Neurological Flashcards
1
Q
Increased Intracranial Pressure
A
High pressure inside cranium which puts increase pressure on the brain, eventually crushing the brain stem which controls breathing and heart rate = eventually kills patient
2
Q
ICP Causes
A
Increased Blood - Stroke
Increased pressure in the brain
Head trauma
Meningitis
Increased brain tissue
3
Q
ICP Pathophysiology
A
Increased pressure that compresses the brain
Compresses blood vessels that carry oxygen to the brain
Less blood means less oxygen resulting in a change of LOC (cerebral hypoxia)
4
Q
Earliest Sign of ICP
A
Reduced LOC or Decreased mental status
5
Q
ICP Early signs and symptoms
A
Altered LOC: irritability, restlessness
Decreased mental status
Sleepiness
Flat affect and drowsiness
6
Q
ICP Moderate Signs
A
Headache: Constant
Sudden vomiting without nausea
7
Q
Late Deadly signs and symptoms
A
Cheyne stokes respirations
Neck: Nuchal rigidity (stiff neck)
Cannot flex chin towards chest
8
Q
Symptoms off ICP if brainstem is involved
A
Brain stem affected:
Eyes: pupils sized and dilated, unequal
8mm (normal 2-6)
Foot: Babinski reflex (toes fan out when stimulated = BAD
Seizures and coma
Abnormal posturing
Decorticate
Decerebrate
9
Q
priority assessment findings for a client recovering from a bad trauma
A
Extremities that contracted to the core of the body
Fixed pupils that remain 8mm when assessed with a pen light
Toes that can out when the sole of the foot is stroked
10
Q
Cushing Triad
A
Low HR
Low RR
Wide pulse pressure (BP numbers farther apart from each other)
High BP
11
Q
ICP Diagnostics
A
CT scan
No lumber puncture - can cause worsening ICP
ICP monitoring: Normal ICP between 5-15
12
Q
Client found non the floor, appearing lethargic bleeding at the back of head, heart rate of 45 bPM and a BP of 220/88. What is your first action?
A
Immediate C spine and CT scan to rule out intracranial bleed
13
Q
ICP Nursing Interventions
A
immobilize head
Long roll as one unit
CO2 is low = low ICP
HOB semu fowlers - 30-35%
No flexion and bending extremities
No coughing, sneezing, blowing nose
no valsalva maneuvers
Suctioning: 1only when necessary 0 seconds or less, 100% O2 before and after suctioning
14
Q
GCS Score
A
15 = Highest score
8 = Intubate
3 = lowest score
Report decreasing GCS
15
Q
ICP Treatment
A
1 drug to know: Mannitol - osmotic diuretic
Seizure prevention: Phenytoin
Swellin: Dexamethasone. Phenoobarbital
16
Q
Immediate intervention when a client with ICP states…
A
I will turn, cough and deep breath
17
Q
Viral/Bacterial Meningitis
A
The inflammation of the meninges which is the inner lying of the brain and spinal cord
This Inflammation can cause massive swelling in the cranium putting lots of pressure non the brain and leading to deadly ICP
18
Q
Causes of Meningitis
A
Infection: Viral or bacterial
*Bacterial = bad, most contagious
Viral = Very common, most tested
Head trauma
Autoimmune disease - lupus
19
Q
Signs and Symptoms of Meningitis
A
Headache and Photophobia
Hard stiff neck “Nuchal rigidity”
High Temp “Fever”
20
Q
Signs and Symptoms Meningitis Paediatrics
A
High pitched Cry
Bulging Fontanella
21
Q
3 Layers of Meninges
A
Meninges are comprised of three layers
Dura mater
Arachnoid mater
Pit mater
22
Q
Meningitis Diagnosis
A
Positive Kernig sign
lying on back and straightening leg, very painful if patient has meningitis
Positive Brudzinski Sign
When neck is flexed, hips and knees also flex
CT Scan done before lumbar puncture (lumbar puncture can worsen ICP)
LP (lumbar puncture, spinal tap)
Test the CSF - cerebrospinal fluid for infection
Viral - Very clear
Bacterial - Bad cloudy
Both will have elevated WBC count since there is an infection inside the body
23
Q
Nursing Care Lumbar Puncture
A
Have pt empty their bladder
Pt lying, round back pulling their knees too their chest like a cannonball for over bedside table
Never prone
Monitor insertion site dressing for clear fluid - report this to HCP immediately
24
Q
Meningitis Interventions
A
Place client on droplet precautions PPE comes first
Blood cultures
Give antibiotics
Fluids
25
Client is admitted for bacterial meningitis with a BP off 78/56 priority action?
