RN mastery and U world- Neuro DONE
MS -Too much exposure to heat or cold can exacerbate multiple sclerosis symptoms -there are no dietary restrictions. -no vigorous exercises -think women in their 20s or 30s with BOWEL/bladder problems. A cerebral arteriogram -angiogram of the blood vessels of the brain. -arterial access is usually obtained via the femoral artery. -Maintaining a pressure dressing over the site for at least 4 hours is important to prevent bleeding, swelling, or hematoma formation. -The patient must be placed on bed rest for 4 to 24 hours, -During that time they must remain flat. -The affected extremity should be kept straight for the length of bed rest. -Npo before the test and a dye contrast is used Post-arteriogram, a quiet environment is NOT needed. A patient who just underwent *infratentorial* craniotomy for a brain tumor is newly admitted to the ICU. Which of the following should the nurse include in the plan of care? -incision made at the nape of the neck - keep the head of bed flat and place a small pillow under the nape of the patient's neck to promote venous return and reduce ICP. -no flexion of the neck bc it could mess up the suture line and it could inc ICP Generally Post-craniotomy patients must be monitored for neuro and vital signs every 30 minutes NOT routinely aka q 4 hours -Post-craniotomy patients are at risk for cerebral edema and increased ICP. Fluids at 175 ml/hr could lead to fluid overload.
"Some Say Money Matters But My Brother Says Big Brains Matter Most." Sensory-CN I-Olfactory Nerve Sensory-CN II-Optic Nerve Motor-CN III-Oculomotor Nerve Motor-CN IV-Trochlear Nerve Both-CN V-Trigeminal Nerve Motor-CN VI-Abducens Nerve Both-CN VII-Facial Nerve Sensory-CN VIII-Vestibulocochlear Nerve Both-CN IX-Glossopharyngeal Nerve Both-CN X-Vagus Nerve Motor-CN XI-Spinal Accesory Nerve Motor-CN XII-Hypoglossal Nerve
*lumbar puncture* -positioning focuses on widening the space between the vertebrae so either lying down with tucked in knees to chest or sitting with a hunched back -Empty the bladder before the procedure -sterile needle will be inserted between the L3/4 or L4/5 interspace -Pain may be felt radiating down the leg, but it should be temporary After the procedure, instruct the client as follows: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache Increase fluid intake for at least 24 hours to prevent dehydration
*GBS* Early signs indicating impending respiratory failure include: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation.
if a pt is bedridden check for pitting edema in the sacral area. this is the best place for that specific person.
*Glasgow Coma Scale* (E)ye opening (Maximum = 4) 4 - Spontaneous (open with blinking at baseline) 3 - To speech 2 - To pain only 1 - None (C - Not assessable [eg, trauma, edema]) (V)erbal response (Maximum = 5) 5 - Oriented 4 - Confused (converses but confused, disoriented) 3 - Inappropriate (inappropriate words) 2 - Incomprehensible (sounds, no words) 1 - None (T - Not assessable [intubated]) (M)otor response (Maximum = 6) 6 - Obeys commands for movement 5 - Localizes to pain 4 - Withdraws from pain 3 - Flexion in response to pain (decorticate posturing) 2 - Extension in response to pain (decerebrate posturing) 1 - None *Use best response for each category (range = 3-15). *Coma: Does not open eyes, does not follow commands, and does not utter understandable words; Glasgow Coma Score (GCS) 3-8. *Head injury classification: Mild, GCS 13-15; moderate, GCS 9-12; severe, GCS ≤8. * TIP: if it is 8 then intub8
Opisthotonos is an ominous sign associated with meningitis in which the patient has a rigid body spasm with his/her head and heels bent back and a fully-arched back. Pt with TBI ....Discussion of the patient's case should not be done at the bedside, because it may cause emotional distress to the patient. Patients with a right-sided CVA are impulsive and lack judgment. They are often unaware of their deficits, which puts them at a high safety risk. • Impairments in speech and language are seen with a left-sided CVA. Damage to Broca's area causes expressive aphasia. Damage to Wernicke's area is associated with receptive aphasia.
