1
Q
Cranial Nerve 1
What is it?
What is it’s function?
Is it sensory or motor?
A
- Olfactory (have patient identify scents, occlude one nare)
- Sense of Smell
- Sensory
2
Q
Cranial Nerve 2
What is it?
What is it’s function?
Is it sensory or motor?
A
- Optic (Pt tell time on clock/look at eye structures)
- Vision in eyes
- Sensory
3
Q
Cranial Nerve 3
What is it?
What is it’s function?
Is it sensory or motor?
A
- Oculomotor (PERRLA)
- Movement of eyes
- Motor
4
Q
Cranial Nerve 4
What is it?
What is it’s function?
Is it sensory or motor?
A
- Trochlear (Cardinal Gaze / Convergence)
- Movement of eyes
- Motor
5
Q
Cranial Nerve 5
What is it?
What is it’s function?
Is it sensory or motor?
A
- Trigeminal (Touch Pt. with soft and sharp side of object, move jaw side to side)
- Sensation in face / movement of jaw muscles
- Both
6
Q
Cranial Nerve 6
What is it?
What is it’s function?
Is it sensory or motor?
A
- Abducens (Cardinal field of gaze / lateral vision test)
- Eye movement
- Motor
7
Q
Cranial Nerve 7
What is it?
What is it’s function?
Is it sensory or motor?
A
- Facial (smile, frown, puff cheeks, expressions)
- Taste / movement of face for facial expressions
- Both
8
Q
Cranial Nerve 8
What is it?
What is it’s function?
Is it sensory or motor?
A
- Vestibulocochlear (Whisper test / Weber Rinne air conduction test)
- Hearing
- Sensory
9
Q
Cranial Nerve 9
What is it?
What is it’s function?
Is it sensory or motor?
A
- Glossopharyngeal (Taste test/rise of palate and uvula when patient says “ahhh”)
- taste / movement of pharynx
- Both
10
Q
Cranial Nerve 10
What is it?
What is it’s function?
Is it sensory or motor?
A
- Vagus (Pt swallow look @ pallets and uvula)
- Pharynx sensation / movement of viscera organs (heart, lungs, intestines, etc)
- Both
11
Q
Cranial Nerve 11
What is it?
What is it’s function?
Is it sensory or motor?
A
- Accessory (Have pt. shrug shoulders)
- Movement of neck muscles
- Motor
12
Q
Cranial Nerve 12
What is it?
What is it’s function?
Is it sensory or motor?
A
- Hypoglossal (Have pt. stick tongue out and watch for drifting to one side)
- Movement of tongue
- Motor
13
Q
What are the mnemonics to remember cranial nerves?
A
- Oh Oh Oh To Touch And Feel Very Good Velvet, Ah Heaven! (Nerves)
- Some Say Marry Money But My Brother Says Big Boobs Matter Most. (Function)
14
Q
In a patient with an altered level of consciousness (ALOC), which assessments should the nurse perform?
A
- Glasgow Coma Scale rapid neuro checks.
- Vital Signs
- Pupil size, limb movements, bladder, lung sounds, cardiac status
15
Q
Why is it important to include an ALOC patient’s significant other and family members in the patients care?
A
If the patient is unresponsive it’s important to know their background and medical history.
16
Q
A decrease of ___ or more on the Glasgow Coma Scale is significant. What must the nurse do?
A
- 2
- Must report to the PHCP!
17
Q
Why is any new abnormal flexion noteworthy for an ALOC patient on the GCS?
A
May be R/T intracranial pressure or worsening of neurological condition
18
Q
On the Glasgow Coma Scale, what score indicates a client is comatose?
A
8 or less
19
Q
On the Glasgow Coma Scale, what score indicates a client is totally unresponsive?
A
3
20
Q
On the Glasgow Coma Scale, what score range is considered acceptable?
A
9-15 (15 is best)
21
Q
What are some common causes of ALOC?
A
Neurological, toxic, or metabolic issue may cause ALOC.
22
Q
What cranial nerve checks PERRLA?
A
Cranial nerve 3 (occulor motor nerve)
23
Q
What is ‘pronator drift’ and what does it check for?
A
- Checks for brain stem function.
- Patient holds their arms out in front of them with their eyes closed, if one arm starts drifting, it could signal brain stem issue.
24
Q
What is decorticate rigidity?
A
Extremities go towards the care of the body due to brainstem dysfunction.
25
What is decerebrate rigidity?