Admin bolus of IV normal saline
26
Client with suspected meningitis, when neck flexes, the hip and knee also flex. Priority action?
Immediately report this finding to the HCP
27
Stroke
Also called CVA (cerebrovascular Accident)
Happens when the brain lacks oxygen typically due to clot in blood vessel that cuts off oxygen supply to the brain - Brain begins to die
28
TIA
Transient Ischemic Attack
Come and go and often resolve themselves
29
CVA
cerebrovascular Accident
NO oxygen = permanent damage
Two types
Ischemic: Clot = low O2
Hemorrhagic Bleed = HIGH ICP
30
Risk and Cause Stroke
Hypertension (over 140 sys)
Instruct pt to take antihypertensive medications regularly
31
over 200 systolic intervention
Keep systolic BP above 170 mmHg for the first 24-48 hours
Lower the BP slow and smooth no big drops
32
Stroke Causes
Smoking
Hyperlipedemia (high cholesterol)
uncontrolled diabetes
Increased risk for clots (afib)
33
stroke Signs and symptoms
Hemiparesis - Unilateral weakness: one sided weakness
New, sudden “arm drift”
FAST
Facial and smile drop
Arm drift
Speech impairment
Time to call 911 (CT scan immediately)
1 hour to seek medical attention
34
Hemorraghic Stroke Sign and Symptoms
Key sign: Severe headache
“worst headache of my life"
35
Stroke Affect on Body
Left sided stroke affects right side of body
Right sided stroke effects left side of body
36
Left Brain
Controls the L’s
Language and Logic
Dysphasia
Reading or writing problems
Right Hemiparesis
Right side neglect
37
Right Brain
Lack of impulse control
Behavioural changes
left side neglect
Left hemiparesis
38
Teaching for families of patients with right-sided brain injury
Lack of impulse control and behaviour changes
39
Stroke Diagnostic
CT scan immediatly to rule out type of stroke
40
Treatment for Ischemic Stroke
Clots: thrombolytics within 4.5 hours of onset of symptoms
ex. TPA, alteplase, streptokinase
41
Treatment for Hemorrhagic Stroke
Implement seizure precautions
No blood thinners
No aspirin and clopidogrel
No heparin and enoxaparin
No warfarin
No thrombolytics
Limit any activity that may increase ICP
Administer PRN stool softeners daily to precent straining
42
Interventions for initial plan off care for patient with suspected embolic stroke
Obtain a STAT CT of the head
Perform neuro assessment
Prepare to initiate alteplase with 4.5 hours of symptom onset
43
Priority nursing action for a patient with left sided weakness, lack of verbal response and dropping face
Maintain patient airway
44
Patient Education Hemianopsia
Half vision
Risk off self neglect
Dress the weaker side first
Apply clothing soon affected side first
Safety:
scan surroundings ed side
Turn head to the affected side
Approach patient from unaffected side
45
Stroke Nursing Interventions
NPO until swallow screen
Eating: protect airway
1. FLex neck while swallowing
Avoiid sedating med before meals
HOB up - high fowlers “upright”
Dysphagia (diff swallowing)
Puree diet
add thinking agent to fluids
Implement seizure precautions
Frequent neurological assessments
Cluster Care
Use transfer belt when transferring: strong side first
Avoid completing tasks for the client
46
Prevention of sensory overload in client with stroke
Obtain vitals and assist with morning care in one visit
47
The nurse provides instructions too help the client perform ADL's
Paiently allow time to understand each instruction
Simple gestures (point) and show pictures
Ask yes or no questions
Normal voice not too loud
48
Broca Aphasia
Expressive
Easily frustrated attempting to speak
can understand but not speak
Speech limited to short phrases
49
Wernicke Aphasia
Receptive
Can speak but does not understand
Unable to comprehend speech
50
Epilepsy
Epilepsy, which is sometimes called a seizure disorder, is a disorder of the brain. A person is diagnosed with epilepsy when they have had two or more seizures.
51
status epilepticus
A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death.
52
Seizures
What are seizures? Seizures occur when abnormal electrical signals are being rapidly fired for neurons in the brain. This can happen throughout the brain affecting both sides (generalized seizure) or being located in a specific area of the brain (partial or focal seizure).
