Neuro Flashcards
What is the function of the neurological system?
Controls motor, sensory, autonomic, cognition and behavioral activities
- Links motor and sensory pathways,
- monitors body posturing,
- responds to internal/external environment
- Maintains homeostasis
- Directs all psychological, biologic and physical activities via chemical and electrical messages
- Acetacholine,seratonin,dopamine,GABA,endorphins
Divided into 2 systems
- Central nervous system (CNS) – Brain and spinal cord
- Peripheral nervous system (PNS) - Cranial nerves spinal nerves
- PNS divided into 2 systems
- Autonomic – involuntary
- Somatic - voluntary
BBB- sometimes have to give meds in the spine in order for it to get to the brain cells
Must have a MAP of over ____ to make sure the circulation in the brain is happening
60
Autonomic Nervous System
Hypothalamus is major center for regulation
Maintains and restores internal homeostasis
Regulates activities of internal organs
Lungs, blood vessels, digestive organs /glands
Divided into 2 systems – both producing stimulatory and inhibitory effects
Sympathetic
Fight or flight
Parasympathetic
Controls visceral functions
In nonstress situations parasympathetic rules
*Sympathetic and parasympathetic act to create the variables in the heart rate
If a patient vagals out what do we do?
give 400mL bolus of fluid
Assessment of the neurological system
Health History: - Include genetics - Clinical Manifestations – subtle/intense, fluctuating/permanent, inconvenient/devastating Pain - - Seizures - - Dizziness - - Visual Disturbances - - Weakness - - Abnormal Sensation - Could be subtle- numbness in feet, tingling in toes, top of feet feel sunburnt Vertigo
Physical Examination:
- Cerebral Function
- Mental Status
- Intellectual Function
- Thought Content
- Emotional Status - appropriate mood swings?
- Perception - motor or language, *Agnosia- can describe something but cannot name it or tell you the function
- Motor /language abilities
- Cranial Nerves
- Motor System
- Muscle Strength
- Chart 60-3
- Balance and Coordination
- Romberg- close eyes and hold hands out straight, they will fall to one side if there is a problem
- Reflexes
- Name and assess - 0-4, 2-3 considered normal, 4 is excessive and might have a seizure.
Sensory –
- Collection of subjective data
- Most deficits are peripheral neuropathies
- Tests – tactile sensation, superficial pain, vibration, position sense
Motor ability
Language ability
Impact on life
Notes:
- Dementia- chronic, not reversible
- Mental statuses can change because of drug toxicity
= Delirium- CNS damage, can be reversed, sometimes just need hydration, look at vitamin B, thyroid function
Infection and high temp- might cause delirium
Gerontology
- Structural changes, motor alterations, sensory alterations, temperature and pain perception, taste/smell alterations, tactile/visual alterations, mental status
- Gerontology- makes neuro testing harder. Slower reflexes. CT and MRI, PET scans
Define seizures
Disorders that involve periodic disturbances in the brain’s electrical activity, resulting in some degree of temporary brain dysfunction
- Paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupt normal function
- May be associated with loss of consciousness, excess movement, or loss of tone/movement, disturbed behavior, mood, sensation, perception
- Most seizures are sudden and transient
- Often the symptom of underlying condition- systemic or metabolic disturbances are not considered to be epilepsy if seizures leave after condition clears
Etiology: High fevers Brain infections Metabolic disorders Inadequate brain oxygenation Structural damage (stroke, tumor) Fluid accumulation Toxic drugs/substance Withdrawal Certain drugs Drug allergy, defective genes that can’t take the drug Heart problems- not pumping enough blood to your brain Sleep deprivation
Seizure disorders
Classifications
- Partial Seizures - begin in 1 part of brain
- Simple partial
- Complex partial
- Generalized Seizures - involve electrical discharges in whole brain
- Tonic-Clonic (grand mal)
- Tonic
- Clonic
- Absence
- Atonic (fall down)
- Myoclonic (one muscle)
Nursing considerations for Tonic-Clonic (and all) Seizures
Lay on the floor (side-lying position), loosen clothes, roll on side, leave alone, DO NOT HOLD DOWN, Have suction available- nothing in the mouth, around the lips, Bed in low position, siderails up, padded, NO bite sticks
Speak calmly
Time each section if possible
Can last 1-5 minutes
Tonic- Neuronal hyperexcitation Loss of consciousness Apnea Dilated pupils Duration = 15-60 seconds
Clonic-
breathing, maybe try to get them oxygen.
Inhibitory neurons interrupt seizure discharge
Hyperventilation
Rhythmic jerking of extremities
Duration = 60-90 seconds
After seizure (Postictal) Deep sleep Muscle soreness Headache Amnesia Visual disturbances Dysphagia Aphasia Duration = variable Todd’s paralysis: temporary motor deficit of arm or leg that can last up to 24 hours
Diagnosis- can’t count on patient telling you they had a seizure, needs to have witnessed seizures, epilepsy means 2 witnessed seizures.
EEG
Deprive of 18-24 hours of sleep
take off of any neuro medications
check electrolytes and CBG
check for anemia
check kidney and liver function
anything that can cause low oxygenation, we check, then we hook them up to an EEG.
If we know the underlying cause, we will treat it. Probably do a CT or MRI of the brain to see any underlying cause.
Brain infection – encephalitis.