Extremities are distended and flexed outwards away from the body due to brainstem dysfunction.
26
What is the main concern for for ALOC patients?
Breathing is the main concern for ALOC patients. (can't cough to clear secretions, can't breathe, risk for aspiration, etc.)
27
What interventions should the nurse perform for ALOC patients?
- Maintain respiratory function (suction, insert airway, etc)
- nutrition/fluid support
- monitor for changes in condition (document and report)
- prevent immobility complications
28
What is the safest position for an ALOC patient to be in, in order to maintain resp. function?
Semi-Fowlers.
29
What is important to remember for ALOC patients in terms of nutritional and fluid support?
NPO until responsive and safe swallowing has been established.
30
Nurses should re position an ALOC pt every two hours to prevent what?
Skin breakdown (ALOC = high risk)
31
If a nurse is caring for an ALOC pt. with skin breakdown, she must do what in order to change the surface the patient is lying on?
Initiate an order to/from the physician.
32
Contractures happen quickly (~ 4 days) in an immobile ALOC patient, how should the nurse help prevent this?
- Positioning patient in a non-bent or non-flexed position
| - Perform passive ROM exercises on the patient.
33
What are some signs of changing condition in ALOC patients?
HR, Rise in BP, widening pulse pressure, temperature fluctuations, LOC changes, pupillary changes
34
Temperature changes in ALOC pts. are important because it can lead to _______?
Edema, which leads to IC pressure.
35
What is the definition of migraine?
Recurrent episodic pain in the head that may be accompanied with photophobia, phonophobia, N/V, movement of head makes S/S worse.
36
What is the cause of migraines?
No organic cause, etiology is unknown.
37
What are some common migraine triggers?
MSG, wine, aspartame, smells, foods with TYRAMINE in them (chocolate, cheese, caffeine), stress, hormones, fatigue.
38
Migraines are a ______, not a disease!
Symptom
39
If a patient experiences frequent migraines, they are also more at risk for _______ and _______.
Epilepsy and Stroke
40
Migraine with aura (Classic migraine)
Change in sensation that precipitates the migraine.
41
Migraine without aura (common migraine)
Most common, no aura.
42
Atypical Migraine
Migraine that lasts longer than 72 hours, may have a stroke with this.
43
What are the four stages of migraines and what occurs in each stage?
1. Prodromal (before pain) - mood changes, cravings, neck stiffness, constipation.
2. Aura - visual disturbances, neurological changes.
3. Attack - PAIN, sensitive to light/sound/smells/touch, N/V, lightheaded.
4. Postdromal - Confusion, weakness, dizziness, light/sound sensitivity, moodiness.
44
What is Dihydroergotamine (DHE?)
- abortive migraine medicine used to stop the pain
- do NOT give with Triptan drugs (causes coronary artery vasospasms if used together)
- can give IM, IV, SubQ, intranasal
45
What is Sumatriptan? What are the side effects?
- abortive migraines medicine used to stop the pain
- flushing, tingling, hot are common side effects
- do not use with MAOIs, SSRIs (may cause neuropathic malignant syndrome), DHE
- Do not give to patients with HTN, heart disease, cerebrovascular disease.
46
What is the priority nursing management once a migraine occurs in a patient?
STOP the migraine! Pain management.
| - Opioids, NSAIDs, Tylenol, Antiemetics
47
What medications can help prevent migraines?
- Beta Blockers (end in -lol) (vasoconstricting)
- Calcium Channel Blockers (vasoconstricting)
- Anticonvulsants
- Tricyclic antidepressants
- Botox injections
48
What are the two types of seizures?
- Primary: unknown etiology, no identifiable cause
| - Secondary: results from underlying brain lesion or identifiable cause
49
What a person experiences 2 or more primary seizures in their lifetime, they are considered to have ____________.
Epilepsy
50
How long do seizures usually last? What time frame is considered a medical emergency?
Seizures last 30 seconds - 2 minutes.
| *5 minutes or longer is a medical emergency*
51
What are the three categories of seizures?
- Generalized
- Focal (partial)
- Unclassified
52
What is a generalized seizure?
Occurs in both hemispheres of the brain, the whole brain turns on at once. Pt is unconscious.
53
Tonic Clonic (generalized seizure)
- also called grand mal seizure.
| - alterations between muscle contractions and jerking of all four extremities.
