Neurological Dysfunctions Flashcards
Glasgow Coma Scale
Eye opening (1-4) Verbal response (1-5) Motor response (1-6)
Total score:
- best = 15
- comatose = 8 or less
- unresponsive = 3 or less
Painful Stimulation
trapezius squeeze
supraorbital pressure (unless contraindicated)
sternal rub
nail bed pressure
*used to do nipple twist (not ok anymore)
Neuro Assessment - Consciousness
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)
Neuro Assessment - Orientation
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
Neuro Assessment - Eyes
look at:
- size of pupils
- reaction to light: sluggish or brisk
- shape: round or oval
- shine light to look for constriction
- symmetry or anisocoric
Abnormal Findings of Eye Assessment
- 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
Motor Response
- 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)
Strength Scale
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)
Neuro Assessment - Motor Response - Posturing
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
Increased ICP: Cause and Concern
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)
How much CSF do our bodies make in 1 hour?
20-30ml/hr
total of 150ml circulating in body
Increased ICP: early S/O
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
Increased ICP: late S/O
- 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
Neuro Dx Tests
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
LP
- 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)
HA: Definition and Types
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
Meningioma
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
Glioma
- 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
Metastatic Tumors
secondary tumors
20% of Ca pts have mets to the brain- most common primary site is lung or breast
Brain Cancer/Tumor: S/O
- 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
Brain Cancer/Tumor: Dx
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
Complications of Tumors
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
Brain Cancer/Tumor: Interventions
- 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
Brain Cancer/Tumor: Post-op Care to Prevent increased ICP
- 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)
Brain Cancer/Tumor: Radiation and Chemo
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
Arteriovenous (AV) Malformation
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
Cerebral Aneurysm
- 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
Cerebral Aneurysm: Causes
- congenital or associated with connective tissue diseases, AV malformation and others
- associated causes: head injury, HTN, infection, tumors, hyperlipidemia, cigarette smoking, drug abuse
Cerebral Aneurysm: Complications and Sx
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
Cerebral Aneurysm: Dx and Tx
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
