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What makes up the central nervous system? What make up the peripheral nervous system?
- Central nervous system: brain, spinal cord
- Peripheral nervous system: cranial nerves, spinal nerves, autonomic nervous system
Describe cerebral circulation
- Blood supplies oxygen, glucose, and nutrients
- Brain receives 15-20% of cardiac output
- Arterial supply from the internal carotid arteries and vertebral arteries
- Venous return through the jugular veins
What are the aspects of a neuro assessment?
- Subjective data from the patient
- Physical exam including reflexes, bilateral strength, PEARLA
- Glascow coma scale
- Mental status (a+ox3)
- Cranial Nerve testing (Especially sticking out tongue)
How do you calculate the Glasgow coma scale?
What are some ways to stimulate a person during a GCS assessment?
- Call name
- Try to sit up
- Needle prick
- Trapezius muscle pinch
- Sternal Rub
What is the difference between decorticate and decerebrate posturing? What does each posture mean?
- Decorticate: arms flexed, legs straight
- -caused by hemorrhage or lesion interrupting corticospinal pathways
- -brain tumors, CVA,TBI
- Decerebrate: extension of arms and legs
- -caused by a dysfunction or hemorrhage in the brain stem
- -brain stem tumor, cerebral CVA, TBI
What is a lumbar puncture? What is being assessed? What abnormal findings would indicate trouble?
- Lumbar puncture: insertion of a spinal needle into the lumbar space to extract and assess CSF
- May also be used to inject contract dyes (assess for allergies prior to procedure)
- Increased protein: infection, viral infection, guillan-barre syndrome, hyperthyroidism
- Decreased glucose: bacterial infection
- CSF should be clear and colorless
What is the nurse's role in a lumbar puncture? What complications should you monitor for?
- Position the patient in a side-lying fetal position
- Instruct and assist patient to remain still during puncture
- Send collected CSF to lab with pt info
- Instruct pt to lay flat after LP to keep lumbar spine closed
- Complications: infection, hematoma, spinal leak causing spinal headache and possible brain herniation (Esp for increased ICP)
What is a migraine HA and what are the S/S? What are some possible triggers?
- A unilateral throbbing headache
- Photophobia or phonophobia
- Motion sickness
- May occur with diplopia and aura, even upon waking
- Triggers include stress, caffeine, redwine, MSG, and hormonally induced
What treatments are available for migraine HAs?
- Beta Blockers
- Ergotamine Preps
- Triptan Preps
Describe cranial edema and the normal ICP
- Swelling of the brain or meninges
- Fluctuations of blood flow
- Increase in CSF
- Normal ICP: 0-15mm Hg
What are some causes of intracranial edema?
- TBI: crushing, blunt force trauma, GSW
- Ischemic Stroke: blood clot or blockage
- Cerebral Hemorrhage: hemorrhagic stroke (HTN)
- Brain Infections: meningitis, encephalitis
- Tumors: golf ball, pancake
What can cause fluctuations in ICP?
- Coughing and sneezing
- Valsavas maneuver
- Stress or emotional response
- Exercise, lifting
What are the clinical manifestations of increased ICP? What serious complication should you monitor for?
- Decrease in LOC
- Changes in vital signs- widening pulse pressure
- Changes in vision or pupils
- Changes in motor function
- HA and vomiting
- Serious complication is brain herniation leading to brain death!
What nursing interventions can be performed for a client at risk for increased ICP?
- Monitor vitals
- Monitor neuro status
- Monitor ICP
- Maintain airway
- Assess ABGs for changes
- Maintain pt's head in a neutral position, reposition q2h
- Daily weights for fluid maintenaince
- Monitor I/O and electrolytes
- Nutritional support (dietary)
- Admin medications as ordered
What are the difference mechanisms of head injury? What is a primary brain injury?
- Closed head injury
- Open head injury
- Acceleration-deceleration injury (at coup and contrcoup)
- Rotational injury
- Primary brain injury: direct injury that occurs to the brain from impact
What are the different types of skull fractures?
- Linear: most common, clean break
- Depressed: bone pressed inward
- Comminuted: bone fragments into the brain tissue
- Basilar: at base of skull, results in CSF leakage into ears and nose with black raccoon eyes. HR for nerve damage
What are the different types of brain injury?
- Concussion (widespread)
- Contusion (localized bruising)
- Penetrating injury
- Intracerebral hemorrhage
What are some clinical indications for cranial surgery?
- Vascular abnormalities
- Parkinson's disease
What is stereotatic surgery?
