Neuro

Question 1

Neuro assessment

• Onset? Description? Triggers? Note client’s general appearance?
• Mental Status
• Glasgow Coma Scale
• Pupil changes
• Strength?
• Reflexes?

Answer 1

• Onset (when it started); Description (location, how long sx persisted, how severe); Triggers/aggravating factors (did anything help relieve the sx); Note client’s general appearance and behavior (obvious signs of neurological deficit)
• Mental Status - alert, awake oriented x 3 (person, place, time) – x4 (situation); LOC (level of consciousness)
• Glasgow Coma Scale - eye opening, motor responses, verbal response(we like a score of 13-15)
• Pupillary changes (normal pupil size 2-6 mm) – Pupils Equal Round Reactive to Light and Accommodation (PERRLA)
• Hand grips/leg lifts/pushing strength of feet
• Babinski reflex (only normal in infant up to 1 year, abnormal in adult) – fanning of toes when the bottom of the foot is stroked
• Plantar reflex - normal in adults children >1 (curling of the toes when the bottom of the foot is stroked)
• Deep Tendon Reflex Scale
• 0 no response
• 1 hypoactive
• 2 NORMAL
• 3 slightly hyperactive
• 4 hyperactive w/ clonus (abnormal movements of foot)
• Document as 2+/4+

Question 2

Glasgow Coma Scale

Answer 2

Eye Opening:
Spontaneous - 4
Verbal command - 3
Pain - 2
No response - 1

Motor Response:
Verbal command - 6
Localized - 5
Flexed Withdraws - 4
Flexes abnormally (decorticate) - 3
Extends abnormally (decerebrate) - 2
No response - 1

Verbal Response:
Oriented talks - 5
Disoriented/talks - 4
Inappropriate words - 3
Incomprehensible sounds - 2
No response - 1

Question 3

_____ is always #1 with neurological assessment

Answer 3

LOC (level of consciousness)

Question 4

What does it mean if the adult has a Babinski reflex?

Answer 4

Severe CNS problem – tumor or lesion on the brain or spinal cord, meningitis, multiple sclerosis, Lou Gehrig’s disease

Question 5

CT

Answer 5

a. With/without contrast (dye) – check for allergies
The client will need to sign a consent form prior to the test when using dye.
b. Takes pictures in slices/layers
c. Keep head still
d. No talking

Question 6

MRI

Answer 6

a. MRI is better than CT
b. dye not usually used
c. magnet is used - no jewelry, credit cards, pacemakers
d. will be placed in a tube where client will have to lie flat.
e. Do fillings in teeth matter? No
f. Do tattoos matter? Old ones do w/ lead–Veterans could have shrapnel from IED’s/bombs
g. Will hear a thumping sound – tell client about this
h. What type of client cannot tolerate this procedure? Claustrophobic
i. Can talk and hear others while in the tube

Question 7

PET scan

Answer 7

Nuclear image test to view parts of brain/any organ as it’s working

a. dx for Alzheimer’s, brain tumors, CVA (stroke), Parkinson’s, aspects associated w/ mental illness
b. need informed consent
c. client must inhale a radioactive gas or be injected w/ a radioactive substance
d. no contact with children or pregnant women for 24 hrs after scan

Question 8

Cerebral angiography

Answer 8

X-ray of cerebral circulation using iodine dye
Go through the femoral/brachial artery (like ♡ cath)
a. Pre:
1) Check for allergies to iodine and shellfish
2) Well-hydrated/void/peripheral pulses/groin prepped
• Hydrate client promotes excretion of the dye after.
3) Explain they will experience facial flushing and metallic taste
4) Monitor BUN, Creatinine, UOP
5) Hold metformin

b. Post:
1) Bed rest for 4-6 hours; Monitor BUN, Creatinine, UOP
2) Major complication: Bleeding/hemorrhage (coz femoral artery was used), Embolus
• An embolus can go lots of different places: Arm, Heart, Lung, Kidney
• embolus in brain s/sx – change in LOC, one-sided weakness, paralysis, motor/sensory deficits.

