Neuro Flashcards
Neuro assessment
- Onset? Description? Triggers? Note client’s general appearance?
- Mental Status
- Glasgow Coma Scale
- Pupil changes
- Strength?
- Reflexes?
- Onset (when it started); Description (location, how long sx persisted, how severe); Triggers/aggravating factors (did anything help relieve the sx); Note client’s general appearance and behavior (obvious signs of neurological deficit)
- Mental Status - alert, awake oriented x 3 (person, place, time) – x4 (situation); LOC (level of consciousness)
- Glasgow Coma Scale - eye opening, motor responses, verbal response(we like a score of 13-15)
- Pupillary changes (normal pupil size 2-6 mm) – Pupils Equal Round Reactive to Light and Accommodation (PERRLA)
- Hand grips/leg lifts/pushing strength of feet
- Babinski reflex (only normal in infant up to 1 year, abnormal in adult) – fanning of toes when the bottom of the foot is stroked
- Plantar reflex - normal in adults children >1 (curling of the toes when the bottom of the foot is stroked)
- Deep Tendon Reflex Scale
- 0 no response
- 1 hypoactive
- 2 NORMAL
- 3 slightly hyperactive
- 4 hyperactive w/ clonus (abnormal movements of foot)
- Document as 2+/4+
Glasgow Coma Scale
Eye Opening: Spontaneous - 4 Verbal command - 3 Pain - 2 No response - 1
Motor Response: Verbal command - 6 Localized - 5 Flexed Withdraws - 4 Flexes abnormally (decorticate) - 3 Extends abnormally (decerebrate) - 2 No response - 1
Verbal Response: Oriented talks - 5 Disoriented/talks - 4 Inappropriate words - 3 Incomprehensible sounds - 2 No response - 1
_____ is always #1 with neurological assessment
LOC (level of consciousness)
What does it mean if the adult has a Babinski reflex?
Severe CNS problem – tumor or lesion on the brain or spinal cord, meningitis, multiple sclerosis, Lou Gehrig’s disease
CT
a. With/without contrast (dye) – check for allergies
The client will need to sign a consent form prior to the test when using dye.
b. Takes pictures in slices/layers
c. Keep head still
d. No talking
MRI
a. MRI is better than CT
b. dye not usually used
c. magnet is used - no jewelry, credit cards, pacemakers
d. will be placed in a tube where client will have to lie flat.
e. Do fillings in teeth matter? No
f. Do tattoos matter? Old ones do w/ lead–Veterans could have shrapnel from IED’s/bombs
g. Will hear a thumping sound – tell client about this
h. What type of client cannot tolerate this procedure? Claustrophobic
i. Can talk and hear others while in the tube
PET scan
Nuclear image test to view parts of brain/any organ as it’s working
a. dx for Alzheimer’s, brain tumors, CVA (stroke), Parkinson’s, aspects associated w/ mental illness
b. need informed consent
c. client must inhale a radioactive gas or be injected w/ a radioactive substance
d. no contact with children or pregnant women for 24 hrs after scan
Cerebral angiography
X-ray of cerebral circulation using iodine dye
Go through the femoral/brachial artery (like ♡ cath)
a. Pre:
1) Check for allergies to iodine and shellfish
2) Well-hydrated/void/peripheral pulses/groin prepped
• Hydrate client promotes excretion of the dye after.
3) Explain they will experience facial flushing and metallic taste
4) Monitor BUN, Creatinine, UOP
5) Hold metformin
b. Post:
1) Bed rest for 4-6 hours; Monitor BUN, Creatinine, UOP
2) Major complication: Bleeding/hemorrhage (coz femoral artery was used), Embolus
• An embolus can go lots of different places: Arm, Heart, Lung, Kidney
• embolus in brain s/sx – change in LOC, one-sided weakness, paralysis, motor/sensory deficits.
Do a good baseline neuro exam to compare
EEG
a. Records electrical brain activity
b. Helps diagnose seizure disorders; Evaluate loss of consciousness and dementia
c. Screening for coma
d. Indicator of brain death
e. Pre-procedure:
• Hold sedatives - No caffeine
• Not NPO (drops blood sugar)
f. During procedure
• Will get a baseline first with client lying quietly; may be asked to hyperventilate or cough; if they are completely unconscious, clap hands in face, blow whistle in face.
