Ch. 15-16 Neuroligical Disorders

What are two types of strokes?

ischemic and hemorrhagic i- blockage of vessels, lack of blood flow to affected area h- rupture of blood vessels; leakage of blood

The newly admitted client is diagnosed with epileptic seizure disorder. The client asks the nurse what an epileptic seizure is? The nurse's best response is:

"Epileptic seizures occur from an unknown cause and are not linked to other illness or injury." -Epileptic seizures are those that are unprovoked; in other words, they are seizures with an unidentified cause but are thought to be genetic.

Which processes are associated with cerebral edema?

- intracellular water accumulation results in secondary brain injury - cerebral edema results from sodium-potassium pump failure or disruption of blood-brain barrier -brain tissue constricts with cerebral edema

What is the normal range for ICP?

0-15 mmHg

What is the highest score a patient can achieve in the Glasgow Coma Scale (GCS)?

15 -Rationale:Eyes can score up to 4 points, verbal up to 5 points, and motor up to 6 points for a total of a 15-point maximum on the GCS.

How many points will a patient receive for spontaneous eye opening on the Glasgow Coma Scale (GCS)?

4 -The patient who spontaneously opens their eyes receives 4 points for spontaneous eye opening, meaning they can open their eyes without direction. They will get 3 points for opening their eyes in response to speech, 2 points for opening their eyes in response to painful stimuli, and 1 point for no eye opening.

Cerebral spinal fluid and cranial blood flow may be able to?

Adjust to relive ICP

Brain herniation is the movement of the brain from a compartment of high pressure to a compartment of lower pressure. The movement of the brain:

increases hypoxia and ischemic injury to brain tissue, reducing the level of consciousness

Onset: Slow, progressive, painless weakness Cause: Neurodegeneration in upper and lower motor neurons Clinical S/S: Weakness, spasticity, hyperflexia, stiffness, and incoordination Key Feature: Lou Gehrig Disease, death within 2-5 years

Amyotrophic Lateral Sclerosis (ALS)

Which functions are associated with the temporal lobe of the brain? (Select all the apply.)

Auditory recognition, Long-term memory -The temporal lobe is responsible for auditory discrimination such as that which occurs with sound in opposite ears, and it houses the auditory recognition of the sound heard. The remainder of the temporal lobe is associated with long-term memory such as recognition of what (geometric figures) or who (face pattern recognition). The occipital lobe is associated with is gnostic visual function such as that associated with color and its meaning. It is also associated with depth perception, the ability to recognize an object by its 'feel.' The parietal lobe is used to determine where in space an object is in relation to the body.

Following a collision while mountain biking, the diagnostic workup of a 22-year-old client indicates the presence of an acute subdural hematoma. Which pathophysiologic process most likely underlies his diagnosis?

Blood has accumulated between the client's dura and subarachnoid space. -A subdural hematoma develops in the area between the dura and the arachnoid space, while epidural hematomas exist between the skull and dura. Intracerebral hematomas are located most often in the frontal or temporal lobe, and the ventricles are not directly involved in a subdural hematoma.

Which parts of the brain and its structures contribute to the formation cranial pressure?

Blood, brain tissue, and cerebral spinal fluid

______________ occurs when pressure within the cranium is greater than what the brain can compensate for

Brain Herniation - when pressure increases this high of a level, it causes brain tissue to be displaced

__________ tunnel syndrome is a common mononeuropathy.

Carpal

What are effects of intracranial pressure?

Cerebral Edema and Brain herniation

The nurse notes a patient has increased pulse pressure, decreased pulse, and irregular respiration. The nurse recognizes these as symptoms of increased intracranial pressure (ICP) and understands that the patient's autoregulation of cerebral blood flow in the brain has failed. Which findings are consistent with a failure of autoregulation of blood flow in the brain? Select all that apply.

Cerebral perfusion pressure of 40 mm Hg, Mean arterial pressure of 170 mm Hg, Intracranial pressure of 35 mm Hg -For autoregulation to be functional, carbon dioxide levels must be in an acceptable range and hemodynamic pressure targets must be within the following ranges: cerebral perfusion pressure greater than 60 mm Hg, mean arterial pressure less than 160 mm Hg, systolic pressure between 60 and 140 mm Hg, and ICP lower than 30 mm Hg.

