prepped
Watch BUN and creatinine, output
Explain they will have a warmth in face and metallic taste
Check for allergies to iodine or shellfish
What med do you hold before a cerebral angiography?
Metformin
Why does the client receiving a scan with dye need to be well hydrated?
Dye is excreted through the kidneys
Post procedure cerebral angiography
Bed rest for 4-6 hours
Watch for bleeding at femoral artery site
Embolus can go to arm, heart, lung, kidney
If it goes to the brain, the client will have a change in LOC, one-sided weakness, and paralysis, motor/sensory deficits.
EEG
Records electrical activity of the brain
Helps diagnose a seizure disorder
Evaluates loss of consciousness and dementia
Indicator of brain death
Diagnoses sleep disorders like narcolepsy, cerebral infarct, brain tumors or abscesses
Pre procedure EEG
Hold sedatives bc they decrease the electricity of brain
No caffeine-increases electricity
Not NPO be drops BS
During EEG procedure
Get a baseline first with client lying quietly
May be asked to hyperventilate for 2-3 minutes to assess brain circulation, assess photo stimulation for seizures, or sedate for sleep study
If you have someone who is completely unconscious, a pain response or noxious stimuli may be introduced to stimulate a brain wave. This can be anything from a strong smell like ammonia to a bright light
Lumbar Puncture site
Lumbar subarachnoid space
Purpose of lumbar puncture
To obtain spinal fluid to analyze for blood, infection, and tumor cells
To measure pressure readings with a manometer
To administer drugs intrathecally (brain, spinal cord)
How is the client positioned for lumbar puncture?
Propped up over the bedside table to arch back for space to form between the vertebrae and needle will go in easily, or side lying fetal position
Care during lumbar puncture
Inspect surrounding skin at puncture site for any infection
CSF should be clear and colorless (looks like water)
Post procedure lumbar puncture
Lie flat or prone for 2-3 hours
Increase fluids to replace lost spinal fluid
What is the most common complication of a lumbar puncture?
HA, increases in when they sit up, decreases when they lie down
How is the HA from lumbar puncture treated?
Bed rest, fluids, pain med, blood patch
Life threatening complications of lumbar puncture
Brain herniation: with known increased ICP, lumbar puncture is contraindicated (tell doc immediately if you suspect increased ICP)
Meningitis- bacteria can get into the puncture site and into spinal fluid
Early signs of increased ICP
Change in LOC
Slurred or slowed speech
Restless with no apparent reason
Late signs of increased ICP
Marked change in LOC progression to stupor, then coma
Cushing’s Triad-requires immediate intervention to prevent brain ischemia
Posturing-response to painful or noxious stimuli
Cushing’s Triad
Systolic HTN with widening pulse pressure
Slow, full, bounding pulse
Irregular respirations-look for change in pattern (cheyne stokes or ataxic respirations)
Posturing indicates what?
That the motor response centers of the brain are compromised. The client will be rigid and tight and burning
Decorticate posturing
Arms flexed inward and bent in toward the body and the legs are extended. Think towards “core”
Decerebrate posturing
All 4 extremities in rigid extension. Think away from body
Is decorticate or decerebrate worse?
Decerebrate
What does the posturing client need?
Calories, doc will start feedings ASAP
Miscellaneous signs of increased ICP
HA
Changes in pupils and pupil response (fixed, dilated)
Projectile vomiting
Complication of increased ICP
Brain herniation-obstructs blood flow to the brain leading to anoxia and then brain death
DI and SIADH-assess for both
Tx of increased ICP
Maintain oxygenation
Maintain adequate cerebral perfusion-don’t want hypotension or bradycardia bc that decreases brain perfusion
Keep temp below 100.4-increased temp increases cerebral metabolism which increases ICP, hypothalamus may not be working and a cooling blanket may be used, hypothermia is used as tx to decrease cerebral edema by decreasing the metabolic demands of the brain
Elevate HOB
Keep head in midline so jugular veins can drain
Watch ICP monitor with turning-it should come back down within 15 min, if not then try another position
Avoid restrains/bowel/bladder distention, hip flexions, valsalva, isometrics. No sneezing/blowing
Limit suctioning and coughing
Spaced nursing interventions
Barbiturate induced come to decrease cerebral metabolism: phenobarbital
Osmotic diuretics like mannitol to pull fluid from brain cells and filter it out through kidneys
Steroids like dexamethasone to decrease cerebral edema
Decreased O2 levels and increased CO2 causes what?