54
Tonic (generalized seizure)
- Increased muscle tone
| - (tone = ton)
55
Clonic (generalized seizure)
- Muscle contractions and relaxations
| - (C in clonic, C in contractions)
56
Myoclonic (generalized seizure)
- Muscle jerking in extremities
| - Can be mistaken for clumsiness
57
Atonic or Drop Attack (generalized seizure)
Sudden loss of muscle tone and consciousness.
58
Absence or petit mal (generalized seizure)
Quick sudden loss of consciousness, staring spells.
59
Which types of generalized seizures have a posictal period of confusion and sleepiness?
Tonic Clonic and Atonic seizures.
60
What is a Focal Seizure?
A seizure that affects one hemisphere of the brain.
61
What are the two types of focal seizures?
- Focal Aware (simple partial): Pt is concious, autonomic changes, Aura
- Focal Impaired Awareness (complex partial): Pt loses consciousness, confusion, aura may premeditate this.
- Presentation depends on which hemisphere is affected.
62
Right vs Left Hemispheres
- Right: Visual/Spacial, Music, Face Recognition
| - Left: Language, Math, Logic
63
Causes of Seizures?
Primary: Idiopathic/Genetics
Secondary: Hypoxemia, Fever (quick increase in temp = seizure), Fluid imbalance, head injury, brain tumor, infection, toxins, allergens, metabolic condition.
64
What information would a nurse want to gather about a patient regarding history of seizures?
- Aura or no?
- Length of seizure and description of seizure
- Patient condition during seizure
- Recovery period
65
What are seizure precautions?
- padded side rails up
- suction and oxygen at bedside
- IV access for emergency med administration
- NPO, nothing in patients mouth except oral airway if there is seizure down time.
66
What are some nursing seizure interventions?
- protect pts head
- turn patient on side to prevent aspiration
- do not restrain pt.
- suction as needed
- ensure patent airway after seizure
- oxygen as needed for after seizure
67
What should patients who are taking antiepileptic drugs (AEDs)/anticonvulsant drugs for seizures know?
- Frequent lab work is needed to check for therapeutic range
- avoid citrus juice, it decreases absorption of AEDs (grapefruit juice can cause toxicity)
-
68
What are two common AED/anticonvulsant medications?
- Phenytoin (also known as Dilantin)
| - Carbamazapine
69
What is Phenytoin's small therapeutic range?
10-20; patients on this need frequent lab work.
70
Is a patient who was put on AEDs ever allowed to stop the medication?
No, even without seizures they must never be stopped for the rest of the patients life.
71
AEDs can cause _______ and ___________ so the patient must get frequent CBC and live function tests done.
Leukopynia and liver damage
72
The AED medication Phenytoin is contraindicated in patients who also take ___________ due to increased risk of bleeding.
Coumadin (AKA warfarin)
73
What is status epilepticus?
Seizures >8 minutes long or clusters of seizures >30 minutes. MEDICAL EMERGENCY. STOP THE SEIZURE.
74
What causes status epilepticus?
- Most common cause is pt's sudden stopping of AED medication.
- infection, trauma, brain edema, drug/alcohol use.
75
Seizures that last longer than 10 minutes can result in ___________.
Brain death
76
What medicines are given during status epilepticus seizures?
Benzos (end in -pam)
- Lorazepam (ativan) (IVP 4mg/2 min up to 8 mg)
- Diazepam (valium) (IVP/IM 5-10mg q. 5-10min up to 30 mg)
- Diazepam Rectal Gel
77
When is Phenytoin (dilantin) or Fosphenytoin (cerebyx) given?
AFTER status epilepticus seizure is over. Fosphenytoin has less cardiac effects than phenytoin.
78
What are some surgical interventions for patients with seizures?
- Vagal Nerve Stimulator (avoid microwaves, short wave radios, ultrasound diathermy)
- Corticectomty (remove area causing seizure in brain)
- Partial Corpus Callosotomy (partially sever corpus callosum to lessen seizure signals)
79
What are the three types of meningitis?
- Bacterial (medical emergency, most deadly)
- Fungal (AIDS patients susceptible)
- Viral (most common)
80
What clinical manifestation is specific to meningococcal meningitis?
Petechial Rash (Neisseria)
81
A positive Brudzinski's Sign may indicate a patient has meningitis. What is this sign?
Lifting of patients head causes pt's knees to pull up in a crunch fashion (Has a Z in it, grants last name has a Z, grant does crunches)
82
A positive Kernig's Sign may indicate a patient has meningitis. What is this sign?