- Precision (computer guided) apparatus to assist the surgeon to a precisely targeted area of the brain
- May use a burr hole or bone flap to access brain
- Involves closed skull destruction of an intracranial target using ionized radiation
Describe the different types of seizures
- Generalized seizures
- Tonic- decreased LOC, stiffening of arms/legs
- Clonic- rhythmic jerking
- Absence- blank stare with possible automatisms
- Myclonic- stiffening/jerking of a muscle system
- Atonic/Akinetic- sudden loss of muscle tone & consciousness, often resulting in falling
- Status Epilepticus- continued or back to back seizures without recovery
What is the nurse's responsibility during a seizure?
- Remove restricting clothing, move to floor if necessary and protect head if possible
- Put into side lying position to avoid aspiration
- After seizure, apply O2, saline lock, suction, and pad siderails for seizure precautions
- Document what you saw, if anything occurred prior to the seizure (aura, smell), vital signs, and postictal state
- Allow for quiet during postictal state
What medications are commonly used for seizure disorders?
- Phenytoin (Dilantin): Can be used for all seizure types. Side effects include gastric distress, gingival hyperplasia, ataxia, and nystagmus. Therapeutic levels must be drawn
- Gabapentin (Neurontin): Used for partial seizures. SE include weight gain and increased appetite, ataxia, irritability, dizziness and fatigue
What is Parkinson's disease? What are some common clinical manifestations?
- A progressive, neurodegenerative disease caused by heredity or environment
- Decreased dopamine in the brain allows an increase in acetycholine
- Dopamine is responsible for fine, voluntary movement
- S/S include tremors (chorea), rigidity, shuffled gait, bradykinesia and akinesia. Behavioral changes can also occur
Describe the different stages of Parkinson's disease
- Stage 1: weakness, trembling,
- Stage 2: mild, mask-like face, difficulty swallowing/chewing
- Stage 3: Moderate, can't stand, poor gait, bladder/bowel incontinence
- Stage 4: Akinesia, rigidity
- Stage 5: total dependence
What medications are often used to treat Parkinson's disease? What other treatment may be effective in interrupting tremors?
- Dopamine agonists: very effective during the first 3-5 yrs.
- Stimulates dopamine receptors in the brain
- Ropinirole (Requip)
- Can exacerbate orthostatic hypotension
- "Wearing off" effect where there is a loss of response to drug
- Patch: Neupro
- Sinemet: a levodopa-carbidopa combo given before meals
- Deep Brain stimulation: electrodes implanted in the brain interfere with tremor cells
Describe the progression of Alzheimer's disease
- Early (mild): short term memory, pt may attempt to hide symptoms
- Middle (mod): cannot recognize familiar objects or know people
- Late (Severe): cannot communicate
- Apraxia- inability to use words correctly
- Aphasia- inability to speak
- Anomia- inability to think of words
What changes of behavior can occur in alzheimer's disease?
- Aggression-physical, cursing
- Sudden mood swings
- *Risk for Injury
What treatment is available for alzheimer's?
- Structured, consistent environment
- Perpetual orientation in early stages, validation theory in later stages
- Promote ADLs and keep items in designated places
- Keep family pictures
- Locked unit
- Cholinerase inhibitor: Donepezil (Aricept)- slows down but does not stop disease
What are some common causes/types of Spinal Cord Injuries (SCI)?
- Fractures, often from MVA
- Penetrating trauma (GSW, knife)
- Contusion (bruise)
- Compression from falls
- Rotation leading to tearing and stretching
- Axial Loading from vertical compression
How can you assess a SCI?
- Level of Injury:
- -Quadriplegia- all four extremities
- -Paraplegia- lower extremities only
- -Spinal shock lasts 48 hrs, motor, sensory, reflex
What are halo fixation devices and what nursing care should be provided?
- Four screws into the skull using sedation or general sedation, has a jacket/collar to keep in place
- Halo keeps the cervical spine in place
- Check the jacket for pressure points
- Assess points for loosening and provide pin care
- Methylprednisone (solu-medrol) may be prescribed to decrease inflammation
What is autonomic dysreflexia? What the the S/S and causes?
- An excessive, uncontrolled sympathetic output usually occurring when theres an SCI above T6
- S/S include acute, uncontrolled HTN, HA, bradycardia, flushing
- Caused by distended bladder, impacted feces, goosebumps
- This is a nursing emergency! Put pt in sitting position and call MD
- Remove case and treat HTN with Apresoline
What the different kinds of CVAs?
- Ischemic: thrombus or embolus
- Hemorrhagic: Aneurysm
- PE: sudden onset, large clot from DVT
- Fat Embolism Syndrome: gradual onset, multiple small fat droplets, surgical complication from long bone fracture
What are the S/S of a CVA?
- Memory Impairment
- Contralateral hemiparesis
- Aphasia, Anomia
- Facial Palsy (unilateral)
- Impaired swallowing