Neuro Flashcards
When will we use Glascow?
Where there is an ALTERED consciousness or potential to (injury)
3 components of Glascow
Best score?
Eye opening /4
Motor Response /6
Verbal Response /5
High: 13-15
No response gets a 1
Normal Pupil size
2-6 mm
Babinski
Response?
When is it normal?
What does an abnormal response mean?
Toes fan
Normal up to 1 year
>1 year should have toes curl
Severe CNS problem
Grading reflexes
0+- absent 1+ - sluggish 2+- active/expected 3+- slightly hyperactive 4+- brisk/hyperactive with clonus (abnormal reflex movement induced by dorsiflexion)
How is a normal reflex documented??????
2+/4+
How does CT work?
Consent?
Positioning?
Takes picture in layers
Consent if using dye
Keep head STILL and NO talking
Is a CT or MRI better? Why?
MRI - it can pick up problems earlier (Bc powerful magnetic field and radio frequency)
CT uses XR + computer
What is used during an MRI?
Is dye used?
Is radiation used?
A Magnet
It can be
NO
Things that will mess up an MRI?
What will the patient hear?
What patients can’t tolerate this?
Jewelry Credit cards Pacemakers Old tattoos - lead Veterans - metal pieces
*Teeth fillings aren’t real metal
A thumping sound
Clastrophobics
Can you talk in a CT or MRI?
Can talk in an MRI
Angiography means we are using what?
DYE
What is a cerebral angiogram?
How to we get there?
XR of the cerebral circulation
Through the femoral artery
Pre-op Cerebral angiogram
What to monitor?
What to hold?
What does the dye cause the patient to feel like?
Think like a heart cath
Well hydrated to excrete dye, void, pulse assessment
Allergic to iodine or shellfish?
Monitor kidneys bc dye
BUN & creatinine
I/O
HOLD Metformin
Warm and metallic taste
Post-op Cerebral angiogram
Position?
Watch for what?
Bed rest 4-6 hours
BLEEDING and EMBOLUS! Especially since we are in the brain
What is an EEG?
What is it used for?
Electroencephalogram
Seizure disorders Reasons for loss of consciousness and dementia Coma screening Brain death Sleep disorders
What do we hold before an EEG?
Are they NPO?
Sedatives - we want that increased electrical activity on the brain
Caffeine
NO!!! This drops blood sugar
How does an EEG begin?
Then what might they assess?
Patient lies normally to get a baseline
May then ask patient to hyperventilate to assess brain circulation
Assess photo stimulation for seizures
Sedate for a sleep study
What if you have a patient that is completely unconscious and want stimuli?
May use a painful response or noxious stimuli (strong smell, bright light)
Where does a lumbar puncture go in to?
What 3 reasons is this used for?
Position?
The lumbar subarachnoid space
- Obtain spinal fluid to analyze for blood, infection, tumor cells
- Measure pressure readings with a manometer
- Administer drugs intrathecally (brain, spinal cord)
Crunches forward or side-lying fetal - may need help to hold them
How should CSF look?
CLEAR like water
Post-op Lumbar Puncture
Position?
Fluids?
Common complication?
What makes this worse?
Lie flat or prone for 2-3 hours
Increase fluids to replace what was lost**
HEADACHE - worse when sitting up and better when lying down
How to treat lumbar puncture headache
Bedrest
Fluids
Pain meds
BLOOD PATCH - draw blood elsewhere and inject it at the lumbar site to form an instant seal and stop CSF from coming out
Life-Threading complications of Lumbar puncture?
Brain herniation - brain pushes down on spinal cord obstructing blood flow to the brain and brain death
Meningitis - bacteria can get to the puncture site and spinal fluid!!
Do not do a lumbar puncture with what?
INCREASED ICP
What is the normal ICP
0-10
Early signs of increased ICP
Change LOC Slurred/slow speech Delayed response to people Increased drowsiness Restless for no reason confused
ASSUME THE WORST
Late signs of increased ICP
Change of LOC progressing to stupor and coma Cushing's Triad Posturing Pupils (fixed and dilated) Projectile vomiting
What is Cushing’s Triad?
