Neruo Part 1

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  1. Glascow Coma
    Eye Opening
    • 1. Spontaneous = 4
    • 2.To Speech = 3
    • 3. To Pain = 2
    • 4. No Response = 1
  2. Glascow Coma
    Motor Response
    • 1. Obeys Commands = 6
    • 2. Localizes Pain = 5
    • 3. Nonpurposeful Movement = 4
    • 4. Abnormal Flexion = 3
    • 5. Abnormal Extension = 2
    • 6. No Response=1
  3. Glascow Coma
    Verbal Response
    • 1. Oriented = 5
    • 2. Confused Conversation = 4
    • 3. Inappropriate Words = 3
    • 4. Incomprehensible Sounds = 2
    • 5. No Response = 1
  4. Cerebral Function Deficits
    • Disturbances in mental status
    • Intellectual functioning and thought content
    • Patterns of emotional behavior
    • Perception
    • Motor and language abilities
    • Lifestyle changes
  5. Agnosia
    inability to interpret or recognize objects seen through the special senses
  6. Aphasia
    Language impairment including speaking, writing, reading, or comprehension
  7. Eye Movement
    Cranial Nerves
    • III. Oculomotor: Motor: Eye & Lid Movement, Pupil Constriction
    • IV. Trochlear: Motor: Eye Movement
    • VI. Abducens: Motor: Eye Movement
  8. Dysphagia
    Cranial Nerves
    • IX. Glossopharyngeal: Both: Pain & Temperature of ear; Taste & Sensation from posterior 1/3rd of tongue; Throat muscles, Parotid gland
    • X. Vagus: Both: Pain & Temperature of ear; Sensations of pharynx, larynx, thoracic, & abdomen; Viscera, cardiac, & smooth muscle to level of splenic flexure
    • XII. Hypoglossal: Motor: Tongue muscles
  9. Ataxia
    incoordination of voluntary muscle action
  10. Deep Tendon Reflexes
    • Assess involuntary reflex arcs that depend on the presence of afferent stretch receptors, spinal synapses, efferent motor fibers, and a variety of modifying influences from higher levels
    • Biceps, Brachioradialis, Triceps, Patellar, Ankle, Abdominal, Plantar
  11. Clonus
    very hyperactive reflexes, continues to “beat”
  12. Superficial reflexes
    Clean wisp of cotton and lightly touching the outer corner of each eye on the sclera
  13. Superficial Reflexes
    Dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stroked with a pointed object (e.g., rounded end of bandage scissors)
  14. Superficial Reflexes
    Gently touch the back of the pharynx with a cotton-tipped applicator
  15. CT Findings
    lesions, tumor masses, brain infarction, ventricle displacement, cortical atrophy, hemorrhage, hydrocephalus, bone malformations
  16. MRI used for
    Used for cerebral abnormality identification, determination of a tumor’s response to treatment, diagnose MS, describe activity & extent of disease in the brain and spinal cord
  17. Cerebral Angiography
    • An X-ray study of the cerebral circulation with a contrast agent injected into a selected artery
    • A catheter is introduced into the femoral artery, flushed with heparinized saline, and filled with contrast agent
    • Use to investigate vascular disease, aneurysms, AV malformations, tumors, strictures/occlusions, traumatic injuries
  18. Nursing Interventions: Cerebral Angiography
    • Well hydrated: Clear liquids
    • Void before procedure
    • Pulses marked with a felt-tip pen
    • Warmth in face, behind the eyes, jaw, teeth, tongue, lips, and metallic taste when dye injected
    • Post procedure observe injection site, may use ice for edema or discomfort
    • Post procedure frequently assess peripheral pulses bilaterally
    • Post procedure monitor involved extremity color and temperature
    • Post procedure s/sx of altered cerebral blood flow
    • Change in LOC, one sided weakness, motor or sensory deficits, speech disturbances
  19. Cerebrospinal Fluid (CSF)
    • Color: clear or colorless
    • Pink, blood-tinged, bloody = subarachnoid hemorrhage