Lifting patients leg up causes pain in other areas. (Eg: back)
83
What does the CSF of a patient with viral meningitis look like?
- Clear Color
| - No Culture
84
What does the CSF of a patient with bacterial meningitis look like?
- hazy cloudy color
| - culture grows
85
Meningitis can cause what complications?
Seizure
Shock
Increased ICP
86
What is the best way to treat meningitis?
Vaccination for it!
ABX
Antivirals
Antifungals
87
Which age group is most at risk for meningitis?
Ages 16-24 highest risk. (college ages)
88
What are the four cardinal symptoms of Parkinson's Disease?
T- Tremors
R- Rigidity
A- Akinesia
P- Postural Instability
89
What are some common drugs that can cause drug induced Parkinson's (DIP) when taken?
```
Antipsychotics
GI motility (reglan)
Ca++ Channel Blockers
Lithium
SSRIs
```
90
A decrease in which neurotransmitter is involved in Parkinson's Disease?
Dopamine
91
In which part of the brain is Dopamine produced in?
Substantia Nigra
92
Which clinical manifestation is normally the first sign of Parkinson's tremors in the general population?
Pill-Rolling; arm at rest but hand and thumb tremoring.
93
By the time symptoms are present and noticeable about ____% of the dopamine has already been destroyed.
80%
94
What are some S/S of parkinson's disease?
```
Tremors
Handwriting changes
Rigidity in extremities (cogwheeling/lead piping)
Drooling
Difficulty swallowing
Bad posture/gait
```
95
Patients taking Parkinson drugs need to be monitored for drug toxicity and tolerance. Mild toxicity can look like what?
Anxiety
Confusion
Tachycardia
96
Patients taking Parkinson drugs need to be monitored for drug toxicity and tolerance. Chronic toxicity can look like what?
Delirium
Hallucinations
Dyskinesia
97
In patients with Parkinson's Disease we want to increase the level of Dopamine, but dopamine can't cross the BBB by itself so we have to give the patient ________, the precursor to dopamine which converts into dopamine once it reaches the brain.
Levodopa
98
Why is carbidopa added to levodopa?
It helps increase availability and transport to the brain..
99
What is the function of MAOI Type B in treating parkinsons?
Reduces the rate at which monoamine oxidase in the brain breaks down dopamine
100
What function do COMTs (catechol O-methyltransferases) serve in treating Parkinson?
Prevents methyl groups from being transferred onto dopamine and disabling it.
101
How do dopamine agonists work in treating parkinsons and when should they be used?
Mimic dopamine by stimulating dopamine receptors in brain. They are good for early on when the disease isn't too severe,
102
What classes of medications are used to primarily treat Parkinson's Disease?
Dopaminergics (carbadopa-levodopa)
Dopamine Agonists
Monoamine Oxidase Type B Inhibitors (selegiline)
Catechol O-methyltransferases
103
What is dementia?
loss of brain function that is CHRONIC and PROGRESSIVE
104
What is the most common type of dementia?
Alzheimers Disease
105
What are major risk factors for dementia?
Female
African American
Older Age (>65)
106
What is the usual cause of death in patients with dementia?
Immobility.
107
What neurotransmitter involved in Alzheimer's Disease is decreased?
acetylcholine; low levels of acetylcholine leads to plaque build up in brain.
108
What is the only definitive way to know if someone has alzheimer's or not?
Autopsy after death.
109
People which Alzheimer's also have abnormal protein in their brain often known as _______
beta-amyloids
110
What are the three stages of dementia?
Early - mild memory loss, difficulty concentrating, may hide symptoms from others
Middle - longest stage, personality changes, moodniess, increased memory loss, increased confusion, wandering, ADL difficulty
Late - severe memory loss, increased risk for everything, maybe can't talk/walk/eat.
111
What are the four alterations in communication that dementia patients may suffer? (Four A's)
Apraxia - inablility to use words appropriately
Aphasia - inability to speak or understand
Anomia - inability to find the name of the word (nomenclature)
Agnosia - loss of sensory perception (AKA smell, agNOSia)
112
What is 'sundowning' during the middle stage of dementia?
Increased confusion and agitation at night time.
113
What are some ways to promote cognitive functioning in patients with dementia?
Intellectual stimulation, memory training, promote communication, reduce distractions, reminiscent remember therapy (talk about past memories and relate them to present)
Nursing Process 2
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