Neurological alterations pt 1

Question 1

The brain does not have energy stores; it is dependent on ___.

Answer 1

aerobic metabolism

Question 2

A brief interruption in blood supply-> significant ___

Answer 2

ischemic damage

Question 3

A change in mental status is frequently not a ____.

Answer 3

primary neurological issue, so always remember to assess for other causes.

Question 4

A drop in cardiac output will impact the ___

Answer 4

brain and other organs

Question 5

The CNS is composed of:

Answer 5

Brain, Spinal cord, and cranial nerves I & II

Question 6

The PNS is composed of:

Answer 6

Cranial nerves III-VII, Spinal Nerves, Peripheral components of the ANS

Question 7

2 types of cells:

Answer 7

neurons and glial cells

Question 8

Subjective neuro assessment includes:

Answer 8

1. PMH/PSH
2. Medications

3. Functional health patterns
Health perception
Nutrition/metabolic
Elimination (urine, BM)
Activity/exercise
Sleep-rest
Cognitive/perception
Self-percept/self-concept
Role-relationship
Sexuality/reproductive
Coping-stress
Value-belief

Question 9

Objective neuro assessment includes:

Answer 9

Mental status, 
Cranial nerve function, 
Motor function, 
Sensory function, 
Cerebellar function, 
Reflexes

Question 10

Mental Status includes:

Answer 10

1. Level of consciousness (awake, asleep, comatose)
2. Orientation
3. Cognition- responses to simple questions
4. Motor activity
5. Body posture
6. Dress/hygiene
7. Facial expression
8. Speech pattern

Question 11

Motor Function includes:

Answer 11

strength,
tone (hypotonia and hypertonia),
coordination (for ataxia),
symmetry of muscle groups,
pronator drift (motor cortex),
involuntary movements (chorea),
balance/coordination,
gain,
speech

Question 12

how do you grade strength in the extremities?

Answer 12

+1 Trace movement
+2 Limb movement, but not against gravity
+3 Movement against gravity, but not against resistance
+4 Movement against some resistance
+5 Full strength

Question 13

how do you assess for ataxia?

Answer 13

Cerebellar Function (balance)

1. Gait assessment
2. Romberg test

symptoms of Ataxia mimic those of being drunk,
such as slurred speech, stumbling, falling, and incoordination.
These symptoms are caused by damage to the cerebellum, the part of the brain that is responsible for coordinating movement.

Question 14

How do you assess the motor cortex?

Answer 14

pronator drift test

region of the cerebral cortex involved in the planning, control, and execution of voluntary movements

Question 15

Cerebral Blood Flow (CBF)

Answer 15

15-20% of total cardiac output

Brain uses 20% of the O2 in the body and 25% of glucose

Factors influencing CBF

i. CO2
ii. O2
iii. Hydrogen ion concentration

Cerebral Circulation

i. Brain makes up only 2% of total body mass, but requires 15-20% of total cardiac output
ii. Extremely sensitive to hypoxia; Any hypoxic damage to the brain becomes irreversible after only a few minutes

Question 16

What are the 3 factors that influence cerebral blood flow (CBF)?

Answer 16

CO2, O2, Hydrogen ion concentration

An increase in CO2 and hydrogen ion level, decrease in O2 = NEGATIVE effect on CBF

Question 17

What conditions cause a drop in cardiac output that could negatively affect the brain?

Answer 17

CO = SV x HR

1. SV affected by dehydration and hemorrhage
2. HR affected by dysrhythmias, bradycardia, hypothermia, beta blocker overdose, MI, cardiac arrest
3. These are just a few examples

Question 18

Intracranial Pressure (ICP)

Answer 18

the hydrostatic force measured in the brain CSF compartment

Normal ICP is 0 – 15 mmHg
↑ ICP > 20 mmHg for >5 minutes is an emergency
Measured by LP or with a ventriculostomy

3 components in the skull impact ICP:
Brain tissue
Blood
CSF
If one of these increases, another must drop OR will have brain damage from pressure

