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cerebrospinal fluid (CSF) for analysis
- 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.
- -signs include: bradycardia, hypertension, diaphoresis, "goose flesh", flushing, dilated pupils, blurred vision, restlessness, nausea, severe headache, nasal stuffiness.
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
- -brain attack
- -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
- Semi Fowlers
- 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
- Increasing temp
- Increasing B/P
- decreasing pulse
- decreasing respirations
Activities that cause indirect elevation of ICP
- Increased intrathoracic pressure
- Increased intra-abdominal pressure
- Valsalva maneuver
- blowing nose
Identifying Cerebral Spinal Fluid
- separates into bloody and yellow concentric rings
- tests positive for glucose
S/S of concussion
- difficulty awakening and speaking
- one-sided weakness
- severe headache
- 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
- distended bladder
- fecal impaction
- 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
- bed rest
- head elevated
- quiet setting
- 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 alcohol
- avoid OTC
- 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
- crocodile tears
- abnormal facial movements
Early s/s of increased ICP
- changes in LOC including episodes of confusion and drowsiness
- slight pupillary changes
- breathing 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
- impulsive behaviors
- 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.
- loss of balance is positive test result
- positive Kernig's
- red macular-type rash
- severe headache
- stiffness of neck