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What makes up the Central nervous system? The peripheral nervous system?
- CNS: brain, spinal cord
- PNS: Cranial nerves, spinal nerves
What is the importance of cerebral circulation? How much of total cardiac output does it receive? How Does the brain get blood?
- It provides sufficient blood to supply, O2, glucose and nutrients
- receives approx 15-20% of total cardiac output
- Arterial: internal carotid, and vertebral arteries
What is the subjective and objective data of a neuro assessment?
- Sub: What the patient says- LOC, A+O x 3,
- Objective: Physical Exam including reflexes, Pupils, Glasgow Coma scale, Cranial nerves,
Explain the Glasgow Coma scale
- The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters- Best Eye Response, Best Verbal Response, Best Motor Response
- Eye response has 4 parameters: spontaneous (4 points); To sound (3); To pain(2); never(1)
- Verbal has 5: Oriented(5); confused(4); inappropriate words(3); incomprehensible sounds(2); none(1)
- Motor has 6: Obeys commands(6); Localizes pain(5); Withdraw from pain(4); flexion to pain(3); extension to pain(2); none(1)
- *less than 8 resuscitate
What are examples of "painful" stimuli used to arouse patients?
Sternal rub, 18 gauge needle prick, squeeze trapezius muscle (base of neck)
What is decorticate posturing? what is it caused by? What is decerebrate posturing? what is it caused by? Which is worse, why?
- decorticate: arms flexed, legs straight; caused by hemorrhage, brain tumor, cerebral infarction (stroke), TBI
- Decerebrate: extension of arms and legs; caused by hemorrhage, brain stem injury, stroke, TBI; indicates significant spinal or neuro trauma
- Decerebrate is worse; deeper in the brain with less chance to recover
What is a lumbar puncture? What is the nurse's role? What are 3 nursing diagnoses? What is a treatment for LP spinal headache?
If the pt complains of tingling in legs/toes what does it indicate?
- insertion of a spinal needle into the lumbar space (L3, 4, 5, 6) to withdraw spinal fluid for lab testing. Looking for bacterial, proteins, pressure reading or used to insert spinal anesthesia
- Nurse: position pt in fetal position, lying on one side; instruct pt not to move during procedure, send collected tubes to lab-label with pt info; instruct pt to lay flat after LP to keep lumbar spine closed and to prevent spinal fluid leakage
- Risk For: infection at site, hematoma, spinal leak wish leads to spinal headache;
- Spinal Patch: draws blood from arm and put it into spine to promote a clot which leads to a leak plug
- indicates that the anesthetist should pull back the needle (to far in)
What is a Migraine? Signs and symptoms? What 2 things can induce them?
- Severe throbbing headache; usually unilateral
- Motion Sickness
- lasts 4-72 hours
- Sometimes present upon awakening
- can be stress induced
- can be hormonally induced
What causes the severe pain of a migraine?
The skull is an enclosed box that contains what?
- brain tissue
- cerbrospinal fluid
What is the normal intracranial pressure level?
0-15 mmHg (any higher and it can lead to herniation out the foramen magnum
What are the causes of intracranial edema?
- TBI: crushing, blunt force traume, GSW
- Ischemic stroke: blood clot or blockage
- Cerebral hemmorhage: hemorrhagic stroke (aneurysm)
- Brain infection: meningitis, encephalitis
- Tumors: gold ball, pancake
What are common causes of intracranial pressure fluctuations
- valsalva maneuver
- stress or emotional responses
- exercise, lifting
What is a complication of increased ICP? What are the clinical manifestations of increased ICP?
- decrease in LOC
- Changes in vitals: BP increases; Pulse and RR decrease
- Ocular signs: exophthalmos; convergence (focusing problem)
- changes in motor function (tremors)
What interventions do you do for intracranial pressure?
- monitor vital signs ( bp increases, pulse and RR decreases)
- Monitor neuro status
- Monitor ICP
- Maintain airway; assess ABG's
- Maintain patient's head in a neutral position
- Daily weights
- Monitor fluid and electrolytes
- monitor I&O
- reposition patient every 2 hours
- implement nutritional support ( low sodium 200mg or less)
- administer medications (Lasix, Mannitol)
What are the patient goals (planning) for patients with ICP?