Observation and documentations of seizures
Circumstances prior to seizure Occurrence of an aura First obvious sign of seizure Types of movements Area of body involved Eyes –pupil size, open/closed, turned to one side? Presence of automatisms Incontinence Paralysis/weakness of extremities post Inability to speak post Movements at end Sleeps afterward cognitive status after Are they confused afterwards? How long does it take for the confusion to go away? Take VS, check for any type of injury
Epilepsy
- Condition in which a patient has spontaneous unprovoked recurring seizures caused by a chronic underlying condition
- Etiology is attributed to a group of abnormal neurons (seizure focus) that undergo spontaneous firing- possibly due to scarring (gliosis)
- New evidence that other cells may be the problem
- Incidence rate (new onset) high in 1st year of life (this could be due to high temps so we have to differentiate between high temps and epilepsy) declining in childhood & teens, plateauing in middle age and sharp rise in the elderly
- Previously a stigma but acceptable now
- Primary – idiopathic
- Secondary – cause is known and the epilepsy is a symptom of another underlying cause
- Causes
Idiopathic - genetic/developmental defect
Acquired - Hypoxemia - Medical management:
- Individualized due to the varied forms of the condition. - Management is aimed at prevention and management of seizures.
- Testing =EEG, CT,MRI,SPECT (looking for lesions in the brain, tumors, miswiring, test for genetics, toxic materials, may do lumbar puncture (spinal tap) )
- Pharmacologic Therapy – control w/o side effects (the goal)
- usually start on Dilantin (When on Dilantin: need to have a lot of blood work and monitor the levels. Take on an empty stomach. Make sure the doctor knows ALL medications they are currently taking. NO ALCOHOL!)
- Many available
- Start with single med with increasing dose, Monitor levels
- May need to switch meds if not working
- When sick or with weight change/stress may need dose adjustment
- SUDDEN WITHDRAWAL can cause freq seizures or status E
- Side effects – 1) idiosyncratic/allergic, 2) acute toxicity, 3) chronic toxicity
- If the patient gains or loses weight, could be over or underdosing. If the patient runs out of medicine and stops taking it, could go into status epilepticus, you can pretty much guarantee they will have at least one seizure.
Nursing management:
- Preventing Injury
- Reducing fear
- Improving coping
- Teach to keep a seizure diary
- Make sure they are getting proper rest
- Monitoring and managing potential complications
- PC Status Epilepticus, toxcity
Monitor drug levels: Subtherapeutic and toxic - - Speaking specifically about phenytoin, or Dilantin, drug levels must be monitored. - - Subtherapeutic and toxic levels are highly individualized. Toxic for one may be subtherapeutic of another. - - Breakthrough seizures - - Adverse effects - - - - Lethargy - - - - Nystagmus - - - - Ataxia, dysarthria
Food and drug interactions
- Delayed absorption
- Potentiated
- Inactivated
Phenytoin should not be taken with food.
Patients taking Dilantin should make sure that their physician is aware of all the medications they are taking because it commonly interferes with other drugs or it is interfered with by other drugs.
Diet to treat epilepsy
Ketogenic diet
- 4:1 fats to protein and carbohydrates
- May be useful in children
- Difficulty with compliance
The extremely high fat ketogenic diet seems to improve seizure control for a limited number of patients, more frequently children.
The mechanism by which this occurs is unknown.
Compliance with the regimen is problematic as it’s a distasteful diet. (No pun intended.)
Surgery for Epilepsy
- Extensive preoperative testing to determine eloquent areas (may include the use cortical stimulation to determine eloquent areas, such as the WADA test.)
- Prior to the surgery, subdural grids are placed.
These are internal EEG electrodes placed closely together that are laid over the areas of the brain where the seizure focus is thought to be. - The patient is videotaped and hooked up to a continuous EEG machine postoperatively.
- Seizure medications are withheld or reduced so that a seizure will be triggered.
- The results will help the neurologist and neurosurgeon decide if the patient is a surgical candidate.
- The epileptogenic focus must be identified and be unilateral.
- Usually these subdural grids are left in no longer than a week due to the risk of infection.
- Infection risk increases with each day.
Considerations
- Medically intractable epilepsy
- Feasibility of surgery
- Likelihood of success
- Risks and benefits are weighed.
- Surgery as an intervention for seizures is considered only when there is no control from medications.
(Usually multiple drugs have been tried over extended periods of time.) - Patients that are considered surgical candidates are often those who experience many recurrent seizures in a day and are unable to live normally either as a result of these frequent seizures or due to the side effects from the high doses of medications necessary to control the seizure activity.
*Complications of surgery include cranial nerve damage, hemorrhage, infection, and memory, speech, and/or visual deficits.
Vagal Nerve Stimulator
A non-surgical option that can now be offered is the vagal nerve stimulator.
It seems to be most useful for partial seizures.
The exact mechanism of action is not known.
The effect of the VNS controlling seizures was discovered by accident.
The vagal nerve lies between the carotid and the jugular vein. (It’s the only cranial nerve that is more easily accessible.)
The electrodes are wrapped around the left vagal nerve.
Medicines may be reduced with this
Status Epilepticus
Series of generalized seizures
- Clinical/electrical > 30 minutes
- Medical emergency
- Heavy metabolic load- low blood sugar
Respiration interruption and even arrest at peak, producing hypoxia
- Can lead to anoxia, cerebral edema, possible irreversible - brain damage and death
Precipitating factors – drug withdrawal, fever, infection
Medical Management-
- stop seizures (number one pirority) to promote adequate cerebral oxygenation
- Give Dilantin (Check Dilantin level) and lorazepam, Ativan, anti-seizure meds
- Airway, ET tube, O2
- Meds IV- if you can’t get an IV, give IM
- Monitored EEG,VS, labs to include lytes, glucose, med levels
- Position on their side
- Nothing in their mouth!!!
Nursing Management-
- Monitor respiratory and cardiac function
- Prevent injury to patient and self
- Suction/positioning
