1
Q
What is the most sensitive indicator of neuro status?
A
Level of consciousness.
Assess for restlessness, irritability, and confusion.
2
Q
What is the highest score on the Glasgow coma score?
A
15
At 15, the client is completely alert and oriented
- eyes open spontaneously
- verbalizes pain
- oriented and converses
3
Q
What is the lowest score on the Glasgow coma scale?
A
3
At 3, the client is not responsive
- eyes have no response
- no response to pain
- no verbal response
4
Q
At what Glasgow coma score is the client typically intubated?
(Immediate complication)
A
“Less than 8, intubate”
8 indicates a coma.
5
Q
Unconscious clients are completely dependent on caregivers. What are the priority safety concerns?
A
- assure an airway: may be on a ventilator
- tube feedings: prevent aspiration
- turn every 2 hours: to prevent pressure ulcers
- prevent falls: by keeping side rails up and bed in low position
6
Q
What is decorticate and decerebrate posturing?
A
Both postures indicate a deteriorating condition in the brain.
7
Q
What life-threatening condition are clients at risk for after a head injury, stroke, or brain surgery?
(Immediate complication)
A
Increased intracranial pressure (ICP)
Increased pressure in the brain due to edema.
8
Q
What is a late sign of increased intracranial pressure?
A
- increased systolic blood pressure
- widened pulse pressure: big difference between systolic and diastolic pressure
- bradycardia: due to compensation of a high BP
9
Q
What position is a client placed in to prevent increased intracranial pressure?
A
- elevate HOB 30 to 40 degrees
- don’t flex the neck or hips (keep body midline)
10
Q
What common actions should the client avoid to prevent increased intracranial pressure?
A
- avoid straining such as coughing, sneezing, and Valsalva’s maneuver
- stool softeners daily
- no toothbrushing; use soft swab
- don’t shiver: keep client warm
11
Q
Why is there a fluid restriction with increased intracranial pressure?
A
Due to edema and extra fluids in the brain: fluids are restricted to less than 1200 mL per day to prevent more edema.
12
Q
Medications:
Increased intracranial pressure
A
- anticonvulsants: to prevent seizures
- muscle relaxers: to prevent shivering
- antihypertensives: to maintain cerebral perfusion
- steroids: to decrease edema and inflammation
- osmotic diuretic (mannitol): to decrease edema
13
Q
How is intracranial pressure monitored?
A
With an ICP machine that measures the pressure in the brain.
14
Q
How are head injuries prevented?
A
By wearing a helmet when riding a motorcycle or bicycle.
15
Q
What is a concussion?
A
It is when there is a jarring movement of the brain inside the skull.
The client may or may not lose consciousness.
16
Q
What is an epidural hematoma?
(Immediate complication)
A
The most serious bleeding head injury. It occurs above the dura and is arterial blood (bleeds fast).
Client can rapidly progress into a coma.
17
Q
What is a subdural hematoma?
A
Occurs below the dura and is venous blood (bleeds slowly).
It can resolve on its own or be life-threatening.
18
Q
What is an intracerebral hemorrhage?
(Immediate complication)
A
When a blood vessel within the brain has ruptured.
It can occur from a traumatic brain injury (TBI) or cerebral aneurysm.
19
Q
What is always the concern after a head injury?
A
Increased intracranial pressure.
20
Q
What fluid can leak out of the ears or nose after a head injury?
A
Cerebral Spinal Fluid (CSF)
21
Q
What are the interventions if cerebral spinal fluid is leaking out of the nose or ears?
A
- do not suction the nose and don’t allow the client to blow their nose
- if drainage is coming out of the ear, don’t clean it, just put a sterile dressing over the ear.
- tell client not to cough
22
Q
How is a cerebral spinal fluid leak tested for?
A
Halo test
23
Q
What is a craniotomy?
A
A surgery of the brain to remove blood or a tumor.
24
Q
What are the priority interventions after a craniotomy?
A
- make sure the client can breathe (may be on a ventilator)
- prevent increased ICP
25
What is a **seizure**?
| (Immediate complication)
A **sudden, uncontrolled electrical disturbance in the brain.** It can cause changes in behavior, movements or feelings, and in levels of consciousness.
## Footnote
Epilepsy is a seizure disorder of two or more seizures or a tendency to have recurrent seizures.
