The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3/mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) are normally present in CSF.
client with a head injury and notes that the client is assuming this posture
In decorticate posturing, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate posturing indicates a hemispheric lesion of the cerebral cortex.
client with a diagnosis of meningitis and notes that the client is assuming this posture
Opisthotonos is a prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation
Extension of the extremities and pronation of the arms
complications associated with Bell's palsy
Complications of Bell's palsy include abnormal return of nerve function; "crocodile tears" (autonomic fibers reconnect to the lacrimal duct instead of the salivary glands, so the client develops excessive tearing while eating); abnormal facial movements because of reinnervation of inappropriate muscles; and spasms, atrophy, and contractures caused by incomplete motor fiber reinnervation.
Alzheimer's disease characteristics
Dementia is the hallmark of Alzheimer's disease. Recent memory loss is one characteristic. Others include problems with abstract thinking, problems with speech (not hearing), and difficulty in performing familiar tasks.
C5 spinal cord injury spinal shock findings
During the period of areflexia that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.
myasthenia gravis exacerbation
Because dysphagia is a classic sign of myasthenia gravis exacerbation, observing how a client is able to ingest food is an important assessment.
information will the nurse reinforce to the client scheduled for a lumbar puncture
Client preparation for lumbar puncture includes obtaining informed consent from the client. No dietary or food restrictions are required before the test. The client is told that the test will take approximately 15 to 60 minutes. The nurse needs to inform the client about the need for bedrest following the test.
lumbar puncture position
The client is assisted into a fetal position at the edge of the bed with the knees drawn up to the chest. This position allows full flexion of the spine and wider spaces between the vertebrae. The nurse should also place a pillow between the client's legs to prevent the upper leg from rolling forward and a small pillow under the client's head to support the spine in a horizontal position.NCLEX
lumbar puncture position immediately after procedure
For 1 hour after the procedure, the client assumes a prone position if able with a pillow under the abdomen to increase intra-abdominal pressure. This position retards leakage of cerebrospinal fluid. NCLEX
digital subtraction angiography
A total or partial loss of the ability to recognize familiar objects by sight, touch, or hearing or to recognize familiar people through sensory stimuli as a result of organic brain damage.
localized dilation of the wall of a blood vessel usually caused by atherosclerosis and hypertension or, less frequently, by trauma, infection, or a congenital weakness in the vessel wall. Mosby
an abnormal neurologic condition in which the language function is defective or absent because of an injury to certain areas of the cerebral cortex-Broca's area in the frontal lobe and Wernicke's area in the posterior part of the temporal lobe. Mosby
an inability to carry out learned sequential movements on command, perform purposeful acts or use objects properly
impaired ability to coordinate movement
a sensation, such as of light or warmth, or emotion, as of fear, that may precede an attack of migraine or an epileptic seizure.
slowing down in the initiation and execution of movement
deep brain stimulation DBS
placing an electrode in either the thalamus, globus pallidus, or subthalamic nucleus and connecting it to a generator placed in the upper chest.
difficult, poorly articulated speech that usually results from interference in control over the muscles of speech.
weak, soft and flabby and lacking normal muscle tone
Glasgow coma scale
a quick, practical, and standardized system for assessing the degree of consciousness impairment in the critically ill and for predicting the duration and ultimate outcome of coma, particularly with head injuries.
global cognitive dysfunction
generalized impairment of intellect, awareness and judgement
also called acute inflammatory polyradiculopathy or postinfectius polyneuritis.
an acute, rapidly progressing, and potentially fatal form of polyneuritis. Results from a widespread inflammation and demyelination of the peripheral nervous system.
Autoimmune reaction involving the peripheral nerves.
Often follows a viral infection, trauma, surgery, viral immunizations or HIV infection.
defective vision or blindness in half of the visual field
or autonomic dysreflexia
-a neurologic condition characterized by increased reflex action.
-occurs in patients with cord injuries of the sixth thoracic vertebra or higher and most commonly in patients with cervical injuries.
