Neuro Exam 3 Flashcards
intracranial compliance
ability of body to compensate for increased intracranial pressure
increased intracranial pressure
occurs when brain tissue, CSF, or blood increase causing the other components to decrease –> further injury r/t compression of tissue
causes of IICP
injury
bleeding
hematoma
hydrocephalus
tumor
encephalitis / meningitis
factors that influence ICP
body temp
oxygenation status
body position
arterial / venous pressure
vomiting / bearing down –> pressure in intra-abd wall
normal ICP
0-15 mmHg
increased ICP range
pressure > 20 mmHg for 5 min or more
**sustained IICP = herniation
cerebral perfusion pressure (CPP)
pressure that pushed blood to the brain
**when it is too low the brain is not perfused –> brain tissue DEATH
CPP range
60-100 mmHg
**MUST be maintained at 70 for those with brain injury
CPP formula
CPP = MAP - ICP
early s/s of IICP
DECREASED LOC!!!
restless
confused
not responding
**any mental status changes are early sign
late s/s of IICP
irregular breathing - Cheyne Stokes hyperventilation –> apnea!!!
Cushing’s Triad
babinski reflex
HA
seizure
posturing
doll’s eye
vomiting
Cushing’s triad
increased systolic BP / decreased diastolic BP
bradycardia
irregular RR
decerebrate posturing
arms beside body
hands flexed
forearm pronated
**more ominous posture
decorticate posture
arms pulled into body , hands flexed
IICP monitoring
catheter or sensor
-subarachnoid bolt
-intraparenchymal sensor
-intraventricular catheter
subarachnoid bolt
bolt / screw inserted into hole drilled into skull and threaded into place at inner table of skull
-decrease infection risk
-inability to drain CSF, risk of bolt becoming occluded w/ blood, tissue, dura
-increase risk of drifting
intraparenchymal sensor
inserted below dura into white matter of frontal lobe
-less drifting overtime
-CSF not able to drain
intraventricular catheter
used for monitoring ICP and DRAINING CSF
-MUST be leveled to external auditory meatus of ear
-drainage controlled by raising or lowering collection burette
-high infection risk and bleeding
IICP dx labs
ABGs
CBC
coagulation
electrolytes
serum osmolality
urinalysis and osmolality
IICP dx tests
CT
MRI
cerebral blood flow with transcranial doppler
EEG
IICP surgical management
remove section of cranium and dura to allow space for swelling brain
**hemicraniectomy
IICP medical management
- oxygenation
- diuretics
- fluids
- BP management
- seizure precautions
IICP oxygenation
-mechanical ventilation
-MAINTAIN PaO2 > 80 mmHg
-MAINTAIN PaCO2 > 35-45 mmHg
**DO NOT allow hyperventilation
IICP diuretics
reduce brain tissue volume
-osmotic = mannitol and hypertonic saline
-loop = lasix
mannitol diuretic
need good kidney / heart function
use FILTER NEEDLE
strict i/o management
IICP fluids
optimize MAP
-normal saline
-i/o
-serum osmolality < 320
IICP blood pressure
MAP 70-90 mmHg
CCP at least 70 mmHg
**AVOID HTN
HTN can cause….
increase cerebral blood volume
use antihypertensives –> nicardipine and labetolol
IICP seizure precautions
dilantin
fosphenytoin
keppra
valium
ativan
**all prophylaxis
IICP sedatives
morphine
versed
fentanyl
propofol
**reduce pain, agitation, restlessness
IICP neuromuscular blockade or barbiturates
used for pts unresponsive to other tx
**pts MUST have arterial pressure monitor, mechanical sedation, and intensive nursing management
IICP nursing actions
HOB 30-35 degrees!!!
head midline
no flexion of neck / hips
suction only when necessary
neuro exams
vitals
ICP and CPP measurement
temp control
sedatives
IICP suctioning protocol…
suction as needed
10-15 seconds –> coughing when increases ICP
HYPERVENTILATE before and after!!!
IICP temperature control
cooling blankets , ice packs placed in axilla and groin , centrally placed catheter with cooling water flow
serum sodium / osmolality
monitor after mannitol administration
serum sodium ensures pull of water out of brain tissue
-160 mEq / L !!!