26
# Signs and symptoms:
Seizure
* confusion
* aura
* sudden falls
* staring
* uncontrollable jerky movements
* strange sensations and emotions
* loss of consciousness or awareness
27
# Interventions:
During a seizure
* maintain airway and DON'T put anything in the mouth
* place client on floor and protect head and body
* don't restrain the client
* loosen clothing
* note the type of seizure
* give anticonvulsant IV to stop seizure
28
# Interventions:
After a seizure
* turn client to the side so secretions can drain - possibly suction
* assess respirations and oxygen reading
* document time and duration of seizure
* implement seizure precautions
## Footnote
*Notify HCP.*
29
# Teaching:
Seizure
1. **take medication for life**: may need to monitor medication blood levels
2. **avoid substances and situations that cause seizures**: avoid alcohol, excessive stress, fatigue, strobe lights
30
What is the **difference** between a thrombotic CVA (cerebral vascular accident) and embolic CVA?
| (Immediate complication)
A _thrombotic CVA_ is caused by a **blood clot that develops in the brain**.
An _embolic CVA_ is caused by a **blood clot or plaque debris that develops somewhere else in the body** and then travels to the brain.
## Footnote
Both types are considered ischemic CVAs, where a clot blocks oxygen and blood.
31
What is a **hemorrhagic CVA**?
| (Immediate complication)
It is caused by **bleeding in the brain** from hypertension or an aneurysm.
32
What is the most **common test** to diagnose a CVA?
A **CT scan** to see if it's caused from a blood clot or from bleeding.
## Footnote
There are different interventions based on the type of stroke.
33
What are the **characteristic signs and symptoms** of an acute CVA?
**FAST**
* severe onset headache
* one-sided face drooping
* Arm weakness/ataxia
* Speech difficulties
* Time to call
34
What **medications** are given if the client is having a CVA from a blood clot?
**Thrombolytics** are given to break up the blood clot.
35
Would thrombolytics be given to a client having a hemorrhagic CVA?
**NEVER.** The client will bleed more.
## Footnote
Never give thrombolytics to a client having a hemorrhagic stroke or to a client who is actively bleeding. Make sure the CT scan is completed to determine what kind of stroke it is before thrombolytics are given.
36
What is **Neglect syndrome**?
When the client is **unaware of the existence of the paralyzed side**.
## Footnote
Encourage activity on the neglected side.
37
# Define:
Agnosia
The inability to recognize familiar objects or people.
38
# Define:
hemiplegia paralysis
Paralysis on one side.
39
# Define:
Apraxia
The **inability to carry out physical movements**, even though having the desire and ability to perform them.
40
# Define:
Expressive aphasia
When the **client understands what is being said, but can't communicate verbally**.
## Footnote
The client cannot _express_ information.
41
# Define:
Receptive aphasia
When the client **cannot understand what is being said or written**.
## Footnote
They cannot _receive_ information.
42
# Define:
Hemianopsia
Blindness in half the visual field.
43
# Define:
Dysphagia
Difficulty swallowing.
44
What is a **common referral** due to risk of dysphagia in stroke clients?
**The speech therapist** comes and sees the client to evaluate the gag reflex and swallowing, in order to recommend a diet.
45
What is the typical recommended **diet** for a client with dysphagia?
* thickened fluids
* soft foods
46
How is a client with dysphagia **positioned** when eating?
* sit client high up in bed
* put head and neck slightly forward and chin tucked
* put food in the back of the mouth on the unaffected side to prevent trapping of food
* no straws
47
What are the **interventions** for a client with hemianopsia?
* approach client from the unaffected side
* place objects on the side that they can see on
48
What do all these neuro diseases all have in **common**?
* *multiple sclerosis*
* *myasthenia gravis*
* *Parkinson's disease*
* *Guilain-Barre syndrome*
All the clients with these neuro diseases have **fatigue and muscle weakness** (including respiratory muscle weakness).
## Footnote
Assess for difficulty with breathing, swallowing, and prevent falls.
49
# Describe:
Multiple sclerosis
A **muscle weakness disease of the CNS** due to demyelination of the neurons.
## Footnote
The cause is unknown, but more common between the ages of 20 - 40.
50
# Describe:
Myasthenia Gravis
An autoimmune disease that causes **muscle weakness due to a defect in nerve impulse transmission**.
## Footnote
There is not enough secretion of acetylcholine and too much secretion of cholinesterase.
51
What is an **early sign** of myasthenia gravis?
A droopy eyelid (Ptosis) and double vision.
52
# Describe:
What are the **late signs** of myasthenia gravis?
* difficulty chewing, swallowing and breathing
* respiratory paralysis and respiratory failure
53
# Medications:
Myasthenia gravis
* pyridostig**_mine_**
* neostig**_mine_**
## Footnote
end in -_mine_
54
What is a **myasthenic crisis**?
| (Immediate complication)
When the **client doesn't get enough of their medication (undermedicated)**, causing muscle weakness.
## Footnote
It usually occurs about 3 hours after med administration.
55
What is a **cholinergic crisis**?
| (Immediate complication)
When a client gets **too much of their medicine (overmedicated)**, causing muscle weakness.
## Footnote
It usually occurs about 1 hour after med administration.