53
Types of Seizures
Tonic seizure: stiffening of the body, risk for falling
Clonic seizure: jerking, can be symmetrical or asymmetrical
Tonic-clonic: looses consciousness will experience a tonic phase then a cloning phase - usually no more than 3 minutes at risk for status epileptics with this type of seizure
54
Seizure duration
if greater than 5 minutes or having multiple seizures in a row…activate emergency response team (will need immediate treatment to stop seizure (more on this in the nursing interventions)
55
Absense Seizure
most common in paediatric patients
hallmark: staring into space
seems like child is daydreaming but can’t be snapped out of it
56
Myolconic Seizure
Quick duration of jerking of the muscles, pt is aware and conscious
Very short... few seconds
57
Nursing Interventions for seizures
Seizure precautions may include:
at bedside have suction and oxygen ready
IV access (to given anti-seizure medication, if needed)
padded side rails
pillow under head (to protect head)
bed in the lowest position
remove objects that can cause injury (remove any restrictive clothing or items the patient may be wearing….eye glasses etc. )
58
What to do when your patient has a seizure?
Protect patient if they are standing up or sitting down
Turn them to they side
Do not restrain patient or try to hold them down
Protect head and extremities (pillow and bed pads help with this)
Doo not put anything in the patients mouth
Remove anything that can impede breathing
Note the time it started and Stopped
59
Multiple Sclerosis
Auto immune disease where body attacks the myelin sheaths
Muscle spams and stiffness
60
Myelin Sheaths
Protective layer of fatty tissue around the nerve cells in the central nervous system (brain and spinal cord) which help the body move by sending electric impulses from the brain to the rest of the body
61
Diagnosis MS
MRI and CT scan
3-1mm sclerotic brain plaques on MRI
Lumbar spinal punture
Elevated gamma globulin in cerebrospinal fluid (CSF)
62
Causes MS
Specific causes are unknown
Linked to genetics - female
Environmental factors: infection and vitamin D
63
MS Signs and symptoms
Can look perfectly fine on the outside but on the inside they can have
burning sensations
Numbness and tinglig
Key Signs:
Muscle spasticity
Weakness
Ataxia
Urinary retention
Hyperreflexia off extremities
Decreased concentration
fatigue
Paralysis
Eye and vision problems
64
MS patient education
Balance exercise with rest
Avoid 4’s = trigger flare ups
65
MS triggers
Stress (exercise, surgery, injury)
About sickness or sepsis
Avoid smoking
aAvoid sun and extreme heat (hot tub, bath sauna)
66
Which action requires immediate intervention...patient with MS
Preparing to place a client with MS in a bath tub with hot water
67
Which instructions regarding techniques to avoid fatigue with multiple sclerosis?
rest in air conditioned surroundings
68
MS Treatment
IVIG
Interferon
Steroids - Prednisone
Muscle relaxants - Baclofen
cyclosporine - immunosuppressant
69
Parkinson's Disease
Progressive disorder
Unlike MS and MG (body attacking itself)
Your body progressively stops making dopamine
When your body stops making dopamine the messages from the brain to the body do not get relayed = breakdown in central nervous system = breakdown in motor function of all out other muscles
Low dopamine
High acetylcholine
70
Signs and Symptoms Parkinson's
Progressively slow movements
Freezing and rigidity walking
Shuffling gait - decreased arm swinging
Pill rolling
Tremors at rest
No expression face
Balance problems
71
Parkinsons Diagnosis
No way to diagnosis
Only S/S
Writing test - writing gets smaller
72
Parkinsons Pharmacology
Levodopa and Carbidopa
Avoid Protein (levodopa)
73
Myasathesin Gravis
It’s an autoimmune condition where the body attacks the receptors that allow for voluntary muscle control, which leads to muscle weakness.
74
What voluntary muscles are involved In MG?
Eyes: most likely will be the first sign something is wrong
Throat: another common sign…hoarse voice and problems swallowing
Face
Arms/Legs
Respiratory muscles for breathing (in severe cases)
75
Signs and Symptoms of Myasthenia Gravis
HALLMARK: muscle weakness becomes worse with activity (especially repetitive activity) but will improve after resting the muscle.
