Test 4 Flashcards
Wha are the two major nervous systems?
The central nervous system and the peripheral nervous system
The peripheral nervous system has two further divided systems, what are they and what do they do?
The autonomic system and the somatic system. They work together to control cognition, mobility, and sensory perception
What is the CNS composed of and what does each composition do?
BRAIN: which directs the regulation and function of the nervous system and other body systems.
Spinal cord: which initiates reflex activity and transmits impulses to and from the brain.
What is the peripheral nervous system composed of
12 pairs of cranial nerves
31 pairs of spinal nerves and autonomic nervous system (ANS)
What sled the posterior and anterior part of the spinal nerves do ?
Posterior: carries sensory information (sensory perception) to the cord.
Anterior: transmits motor impulses (mobility) to the muscles of the body
The ANS is divided into what two other categories?
Sympathetic (fight to flight) and parasympathetic (rest and digest)
What do neurons do and what two different types are there?
Transmits or conduct nerves impulses, by either excitation or inhibition. They can also process information or retain information
Motor: enable mobility
Sensory: enable sensory perception
What do neuroglia cells do
Provide protection, structure, and nutrition for neurons. These cells are also part of the blood brain barrier and help regulate CSF
What are the keys parts of a neuro assessment
Appearance Speech Affect Motor function Medical history ADL performance Family medical history Patients memory (especially recent memory) Mental status (orientation) Establish baseline Compare left and right sides and upper and lower extremities LOC Cranial nerves PERRLA Glasgow coma scale The cardinal fields of gaze
What are the components of sensory perception
Superficial and deep sensation
Pain
Light touch
Proprioception: the ability to sense stimuli araising within the body regarding position, motion, and equilibrium
What does a decrease in mental status of an older adult often mean? What are important assessments to make?
An infectious process. (Most commonly a UTI)
Also can mean hyper or hypoglycemia and hypoxia
Sp02/FSBS/assess for s/sx of infection i.e./fever.sputum production/urine with sediment or odor/red or draining wounds
What is the Glasgow coma scale
What are the 3 assessments categories and what are the ranges of the scores
Used reliably to help describe the patients LOC.
Eye opening, motor response, and verbal response.
Scores range from 3(coma) 15(best/normal)
What is the 1st category of GCS
Eye opening: Spontaneous 4 Sound 3 Pain 2 Never 1
2nd category of GCS
Motor response: Obeyed commands 6 Localized pain 5 Normal flexion (withdrawal) 4 Abnormal flexion 3 Extension 2 None 1
3rd category of GCS
Verbal response: Orientated 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
What are the signs of altered cognition
Headache, restlessness, irritability, or unusual quietness, slurred speech and change in the level or orientation
What is decerebrate and decorticate posturing
Decerebrate: outward flexion (more severe)
Decorticate: inward
What is decerebrate or decorticate posturing and pinpoint or dilated nonreactive pupils a late sign of? And what is each associated with?
Neurological deterioration
Decerebrate is usually associated with dysfunction i the brainstem area.
Decorticate is seen in the patients with lesions tha interrupt the corticospinal pathways
What is one of the first priorities in head trauma or multiple injuries
Rule out cervical spine fracture
What is alert
Awake and orientated
Lethargic
Drowsy but easily awakened
Stuporous
One who is aroused with vigorous or painful stimulation
Comatose
Patient who is unconscious or unable to arouse
What are nervous systems changes r/t aging
Slower processing time Recent memory loss Decreased sensory perception of touch Change in perception of pain Sleep patterns Altered balance and coordination Increased risk for infection
What are intervention for slower processing time and its rational
Provide sufficient time for the affected older adult to respond to question and or direction
Allowing adequate time for processing helps differentiate normal finding from neurological deterioration
What are interventions for recent memory loss and its rational
Reinforce teaching by repetition
Using written teaching and employing memory aids like electronic alarms or application for electronic devices that provide recurrent alerts.
greatest loss of brain weight is in the white matter of the frontal lobe. Intellect is not impaired but the learning process is slowed.
Repetition helps the patent learns new information and recall it when needed
What are the nursing intervention for decreased sensory perception of touch and its rational
Remind the patient to look where his or her are placed when walking
Instruct the pt to wear shoes that provide good support when walking
If the pt is unable change his or her position frequently qtr while he is in the bed or chair. Decreased sensory perception may cause the patient to fall
What are the nursing intervention for change in perception of pain and its rational
Ask the pt to describe the nature and specific characteristics of pain
Monitor additional assessment variable to detect possible health problems
Accurate and complete nursing assessment ensures that the intervention will be appropriate
Accurate and complete nursing assessments ensures that the intervention will be appropriate for the older adults
What re nursing intervention for changes in creep patterns and its rational
assess and sleep patterns and preferences
Ask if the sleep pattern interferes with adl’s adjust the patients daily schedule to his or her sleep pattern and preference as much as possible older adults require as much as younger adults
it is more common for older adults to fall asleep early and arise early
Assess sleep habits provide usual bedtime routine decrease noise and light at night. age related changes include more time in bed spent awake before falling asleep, reduce to sleep time, daytime napping and changes in circadian rhythm leaving to early to bed and early to rise
What are the nursing interventions for alter the balance and decreased coordination and it’s rationale
Instruct patient to move slowly when changing positions, if needed advise the patient to hold onto hand rails when ambulating.