56
What are the **symptoms** of a cholinergic crisis (overmedicated) and myasthenic crisis (undermedicated)?
**Basically the same:**
* muscle weakness
* dyspnea
* dysphagia
* bradycardia
## Footnote
The similar symptoms make it difficult to determine quickly if the client is undermedicated or overmedicated.
57
What is an **edrophonium (Tensilon) test**?
Used to determine if the client is in a myasthenic crisis or cholinergic crisis:
1. it's a _myasthenic crisis_ if edrophonium is given and **strength improves**
* client needs more medicine
2. it's a _cholinergic crisis_ if edrophonium is given and the **weakness gets worse**.
* client needs less medicine
58
What is the **antidote** to a cholinergic crisis?
**Atropine sulfate** (an anticholinergic)
59
# Describe:
Parkinson's Disease
A **neuromuscular weakness disease** caused by the depletion of dopamine.
## Footnote
Dopamine is needed for good muscle control.
60
What are the **characteristic symptoms** for Parkinson's disease?
61
What are the **late signs** of Parkinson's disease?
**Due to muscle weakness:**
* difficulty swallowing and speaking
* drooling
62
What are the **basic interventions** for most neuromuscular disorders that cause muscle weakness?
* prevent falls
* don't rush client
* provide frequent rest periods
* assess the ability to chew and swallow
* assess breathing
* promote independence
63
# Describe:
Guillain-Barre Syndrome
## Footnote
*Immediate complication*
Occurs **after an infection where the immune system overreacts and destroys the myelin sheath** (the part that connects nerves).
## Footnote
The client gets ascending paralysis, eventually affecting the respiratory muscles.
64
What is the **priority** **assessment** with Guillain-Barre syndrome?
**Assess ability to breathe** and respirations due to ascending paralysis.
65
Is there a **cure** for Guillain Barre?
**No.** There is no known cure for Guillain Barre, but client may get **immunoglobin therapy** to boost the immune system - the client will be on a ventilator.
## Footnote
Most clients recover within 1 year.
66
# Describe:
Meningitis
| (Immediate complication)
An infection in the brain and spinal cord.
67
# Risk factors:
Meningitis
* skull fractures
* brain or spinal surgery
* upper respiratory infections
* using nasal sprays
* living in crowded areas
68
How is meningitis **diagnosed**?
By **lumbar puncture** for a cerebral spinal fluid culture.
69
What populations are most at **risk** of getting meningitis?
**Those who live in crowded areas:**
* college dorms
* prisons
* group homes
70
What are the infection control precautions for meningitis?
Droplet precautions.
## Footnote
Implement airborne and contact precautions.
71
What are the **characteristic signs and symptoms** of meningitis?
* fatigue/lethargy/headache
* photophobia
* decreased LOC
* possible rash
72
What is **Kernig's sign**?
A **sign of meningitis**: when client lays supine, the leg stays flexed at the knee.
73
What is **Brudzinski's sign**?
A **sign of meningitis**: when the neck is flexed, the hip and knee involuntary flex also.
73
If a client is found unconscious, what should you do?
Check airway and pulse. Start CPR if needed.
74
# Interventions:
Meningitis
* assess for increased ICP
* seizure precautions
* droplet precautions with pneumococcal meningitis
* airborne precautions with other types of meningitis
* give antibiotics and analgesics for pain
75
# Define:
Electromyography
A diagnostic test for neuromuscular diseases. A needle is inserted in the muscle and records electrical activity.
76
# Teaching:
Electromyography
No stimulants or sedatives 24 hours before procedure.
77
# Describe:
Trigeminal neuralgia
A sensory disorder of 5th cranial nerve that causes pain.
78
What foods are avoided with trigeminal neuralgia?
Hot or cold foods.
## Footnote
These foods irritate the 5th cranial nerve.
79
# Describe:
Bell's palsy
Facial paralysis caused by a lesion on the cranial nerve VII with paralysis of one side of the face.
## Footnote
This condition can get confused with an acute CVA.
80
What can cause both trigeminal neuralgia and Bell's palsy?
* trauma
* infection
* hemorrhage
* tumor
## Footnote
Treat the cause.
81
# Describe:
Migraines
Head pain with unknown cause but can be triggered by:
* caffeine
* red wine
* MSG
* weather changes
82
Are migraines more common in men or women?
Women; mostly due to hormone changes and fluctuations.
83
What are the characteristic signs and symptoms of migraines?
* severe head pain or headache
* nausea and vomiting
* sensitivity to light
* an "aura"
84
# Medications:
Migraines
NSAIDs, acetaminophen, antimigraine medications, botox
85
# Interventions:
Migraines
* pain medicine
* keep the room dark
* wear sunglasses
* CAM
* avoid triggers
NCLEX-PN (5) Adult Health
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