Lumbar Puncture
- puncture site - lumbar subarachnoid space
- Purposes
- obtain CSF fluid to analyze blood, infection, tumor cells
- measure pressure reading w/ manometer and reduce CSF pressure
- administer drugs intrathecally into spinal canal
• Position - propped up over bedside table w/ head down and a lot of arch to the back like an angry cat or fetal position (chin to chest and knees flexed)
- inspect skin for infection
- CSF should be clear and colorless like water
• Post-procedure
- lie flat or prone 4-8 hrs
- increase fluids to replace lost fluids
- common complication: HEADACHE - pain increases when sitting/standing, pain decreases when lying down
- tx for headache - bed rest, fluids, pain meds, blood patch (for leaking–instant seal)
• BIG COMPLICATION:
- brain herniation: known high ICP = no lumbar puncture
- infection: bacteria can get into puncture site and into spinal fluid = cause MENINGITIS
Early Signs of ↑ ICP
- change in LOC - going into coma or subtle change in attention span
- speech slurred/slowed
- delay in response to verbal suggestion (slow to respond to commands)
- increased drowsiness
- restlessness w/o apparent reason
- confusion
Late Signs of ↑ ICP
• change in LOC -> stupor/daze -> coma
• Cushing’s triad (pressure in brain stem) - ↑BP, ↓HR, ↓RR
- systolic HTN w/ widening pulse pressure;
- slow, full, bounding pulse;
- irregular RR pattern (Cheyne stokes or ataxic)
Decerebrate and Decorticate Posturing
- responses to painful or noxious stimuli = indicates motor response centers of brain, mid-brain, brain stem are COMPROMISED
- may posture on one side only
- may have different posturing on each side
Decorticate
arms flexed inward and bent in toward the body and legs extended (GCS score 3 in motor responses)
De “Cor” ticate is towards the “CORE: of the body or inward flexion; think “wakanda” pose
Decerebrate
present with all 4 extremities in rigid extension
WORST (GCS score 2 in motor responses)
Decerebrate is away from the body
Complications of ↑ ICP
- BRAIN HERNIATION - obstructs blood flow to brain leading to anoxia (no O2) = BRAIN DEATH
- DI and SIADH (head things, think ADH)
Complications of ↑ ICP
- BRAIN HERNIATION - obstructs blood flow to brain leading to anoxia (no O2) = BRAIN DEATH
- DI and SIADH (head things, think ADH)
Treatment for ↑ ICP
Goals: Reduce cerebral edema, reduce amt of CSF, reduce blood volume in brain
a. Maintain oxygenation: (acidosis/↑CO2) = ↑ ICP
b. Maintain adequate cerebral perfusion
- ↓BP, ↓HR = ↓ brain perfusion
- give isotonic NS and inotropic agents: dobutamine (Dobutrex) and norepinephrine (Levophed) – short term only – these are EMERGENCY drugs
c. Keep temperature <100.4 F (38 C)
- ↑temp = ↑ ICP
- cooling blanket and hypothermia as tx to ↓ metabolic demands of brain
d. elevate HOB (this ↓ ICP)
e. keep head midline so the jugular veins can drain
f. watch ICP monitor w/ turning
- if ICP has not come back down in 15 mins after turning client = NOT tolerating that side very well
g. Avoid restraints, bowel/bladder distention, hip flexion, Valsalva, isometrics. No sneezing, no nose blowing
h. Limit suctioning and coughing (these ↑ ICP)
i. spaced nursing interventions – NO CLUSTERED CARE (mess w/ client = ↑ ICP); Fluid restriction (LESS VOLUME = LESS PRESSURE)
j. MONITOR THE GLASGOW COMA SCALE (<8 = intubate)
k. Monitor VS for Cushing’s triad - ↑BP, ↓HR, ↓RR
Rule: If the Glasgow coma scale is below 8, think ____
intubate!!!
ICP monitoring devices
- greatest risk? ____
ventricular cath monitor or subarachnoid screw
- INFECTION
tx for ↑ ICP: Barbiturate
induced coma - decreases cerebral metabolism: phenobarbital (Luminal®)
tx for ↑ ICP: Osmotic diuretics
mannitol (Osmitrol®) → pulls fluid from brain cells → filter it thru kidneys = ↓ ICP
mannitol ↑ circulating blood volume = ↑ workload of the heart
tx for ↑ ICP: Hypertonic saline (3%)
acts like osmotic diuretic → pulls fluid from brain = reduce cerebral edema
tx for ↑ ICP: Steroids
dexamethasone (Decadron)
- used to decrease cerebral edema when a tumor is cause of ↑ ICP
Meningitis definition, causes, s/sx
- inflammation of the covering of spinal cord and brain
- causes: either viral or bacterial infection
S/SX • chills, high fever • severe headache • disorientation → coma • N/V • nuchal rigidity (stiff neck) • photophobia (light hurts the eyes) • seizures • (+) Kernig - severe stiffness of the hamstrings, inability to straighten leg when hips flexed 90° • (+) Brudzinki - severe neck stiffness causes hips and knees to flex when neck is flexed
Meningitis definition, causes, s/sx
- inflammation of the covering of spinal cord and brain
- causes: either viral or bacterial infection
S/SX • chills, high fever • severe headache • disorientation → coma • N/V • nuchal rigidity (stiff neck) • photophobia (light hurts the eyes) • seizures • (+) Kernig - severe stiffness of the hamstrings, inability to straighten leg when hips flexed 90° • (+) Brudzinki - severe neck stiffness causes hips and knees to flex when neck is flexed
Traumatic Brain Injury: (injury = damage to brain)
Closed TBI and Open TBI
a. Closed TBI - not broken/fractured/penetrated → dura not torn
b. Open TBI - broken/fractured/penetrated → dura is torn
- Basilar fx - MOST SERIOUS
- w/ basilar skull fractures you see bleeding where? EENT (eyes, ears, nose, throat)
- Battle’s sign: bruising over mastoid (bone behind ear)
- Raccoon eyes (peri-orbital bruising)
- Cerebrospinal rhinorrhea - leaking spinal fluid from nose (let it flow freely until it heals itself)
- how do we tell CSF from other drainage? (+) for glucose and the halo test (form ring around blood spot)
- Non-depressed skull fractures usually do not require surgery; depressed do require surgery.