Do a good baseline neuro exam to compare

Question 9

EEG

Answer 9

a. Records electrical brain activity
b. Helps diagnose seizure disorders; Evaluate loss of consciousness and dementia
c. Screening for coma
d. Indicator of brain death
e. Pre-procedure:
• Hold sedatives - No caffeine
• Not NPO (drops blood sugar)
f. During procedure
• Will get a baseline first with client lying quietly; may be asked to hyperventilate or cough; if they are completely unconscious, clap hands in face, blow whistle in face.

Question 10

Lumbar Puncture

Answer 10

• puncture site - lumbar subarachnoid space
• Purposes
• obtain CSF fluid to analyze blood, infection, tumor cells
• measure pressure reading w/ manometer and reduce CSF pressure
• administer drugs intrathecally into spinal canal

• Position - propped up over bedside table w/ head down and a lot of arch to the back like an angry cat or fetal position (chin to chest and knees flexed)

• inspect skin for infection
• CSF should be clear and colorless like water

• Post-procedure

• lie flat or prone 4-8 hrs
• increase fluids to replace lost fluids
• common complication: HEADACHE - pain increases when sitting/standing, pain decreases when lying down
• tx for headache - bed rest, fluids, pain meds, blood patch (for leaking–instant seal)

• BIG COMPLICATION:

• brain herniation: known high ICP = no lumbar puncture
• infection: bacteria can get into puncture site and into spinal fluid = cause MENINGITIS

Question 11

Early Signs of ↑ ICP

Answer 11

• change in LOC - going into coma or subtle change in attention span
• speech slurred/slowed
• delay in response to verbal suggestion (slow to respond to commands)
• increased drowsiness
• restlessness w/o apparent reason
• confusion

Question 12

Late Signs of ↑ ICP

Answer 12

• change in LOC -> stupor/daze -> coma
• Cushing’s triad (pressure in brain stem) - ↑BP, ↓HR, ↓RR
- systolic HTN w/ widening pulse pressure;
- slow, full, bounding pulse;
- irregular RR pattern (Cheyne stokes or ataxic)

Question 13

Decerebrate and Decorticate Posturing

Answer 13

• responses to painful or noxious stimuli = indicates motor response centers of brain, mid-brain, brain stem are COMPROMISED
• may posture on one side only
• may have different posturing on each side

Question 14

Decorticate

Answer 14

arms flexed inward and bent in toward the body and legs extended (GCS score 3 in motor responses)

De “Cor” ticate is towards the “CORE: of the body or inward flexion; think “wakanda” pose

Question 15

Decerebrate

Answer 15

present with all 4 extremities in rigid extension
WORST (GCS score 2 in motor responses)

Decerebrate is away from the body

Question 16

Complications of ↑ ICP

Answer 16

1. BRAIN HERNIATION - obstructs blood flow to brain leading to anoxia (no O2) = BRAIN DEATH
2. DI and SIADH (head things, think ADH)

Question 17

Complications of ↑ ICP

Answer 17

1. BRAIN HERNIATION - obstructs blood flow to brain leading to anoxia (no O2) = BRAIN DEATH
2. DI and SIADH (head things, think ADH)

Question 18

Treatment for ↑ ICP

Answer 18

Goals: Reduce cerebral edema, reduce amt of CSF, reduce blood volume in brain

a. Maintain oxygenation: (acidosis/↑CO2) = ↑ ICP

b. Maintain adequate cerebral perfusion
- ↓BP, ↓HR = ↓ brain perfusion
- give isotonic NS and inotropic agents: dobutamine (Dobutrex) and norepinephrine (Levophed) – short term only – these are EMERGENCY drugs

c. Keep temperature <100.4 F (38 C)
- ↑temp = ↑ ICP
- cooling blanket and hypothermia as tx to ↓ metabolic demands of brain