*Lumbar puncture* -pt. must not move during the insertion of the needle into the spinal canal. -The patient will need to lie on his/her side, curling forward so that the knees are flexed toward the chest with the chin touching the knees. -After the procedure the patient will have to lie flat for 4-8 hours depending on physician, hospital protocol, or if the patient has continued signs of a headache. -does not require that dyes Electroencephalography (EEG) involves studying brain waves Hypothalamic injury check urine output and temperature
Remember you need ORDERS before assessing urine gravity etc. So notifying a doctor before assessing anything that involves getting urinalysis blood culture etc is important to get the order Only the MRI requires consent as the EEG is noninvasive and does not expose the patient to radiation or dye. NPO NOT required for neither test. ALS - decline in muscle strength -no exacerbations and remissions. -progressive motor neuron disease that is incurable and eventually leads to death
*Neuroleptic malignant syndrome* -emergency state caused by an adverse reaction to antipsychotic medications *Early signs of neuroleptic malignant syndrome* are muscle stiffness, fever, sweating, and tremors. FEVER mnemonic for NMS • Fever • Encephalopathy • Vitals unstable • Elevated enzymes (CK) • Rigidity of muscles Prevent disuse syndrome after stroke: The patient should be encouraged to use the weak side (which is the left, not the right) for ADLs as much as tolerated to promote a return to function. *nurse is assisting a patient who has hemiparesis after a cerebrovascular accident (CVA). The nurse assists the patient with a safe transfer from sitting on the bed to the wheelchair by implementing which of the following?* -Blocking/supporting the patient's unaffected/strong knee if it buckles while supporting his or her full weight helps maintain stability during transfer. -When there is a weak lower extremity, the chair is placed beside the patient's strong/unaffected side to allow the patient to use his or her unaffected leg effectively. The nurse should stand on the weaker side to help. -The nurse should stand on the patient's affected/weaker side to hold or support the affected limb.
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*concept* Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema. *mannitol complication= crackles in lungs* due to fluid volume overload.... since mannitol is pulling all that cerebral fluid into the vascular system that fluid is going back into the heart then the lungs. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. Monitor for this complication: serum osmolarity, input and output, serum electrolytes, and kidney function.
A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous (IV) infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? 1. Assess hourly urinary output [19%] 2. Increase pump setting to correct administration rate to 100 mL/hr [8%] 3. Keep systolic blood pressure above 170 mm Hg [35%] 4. Monitor for a widening QT interval [36%] correct 3-->
A client with an acute stroke presentation (brain attack) requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues. However, the blood-brain barrier is no longer intact once the blood pressure is >220/120 mm Hg. Therefore, "mild" lowering is required, usually to a systolic pressure that is not below 170 mm Hg. Nicardipine (Cardene) is a prototype of nifedipine and is a potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood pressure is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex tachycardia occurs.
Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days. -Any change in level of consciousness, dizziness, nausea, or other side effects of opioids could be misinterpreted as symptoms of a worsening condition related to the head injury. Clients are typically advised to use non-narcotic or nonsteroidal anti-inflammatory pain medications. A client with a head injury should be taught the following: Notify the health care provider if you experience increased drowsiness, nausea or vomiting, worsening headache, seizures, vision changes, behavioral changes, weakness or numbness, or difficulty with balance or walking Avoid alcohol and other central nervous system (CNS) depressants (eg, benzodiazepines) (Option 2) Have someone stay with you (Option 4) Avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days (Option 3)
A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. (Options 1 and 4) The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting (indicate high intracranial pressure) Sleepiness and/or confusion (indicate high intracranial pressure) Visual changes Weakness or numbness of part of the body
A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? 1. Expressive speech, vision [72%] 2. Light touch, hearing [3%] 3. Sense of position, graphesthesia [16%] 4. Weber tuning fork test, cranial nerve I [7%] correct: 1 Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where vision is processed. (Option 2) The temporal lobe (lateral aspect of the brain) controls hearing and integrates sensory data (eg, auditory, visual, somatic). The Wernicke speech area in the temporal lobe is responsible for language comprehension. Light touch is processed by the sensory cortex in the parietal lobe. (Option 3) An interruption of sensory function indicates injury to either the spinal column or the parietal lobe. These injuries affect proprioception (awareness of body positioning) and graphesthesia (ability to identify writing on the skin, by touch). (Option 4) The Weber test screens for conductive hearing loss by checking whether a tuning fork held along the midline of the head is heard evenly in both ears. Cranial nerve I is the olfactory nerve. Hearing and smell are both processed by the temporal lobe. Educational objective: Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision.
