NEURO ASSESSMENT AND DX

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Author:
hrisney
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248129
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NEURO ASSESSMENT AND DX
Updated:
2013-11-20 19:45:57
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NEURO
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CRITICAL CARE NURSING
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  1. NORMAL ICP
    1-15 MMHG
  2. 1st sign of neuro deterioration
    changes in LOC
  3. assessment of awareness
    • orientation to person, place, time
    • changes in loc
  4. How to evaluate arousal
    • begin with verbal stimuli of normal tone
    • shout at pt
    • shake pt
    • noxious stimuli-central stimulation
  5. trapezius pinch and sternal rub
    central stimulation
  6. 3 categories of GCS
    • eye opening
    • verbal response
    • best motor response
  7. one of most important tools to recognize LOC
    GCS
  8. Pt responds immediately to minimal stimuli
    ALERT
  9. Pt is disoriented to time and place but is oriented to person with impaired judgment and decision making
    CONFUSED
  10. pt is disoriented to time, place, and person with loss of contact with reality and often has hallucinations
    DELIRIOUS
  11. pt displays a state of drowsiness or inaction in which the pt needs in increase stimulus to be awakened
    LETHARGIC
  12. pt displays a dull indifference to external stimuli and response is minimally maintained. questions are answered with minimal response
    OBTUNDED
  13. pt can be aroused only with vigorous or continuous external stimuli.  motor response is often withdrawal or localizing to stimulus
    STUPOROUS
  14. vigorous stimulation fails to produce any voluntary mental response
    COMATOSE
  15. Highest GCS
    15
  16. Lowest GCS
    3
  17. what will pt look like with lowest GCS
    will not open eyes, move, or verbalize no matter what
  18. GCS that indicates coma
    8
  19. nail bed pressure or pinching inner aspect of arm
    peripheral stimulation for testing motor fx
  20. abnormal flexion
    decorticate posturing
  21. abnormal extension
    decerebrate posturing
  22. occurs when extremity opposite of the extremity receiving pain crosses midline of the body in an attempt to remove noxious stimuli from the affected limb
    localization
  23. no response to painful stimuli
    Flaccid
  24. assessment of CN III, IV, AND VI
    EOM extraocular eye movements
  25. how to assess EOM
    6 cardinal directions of gaze
  26. how to assess CN III
    direct pupillary light response
  27. Assess CN II
    consensual pupillary light response
  28. Assessment of eye movement/brain stem  in unconscious patient
    oculocephalic reflex (doll's eyes)
  29. normal response for doll's eyes test
    eyes should move to opposite side that head is turned-positive test
  30. assessment of brain stem in unconscious pt
    cold caloric test-oculovestibular
  31. normal response in cold caloric/oculovestibular test
    nystagmus towards ear that has been injected with water
  32. what does cheyne stokes indicate
    bilateral deep cerebral lesions or some cerebellar lesions seen in pts with cerebral hemispheric dysfunction or metabolic suppression.
  33. set of 3 clinical manifestations related to pressure on the medullary area of the brainstem.  Occur as a response to intracranial htn and herniation syndrome-
    Cushing's triad
  34. Manifestations of Cushing's triad
    • Bradycardia
    • Systolic HTN
    • Widening pulse pressure
  35. What does CT show
    differentiates tumor, hemorrhage, infarction
  36. what does angiography show?
    id aneurysm, AVM's , and vasospasms/ allows for treatment for identified abnormalities unlike MRA
  37. what does EEG show?
    seizure activity, cerebral blood flow, designation of brain death
  38. CPP
    tells us BP across brain/ CPP=MAP-ICP
  39. normal CPP
    80 to 100 mmhg
  40. What does CPP need to be to maintain perfusion of brain?
    at least 80 mmhg
  41. 2 main causes of coma and examples
    • 15% lesions
    • ischemic stroke
    • intracerebral hemorrhage
    • brain tumors
    • trauma
    • 85% medical conditions
    • drug overdose
    • infectious disease
    • endocrine disorder
    • poisoning
  42. Treatment of coma
    Identify and treat underlying cause
  43. If cause of coma not known administer:
    • thiamine
    • glucose
    • narcotic agonist
  44. acute neurological deficit lasting > 24 hours
    stroke
  45. neurological deficit lasting < 24 hours
    TIA
  46. cause of ischemic stroke
    interruption in blood flow to brain/either  embolic or thrombotic
  47. How long do ischemic stroke patients have to receive TPA?
    3 HOURS
  48. SAH two main causes
    cerebral aneurysm and AVM rupture
  49. patho of cerebral aneurysm
    congenital defect as they get older BP rises and puts stress in thinned blood vessel walls/ rupture and blood sent into subarachnoid space
  50. abrupt onset of HA, N/V, syncope, neuro deficit
    clinical presentation of SAH
  51. tx of SAH
    • support vital functions
    • venticulostomy to control and monitor ICP
    • surgical aneurysm clipping/surgical AVM excision
    • embolization therapy (beads, glue, or coiling)
  52. ways to control or prevent cerebral vasospasm
    • HHH therapy
    • nimodipine
    • transluminal cerebral angioplasy
  53. what is HHH therapy
    hypertensive/hypervolemic/hemodilution

    increases BP AND CO, decreases viscosity and increases volume to keep vessels open and prevent vasospasm
  54. Early signs of Intracranial HTN
    • decreased loc
    • vomiting/HA
  55. Late signs if intracranial HTN
    • changes in pupillary reaction to light and size
    • cushing's triad
    • abnormal posturing
    • change in respiratory pattern
  56. Why use therapeutic hypothermia in stroke pts?
    it decreases cerebral metabolic rate

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