Weakness neck, face, arms/legs/hands
Eyelid drooping
mask-like: no expression…looks very sleepy
choking or gagging when eating (difficulty swallowing)
No energy…very fatigued…gets worse throughout the day as muscles are used
double vision
Slurred speech
Short of breath (can extend to respiratory muscles)
76
Complications of Myasthenia Gravis
Myasthenia gravis can go into remission where the patient doesn’t have signs and symptoms, but some patients can experience severe acute exacerbation with a complication called Myasthenic Crisis.
This is where the disease is becoming worse and the patient may need intubation and mechanical ventilation to breathe.
Risk factors for experiencing Myasthenic Crisis: improper dosage (not enough) of anticholinesterase meds to treat this condition, stress (physical…surgery or mental), and respiratory infection.
77
cholinergic crisis
A cholinergic crisis develops as a result of overstimulation of nicotinic and muscarinic receptors at the neuromuscular junctions. This is usually secondary to the inactivation or inhibition of acetylcholinesterase (AChE), the enzyme responsible for the degradation of acetylcholine (ACh)
78
Signs and Symptoms of Cholinergic Crisis:
Think of the signs and symptoms experienced during cholinergic crisis similar to the parasympathetic nervous system being in overdrive:
Pupil constriction
Bronchoconstriction….eventually respiratory failure
Increased salivation and mucous production
GI problems: abdominal cramping, vomiting, diarrhea
Bladder incontinence
Bradycardia
79
Huntington's Disease
Progressive brain disorder that causes u controlled movement, emotional problems as well as dementia
Autosomal dominant genetic disorder
Symptoms: Chorea with chorea we have abnormal excess involuntary movements
Cognitive issues: memory loss, poor impulse control, psychiatric issues - depression, mania, personality changes
No cure, help manage symptoms of chorea
80
Huntington's Disease Symptoms
Symptoms: Chorea with chorea we have abnormal excess involuntary movements
Cognitive issues: memory loss, poor impulse control, psychiatric issues - depression, mania, personality changes
No cure, help manage symptoms of chorea
81
Alzheimer's
It’s a chronic brain disease that is a type of dementia.
It occurs because neurons in the brain lose the ability to communicate and eventually die.
This is mainly due to the development of plaques and tangles. These plaques and tangles lead to a progressive loss of the ability to:
problem solve, communicate, recall memories, perform everyday tasks, and care for one self
patients will be completely dependent on someone for care. It is not reversible and no cure is currently available. Medications are available to help manage symptoms.
82
Signs and Symptoms Alzheimers
Apraxia: Inability too perform certain motor activities
Aphasia: cannot understand speech for create speech
Agnosia: Cannot recognize everyday objects, people or interpret their senses (taste, sound,smell)
Amnesia: memory loss
Anomia: Inability to recall name off objects
83
Stages of Alzheimer’s Disease
Preclinical Alzheimer's disease: Changes occurring in the brain but no symptoms noted
Miild Cognitive impairment: Memory changes that are subtle but doesn’t affect their activities
Cant think clearly
Mild Alzheimers (early stage)
Miild forgetfulness that is noticed by others, losing objects, can’t remember new material just learned, asking the same questions, language problems, mental inability
Moderate Alzheimer's disease
Confusion sets in that affects how patient functions and they need help
Jugement is lapsed
Sundowners syndrome
Must be monitored at all times
Severe Alzheimer's (Laye stage)
Language communication and motor activities very limited
Problems swallowing and eating
Need contact care
84
Treatment for Alzheimers
Not treatment
Early detection is key in helping patients prepare and get treatment to help symptoms
85
Alzheimers Diagnosis
No conclusive test
Cognitive assessment
CT scan, MRI look at brain changes and rules out other causes
86
Nursing Interventions Alzheimers
Reorient patient
Remind them soon things they have forgotten
Movement: keep patient as independent as possible
Mental health: keep clam during outbursts, provide with distractions
87
Delirium
Acute and sudden onset but is transient and reversible
caused by metabolic imbalances, infections and toxins.
Can Change LOC and behaviour, cause hallucinations and sleep problems
88
Gullen Barre Syndrome
It’s an autoimmune neuro condition where the immune system attacks the nerves in the peripheral nervous system and cranial nerves.