Assess the need for an ambulatory aid such as a cane the patient may fall in moving too quickly assistant and adaptive aids provide support and prevent falls
What are the nursing interventions for increased risk for infection and it’s rationale
Monitor carefully for infection older adults often have structural deterioration of microglia, The cells responsible for the cell mediated immune response in the central nervous system
What does PERRLA mean, and what are the cranial nerve in this testing
Pupils Equal round reactive to light accommodation Cranial nerve III oculomotor (pupil constriction)
What is pronation drift
If there is cerebral or brainstem reason for muscle weakness the arm on the weak side will start to fall or drift with the palm pronating (turning inward)
What is deep tendon reflex is and how was it assessed
Striking the tendon with the reflex hammer should cost contraction of the muscle the appropriate muscle contraction indicates an intact reflex arc the tendon is taped quickly but not with too much force if the patient is tending the muscles the reflexes will not respond having the patient interlock his or her hands and pull out word will help decrease muscle tensing so the reflex can be tested
What are cutaneous (superficial reflexes) and how are they assessed
Usually tested are the planter reflexes and sometimes the abdominal reflexes. the planter reflex is tested with a pointed but not sharp object the response should be plantarflexion of all toes
What is the Babinskis sign and what does a positive one mean and what could because from
Hey dorsiflexion of the great toe and sanding of the other toes is abnormal and anyone older than two years and represents the presence of central nervous system CNS disease positive (abnormal) which is “up going” of the toes they can mean drug and alcohol intoxication after a seizure or in patients with multiple sclerosis or liver disease
What can hyperactive reflexes mean
Hyperactive reflexes indicate possible upper motor neuron disease to Tetanus or hypocalcemia
What can hypoactive reflexes me
Hyperactive reflexes may result from lower motor neuron (damage to the spinal cord) disease of the neuromuscular junction, muscle disease or health problems such as diabetes mellitus, hypothyroidism or hypokalemia
What does FAST stand for and what is it used for
Face (symmetrical/smile/stick out tongue)
Arms (raise both equally)
Speech (slurred, can they make a sentence recognition and recall)
Time (window of time for intervention orientation times 3)
Time is brain cells
A tool used to recognize a stroke
The three steps to stroke recognition
Ask the person to smile or stick out their tongue
ask the person to make a complete sentence
ask the person to raise both arms
Intracranial pressure
Normal ICP 10 to 15mm Hg:
Elevated if >20 mm Hg sustained
Factors that influence ICP:
Arterial pressure
Venous pressure
Intraabdominal and intrathoracic pressure
Posture- laying down tends to decrease pressure
Temperature-
Blood gases (CO2 levels) (lack of 02) increase icp
Cushing’s Triad increase pulse pressure (BP)- systolic goes up diastolic goes down, decrease pulse, irregular respirations (classic sign of ICP)
Regulation and maintenance
Normal compensatory adaptations: Changes in CSF volume Changes in intracranial blood volume Changes in tissue brain volume Ability to compensate is limited: If volume increase continues, ICP rises → decompensation
Cerebral blood flow
Definition
The amount of blood in milliliters passing through 100 g of brain tissue in 1 minute
About 50 mL/min per 100 g of brain tissue
Cerebral blood flow
Definition
The amount of blood in milliliters passing through 100 g of brain tissue in 1 minute
About 50 mL/min per 100 g of brain tissue
Cerebral blood flow
Cerebral perfusion pressure (CPP) CPP = MAP – ICP Normal is 70 to 100 mm Hg. <55mm Hg is associated with ischemia and neuronal death. Effect of cerebral vascular resistance CPP = Flow x Resistance
Cerebral blood flow
Factors affecting cerebral blood vessel tone
CO2 to much blood vessels tend to dilate which increases icp
O2 lack of causes edema which increases icp
Hydrogen ion concentration