- improved tissue profusion
- free from infection
- patent airway
- hemodynamic stability
- no complications as a result of immobility
- maintain ICP of less than 20mmHg
What are medical interventions for ICP?
- Diuretic therapy
- blood pressure management
- reduce metabolic demands (cluster care, therapeutic rest) (if not will lead to decreased healing)
What are the surgical interventions for ICP?
- removal of cause
what is the leading cause of trauma related death for persons under 45 years? It is twice as often in males
Head injury; most commonly caused in mva especially 20 y/o; 100 billion spent in the US on TBI
What are the different mechanisms of head injury?
- closed head injury (concussion/ nonvisible on outside)
- open head injury (visible on outside)
- Acceleration-deceleration (front and back trauma)
- Rotational: stretches or rotates spine
What are the types of head injury?
- Scalp lacerations:(stitches)
- Skull fractures:
- depressed (crushing fractures)
- Communited (crushing fracture)
- Basilar- base of brain
What is primary brain injury?
direct injury that occurs to the brain from impact
What are the different types of brain injury?
- Concussion: blunt force; lose consciousness momentarily
- Contusion: bruise on inside of the brain
- Penetrating injury: gun shot/knife
- Hematoma: epidural, subdural, intracerebral
- Intracerebral hemorrhage: stroke inside of brain
What are the indications for cranial surgery?
- vascular abnormalities
- Parkinson's disease(deep brain stimulation)
What are the different cranial surgery approaches?
- infratentorial approach: back of head
- Transsphenoidal: nose
- Burr Holes: small hole with drill, can than pull apart small part of skull
What is a stereotatic surgery?
- precision (usually computer guided) apparatus to assist surgeon to a precisely targeted area of the brain
- May use a burr hole or create a bone flap
- Involves closed skull destruction of an intracranial target using ionized radiation focused with assistance of an intracranial guiding device
What causes seizures? What is a generalized seizure? what does tonic mean? what does clonic mean? What is status epilepticus? What is an absence seizure?
- uncontrolled electrical discharges
- Generalized: all over
- Tonic: decreased LOC, stiffening of arms/legs
- Clonic: rhythmic jerking
- Status epilepticus: continued seizure or back-to-back seizure without recovery
- absence: blank stare/no recollection
What is the nurse's responsibility for seizures?
- Document every detail you see
- time: when it began and ended
- pre-sz activity-behavior aura
- postictal confusion
- recovery time
- Put pt in sidelying position, have O2 and suctioning on hand, saline lock if not in place
- Seizure precautions (pad rails, and tongue blade)
- Class: anticonvulsant
- Indication: Treatment/prevention of tonic-clonic (grand mal) seizures and complex partial seizures
- Action: Limits seizure propagation by altering ion transport; May also decrease synaptic transmission
- IV Peak/duration: rapidly; lasts 12-24 hours
- Contra: hypersensitivity
- Adverse effects: suicidal thoughts, Steven-Johnson syn., toxic epidermal necrolysis, agranulocytosis, aplastic anemia
- IV: (Adults) Status epilepticus loading dose– 15–20 mg/kg.
- Labs: Monitor CBC, serum calcium, albumin, and hepatic function tests prior to and monthly for the first several months, then periodically during therapy, MONITOR PHENYTOIN BLOOD LEVELS
- Nursing: Assess patient for phenytoin hypersensitivity syndrome (fever, skin rash, lymphadenopathy; assess behavior changes, monitor for rash, assess mental status
- Class: anticonvulsant
- Indication: Partial seizures (adjunct treatment)
- Action: May affect transport of amino acids across and stabilize neuronal membranes.
- Contra: hypersensitivity
- Adverse effects: suicidal thoughts, Rhabdo, multiorgan hypersensitivity
- PO: (Adults and Children >12 yr): 300 mg 3 times daily initially.
- Nurse: monitor for behavioral changes, for hypersensitivity reactions,
What is Parkinson's disease?
- A progressive neurodegenerative disease
- Causes: environmental and heredity
- Affects motor ability
- Characterized by: tremors, rigidity, bradykinesia(slow movement); akinesia (no movement)
- there is a decrease of dopamine in the brain which causes jerky movements (dopamine is responsible for fine, fluid, voluntary movements)
What are the 5 stages of Parkinson's?