Systolic HTN
Widened pulse pressure
Slow bounding pulse
Irregular RR (Cheyne Stokes or ataxic)
What is posting a response to?
Can they be different on different sides of the body?
What is their nutrition like?
Painful or noxious stimuli
Yes
They are burning calories MORE THAN EVER - will probably need a feeding tube
What fluid problems may result from increased ICP?
What about an obstruction?
SIADH and DI –> Need to assess for both
Brain herniation! - Blood can’t get to the brain –> brain death
Why do patient’s ned increased O2 when they have increased ICP?
What do we monitor closely?
Decreased O2 and high CO2 causes an increased in ICP d/t increased vasodilation
*Need an accurate HR and BP so the brain can get O2 and nutrients
How will we maintain cerebral perfusion in patients with increased ICP?
What do we want to prevent?
Give Isotonic saline and positive inotropes (Dobutamine and NE)
Avoid HTN or bradycardia because they decreases cerebral perfusion
What do we want to keep our temperature at when there is increased ICP?
Why?
What if the hypothalamus isn’t working properly?
What will having a low T do?
Below 100.4 F
Increased T will increase cerebral metabolism, which increases ICP
They may nee a cooling blanket
Hypothermia is used to decrease cerebral edema by decreasing the brain’s metabolic demands
How should we position the patient with increased ICP?
Be careful with what?
Elevate HOB
Keep head midline - allows jugular veins to drain
**Be careful with turning (result ^ICP should go back down within 15 minutes)
What should we avoid with increased ICP to prevent further increases?
What should we limit?
Restraints Bowel/bladder distention Hip flexion Valsalva Isometrics Sneezing/nose blowing
Limit suctioning and coughing
How should our nursing care be organized when a patient has increased ICP?
Spaced interventions - Because any time we are going to mess with the patient, their ICP will increase
What is an indications for intubation with the ICP patient?
If the Glasgow score is below 8
~below 8, think intubate~
What key things do we want to watch with an ICP patient’s vital signs?
Cushing’s Triad
S HTN
Widened Pulse pressure
Irregular respirations
Bradycardia - slow bounding pulse
What does a Barbiturate coma do? Example med?
Increases cerebral metabolism and used especially when other measures fail
Phenobarbital
How does mannitol work?
What kind of med is this?
What about steroids?
Example?
It pulls fluid from the brain cells and filters it through the kidneys, resulting in decreased ICP
Osmotic Diuretic
Steroids decrease cerebral edema
Dexamethasone
ICP MONITORING DEVICE
Other name?
Greatest risk?
What to be careful with?
Ventricular catheter monitor or subarachnoid screw
INFECTION
No loose connections
Keep dressings dry because bacteria travel easier on a moist surface
If a neuro patient has a headache, what will we assume?
NCLEX
INCREASED ICP
What are we going to assume if a neuro patient is vomiting?
NCLEX
INCREASED ICP
Does vasodilation or vasoconstriction cause increased ICP?
VASODILATION
QUICK MEMORY TRAINING
Cushing’s Triad vs
Cardiac tamponade
Cushings: NARROW PP
Cardiac tamponade: WIDE PP
Where is inflammation in meningitis?
What is is caused by?
How is it transmitted?
Brain or spinal cord
Viral or bacterial infection
Lumbar Puncture
Bacterial: Transmitted primarily through the respiratory system
Viral: Through feces
S/S of meningitis
*Severe HA
*Nuchal Rigidity (stiff neck)
*Photophobia
Chills and fever
N/V
How do we treat meningitis?
What kind of precautions with viral vs. bacterial?
Steroids
Antibiotics of bacterial
Bacterial: Droplet
Viral: Contact
Which form of meningitis is worse?
What is recommended?
What kind of meningitis do infants and children get more often?
BACTERIAL
Very contagious and is a medical emergency!!
HIGH mortality
Immunizations are recommended especially for college aged students
Viral
Is a seizure a disease?
What is epilepsy?
Think of it more as a symptom of an underlying issue
Epilepsy is a disorder in which seizures don’t go away when the disease goes away
Partial seizure vs Generalized seizure?
Different names for each?
Partial involves a specific local area of the brain while generalized involves the entire brain
Partial: Focal
Generalized: Non-focal
S/S of a partial seizure?