Attacked the myelin sheath
Different from MS since that was attacking nerves in the central nervous systems
89
Cause of Gullen Barre Syndrome
that GBS can happen to any person at any age! There is currently no cure, but treatment can help decrease signs and symptoms if started within 2 weeks of symptoms
Some people start to have symptoms after an infection
90
Signs and Symptoms Guillain barre syndrome
Inability to regulate body temperature
blood pressure issues (orthostatic hypotension and paroxysmal hypertension)
cardiac dysrhythmias
Paralysis, weakness, tingling sensation in lower extremities, migrates upward over time
Severe pain like muscle pain/cramps
Symptoms peak at about 2 weeks
91
Guillain barre syndrome Diagnosis
Electromyography
Lumbar puncture: elevated protein without elevated white blood cells
92
Nursing Interventions GBS
Focus: Respiratory, blood clots (immobility) risk for PE and DVTs, heart rhythm, blood pressure issues, nutrition, infection (urinary retention and lung from vent or pneumonia), pain, pressure injuries, atrophy of muscles, extreme fear
93
CNS nerve disease
brain and spinal cord
MS
Parkinsoons
Alzemiers
Huntington disease
94
PNS Nerve diseases
MG myasthenia Gravis
ALS amyotrophic lateral sclerosis
Guillain Barre syndrome
95
For all Nervous system diseases
No meds or intervention will cure
Key tip:
Promote indepence
Never do all ADLS for the pt
Gait training
96
The nurse is planning care with a client newly diagnosed with myasthenia gravis. Which is an appropriate goal to establish?
Maintain respiratory function
In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure.
97
The nurse is administering eye drops to a client with glaucoma. Which technique is correct for instilling the eye drops?
in the lower conjunctival sac
98
The nurse observes that when a client with Parkinson disease unbuttons their shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors?
The tremors sometimes disappear with purposeful and voluntary movements.
99
A client has chronic open-angle glaucoma. (COAG). What should the nurse ask the client about when conducting a focused assessment?
decreasing peripheral vision
100
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?
C5
101
An older adult has vertigo accompanied by tinnitus as the result of Ménière disease. The nurse should instruct the client to restrict which dietary element?
sodium
102
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing
raccoon's eyes and Battle's sign.
103
The nurse would expect to identify which acid-base disturbance? myasthenia gravis
respiratory acidosis
Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.
104
The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client?
elevating the head of the bed to 30 degrees
105
A client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out?
Administer atropine sulfate. Atropine sulfate causes pupil dilation. This action is contraindicated for the client with glaucoma because it increases intraocular pressure.
106
A client has chronic open-angle glaucoma. (COAG). What should the nurse ask the client about when conducting a focused assessment?
decreasing peripheral vision
107
A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen?
muscle spasms with paraplegia or quadriplegia from spinal cord lesions
108
After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question?
performing a lumbar puncture
109
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
absence of reflexes along with flaccid extremities
110
Acute angle-closure glaucoma:
Is a medical emergency that can rapidly lead to blindness.
111
When completing a nursing assessment on a client admitted with a neck injury, which findings would indicate an incomplete spinal cord injury (SCI)?
vidence of voluntary motor and sensory function below the level of injury
112
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?
increased restlessness
113
A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply.
Monitor the body for any skin rash
Perform good oral hygiene, including daily brushing and flossing
Receive necessary periodic blood wok
Report any problems with walking or coordination, slurred speech, or nausea
114
The client asks when they can stop taking the eye medication for chronic open-angle glaucoma. What should the nurse tell the client?
Use the eye medication for the rest of their life.
115
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
keeping the client in one position to decrease bleeding
116
A client uses timolol maleate eye drops. What is the expected outcome of this drug?
educing aqueous humor formation
117
The adult child of an older adult reports that their parent just “stares off into space” more and more in the last several months but then eagerly smiles and nods once the son can get their attention. What additional assessment should the nurse make to better understand the client’s behavior?
hearing loss
118
The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.
Turn and position every 2 hour
Perform passive range of motion on the affected side
Support the affected side with pillow
119
The nurse administers mannitol to the client with increased intracranial pressure (ICP). Which parameter requires close monitoring?
intake and output
120
The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestations?
an exaggerated sense of well-being
121
The nurse is teaching a client with Ménière disease to recognize when they might have an attack. What should the nurse tell the client to recognize as an indication they might have an attack?
a feeling of inner ear fullness
122
Cerebellum
The cerebellum is the portion of the brain that controls balance and fine and gross motor function. The cerebellum is located at the base of the skull and above the brain stem.
123
A client in a nursing home is diagnosed with Alzheimer's disease. The client exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease?
Stage 2