- 1: weakness and trembling
- 2: mild masklike faces, difficulty swallowing and chewing
- 3: moderate, can't stand, poor gait, bladder/bowl incontinence
- 4: akinesia, rigidity
- 5: totally dependent
What type of medications/treatment are used for Parkinson's?
- Dopamine agonist: stimulate dopamine receptors in the brain
- s/e: makes orthostatic hypotension worse hallucinations, drowsiness
- deep brain stimulation: electrodes implanted in brain connected to pulse generator
What is Alzheimer's Disease?
- a chronic progressive, degnerative disease
- 40-50 is early onset
- 80+ is senility from old age
What is the progression of Alz's disease? What are the 3 A's of Alzheimer's?
- early (mild): short term memory loss, pt may attempt to hide symptoms
- Middle (moderate): cannot recognize familiar objects or know people
- Late (severe): cannot communicate (3 A's)
- Apraxia: inability to use words correctly
- Aphasia: inability to speak
- Anomia: inability to think words
What are the changes in behavior occur in patients with Alzheimer's?
- Aggression: physical, cursing
- sudden mood changes
- sundown syndrome
What is the treatment for Alz's?
- Care gicer role strain is high
- structured consistant environment
- perpetual orientation-person, place,
- promote ADL's: keep items in place
- family pictures
- locked unit, redirection
What are the common causes of spinal cord injuries?
- Fractures- MVA
- Penetrating: GSW. knife
- contusion (bruise)
- compression (falls)
- rotation (tearing, stretching)
What is the assessment of spinal cord injuries?
- Glasgow coma scale
- Level of injury
- Quadri: all four limbs
- Paraplegia: lower extremities only
- Spinal shock: lasts 48 hours, motor, sensory, reflex
What are the priority problems for patients with spinal cord injury?
- 1: difficulty breathing related to upper motor neuron injury
- 2: potential for neurogenic shock (face is red, lift the head, face is pale lift the tail) ( hypotension and bradycardia, poikilothermia) R/T loss or interruption of sympathetic innervation patients with SCIs above T6
- 3: Potential for further spinal cord injury R/T swelling and or fractures
- 4: impaired physical mobility and or self care R/T to decreased muscle control
- 5: Spastic or flaccid bladder and bowel R/T direct neurologic damage or disruption in nerve impulses
- 6: impaired adjustments R/T disability requiring need for life change
What are halo fixation devices?
- It is 4 screws inserted into the skull using sedation or gen anes.
- Check jacket for pressure points
- Halo keeps cervical spin still
- Pin care- antibiotics, check for lose pins
- methylprednisolone (solu-medrol)
What is autonomic dysreflexia? S&S? Causes? Treatment?
- Excessive, uncontrolled sympathetic output
- requires immediate nursing intervention
- place pt in a sitting positions and notify MD
- S&S: HT, Bradycardia, Headache, flushing
- Causes: distended bladder, breeze causing piloerection, impacted feces
- treatment: remove cause (check urinary catheter for kinks, cath if bladder is distended, check for fecal impaction, close windows, apresoline to tx increased BP)
- Class: Anti-HTN/ vasodilators
- Indication: Moderate to severe hypertension (with a diuretic)
- Action: Direct-acting peripheral arteriolar vasodilator
- S/E: dizziness; ortho hypotension(Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position) ;
What is a stroke? the different types? causes? S&s?
- Episode that causes the brain to not receive oxygen
- Ischemic: occlusive; thrombus or embolism
- Hemorrhagic: aneurysm
- PE: sudden onset, large clot, complication of a DVT
- FES: fat embolism, gradual onset, multiple small fat droplets, complication of surgical intervention to long bones and multiple fractures
- causes: environmental, genetic
- S&S: memory impairment, contralateral hemiparesis, unilateral neglect, aphasia, anomia, facial palsy, impaired swallowing.
What is the goal and intervention for a pt with a stroke?
- Goal: to have an adequate blood flow to the brain and through the cerebral blood vessels to maintain brain function and prevent further brain injury
- Intervention: for ischemic strokes start 2 IV line with non-dextrose isotonic solution; manage patient receiving treatment and monitor for any increasing intracranial pressure
What is the therapeutic level of phenytoin?