Acidosis- hypoxia
Increased ICP is life threatening and may cause brain death
Increased ICP
Life-threatening-may result in “brain death” Increase in any of three components Brain tissue Blood CSF ↑ cerebral edema
Increased Intracranial pressure
Insult to brain Tissue edema ICP Compression of ventricles Compression of blood vessel Decrease cerebral blood flow Decrease 02 with death of brain cells Edema around necrotic tissue Increased ICP with compression of brainstem and respiratory center Accumulation of co2 Vasodilation Increased ICP resulting from increased blood volume Death
Migraine headache
Throbbing and unilateral, can be accompanied by nausea or sensitivity to light,sound or head movement
Can last 4-72 hours
At risk for stroke and epilepsy most common in women
Foods that trigger a migraine attack
Alcohol Aged cheese Chocolate Nitrates Nuts Yeast Sweeteners Smoked fish Tyramine
For a migraine
Mild acetaminophen, nsaids Severe Triptain, ergotamine, isometheptene potential side effect is rebound headache Opioids and barbiturate Beta blockers, ccb. Botox Dark room
Cluster headaches
Brief 30 minuets to 2 hours intense unilateral pain that generally occurs in the spring and fall without warning
Typically men between 20-50 years
Intense pain is felt deep in and around the eye, pain my radiate to the forehead, temple or cheek
Usually occurs with
ipsilateral(same side tearing eye).rhinorrhea(runny nose).ptosis(drooping eyelid).eyelid edema.facial sweating. Miosis(contract pupils)
occurs at the same time of day for about 4-12 weeks followed by a remission for 9 months to 1 year
Care for cluster headaches
Relaxation, meditation, acupuncture, massage therapy and avoidance of the know headache Lithium Corticosteroids To civamide Oral melatonin Oral glucosamine Wear sunglasses, sit way from window High flow o2
Seizures vs epilepsy
Seizure: Generalized Partial Unclassified Secondary seizures Epilepsy: Primary or idiopathic
Seizure
Abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain hat may result in a change in LOC, motor or sensory ability and behavior
Epilepsy
Two or more seizures experienced by a person. Chronic disorder in which repeated unprovoked seizure activity occurs
Generalized seizure
May occur in adults and involve both cerebral hemispheres.
Tonic clonic seizure lasting 2-5 minuets bringing with tonic phase that causes stiffening or ridigity of the muscles, particularly of the arms and legs, and immediate loss of consciousness
Clonic seizure- Last several minuets and causes muscle contraction and relaxation
Tonic seizure - Is an abrupt increase in muscle tone, loss of consciousness and autonomic changes lasting from 30 seconds to several minuets
Clonic or rhythmic
Jerking of all extremities, patient may bite tounge nad become incontinet or urine and feces. Fatigue, acute confusion and lethargy may last up to an hour after the seizure
Partial seizure
Focal or local
Complex partial may cause loss of consciousness or black out for 1-3 minuets as absence seizure patient unsure of environment
And may wander at the start of the seizure, in the period after may have amnesia
Simple partial remains conscious throughout episode reports an aura before the seizure, during they may have one sided movement of extremity, experience unusual sensations, autonomic changes included in heart rate, skin flushing and epigastric discomfort
Unclassified seizure
Idiopathic seizures account for about half of all seizure act icy
Account for half of all seizure activity. They occur for no know reasons do not fit into the generalized or partial classification
Seizure risk
Metabolic disorders Acute alcohol withdrawal Electrolyte disturbance Heart disease High fever Stroke Substance abuse Increased physicals activity, stress, fatigue, alcohol, caffeine and certain food or chemicals
Acute seizure management
Medication depends on type of seizure
Medication for tonic-clonic seizure activity may include:
Lorazepam (Ativan)
Diazepam (Valium)
Diastat
IV phenytoin (Dilantin) or fosphenytoin (Cerebyx)
Status epilepticcus
Prolonged seizures that last more than 5 min or repeated seizures over course of 30 min – medical emergency!