A patient with a history of a seizure disorder has been observed suddenly and repetitively patting their knee. After stopping this repetitive action, the patient appears confused and is oriented to person and place but not time. Which type of seizure did this patient most likely experience?

Complex partial -Complex partial seizures are often accompanied by automatisms, and confusion during the postictal state is common. These symptoms do not accompany simple partial seizures. Atonic seizures are characterized by loss of muscle tone, and myoclonic seizures involve brief involuntary muscle contractions induced by stimuli of cerebral origin.

The parents of a 2-year-old child bring the child to the emergency room. The parents report the client had a fever when she stopped responding and her limbs started jerking for about 15 minutes. Which type of seizure would the nurse expect the child to have experienced?

Febrile seizure -Febrile seizure occur in children from ages 6 to 60 months with a rise in temperature of 100.4°F or higher. The seizure is typically a generalized seizure that may last 15 minutes and does not reoccur within 24 hours.

A patient with severe head trauma remains stable for the first 24 hours after admission with no indication of intracranial hypertension. Suddenly, the patient begins showing signs of Cushing triad. The nurse recognizes that this indicates the patient's compensatory mechanisms have become exhausted. What physiologic changes occur as part of this process? Select all that apply.

Decrease in cerebral perfusion, Decrease in compliance within the intracranial compartment

The patient has an acute subdural hematoma from an acute head injury. What is the most typical symptom that the nurse would expect during the first 2 days after the injury?

Decreasing level of consciousness -Symptoms of acute subdural hematoma manifest in 24 to 48 hours after injury and include headache, focal neurologic deficit, unilateral pupillary abnormalities, and decreasing level of consciousness. The other answers are not typical of acute subdural hematoma and could have many other causes.

Hematoma form when blood collects between the dura and the inside surface of the skull, usually from a head injury in which the skull is fractured. Also caused by a laceration of the middle meningeal artery. What type of hematoma?

Epidural

Rapid bleed Symptoms: ipsilateral pupil dilation, contralateral hemiparesis, brief unconsciousness, lucid period, then rapid unconsciousness. What type of hematoma?

Epidural

A 22-year-old client suffered a car accident in which their skull was fractured. A magnetic resonance imaging (MRI) scan indicates a hematoma. The client was unconscious for a brief period, conscious for a period of days, and then suddenly became unconscious again. Based on the symptoms, which type of hematoma does this client have have?

Epidural -Epidural hematomas are characterized by unconsciousness followed by a lucid period and then a loss of consciousness a second time if the hematoma is not removed right away.

Seizures that recur and are not provoked by other illnesses or circumstances are classified as __________.

Epileptic -The defining characteristic of epileptic seizures is their recurrence. Epileptic seizures may be atonic, absence, or another type of seizure. A convulsion is a specific type of motor seizure involving the entire body.

Seizures that do not stop spontaneously or occur in succession without recovery are called status __________.

Epilepticus

Meningitis is an infection of the cerebral tissue.

False

Multiple sclerosis is caused by various neurotransmitter deficiencies. True or False

False

Must movement disorders can be traced to damage or dysfunction in the pons and brain stem. True or False

False

Neurons are incapable of anaerobic metabolism. True or False

False

Peripheral nerves are incapable of regeneration or recovery following an insult. True or False

False

Seizures are a result of focal disruptions in blood supply to brain tissue. True or False

False

The basal __________ are a group of deep, interrelated subcortical nuclei that play an essential role in control of movement.

Ganglia

Strokes are categorized as either ischemic or __________.

Hemorrhagic

Brain __________ represents a displacement of brain tissue under the falx cerebri or through the tentorial notch or incisura of the tentorium cerebelli.

Herniation

Onset: Usually around 35-44 years Cause: Autosomal dominant inherited disease Clinical S/S: Uncontrolled involuntary movement, dementia, behavior changes Key Feature: No cure and No Treatment

Huntington Disease

An abnormal increase in CSF volume in any part or all of the ventricular system results in __________.

Hydrocephalus

A patient has recently had a hemorrhagic stroke. Which precipitating factor is the most likely contributor in this patient?