A neurological examination includes evaluation with the Glasgow Coma Scale, testing of pupils, and assessment of all 4 extremities for movement, strength, and sensation; this examination should be performed by a clinician. The responsible adult is taught the general indicative symptoms in the list above.
A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? 1. Determine onset of symptoms 2. Ensure that the client has 2 large-bore intravenous (IV) lines 3. Maintain patent airway 4. Prepare for head CT scan correct 3 A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency. Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct course of action with the goal of preventing further brain damage. In any emergency, the first priority nursing action is to maintain a patent airway (Option 3). Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority. The nurse, or another member of the emergency department or stroke alert team, will prepare the client for an immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury (Option 4). This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed (Option 2). (Option 1) It is vital to determine the onset of symptoms as thrombolytic medications are used in a short time frame (typically within 4.5 hours of onset). Thrombolytic medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of stroke (ischemic versus hemorrhagic). With all of these interventions, the priority nursing actions remain the same: ABC - airway, breathing, and circulation. Educational objective: In any emergency, the primary nursing interventions are the ABCs. A patent airway should be maintained while other care is provided and throughout the emergency treatment process. Additional Information
ALS -no cure -progressive -Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure -NO RESTING TREMORS -Most clients survive only 3-5 years after the diagnosis as there is no cure. ALS interventions -Treatment focuses on symptom management. -Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers)
A major complication of chronic alcohol abuse is encephalopathy related to poor thiamine absorption. It is critical that these clients receive thiamine replacement. Wernicke encephalopathy can lead to more significant and progressive complications, including death.
An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? 1. Administer IV antibiotics [21%] 2. Infuse bolus of IV normal saline [67%] 3. Prepare to assist with lumbar puncture [8%] 4. Transport client for head CT scan [2%] Correct 67% Answered correctly 93 Seconds Time Spent 08/16/2018 Last Updated Explanation Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective: For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.
how to prevent aspiration pneumonia bc of dysphagia -Swallowing 2 times before taking another bite of food. -Thickening liquids to assist swallowing -Avoiding over-the-counter cold medications. Antihistamine cold preparation have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing. -Sitting upright for at least 30-40 minutes after meals. -Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. -Smoking decreases mucociliary clearance and increases bacterial count in the mouth. -Positioning the chin slightly downward toward the neck (chin-tuck) is good
An aura is a sensory warning that a complex or generalized seizure will occur. It is a priority over stable or expected findings such as point tenderness in fibromyalgia, low-level location of paralysis in Guillain-Barré syndrome, or scanning speech in multiple sclerosis. Scanning speech is a dysarthria in which there are noticeable pauses between syllables and/or emphasis on unusual syllables. It is an expected finding with multiple sclerosis.
• Elevating the head of bed at 30-45˚ is for the supratentorial approach. The cervical spine -respiratory paralysis occurs from injuries affecting C1-C4. -C5-C7 are likely to produce paralysis, weakness, or spasticity of the muscles used to perform respiration.