IICP EKG
monitor rhythm , catecholamines released in body at time of injury increasing risk of cardiac injury
Traumatic brain injury risks
alcohol use
drug use
sports
not wearing seat belt
men
very young / very old
TBI classification
based off Glasgow Coma Scale (GCS)
-mild = 13-15
-moderate = 9-12
-severe = 8 or less
GCS of 8…
INTUBATE
TBI phases
primary (Coup) - initial impact
secondary (Contrecoup) injury - rattling around of brain
**want to prevent secondary injury
TBI types
- skull fracture
- concussion
- contusion
- penetrating
- diffuse axonal injury
- epidural hematoma
- subdural hematoma
- subarachnoid hematoma
- subarachnoid hemorrhage
linear skull fracture
hallmark sign of basilar skull fracture = visualization of fluid from ear / nose (LEAKING OF CSF)
-CSF will separate from blood on gauze
-NO SUCTION, NO blowing nose, NO tubes
-HOB elevated
-neuro check
-pat fluid w/ gauze
late s/s of basilar fracture
bruising around eyes (raccoon eyes) or ears (battle’s sign)
depressed skull fracture
scalp is lacerated and dura is torn –> meningitis
comminuted skull fracture
multiple linear fractures , “eggshell fracture”
concussion
structural injury does not appear on imaging damage occurs at cellular level
-CAN go to sleep if someone else is w/ them
contusion
superficial bleeding on surface of brain
can expand to hematomas or cerebral edema
-frequent neuro assessments to see development of cerebral edema or hematoma
diffuse axonal injury (DAI)
widespread white matter axonal injury , vasodilation –> increased cerebral blood volume –> IICP
epidural hematoma
collection b/t inner table of skull and dura
-associated with linear fracture
**typically will have brief LOC followed by lucid period before deterioration
epidural hematoma deterioration
LOC decrease
contralateral deficits
pupil on side of lesion becomes fixed and dilated
**emergency neurosurgery to get rid of hematoma , ONLY TX
subdural hematoma
occurs when vein is torn around cerebral cortex
-acute
-subacute
-chronic
acute subdural hematoma
occurs within 48 hrs of injury , risk of death is high r/t expanding
subacute subdural hematoma
occurs 48 hrs - 2 weeks post injury , onset is later because hematoma grows slowly
chronic subdural hematoma
result of low velocity impact, seen in elderly / alcohol abusers / those taking anticoagulants
subarachnoid hemorrhage
most common, may be r/t cerebral aneurysm
local vasospasm occurs
subarachnoid hemorrhage s/s
horner’s sign
-miosis = pupillary constriction
-ptosis = eyelid drooping
-anhidrosis = decrease in sweating
TBI complications
SIADH
Diabetes Insipidus
-IICP
-herniation
-meningitis
diabetes insipidus
occurs w/ NO ADH
-rapid UO increase (polyuria)
-dehydration
-dry mucous membrane
-thirst
-diluted urine
diabetes insipidus tx
replace fluid losses and ADH w/ exogenous form IV , sub-q, intranasally
SIADH
excessive amount of ADH secreted
-retention of water
-weight gain
-low UO
-concentrated urine
-hyponatremia
SIADH tx
fluid restriction , 1000-2000 mL / day so UO exceeds intake sodium returns to normal
TBI medical management
-neuro assessment : GCS
-airway management
-hemodynamic monitor
-ICP
-lab test
-enteral nutrition : AFTER 72 hrs. of not eating
-seizure precaution
-temp control
TBI surgical management
skull fractures = debridement / clean wound
craniotomy
surgical evacuation of EPIDURAL and SUBDURAL hematomas
**surgery not indication for DAI b/c no specific blood removal
Parkinson’s Disease
loss of dopamine, Ach neurons proliferate still causing loss of initiation / control of voluntary movement
Parkinson’s diagnosis
2 or more symptoms with asymmetrical presentation…
-resting tremors
-muscle rigidity
-bradykinesia = slow movement
-akinesia = loss of movement
-postural instability = impaired balance
parkinson’s physical assessment
mood alteration
slow, shuffle gait
widened gait
postural instability
drooling
“pill rolling” tremor
cogwheel rigidity
masklike face
bowel / bladder function
Parkinson’s medications
anticholinergic meds
dopamine receptor agonists
Levodopa
entacapone
anticholinergic meds are avoided….
in OLDER POPULATION and GLAUCOMA
-confusion
-memory impairment
-blurred vision
-dry mouth
-constipation
-urinary retention
anticholinergic meds
Artane and Benzotropine
dopamine receptor agonists avoid….
cardiac / renal / psych disorders
-n/v
-drowsiness
-orthostatic hypotension
dopamine receptor agonist meds
Ropinirole and Pramipexole
Levodopa / Carbidopa
will take about 3 weeks to work
long term use includes “weaning off”
-nausea
-involuntary movements
Entacapone (Comtan)
use with Levodopa / Carbidopa
-blocks COMT enzyme that breaks down Levodopa allowing effects to last longer
Entacapone avoid….