Hypertension -if hemorrhage is the etiology of a stroke, hypertension often is a precipitating factor. Vascular abnormalities, such as cerebral aneurysms, are more prone to rupture and cause hemorrhage in the presence of hypertension. Emboli to the brain most often have a cardiac source, secondary to myocardial infarction or atrial fibrillation. Diabetes is a risk factor associated with stroke in general but is not as strongly associated with hemorrhagic strokes as is hypertension.

What is the earliest sign of decreased level of consciousness?

Inattention -includes mild confusion, disorientation, and blunted responsiveness.

A nurse is working with a patient who has acute head trauma. The nurse understands that the cerebral blood flow in this patient is decreased to compensate for the cerebral edema caused by the trauma. What other compensatory mechanisms should the nurse be aware of that are likely occurring in this patient to maintain a constant intracranial pressure? Select all that apply.

Increased cerebral spinal fluid absorption, Shunting of cerebral spinal fluid into the spinal subarachnoid space

Slow bleed Symptoms: cerebral edema, deteriorating neurologic status What type of hematoma?

Intracerebral

This bleed has collected within the brain tissue from a ruptured blood vessel. It may occur in any lobe of the brain but is most common in the frontal and temporal lobes. May be a single hematoma or multiple. Caused from traumatic injury, depressed skull fractures, penetrating injuries (gunshot wounds) or hemorrhaging stroke. What type of hematoma?

Intracerebral

Which of the finding would indicate intracranial hypertension?

Intracranial pressure of 25 mm Hg

What is the Glasgow Coma Scale (GCS) used to assess?

Level of consciousness -Rationale:The GCS is used to assess level of consciousness. It does not address pulses, arrythmias, or strength.

A client is diagnosed with a hemorrhagic stroke. Which factors will determine the manifestations of this condition? (Select all that apply.

Lobe where the blood flow is lost, Amount of brain compression with the ruptured artery, Region of brain and its associated function, Presence of cerebral edema -Hemorrhagic stroke is caused by a rupture of a blood vessel. Hemorrhage then occurs within the brain resulting in hematomas. The symptoms associated with this type of stroke depend on the area of the brain not receiving adequate blood flow. Blood vessels that rupture are usually arterial and occur when the client is active. Age and a history of hypertension play an integral role in the development of this type of stroke.

Seizures are an abnormal, excessive discharge of electrical activity. Which are manifestations of seizures?

Loss of consciousness, Muscular movement, Loss of attention or focus without loss of consciousness, Loss of bladder control -Seizures are defined as abrupt and transient discharge from a group of neurons. Effects seen from this discharge can include sensory changes, motor changes, autonomic changes, and psychic changes.

Onset: Slow or rapid onset Cause: Demyelination of nerves blocks conduction and dysfunction of Na and K channels Clinical S/S: Plaques that develop in different parts of the CNS Key Feature: Fatigue and Cognitive dysfunction

Multiple sclerosis

Disorder of transmission at the neuromuscular junction that affects communication between the motor neurons and innervated muscle cell Cause: autoimmune disease (type II hypersensitivity, cytotoxic injury, mediated by autoantibodies B cell release. Activates classical complement pathway causing inflammation and muscle cell destruction) caused by antibody-mediated loss of acetylcholine receptors in the neuromuscular junction

Myasthenia Gravis

__________ disease is associated with a tremor and slow movement thought to be related to a lack of dopamine.

Parkinson

Onset: Slow, progressive onset Cause: basal ganglia dysfunction resulting from low dopamine Clinical Signs & Symptoms: Bradykinesia, tremor, postural instability , and rigidity Key Feature: Lewy body formation Disorders of extrapyramidal tracts which results in involuntary movements, rigidity, and immobility without paralysis

Parkinson's Disease

Which type of seizure affects only one cerebral hemisphere?

Partial -Partial seizures affect one cerebral hemisphere; secondarily generalized seizures begin in one hemisphere and then spread to the other side; generalized seizures involve both hemispheres.

A client is admitted to the emergency department after a motor vehicle accident and diagnosed with a subdural hematoma. The nurse is reviewing the electronic medical record to understand the type of subdural hematoma the client has sustained. Which of the following statements are correct regarding subdural hematomas? (Select all that apply.)