Question 19

elevated ICP (intracranial pressure)

Answer 19

Cerebral edema

Increased cerebral blood volume

1. Hypercapnia
2. Hypoxemia
3. Increased metabolic demands
4. Increased intra-abdominal and intra-thoracic pressure
5. Venous outflow obstruction

Too much CSF production

Question 20

Cerebral Perfusion Pressure (CPP)

Answer 20

The net pressure gradient that drives oxygen delivery to cerebral tissue

MAP – ICP = CPP
Normal range = 60 – 100 mmHg
50 mmHg will maintain only basic cerebral functioning
< 30 mmHg = Ischemia and incompatible with life

Question 21

What other non-neurological conditions can cause a change in mental status?

Answer 21

Examples include hypoglycemia and hypercapnia

Question 22

Delirium

Answer 22

temporary, acute mental confusion that can be life-threatening; results in confused thinking and reduced awareness of surroundings.

Sudden onset (unlike dementia)
Sometimes called post ICU symdrome
Typically lasts 1-7 days, but can persist for longer and become chronic

Poorly understood
Contributing factors include:
1. Impairment of cerebral oxidative mechanism (i.e. insufficient oxygen, or trouble using the available oxygen)
2. Neurotransmitter abnormalities (e.g. Cholinergic deficiency, excess release of Dopamine)
3. Proinflammatory state
4. Cortisol excess

Risk factors: Older age, male gender, history of stroke/depression/dementia or other cognitive impairment, substance use history

Question 23

Delirium can develop outside the hospital as a result of?

and inside the hospital?

Answer 23

Can develop outside the hospital as a result of:

1. Alcohol or drug abuse
2. Side effects of prescribed medications
3. Polypharmacy
4. Sleep deprivation
5. Dehydration
6. Electrolyte imbalances
7. Glucose abnormalities
8. A serious acute or chronic medical issue such as an acute infection, sepsis, liver failure, kidney failure, or thyroid hormone abnormalities

Can develop inside the hospital as a result of:

1. All of the above, plus……..
2. Unfamiliar environment
3. Sensory overload or deprivation
4. Emotional stress
5. Pain
6. Restraint use

Question 24

delirium manifestations include:

Answer 24

Either
Hypoactivity and lethargy OR
Hyperactivity, agitation, hallucinations, misinterpretation, and impulsiveness

Others: inability to concentrate, disorganized thinking, irritability, insomnia, loss of appetite, restlessness, “picking” behavior, and confusion, “Sundowning”

Question 25

delirium diagnosis and treatment:

Answer 25

Diagnosis:
H&P, review of labs (UA, thyroid tests, LFTs, alcohol/drug screen, head CT/MRI to rule out an underlying brain etiology, Confusion Assessment Method (CAM) (used in ICUs)

Treatment:

1. Treatment of underlying medical condition if one is found (e.g. correction of glucose level or electrolyte abnormalities, antibiotics for infection, etc.)
2. Switching medications if believed to be medication-induced
   a. Medications if severely agitated: Haloperidol (Haldol or Vitamin H), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel)
   b. Benzodiazepines can worsen delirium, and should be avoided except when the patient is not responding to other therapies
   c. Dexmedetomidine (Precedex) in ICUs

Question 26

Delirium nursing interventions:

Answer 26

1. Assessment for underlying etiologies
2. Reorientation
3. Encouraging family presence
4. Reducing environmental stimuli
5. Treating pain
6. Mobility (when safe)
7. Moving patient closer to the nursing station for observation
8. Avoiding restraints (unless patient is unsafe and not responding to other interventions)
9. Calming music

Question 27

Brain abscess

Answer 27

an accumulation of pus from a local or systemic infection

Etiologies: Direct extension infection from the ear, teeth, mastoid, or sinus; skull fracture; brain trauma

Manifestations- headache, fever of unknown origin, N/V, lethargy, confusion, seizures

i. Terrible headache
ii. Often a sudden onset of projectile vomiting

Question 28

Brain abscess treatment and nursing care:

Answer 28

Treatment: Antibiotics +/- surgical evacuation/drain

Nursing management:
Assess for signs of increased ICP and sepsis,
management of symptoms (n/v, headaches, fevers),
assess surgical incision

Question 29

Meningitis

Answer 29

acute inflammation of the meningeal tissues surrounding the brain and spinal cord

Organisms usually enter the CNS through the upper respiratory tract or bloodstream; may enter through penetrating skull fractures, or fractured sinuses

Types: Bacterial, Viral, Fungal

Question 30

Bacterial meningitis

Answer 30

The most serious form of meningitis

Common causative agents

i. Streptococcus pneumoniae (Gram +)- older adults
ii. Neisseria meningitidis (Gram -)-adolescents & young adults
iii. Haemophilus influenzae (Gram -)
iv. Listeria monocytogenes
v. Group B Streptococcus

Manifestations:
a. Photophobia/phono-phobia (classic sign)**
b. Severe headache (classic sign)**
c. Nuchal rigidity (classic sign)** - Stiffness in neck
d. Fever
e. N/V
f. Focal deficits, signs of increased ICP (diff size pupils,
1 pupil not reactive)
g. Petechial rash with meningococcus

Question 31

Bacterial meningitis diagnosis and treatment:

Answer 31

Diagnosis: H&P, head CT/MRI, lumbar puncture

Lumbar Puncture (LP) fluid white/yellow with high pressure

Treatment:

a. Antibiotics,
b. Dexamethasone (sterioid)
c. pain meds (NO SEDATIVES!!),
d. antipyretics to prevent seizures
i. fever also drives up ICP
e. hydration

Nursing management:

a. Assess for signs of neurological decompensation/seizures (frequent neuro checks)
b. Low lighting
c. Pain/fever management
d. Antibiotic/steroid administration
e. Droplet precautions

Question 32

Viral meningitis

Answer 32

Common organisms: Enterovirus, arbovirus, HIV, HSV

Same signs/symptoms as bacterial meningitis but less severe

Diagnosis: H&P, CT/MRI, LP

LP Fluid is usually clear to slightly white, and less pressure than bacterial

Treatment:

a. initially treat with antibiotics until viral diagnosis confirmed or bacterial is ruled out
b. then antivirals

Nursing management is the same as bacterial, but patients can usually participate more in care

Question 33

Fungal meningitis

Answer 33

Common organisms: Aspergillus and candida

Same signs/symptoms

Diagnosis: H&P, CT/MRI, LP

CT/MRI may show fungal lesions

Treatment: Antifungals
(Fungus is difficult to treat )

Nursing management is the same

Question 34

Encephalitis

Answer 34

acute inflammation of the brain parenchyma caused by a virus

Etiologies- West Nile virus, Equine viruses, HIV, CMV, HSV

S/S: Viral prodromes followed by mental status changes
-Often have a prodrome, a symptom not usually associated with the disease, but appears before acute phase of illness (ie loss of taste)

Neurologic deficits and increased ICP can occur

Diagnosed with an LP or viral blood culture

Treatment: Antivirals

Nursing care: The same as for the meningitises

Question 35

Lumbar Puncture

Answer 35

1. Measure ICP (meningitis)
2. Collect CSF for cultures and cytology (meningitis, cancer)
3. Infusion of chemotherapy (cancer), anesthetics (childbirth), or other medications
4. Can inject contrast for CNS radiographic studies

Question 36

What is the purpose of a blood culture in CNS infections?

Answer 36

Blood cultures may identify a bacterial infection in the blood that came from a non-neurologic source, or a systemic infection caused by the CNS infection

If the blood cultures are negative, the probability that a person has sepsis caused by bacteria or yeasts is LOW

Negative blood cultures may suggest a viral cause.
Viruses cannot be detected using blood culture bottles designed to grow bacteria

Question 37

__ has significant increase in WBC and pressure.

Answer 37

Bacterial meningitis

Bacteria also love glucose so it will be decreased.