d. elevate HOB (this ↓ ICP)
e. keep head midline so the jugular veins can drain

f. watch ICP monitor w/ turning
- if ICP has not come back down in 15 mins after turning client = NOT tolerating that side very well

g. Avoid restraints, bowel/bladder distention, hip flexion, Valsalva, isometrics. No sneezing, no nose blowing
h. Limit suctioning and coughing (these ↑ ICP)
i. spaced nursing interventions – NO CLUSTERED CARE (mess w/ client = ↑ ICP); Fluid restriction (LESS VOLUME = LESS PRESSURE)
j. MONITOR THE GLASGOW COMA SCALE (<8 = intubate)
k. Monitor VS for Cushing’s triad - ↑BP, ↓HR, ↓RR

Question 19

Rule: If the Glasgow coma scale is below 8, think ____

Answer 19

intubate!!!

Question 20

ICP monitoring devices

- greatest risk? ____

Answer 20

ventricular cath monitor or subarachnoid screw

- INFECTION

Question 21

tx for ↑ ICP: Barbiturate

Answer 21

induced coma - decreases cerebral metabolism: phenobarbital (Luminal®)

Question 22

tx for ↑ ICP: Osmotic diuretics

Answer 22

mannitol (Osmitrol®) → pulls fluid from brain cells → filter it thru kidneys = ↓ ICP

mannitol ↑ circulating blood volume = ↑ workload of the heart

Question 23

tx for ↑ ICP: Hypertonic saline (3%)

Answer 23

acts like osmotic diuretic → pulls fluid from brain = reduce cerebral edema

Question 24

tx for ↑ ICP: Steroids

Answer 24

dexamethasone (Decadron)

- used to decrease cerebral edema when a tumor is cause of ↑ ICP

Question 25

Meningitis definition, causes, s/sx

Answer 25

* inflammation of the covering of spinal cord and brain * causes: either viral or bacterial infection ``` S/SX • chills, high fever • severe headache • disorientation → coma • N/V • nuchal rigidity (stiff neck) • photophobia (light hurts the eyes) • seizures • (+) Kernig - severe stiffness of the hamstrings, inability to straighten leg when hips flexed 90° • (+) Brudzinki - severe neck stiffness causes hips and knees to flex when neck is flexed ```

Question 26

Meningitis definition, causes, s/sx

Answer 26

* inflammation of the covering of spinal cord and brain * causes: either viral or bacterial infection ``` S/SX • chills, high fever • severe headache • disorientation → coma • N/V • nuchal rigidity (stiff neck) • photophobia (light hurts the eyes) • seizures • (+) Kernig - severe stiffness of the hamstrings, inability to straighten leg when hips flexed 90° • (+) Brudzinki - severe neck stiffness causes hips and knees to flex when neck is flexed ```

Question 27

Traumatic Brain Injury: (injury = damage to brain) | Closed TBI and Open TBI

Answer 27

a. Closed TBI - not broken/fractured/penetrated → dura not torn b. Open TBI - broken/fractured/penetrated → dura is torn - Basilar fx - MOST SERIOUS - w/ basilar skull fractures you see bleeding where? EENT (eyes, ears, nose, throat) - Battle's sign: bruising over mastoid (bone behind ear) - Raccoon eyes (peri-orbital bruising) - Cerebrospinal rhinorrhea - leaking spinal fluid from nose (let it flow freely until it heals itself) - how do we tell CSF from other drainage? (+) for glucose and the halo test (form ring around blood spot) - Non-depressed skull fractures usually do not require surgery; depressed do require surgery.