Patients with acute subdural hematomas usually show symptoms within 24 hours from the time of injury., Patients diagnosed with subacute subdural hematomas can develop symptoms within days of the injury. -Patients with subdural hematomas have tears in the bridge veins that connect veins on the surface of the cortex to dural sinuses. These veins tear readily when rapid motion of the brain occurs as in the case of traumatic injury. Because the vessels are veins, the bleeding is slow. Therefore, accumulations of blood and changes in intracranial pressures allow for compensatory mechanisms to work.

What type of brain Injury is : Initial Trauma -immediate disruption of: skull, brain structures (meninges, blood vessels, brain tissues, neurons), brain functions (blood flow, oxygenation, cellular metabolism)

Primary Brain Injuries

__________ are coordinated, involuntary motor responses that are "wired into" the CNS

Reflexes

A patient has been diagnosed with an ischemic stroke. Which factor is least likely to be an underlying cause?

Ruptured cerebral aneurysm -Ischemic strokes are caused by cerebrovascular obstruction from thrombi or emboli resulting in ischemia and infarction. Hemorrhagic strokes are caused by intracerebral hemorrhage, ruptured cerebral aneurysm, or ruptured cerebral arteriovenous malformation.

What type of brain injury is: effects of primary injury -uncontrolled ICP, cerebral ischemia, hypotension, hypoxemia, local or systemic infection. Can result in cerebral infarction, coma, increased cerebral edema

Secondary Brain Injuries

What does the Monro-Kellie hypothesis state?

Small increases in volume can be compensated for by one or both of the other components.

Slow bleed Common symptoms: signs of increased intracranial pressure, altered levels of consciousness Symptoms: rapid, delayed, or persistent occurrence of symptoms. What type of hematoma?

Subdural

This bleed is of a venous origin and slowly accumulates blood below the dura and above the arachnoid layer of the brain. It results from a tear in a small bridging veins that connect veins on the surface of the cortex to dural sinuses. What type of hematoma?

Subdural

Hematomas are caused by ruptures of an artery or a vein within the cranium. Which are common types of hematomas? (Select all that apply.)

Subdural, Epidural, Subarachnoid Rationale:Hematomas are vascular injuries that can occur with trauma. When the vascular injury occurs within the cranium, bleeding (arterial or venous) can be seen in various compartments in the cranium. The most common compartments that bleeding can be seen are: epidural, subdural, and subarachnoid or intracerebral.

A client is diagnosed with an intracerebral hematoma. The nurse understands what regarding intracerebral bleeds? (Select all that apply.)

The most common sites of injury are the temporal and frontal lobes., The injury occurs due to severe movement of the brain in the cranium., This type of hematoma occurs more frequently in older adults., This type of hematoma can occur in multiple vessels in the brain. -Traumatic intracerebral bleeds can be caused by a single vessel or multiple vessels and are commonly seen in the temporal and frontal lobes. They are the result of severe brain motion such as that that occurs in car accidents. These types of bleeds occur more frequently in older adults due to the increased friability of the blood vessels due to aging.

A patient scored 4 points for verbal response on the Glasgow Coma Scale (GCS). What does that indicate?

The patient is confused. -Rationale: If the patient is fully oriented, they get 5 points. If they are confused but speaking coherently, they get 4 points. If the patient is saying inappropriate words and jumbled phrases, they'll get 3 points. Incomprehensible sounds scores 2 points, and 1 point is assigned for no verbal response.

What is the best description decorticate posturing?

The patient withdraws into their core. -Rationale:Decorticate posturing is when the patient withdraws into their core. Decerebrate is when the arms extend away from the body.

The symptoms associated with ischemic stroke are due to an interruption in blood flow to a particular region of the brain. Which are primary causes of interrupted blood flow in an ischemic stroke? (Select all that apply.)

Thrombosis, Emboli - Causative factors associated with ischemic stroke are those contributing to a reduction in blood flow to a portion of the brain. These factors include a blood clot and embolus or particle within the bloodstream.