Cerebral vasodilation which increases ICP
How can you prevent hypotension?
Isotonic saline and inotropic agents like dobutamine and norepi to cause vasoconstriction
GCS less than 8, think what?
Intubate
ICP monitoring devices
Ventricular cath monitor or subarachnoid screw
Greatest risk is infection
No loose connections
Keep dressings dry (Bacterial travel faster through something wet)
Meningitis
Inflammation of spinal cord or brain
Causes of meningitis
Either viral or bacterial. Bacterial is transmitted through the respiratory system
S/S of meningitis
Chills and fever Severe HA N/V Nuchal rigidity (stiff neck) Photophobia
Treatment of meningitis
Corticosteroids
ABX if bacterial
Analgesics
What precautions for bacterial meningitis?
Droplet. It is very contagious, medical emergency. Has high mortality and vaccine is recommended for college aged students
Viral meningitis precautions
Transmitted through feces so contact. Commonly seen in infants and children
Partial seizure
Limited to a specific local area of brain
Aura may be only sign
What is also called a focal seizure?
Partial
Simple partial seizure
Without loss of consciousness, will see numbness, tingling, prickling, or pain
Complex partial seizure
Means they have impaired consciousness and may be confused and unable to respond
Generalized seizure
Involves entire brain
Loss of consciousness is the initial manifestation
What is also called a non-focal seizure?
Generalized
Tonic clonic seizure is formally known as what?
Grand mal
Myoclonic seizure
Sudden, brief contractions of a muscle or group of muscles
Absence seizure
Formally called petit mal and characterized by a brief loss of consciousness
Status epilepticus
Continuous seizure without returning to consciousness between seizures
Tx for seizure
Anticonvulsants: long or short term Rapid acting: lorazepam and diazepam Long acting: phenytoin or phenobarbital *Toxic SE, use smallest dose *Abrupt withdrawal can cause seizures
Can you bag a seizing pt if they’re turning blue?
Yes, don’t stick anything in their mouth
Open skull fx
Torn dura
Closed skull fx
Durn not torn
With basal skull fx, you see bleeding where?
Eyes, ears, nose, throat
Battle’s sign
Seen with skull injury
Bruising over mastoid
Raccoon eyes
Seen with skull injury
Peri-orbital bruising
Cerebrospinal rhinorrhea with skull injury
Leaking spinal fluid from nose-don’t blow or absorb, let it flow out freely
How do you tell CSF from other drainage?
Positive for glucose and the halo test
Non-depressed skull fx
Usually don’t require sx, depressed fx do
Concussion
Temporary loss of neurologic function with complete recovery
Will have short (maybe seconds) period of unconsciousness or may just get dizzy or see spots
When will a concussion pt have to come back to hospital?
Difficulty awakening/speaking, confusion, severe HA, vomiting, pulse changes, unequal pupils, one-sided weakness (all signs of increased ICP)
Small hematoma that develops rapidly
May be fatal
Large hematoma that develops slowly
May allow client to adapt
Epidural hematoma
Rupture of the middle meningeal artery (faster bleeding under high pressure)
Injury then loss of consciousness then recovery period then they can’t compensate any longer and have neuro changes
EMERGENCY!
Tx of epidural hematoma
Burr Hoes and remove clot, control ICP
What questions do you ask to identify the type of injury and tx needed with epidural hematoma?
Did they pass out and stay out?
Did they pass out and walk up and pass out again?
Did they just see stars?
Subdural hematoma
Usually a venous bleed
Can be an acute (fast) bleed, subacute (medium) or chronic (slow)
Tx of subdural hematoma
Chronic: imitates other conditions, bleeding and compensation, neuro changes are maxed out
Acute or chronic: immediate craniotomy and remove clot, control ICP
Autonomic dysreflexia
With an upper spinal cord injury (above T6), major complication to look for is autonomic dysreflexia or hyperreflexia.
S/S of autonomic dysreflexia
Severe HTN and HA, bradycardia, nasal stuffiness, flushing, sweating, lured vison, anxiety
Sudden onset, near emergency is not treated promptly.
What can occur with autonomic dysreflexia if not treated promptly?
HTN stroke
Causes of autonomic dysreflexia
Distended bladder, constipation, painful stimuli
Tx of autonomic dysreflexia
First: sit the client up to lower BP
Put in catheter, removed impaction with topical anesthetic, look for skin pressure, painful stimuli, or cold draft breeze in the room