MAO inhibitors
avoid foods high in vitamin B6
high protein meals
parkinson’s nursing action
- meds
- safety precaution
- nutrition intake
- elevate HOB when eating / drinking
- suction equipment @ bedside
- administer stool softener
- self care activities
- PT / OT / speech therapy
Parkinson’s education
MEDICATIONS
safety precautions - take short delicate steps,
psychosocial support - depression is common
dementia
progressive neurodegenerative disease : impaired cortical fxn
impaired cognitive fxn
umbrella term - Alzheimer’s most common
Alzheimer’s disease s/s
first symptoms = forgetfulness
difficult w/ language
short term memory loss
agnosia - inability to process sensory info
emotional lability
personality change
loss of cognitive skills
loss of executive functioning
Parkinson’s safety
shoes with rubber soles
beds low to ground
good nutrition
Alzheimer’s medication
- Donepezil
- Excelon
- Razadyne
**all increase Ach functioning
NMDA antagonist used for Alzheimer’s
memantine : decreases symptoms of dementia and cognitive decline
Alzheimer’s assessment
-weight , I/O
-bowel and bladder fxn
-skin assessment
-ADLs
-environment and safety!!!
-coping
Alzheimer’s action
- encourage feedings
- low bed, grab bars
- toileting routine
- clock / calendar
- routine walks
- calm speech
- diversionary activity
- activities during day to rest at night
Alzheimer’s teaching
-label substances and secure them
-monitor systems that will alert when family member tries to leave
-support groups
myasthenia gravis
no acetylcholine is binding resulting in skeletal muscle weakness, fatigue, ocular and bulbar symptoms
myasthenia gravis s/s
Weakness to neck, face, arms
Eyelid Drooping (ptosis)
Appearance masklike, no expression
Keep choking / gagging when eating
No energy
Extraocular muscle involvement
Slurred speech
SOB
**s/s get worse at night!!
myasthenia gravis tests
- serological testing
- repetitive nerve stimulation / electromyography
- single-fiber electromyography
- tensilon test
- CT chest scan
tensilon test
edrophonium given IV push, if NO change additional doses given every min.
**improvement within 5 min = positive test
myasthenic crisis
- NOT ENOUGH anticholinesterase meds
- stress
- respiratory infection!!!
- surgery
myasthenic crisis tx
IV immunoglobulin or plasmapheresis
cholinergic crisis
TOO MUCH anticholinesterase medication
cholinergic crisis s/s
bradycardia
muscle twitch
sweating
pallor
excessive secretions
small pupils
edrophonium antidote….
atropine –> anticholinergic
myasthenia gravis priority meds
Mestinon
Neostigmine
Immunoglobulin
Plasmapheresis
Immunotherapy
myasthenia gravis actions
meds
elevate HOB
speech consult
dietary education
MEDICATION
rest periods
medical alert bracelet
GET ALL VACCINES
pyridostigmine education
keep this medication on hand AT ALL TIMES…. need to take every 4 hrs
Guillain barre syndrome
occurs after infection progressing into rapid progressing flaccid paralysis
**resp / GI infections are most common
GBS patho
pts immune system begins to destroy the myelin around nerves eventually leading to paralysis
GBS s/s
-SYMMETRICAL ascending motor weakness / paralysis
-after first few days of weakness, neuro assessment diminished
**starts in the toes and up it goes
GBS dx
progressive weakness of 2 or more limbs
electromyography : slowed nerve conduction
Lumbar puncture
GBS tx
supportive care,
-IV immunoglobulin
-plasmapheresis
GBS actions
- respiratory assessment
- CN assessment
- Motor / sensory assessment
- pain assessment
- turn / ROM exercise
- VTE prevention
- method of communication
GBS CSF
will have protein but ABSENT WBCs
multiple sclerosis
neurological disorder where nerves of CNS degenerate
multiple sclerosis s/s
depends on location of affected nerve fibers :
-numbness / weakness of one or more limbs
-partial / complete vision loss , often with pain during eye movement
-double or blurred vision
-tingling or pain
-electric shock sensations w/ head movement
-tremor , lack of coordination , unsteady gait
-fatigue
-dizziness
-bowel / bladder dysfunction
MS tests
NO specific test, must have 2 separate symptomatic events or MRI changes in at least 2 separate locations
**rule out literally everything else
MS meds
-immunodulators
-immunosuppressants
-muscle relaxants
-corticosteroids
-anticonvulsants
-laxatives
complete spinal cord injury
total loss of motor function below level of injury
incomplete spinal cord injury
incomplete structural damage w/ some function below injury
spinal cord injury treatment
maintain airway
adequate breathing and oxygenation
prevent shock
spinal immobilization
restore / maintain BP
thoracic injuries s/s
autonomic dysreflexia
visceral distention from noxious stimuli - distended bladder, impacted rectum
gardner wells tongs
used for cervical traction, pressure control pins are inserted into skull, tongs are attached to wts
halo traction
maintain cervical mobilization, ring around pts head attached to special vest
**think regina george
spinal cord injury interventions
- respiratory assessment
- vitals
- pain management
- i/o
- spinal immobilization
- bowel sounds
- reposition
- ROM and VTE prophylaxis
