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MedSurg 2 > Neurological Dysfunctions > Flashcards

Neurological Dysfunctions Flashcards

1
Q

Glasgow Coma Scale

A 
Eye opening (1-4)
Verbal response (1-5)
Motor response (1-6)

Total score:

  • best = 15
  • comatose = 8 or less
  • unresponsive = 3 or less
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2
Q

Painful Stimulation

A

trapezius squeeze
supraorbital pressure (unless contraindicated)
sternal rub
nail bed pressure

*used to do nipple twist (not ok anymore)

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3
Q

Neuro Assessment - Consciousness

A

arousal or wakefulness is a brain stem function (does not involve the thinking parts of the brain)
*if pt spontaneously opens eyes in response to name or other stimulation this is a brain stem function

awareness is a cerebral cortex function (pt can interact w/ and interpret their environment)

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4
Q

Neuro Assessment - Orientation

A

Person, place, and time

loss of orientation usually begins with time

don’t use yes/no questions if possible

note attention span - what happens when you approach the bedside

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5
Q

Neuro Assessment - Eyes

A

look at:

  • size of pupils
  • reaction to light: sluggish or brisk
  • shape: round or oval
  • shine light to look for constriction
  • symmetry or anisocoric
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6
Q

Abnormal Findings of Eye Assessment

A
  • Danger sign = sudden dilation or grossly unequal (could indicate high ICP)
  • Brisk, sluggish, nonreactive (fixed)
  • narcotics: constricted pupil is expected finding
  • stroke: pinpoint pupils indicate pontine damage
  • hypoxia or some drugs = bilateral dilation
  • ophthalmology: uses drops to dilate eyes.

*some people normally have unequal pupils

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7
Q

Motor Response

A
  • follows commands: if able to follow commands then they are at the highest level (squeezing fingers is not a true test as grasp reflex remains intact in hypoxia or ischemia, having them let go is true test)
  • localized: pulls away from painful stimuli or irritant
  • purposeful: patient has purposeful movements
  • motor strength (0-5 scale)
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8
Q

Strength Scale

A

0-5 scale

0/5: no detection of muscular contraction
1/5: a barely detectable flicker or trace of contraction w/ observation or palpation
2/5: active movement of body part with elimination of gravity
3/5: active movement against gravity only and not against resistance
4/5: active movement against gravity and some resistance
5/5: active movement against full resistance without evident fatigue (normal muscle strength)

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9
Q

Neuro Assessment - Motor Response - Posturing

A

posturing: abnormal movements, limbs extended rigidly
- decerebrate: arms in rigid extension, response is coming from brain stem (brain stem is only thing that’s working)
- decorticate: arms move toward core: pt is functioning with part of brain

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10
Q

Increased ICP: Cause and Concern

A

anything that increases cranial contents:

  • tumor
  • cerebral edema (CVA, trauma, infection)
  • abscess, hematoma
  • congenital abnormality - impedes flow of CSF

concern: increased ICP -> decreased cerebral blood flow -> ischemia (*if >3-5min damage is irreversible)

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11
Q

How much CSF do our bodies make in 1 hour?

A

20-30ml/hr

total of 150ml circulating in body

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12
Q

Increased ICP: early S/O

A

early assessment of increased ICP are subtle:

  • changes in mental status (lethargy, disorientation to time first, restless, forgetful, sudden quietness is strong signal)
  • pupil changes (sluggish, irregular)
  • motor changes (weakness, uneven or weak hand grasp)
  • HA
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13
Q

Increased ICP: late S/O

A
  • decreasing LOC -> coma
  • n/v (especially in younger pts)
  • motor changes (weakness, posturing)
  • VS changes
  • Cushings Triad (increase BP, decrease HR, decrease RR)
  • temp increases with decompensation
  • impaired brain stem reflex, loss of corneal reflex, loss of gag reflex
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14
Q

Neuro Dx Tests

A

CT scan
MRI
EEG (assessment of cerebral activity)
EMG (electrical activity of peripheral nerves and muscles)
Angiography: x-ray study of circulation after injection of a contrast agent into selected artery
LP: spinal tap

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15
Q

LP

A
  • Not done if intracranial mass d/t possible herniation
  • CSF should be clear and colorless
  • traumatic puncture: initially bloody sample but then turns clear
  • pink, blood-tinged, grossly bloody sample can indicate pathology such as cerebral contusion or laceration.
  • can measure protein, cell count, glucose from CSF

-post procedure: risk for HA d/t leak of CSF (have pt lie flat for several hours after to try to prevent)

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16
Q

HA: Definition and Types

A

pain is d/t irritation or distention of the meninges or blood vessels

primary HA: not caused by a disease or other medical condition

  • tension-type migraines
  • cluster HA

secondary HA: caused by condition

  • sinus infection
  • brain tumor
  • neck injury
17
Q

Meningioma

A

most common primary brain tumor

  • benign
  • originate from meningial covering of CNS
  • often slow-growing, and asymptomatic until large
  • often completely resected and rarely require follow-up tx
18
Q

Glioma

A
  • malignant tumors (most aggressive form of brain tumor)
  • more common in men
  • 5-year survival rate 33%
  • originate from supporting structures of brain
  • complete resection is usually not possible requiring follow-up tx (chemo, radiation, etc)
  • more common in frontal and temporal lobes but can occur anywhere in CNS
19
Q