Establish airway
ABGs
IV push lorazepam, diazepam
Rectal diazepam
Loading dose IV phenytoin not more than 50mg/min (iv calculations)
Drug therapy
Evaluate most current blood level of medication, if appropriate
Be aware of drug-drug/drug-food interactions
Maintain therapeutic blood levels for maximal effectiveness
Do not administer warfarin with phenytoin
Document and report side/adverse effects
Patient and family education
Compliance with AEDs
Social service resources to assist with medication costs
Evaluation of employment safety needed to decrease risks
Vocational rehabilitation may be subsidized
Surgical management
Vagal nerve stimulation (VNS)
Conventional surgical procedures
Anterior temporal lobe resection
Partial corpus callosotomy
Carbamazepine (tegretol)
Use: partial, generalized tonic clinic seizure
Intervention: monitor for headache, dizziness, diplopia or blurred vision, n/v, and leukopenia
Monitor cbc
Do not crush or chew sustained release
Clonazepam (klonopin)
Use: absence, myoclonic, and a kinetic seizure
Monitor results of LFT
Diazepam (valium)
Use: Status epilepticcus
Monitor ABC
Depakote
All types of seizure
Monitor for hair los, tremor, increased liver enzymes, brushing, and n/v
Monitor cbc, pt, ptt, and ast
Keppra
Use: adjunctive management of partial seizure
Monitor renal function carefully
Notify health care provider for gait or coordination problems
Lamictal
Partial seizure
Wachovia for diplopia, headaches, dizziness, drowsiness, ataxia, n/v, and life threatening rash when given with valproic acid
Phenobarbital
Generalized tonic clonic , partial
Note that this is less desirable than other antiepileptic drugs (aeds) because of sedation
Be ware that overdose can be fatale
Monitor for drowsiness, sleep disturbance, impaired cognition and depression
Dilantin
All types, except absence, myoclonic and atonic seizure for status epilepticcus
Monitor for gastric distress, gingival hyperplasia, anemia,ataxia, and nystagmus
Check cbc and calcium levels, monitor therapeutic drug levels (10-20 mcg) and tonic levels (>30mcg)
For iv phenytoin, flush catheter with saline before and after administration
For fosheytoin, use phenytoin equivalent for dosing
Drug to drug interaction
Warfarin should not be given with dilantin
Citrus fruits, such as grapefruit can interfer with the metabolism of these drugs.
Self management
AEDS must never be stopped even if seizures have stopped.
A balanced diet, proper rest, and stress reduction techniques usually minimize the risk for breakthrough seizure.
Safety or seizure
Ensuring that oxygen and suctioning equipment with and airway are available, if patient does not have iv insert a saline lock
Care of the pt during tonic clonic or complete partial
Protect the patient from injury
Do not force anything into the patient mouth turn the patient to the side to keep airway clear
Losses an restrictive clothing the patient is wearing
Maintain the patient airway and suction oral secretions as needed
Do not retain or try to stop the patient movement, guide movements if necessary
Record the time the seizure began and ended
At the completion of the seizure
Take vitals
Perform neurological check
Keep patient on side
Allow patient to rest
Document seizure
Nursing observation for seizure
How often the seizure occur Describe seizure More than one Sequence of seizure progression Observation How long it lasted When the last took place Whether seizures are preceded by aura What pt does after How long it took pace to return to pre seizure phase
Seizure precautions
Oxygen Suction equipment Airway Iv access Side rails up and padded
Status epilepticcus
Is a medical emergency and is a prolonged seizure lasting longer than 5 minuets or repeated seizure over the course of 30 minutes.
Seizure longer than 10 minutes can cause death.
Common cause of status epilepticcus
Sudden withdrawal from antiepileptic drugs Infection Acute alcohol or drug withdrawal Head trauma Cerebral edema Metabolic disturbance
Myoclonic seizure
A brief jerking or stiffening of the extremities that may occur singly or in groups
Meningitis
An inflammation of the meninges, specifically the pia mater and arachnoid. Bacterial and viral organisms are most often responsible
Viral meningitis
Most common type, no organisms are typically isolated from culture of the csf.
Herpes simplex virus 2. Varicella, mumps, hiv.
Manifestations of meningitis
Fever Uncalled rigidity Photophobia Phonophobia Headache myalgia Nausea and vomiting Confusion and altered LOC may be preset Potive kernigs, brudzinskis signs Rash
Lab test for meningitis
CSF Ct scan Blood cultures Counterimmunoelectrophroesis- for presence of virus or Protozoa Polymerase chain reaction Cbc X-ray
Care for a patient with meningitis
Maintain abc. Take vitals and perform neuros every 2-4 hours Perform cranial nerve assessment Manage pain Vascular checks Give drugs and iv fluids Record I & O Monitor body weight Labs Perform ROM Decrease environment stimuli Maintain transmission based precautions Monitor for and prevent complications
Intervention for meningitis
Vaccinations: HIB B, varicella and meningococcal. Maintain hand washing before and after entire ring room \2 week course of iv antibiotic, drug therapy should begin with 1-2 hours after prescribed
Rifampin,cipro, rocephin,
standard precaution for all unless bacterial and droplet is placed
Bacterial meningitis
Cloudy WBC: increased Protein: increased Glucose: decreased CSF: elevated
Viral meningitis
Clear WBC: increased Protein:slightly increased Glucose: most often normal but may be decreased CSF: normal or elevated
Encephalitis
Is inflammation of the brain tissue and often surrounding the meninges
Virus travels to the CNS, via blood stream, alongperipheral or cranial nerves or in the meninges. Therefore viral encephalitis can be life threatening or lead to persistent neurological problems such as disability, epilepsy, memory or fine motor