The primary care provider has diagnosed the newly admitted client with generalized seizure activity. The physician notes the client has "grand mal seizures." The nurse knows this is an older term for which type of seizure?

Tonic-clonic -Tonic-clonic seizures were previously known as grand mal seizures, and these are the most common type of seizure. The client experiences sharp tonic contractions of muscles, extension of the extremities, and loss of consciousness. The clonic phase includes rhythmic contraction and relaxation of the extremities with the client remaining in an unconscious state.

A 26-year-old client experienced a 1-minute seizure, during which they lost consciousness while their muscles contracted and extremities extended. This was followed by rhythmic contraction and relaxation of her extremities. The client also experienced urinary incontinence during this. Which type of seizure did this client most likely experience?

Tonic-clonic Rationale:A tonic-clonic seizure often begins with tonic contraction of the muscles with extension of the extremities and immediate loss of consciousness. Incontinence of the bladder and bowel is common. Cyanosis may occur from contraction of airway and respiratory muscles. The tonic phase is followed by the clonic phase, which involves rhythmic bilateral contraction and relaxation of the extremities. A myoclonic seizure involves bilateral jerking of muscles, generalized or confined to the face, trunk, or one or more extremities. Absence seizures are nonconvulsive, and complex partial seizures are accompanied by automatisms.

Brain injuries are categorized as?

Traumatic & nontraumatic -traumatic: contusion, laceration, hemorrhage, concussion, diffuse axonal injury -nontraumatic: stroke, infection, tumor, seizure

Consciousness is usually considered as consisting of arousal and cognition. True or False

True

Lower back pain is often attributable to a herniated intervertebral disk. True or False

True

Strokes are also known as "brain attacks." True or False

True

The spinal cord is the lowest level of the hierarchical organization of movement. True or False

True

Herniation associated with the supratentorial structures is called?

Uncal (transtentorial) herniation

Symptoms associated with epidural hematomas develop rapidly because the bleed is most commonly occurring from:

a large vein known as the cerebral vein. Rationale:With arterial bleeds, blood accumulates rapidly within the compartment. The artery most often associated with epidural hematomas is the middle meningeal artery.

A/an __________ is a bulge at the site of a localized weakness in the muscular wall of an arterial vessel.

aneurysm

The basic pathologic process in a hemorrhagic stroke is that tissue death occurs as a result of ____________.

bleeding from an artery -With a ruptured blood vessel, blood flow does not reach the tissue downstream from the rupture, and tissue below the rupture is denied adequate oxygen and is hypoxic.

Infants are particularly susceptible to neuromuscular toxicity resulting from exposure to Clostridium __________ spores.

botulinum

What are the three components of intracranial pressure (ICP)? select all that apply

brain tissue (80%), cranial spinal fluid (8-12%), cranial blood flow (3-10%)

Herniation associated with brainstem compression is called?

central herniation

What are the two types of cerebral edema?

cytotoxic and vasogenic -cytotoxic results from intracellular sodium potassium pump failure -vasogenic results from disruption to blood-brain barrier

An epidural hematoma causes focal symptoms that can include ____________

ipsilateral pupil dilation -With rapidly developing unconsciousness, focal symptoms related to the area of the brain are involved. These symptoms can include ipsilateral (same-side) pupil dilation and contralateral (opposite-side) hemiparesis. Because bleeding is arterial in origin, rapid compression of the brain occurs from the expanding hematoma. Communicating hydrocephalus occurs as the result of impaired reabsorption of cerebrospinal fluid from the arachnoid villi into the venous system.

It is important for the nurse to understand that as intracranial pressure rises above normal limits and compensatory mechanisms fail:

neurons can be injured and a change in level of consciousness occurs.

Transient ischemic attacks (TIAs) are characterized by ischemic cerebral neurologic deficits that _____________.

resolve within 24 hours -TIAs are defined as deficits lasting less than 24 hours. These reverse before infarction occurs. TIAs are important because they may provide warning of impending stroke. The causes of TIAs are the same as those of ischemic stroke and include atherosclerotic disease of cerebral vessels and emboli. The most common predisposing factors for cerebral hemorrhage are advancing age and hypertension; other causes include aneurysm rupture. Vomiting commonly occurs at the sudden onset, and headache often occurs.