Metastatic Tumors

A

secondary tumors

20% of Ca pts have mets to the brain- most common primary site is lung or breast

20
Q

Brain Cancer/Tumor: S/O

A
  • HA (can be early sx)
  • worse at night or awakens them from sleep, pain is localized and persistent, increased w/ cough and sneeze d/t increased ICP
  • changes in mental cognition and LOC
  • seizures: new onset in adults
  • n/v: if unresponsive to regular tx may indicate tumor in posterior fossa
  • other sx depending on location of tumor
21
Q

Brain Cancer/Tumor: Dx

A

CT Scan or MRI done if tumor suspected and to determine location (done w/ or w/o contrast media)

EEG: helps identify seizures

Endocrine studies: for pituitary tumors

Stereotactic needle bx: done w/ surgery

22
Q

Complications of Tumors

A

hydrocephalus: ventricular enlargement d/t obstruction of ventricle or outlet

Sx of hydrocephalus: n/v, blurred or double vision, sun setting eyes, balance issues, poor coordination, gait disturbance, urinary incontinence, slowing or loss of developmental progress in children/adolescence, lethargy, drowsiness, irritability or other personality or cognition changes including memory loss

*may need ventriculoartrial or ventriculoperitoneal shunt to allow for drainage of CSF into right atrium or peritoneum

23
Q

Brain Cancer/Tumor: Interventions

A
  • if tumor is metastatic, identify and tx/control primary site
  • metastatic work-up includes CT scan of chest, abdomen and pelvis

Tx edema of surrounding tissues w/ corticosteroids, improves sx in 24 hours

  • titrate to lowest dose that controls sx
  • often needed perioperatively

If seizures, tx w/ anticonvulsants.

  • monitor SE of corticosteroids
  • gastritis, PUD -> tx w/ H2R blockers or PPI
  • increased glucose, if pt already diabetic will not need to change meds, add meds for pt who is not diabetic
  • weight gain, may increase CV problems -> CHF (watch for SOB, edema, eat low Na+ diet)

Surgical procedure:

  • stereotactic surgery to precisely target the tumor
  • local or general anesthesia (drills a burr hole through skull), can do bx and/or remove small tumors and abscesses, drain hematomas, ablative procedures for disease (ie. Parkinson’s).
  • stereotactic radiosurgery: gamma knife radiation for tumors <3cm in vital areas that appear less aggressive
  • high dose of radiation targeted to tumor to shrink tumor in one tx or over several weeks depending on tumor.
  • craniotomy: excision into cranium to cut away bone flap, excise tumor and then bone flap is replaced (may not right away)
  • drains are in place post-op
24
Q

Brain Cancer/Tumor: Post-op Care to Prevent increased ICP

A
  • VS and neuro status checks frequently
  • monitor F/E balance (watch for hypovolemia)
  • positioning of pt will depend on area of surgery
  • monitor swelling (max w/in first 24-48 hours)
  • monitor dressing (usually left in place 3-5 days)
  • color, odor, dressing
  • notify surgeon if increased bleeding or clear drainage
  • if craniectomy, pt should not be positioned on the side of surgery
  • monitor for DVT as anticoagulants are contraindicated so risk is increased (wear SCD’s, early ambulation, foot pumps, ROM)
25
Q

Brain Cancer/Tumor: Radiation and Chemo

A

radiation: usually done as f/u tx after surgery
- radiation seeds can be implanted during surgery
- complications: cerebral edema and increased ICP
* managed with high doses or corticosteroids, dexamethasone, prednisone, methylprednisone
- SE: loss of hair, fatigue, n/v, anorexia

Chemo: effectiveness limited to med crossing BBB and drug resistance of tumor cell

26
Q

Arteriovenous (AV) Malformation

A

rare congenital disorder of the arteries and veins that are entangled

sx: HA, seizure, pain, problems with speech, vision, or movement
tx: surgery if it’s causing bleeding in the brain or seizures and if area of brain is accessible

not always life-threatening but does require tx

27
Q

Cerebral Aneurysm

A
  • dilation, bulging or ballooning out of the wall of an artery or vein causing pressure on nerve or surrounding brain tissue
  • may leak or rupture (hemorrhage)
  • if small, they usually don’t cause a problem
  • more common in adults and women but can occur at any age
28
Q

Cerebral Aneurysm: Causes

A
  • congenital or associated with connective tissue diseases, AV malformation and others
  • associated causes: head injury, HTN, infection, tumors, hyperlipidemia, cigarette smoking, drug abuse
29
Q

Cerebral Aneurysm: Complications and Sx

A

Complications: if rupture, hemorrhagic stroke, permanent nerve damage, death

Sx: if small it can be asymptomatic. If large, pain above and behind eye, unilateral facial numbness, weakness and paralysis, dilated pupils, vision changes
if hemorrhage, sudden and severe HA, diplopia, n/v, stiff neck, and/or loss of consciousness

30
Q

Cerebral Aneurysm: Dx and Tx

A

Dx: CT scan, angiography, MRI

Tx: if small just monitor for growth
if large, surgery.

Surgery:

  • microvascular clipping: stops flow of blood to site of aneurysm (very effective)
  • endovascular embolization:: detachable coils or balloons are released in aneurysm, blocking circulation and causing the blood to clot which destroys the aneurysm
  • recover in weeks to months

MedSurg 2 (18 decks)

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