-abnormal cardiovascular response to stimulation of the sympathetic division of th eautonomic nervous system; the condition occurs as a result of stimulation of the bladder, large intestine, or other visceral organs.
involuntary, rhythmic movements of the eye: the oscillations may be horizontal, vertical, rotary or mixed
a lesser degree of movement deficit from partial or incomplete paralysis
rest period after a seizure
the sensation pertaining to the spatial-position and muscular-activity stimuli originating from within the body or to the sensory receptors that those stimuli activate.
involuntary, sudden movement or muscular contraction
-abnormal condition of the blood vessels of the brain, characterized by hemorrhage into the brain or the formation of an embolus or thrombus that occludes an artery, resulting in ischemia of the brain tissue normally perfused by the damaged vessels
a condition in which an individual is perceptually unaware of and inattentive to one side of the body
Position post craniotomy
Semi-Fowlers, head maintained in midline, neutral position to facilitate venous drainage.
Positions post supratentorial craniotomy
Head midline or nuetral
Position for Lumbar Puncture
side-lying with legs pulled up to the abdomen with head bend down onto chest.
Trends for increasing ICP
Activities that cause indirect elevation of ICP
Increased intrathoracic pressure
Increased intra-abdominal pressure
Identifying Cerebral Spinal Fluid
separates into bloody and yellow concentric rings
tests positive for glucose
S/S of concussion
difficulty awakening and speaking
applied after drilling holes in skull.
weight is attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine.
occurs in client with spinal cord injury above the level of T7
severe throbbing headache
flushing of face and neck
sudden severe hypertension
triggered by noxious stimulus below the level of injury
Frequent cause of autonomic dysreflexia
stimulation of the skin from tactile, thermal or painful stimuli
Autonomic dysreflexia nursing actions
sit client up in bed
remove noxious stimulus
bring B/P under control with meds
No pushing, pulling, sneezing, coughing or straining.
No coffee or nicotine
loss of 1/2 of visual field
responds to administration of cholinergic drugs
Cranial II nerve
responsible for balance and coordination
Typical anti-convulsant medication instructions
take daily to keep blood level constant
having a serum drug level drawn before AM dose
avoid D/C abruptly
avoid activities with alertness/coordination until effects are known
good oral hygiene
wear a medic alert bracelet
occurs with emotional trauma or sudden withdrawal of medications
exhibits severe tremors, rigidity, bradykinesia, anxiety, diaphoresis, tachycardia and hyperpnea
prolonged arching of the back with the head and heels bent backward.
indicates meningeal irritation
upper extremities are flexed with adduction of the arms
lower extremities are extended with internal rotation of the plantar flexion
indicates a hemispheric lesion of the cerebral cortex
upper extermities are extended stiffly and adducted with internal rotation and pronation of palms
lower extremities are extended stiffly with plantar flexion.
teeth are clinched
back is hyperextended
indicates lesion in the brainstem at midbrain or upper pons
complete loss of muscle tone and paralysis of all four extremities
indicating a completely nonfunctional brainstem
Complications of Bell's palsy
abnormal return of nerve function
abnormal facial movements
Early s/s of increased ICP
changes in LOC including episodes of confusion and drowsiness
slight pupillary changes
carbonic anhydrase inhibitor
used to decrease cerebrospinal fluid in client with ISP
selegiline hydrochloride (Eldepryl)
increases dopaminergic action, assisting in the reduction of tremor, akinesia and the rigidity of parkinsonism.
Early symptoms of Huntingtons disease
restlessness, forgetfulness, clumsiness, falls, balance and coordination, vertigo, altered speech and handwriting
relieves urinary urgency, frequency, nocturia and incontinence
Right (non dominant) hemispheric stroke
perceptual and spatial disabilities
Post lumbar puncture
remain flat 6-24 hours
liberal fluid intake
check puncture site for redness and drainage
monitor clients ability to void
monitor clients ability to move the extemities
EEG pre-procedure instructions
avoid cola, tea, coffee morning of test
wash hair evening before test-no gels, lotions or hairsprays
test takes 45 minutes to 2 hours
used for detecting carpal tunnel syndrome
percussing the medial nerve at the wrist as it enters the carpal tunnel
checks for cerebellar functioning related to balance.
client stands with feet together and arms at the side and closes eye.