Focal Injuries: Contusions
seen w/ blunt trauma or acceleration-deceleration injuries like a whiplash
- brain is bruised and damaged (mild to severe)
Focal Injuries:
Contusions
from blunt trauma or acceleration-deceleration injuries like a whiplash
- brain is bruised and damaged (mild to severe)
Focal Injuries:
Hematomas
solid swelling of blood clot
- small hematoma that develops rapidly = fatal
- massive hematoma = allow client to adapt
TBI Intracranial Hemorrhage:
Epidural Hematoma
EMERGENCY!
• rupture/laceration of middle meningeal artery (fast bleeder under high pressure)
• Pathophysio
Injury → Loss of consciousness → Recovery period → Can’t compensate any longer → Neuro changes (agitation, restless, confusion, pupil changes, seizures, posturing)
• Tx: Burr Holes to remove clot and control ICP.
Ask questions to identify the type of injury and treatment needed:
• Did they pass out and stay out?
• Did they pass out and wake up and pass out again?
• Did they just see stars?
TBI Intracranial Hemorrhage:
Subdural Hematoma
• Pathophysio
collection of blood between dura and brain
Usually venous
Can be acute (fast), subacute (medium), or chronic (slow)
• Tx:
- Acute: immediate craniotomy and remove clot: control ICP
- Chronic: imitates other conditions; DRUNK, Bleeding and compensating
Neuro changes= maxed out
Could have fallen a month ago
Normal Lab Value: ICP: 0-15mm Hg
Diffused Brain Injury:
Concussion
- temporary loss of neurologic function w/ complete recovery
- short period of unconsciousness or may just get dizzy and see spots
- DO NOT ADMINISTER OPIOIDS OR OTHER SEDATING MEDS!
After a concussion and client is sent home–Teach caregiver to bring client back to ED if the following occur:
DIFFICULTY AWAKENING/SPEAKING Confusion Severe headache Vomiting Pulse changes Unequal pupils One-sided weakness
*signs that ICP ↑
Nursing care for possible head injury or increased ICP
a. Assume a c-spine injury is present until proven otherwise.
• How do we prove otherwise? With an X-ray
b. Keep body in perfect alignment.
c. Keep slight traction on head.
d. How do you tell CSF from other drainage?
• Positive for glucose; halo test
e. Ensure adequate nutrition
f. Need increased calories, hypermetabolic state
g. Steroids increase breakdown of protein and fat. Steroids decrease cerebral edema
h. Cannot have NG feedings if having CSF rhinorrhea. Don’t want feeding to get into brain
i. When a client emerges from a coma→ lethargic→ agitated
• No restraints because restraints will make your ICP go up.
j. Need a quiet environment- stimuli could promote seizure
k. Pad side rails
l. No narcotics
• Affect your neuro checks
*morphine makes pin point pupils
m. Normal ICP = < 15
n. ICP varies according to position.
• We elevate the HOB to decrease ICP
o. The brain can compensate only to a certain point as the skull is a rigid cavity.
Spinal cord injury
Autonomic dysreflexia/Hyperreflexia
LIFE-THREATENING NEUROLOGICAL EMERGENCY - w/ upper spinal cord injury (above T6)
*Sudden onset!!!
S/SX: • severe HTN and headache • bradycardia • nasal stuffiness • sweating on forehead • blurred vision • nausea • anxiety
If Autonomic dysreflexia is NOT treated, what happens?
hypertensive stroke
Autonomic dysreflexia Causes
- distended bladder
- constipation/impaction
- stimuli to skin: pressure, pain, temperature
Autonomic dysreflexia Treatment
- Sit the client up to ↓BP or put bed bound client in semi fowlers
- Treat the cause
- insert a catheter
- remove any impaction (w/ topical anesthetic)
- look for skin pressure, pain stimuli, or a cold draft/breeze in the room - Antihypertensives if BP is still high after stimulus is removed
- Teach prevention measures
12 Cranial nerves
"On Old Olympus Towering Top A Find And German Viewed Some Hops" Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear (auditory) Glossopharyngeal Vagus Spinal accessory Hypoglossal