Simple vs. Complex?
Aura - thoughts, lights, feelings, perceptions
Simple: No loss of consciousness, but will see various sensations (numbness, tingling, prickling, or pain)
Complex: Impaired consciousness and may be confused and unable to respond
S/S Generalized seizure - What is the initial manifestation?
Loss of consciousness
DIFFERENCES
Tonic - Clonic
Myoclonic
Absence
Tonic-Clonic: grand mal
Myoclonic: sudden, brief contraction of a muscle or group of muscles
Absence: Brief loss of consciousness
What is Status epileptics?
What is another complication?
A continuous seizure without returning of consciousness between seizures
Trauma - Protect the patient because it could lead to death
How do we treat seizures?
NCLEX IMPORTANT NOTE
THOROUGH Neuro exam including lab, CT and XR (could result from trauma)
Anti-convulsants
AIRWAY AND SAFETY!!
Don’t put anything in their mouth!!!!!
Anti-Convulsants —
Types? Examples?
Side effects - prevent them?
Monitor what?
What will cause a seizure?
Long or short term therapy
Long-acting: Lorazepam, Diazepam
Short-acting: Phenytoin, Phenobarbital
Toxic SE! Use lowest dose possible!
Monitor for toxicity - labs
Abrupt withdrawal = seizure
Skull injury
Open vs. Closed fracture
*May not damage the brain
Open: Dura torn
Closed: Dura NOT torn
Where do you see bleeding in a basal skull fracture?
Where is this fracture?
At the BASE of the skull
Seeing bleeding in the EENT area
What are 3 different signs of a basal skull fracture?
Battle’s sign: bruising over mastoid (behind ear)
Raccoon eyes: periorbital bruising
CSF rinorrhea: CSF through the nose
How to tell CSF vs other drainage?
Glucose test
Halo test
Which skull fractures require surgery?
Depressed skull fractures
What is a concussion?
Do they lose consciousness?
When do they need to come to the ER?
Temporary loss of neuro function with COMPLETE recovery
They might, or see spots/get dizzy (STAY WITH PATIENT, no driving!)
Signs of increased ICP Difficulty waking/ speaking Confusion Severe HA, vomiting Pulse changes Pupil changes One-sided weakness
Differences between small and massive hematoma?
Small ones that develop rapidly may be fatal, while a massive one that develops slowly may allow the patient to adapt
Major differences between epidural and subdural hematoma?
Epidural:
ARTERIAL bleed
Subdural:
VENOUS bleed
Epidural Hematoma –
What ruptures?
How fast is the bleed?
How does this occur?
Middle meningeal artery
FAST bleed under high pressure
Wil occur due to an injury that causes loss of consciousness, then the patient will recover BUT the continuing bleed will max out the space in the head causing neuro changes (agitation, restless, pupils, seizures)
How to treat epidural hematoma?
What key questions need to be asked?
** This is a WHAT
Burr holes, remove clot, control ICP
Did they pass out and stay passed out?
Did they pass out, wake up, and pass out again?
Did they just see stars?
EMERGENCY
Subdural Hematoma
How fast?
Usually a venous bleed (think that venous is slower that artery)
Can be acute (fast), subacute (medium), or slow (chronic
How to treat subdural hematoma?
What to keep in mind about a slow bleed?
RN may just think they are drunk or had a stroke – Hx is KEY! Ask about recent injuries (even if it was a month ago)
Immediate craniotomy, remove clot, control ICP
SCI and Autonomic Dysreflexia
Occurs to injury where?
S/S
Onset?
Injury above T6 causing abrupt excessive BP
SEVERE HTN and HA, Bradycardia Nasal stuffiness Flushing Sweating Blurred vision Anxiety
SUDDEN onset - Neuro emergency! or else a HTN store may occur!
What causes autonomic disreflexia?
Distended bladder
Constipation
Painful Stimuli
How to treat Autonomic Dysreflexia?
Position?
Teaching?
Sit them up and put in Semi-Fowlers
Treat the cause - catheter, remove fecal impaction, remove painful stimuli or a cold breeze
PREVENTION teaching! These can occur after the spinal cord injury