    • CSF pressure: 10 to 15 mm Hg
    • Minimal WBCs
    • No RBCs
    • Glucose 50-75 mg/dL
  20. LP Complications
    • Post-lumbar puncture headache:
    • Mild to Severe
    • May occur few hours to several days later
    • Caused by CSF leakage at the site
    • Relieved by lying down/bedrest
    • Brain herniation
    • Spinal epidural abscess
    • Spinal epidural hematoma
    • Meningitis
    • Temporary voiding problems
    • Slight elevation of temperature
    • Backache/Spasms
    • Neck stiffness
  21. Nursing Interventions: Lumbar Puncture
    • Void before the procedure
    • Describe procedure
    • Knee to chest position
    • Relax and breathe normally
    • Done with aseptic technique
    • Post LP: possible bedrest
    • Post LP: observe site for leakage
    • Post LP: monitor for complications
    • Post LP: encourage increased fluid intake
  22. Increased Intracranial Pressure: Pathophysiology
    ^ICP = ^ cerebral blood flow = tissue hypoxia = ^ serum pH and ^ CO2 = cerebral vasodilation = edema = ^ ICP = brain herniation = irreversible brain damage (Cheyne-Stokes respirations & pinpoint & nonreactive pupils) = death (uncal herniation or shift of temporal lobe, causes pressure 3rd cranial nerve, characterized by dilated & nonreactive pupils “blown”)
  23. Increased Intracranial Pressure: Etiology
    Commonly associated with head injury, brain tumors, subarachnoid hemorrhages, cerebral edema
  24. Normal Intracranial Pressure
    5 to 15 mm/Hg
  25. The Monro-Kellie hypothesis
    states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of others
  26. Autoregulation
    refers to the brain’s ability to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alterations in systemic blood pressure
  27. Early Indicators of increased intracranial pressure
    • Disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion
    • Pupillary changes: sluggish
    • Hemiplegia to contralateral side
    • Headache that is constant, aggravated by movement or straining
    • Positive Babinski reflex
  28. Late Indicators of increased intracranial pressure
    • LOC continues to deteriorate until comatose
    • Cushing’s Triad: Hypertension, Bradycardia, Bradypnea (Temperature increases also)
    • Cheyne-Stokes breathing; Ataxic breathing
    • Projectile vomiting
    • Decorticate & Decerebrate posturing/ Flaccidity before death
    • Loss of reflexes (pupillary, corneal, gag, swallowing)
  29. Decorticate Posturing
    • Arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs
    • Indicates cerebral cortex damage
    • Indicates damage to the corticospinal tract
  30. Decerebrate Posturing
    • Characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos (tetanic spasm in which the head and heels are bent backward and the body is bowed forward).
    • Usually associated with dysfunction in the brain stem.
    • Indicates entire cerebrum damaged, only medulla oblongata function remaining
  31. Ventriculostomy
    fine-bore catheter inserted into a lateral ventricle
  32. Subarachnoid bolt or screw
    a hollow device that is inserted through the skull and dura mater into the cranial subarachnoid space
  33. Medical/Nursing Management for Increased Intracranial Pressure
    • Obtain & Maintain Patent Airway
    • Assess Breathing: Possible Ventilator
    • Assess Circulation (BP & HR)
    • IV Access
    • Goal: Decreasing Cerebral Edema
    • Osmotic Diuretics: Dehydrate the brain tissue (Mannitol)
  34. Potential Complications for increased intracranial pressure
    • Respiratory Failure
    • Pneumonia
    • Pressure Ulcers
    • Musculoskeletal Deterioration
    • Aspiration
Card Set:
Neruo Part 1
2013-11-09 21:31:00
neuro MTC Test Nur 165 IICP Glascow Coma

Nur 165 test 4 neuro: Cards Part 1 by A. Frazier
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