Question 28

Focal Injuries: Contusions

Answer 28

seen w/ blunt trauma or acceleration-deceleration injuries like a whiplash - brain is bruised and damaged (mild to severe)

Question 29

Focal Injuries: | Contusions

Answer 29

from blunt trauma or acceleration-deceleration injuries like a whiplash - brain is bruised and damaged (mild to severe)

Question 30

Focal Injuries: | Hematomas

Answer 30

solid swelling of blood clot - small hematoma that develops rapidly = fatal - massive hematoma = allow client to adapt

Question 31

TBI Intracranial Hemorrhage: | Epidural Hematoma

Answer 31

EMERGENCY! • rupture/laceration of middle meningeal artery (fast bleeder under high pressure) • Pathophysio Injury → Loss of consciousness → Recovery period → Can’t compensate any longer → Neuro changes (agitation, restless, confusion, pupil changes, seizures, posturing) • Tx: Burr Holes to remove clot and control ICP. Ask questions to identify the type of injury and treatment needed: • Did they pass out and stay out? • Did they pass out and wake up and pass out again? • Did they just see stars?

Question 32

TBI Intracranial Hemorrhage: | Subdural Hematoma

Answer 32

• Pathophysio collection of blood between dura and brain Usually venous Can be acute (fast), subacute (medium), or chronic (slow) • Tx: - Acute: immediate craniotomy and remove clot: control ICP - Chronic: imitates other conditions; DRUNK, Bleeding and compensating Neuro changes= maxed out Could have fallen a month ago Normal Lab Value: ICP: 0-15mm Hg

Question 33

Diffused Brain Injury: | Concussion

Answer 33

* temporary loss of neurologic function w/ complete recovery * short period of unconsciousness or may just get dizzy and see spots * DO NOT ADMINISTER OPIOIDS OR OTHER SEDATING MEDS!

Question 34

After a concussion and client is sent home--Teach caregiver to bring client back to ED if the following occur:

Answer 34

``` DIFFICULTY AWAKENING/SPEAKING Confusion Severe headache Vomiting Pulse changes Unequal pupils One-sided weakness ``` *signs that ICP ↑

Question 35

Nursing care for possible head injury or increased ICP

Answer 35

a. Assume a c-spine injury is present until proven otherwise. • How do we prove otherwise? With an X-ray b. Keep body in perfect alignment. c. Keep slight traction on head. d. How do you tell CSF from other drainage? • Positive for glucose; halo test e. Ensure adequate nutrition f. Need increased calories, hypermetabolic state g. Steroids increase breakdown of protein and fat. Steroids decrease cerebral edema h. Cannot have NG feedings if having CSF rhinorrhea. Don't want feeding to get into brain i. When a client emerges from a coma→ lethargic→ agitated • No restraints because restraints will make your ICP go up. j. Need a quiet environment- stimuli could promote seizure k. Pad side rails l. No narcotics • Affect your neuro checks *morphine makes pin point pupils m. Normal ICP = < 15 n. ICP varies according to position. • We elevate the HOB to decrease ICP o. The brain can compensate only to a certain point as the skull is a rigid cavity.

Question 36

Spinal cord injury | Autonomic dysreflexia/Hyperreflexia

Answer 36

LIFE-THREATENING NEUROLOGICAL EMERGENCY - w/ upper spinal cord injury (above T6) *Sudden onset!!! ``` S/SX: • severe HTN and headache • bradycardia • nasal stuffiness • sweating on forehead • blurred vision • nausea • anxiety ```

Question 37

If Autonomic dysreflexia is NOT treated, what happens?

Answer 37

hypertensive stroke

Question 38

Autonomic dysreflexia Causes

Answer 38

* distended bladder * constipation/impaction * stimuli to skin: pressure, pain, temperature

Question 39

Autonomic dysreflexia Treatment

Answer 39

1. Sit the client up to ↓BP or put bed bound client in semi fowlers 2. Treat the cause - insert a catheter - remove any impaction (w/ topical anesthetic) - look for skin pressure, pain stimuli, or a cold draft/breeze in the room 3. Antihypertensives if BP is still high after stimulus is removed 4. Teach prevention measures

Question 40

12 Cranial nerves

Answer 40

``` "On Old Olympus Towering Top A Find And German Viewed Some Hops" Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear (auditory) Glossopharyngeal Vagus Spinal accessory Hypoglossal ```