Autonomic dysreflexia -above T6 that involves dangerously high blood pressure. A patient has been diagnosed with a concussion and is now being released from the hospital. Which of the following should the nurse include in the discharge instructions? The loss of awareness can persist for moments to hours, Vomiting may be a symptom of increasing intracranial pressure, OTC Tylenol is okay to use for pain, A change in the level of consciousness is typically *the first sign of increased ICP* hemorrhage after the patient underwent a transsphenoidal hypophysectomy= frequent swallowing
Aphasia an umbrella term that is either Broca or Wernicke -Receptive aphasia (wernicke) refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. -Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice (Option 1). The nurse should listen without interrupting and give the client time to form words. this is BROCA
Botulism -caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum -acetylcholine blocked thus MUSCLE PARALYSIS -The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw (wild) honey. The immature gut system in these children makes them more susceptible.
The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? The speech pathologist conducts a swallowing assessment early on to evaluate a client's ability to swallow safely. This consult is not done at discharge. correct: this is the reason you are using special swallowing technique when you eat and drink
Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: Inhale deeply Hold breath tightly to close the vocal cords Place food in mouth and swallow while continuing to hold breath Cough to dispel remaining food from vocal cords Swallow a second time before breathing
*Cranial nerve II is the optic nerve and a sensory nerve. This nerve is assessed by testing the fields of vision for the client's ability to see objects in the field. In contrast to cranial nerves III, IV, and VI, the client does not track the object in the fields of vision, but instead keeps the eyes fixed and uses the peripheral vision to recognize objects or deficits in the field of vision.*
Cranial nerve V is the trigeminal nerve. The *sensory* portion of this nerve is assessed by testing sensation at the ophthalmic (forehead), maxillary (cheekbone), and mandibular (jaw line) branches by light touch.
The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? -The priority assessment in a client newly diagnosed with quadriplegia (tetraplegia) is airway management and oxygenation. -one should asses vital capacity and tidal volume once a shift or PRN -Quadriplegia (tetraplegia) occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. -usually cervical spine injury will do that
Delirium is characterized by behavior changes and confusion that have an acute onset, and it is usually reversible. Common causes in older adults include infection, medications, and hypoxia. anyone c a T6 or above -Autonomic dysreflexia is a life-threatening condition in a client with high spinal cord injury. -*Classic signs/symptoms include severe hypertension, throbbing headache, diaphoresis, bradycardia, flushing, and piloerection. Emergency treatment includes correcting the cause (check bowel or bladder distention), removing tight clothing, and raising the head of the bed.* -
Bells palsy -peripheral, unilateral facial paralysis c -cranial nerve 7 is inflamed -remember 7 is movement -Inability to completely close the eye on the affected side Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1) Flattening of the nasolabial fold on the side of the paralysis (Option 3) Inability to smile or frown symmetrically (Option 4) -loss of taste on the anterior two-thirds of the tongue. -Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea (Option 1) -Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries) (Options 3 and 4). Vision, balance, consciousness, and extremity motor function are not impaired with Bell's palsy. remeber bells palsy is all about the FACE and how it is drooping!!! nothing to do with the neck down
Electric shock-like pain in the lips and gums and severe pain along the cheekbone are symptoms of trigeminal neuralgia (cranial nerve V). cerebellar pathology -2 major functions: coordination of voluntary movements and maintenance of balance and posture. -Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4). Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position
*Sumatriptan is prescribed for moderate to severe, acute migraine headaches that are characterized by severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a change in treatment regimen (eg, ergotamine).*
Fibromyalgia involves neuroendocrine/neurotransmitter dysregulation. Clients experience widespread pain with point tenderness at multiple sites, including the neck and shoulders.
Phenytoin (Dilantin) -, decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives -do not dc -oral hygiene
For a client with epilepsy, it is not necessary to go to an emergency department after a seizure, unless status epilepticus (ie, prolonged, repeated seizures) occurs or the client is injured.
Alzheimer disease (AD) is a form of dementia that causes progressive decline of cognitive and physical abilities. The nurse should educate the client/caregiver to prepare for current and future safety needs. Interventions evolve to meet client needs at each stage of disease progression. Safety promotion for the client with moderate AD includes: Keyed deadbolts (with keys removed) and close supervision to provide a controlled environment for wandering (Option 3) Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option 2) Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury (Option 5) Grab bars installed in showers and tubs (Option 1) (Option 4) All medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed.
For clients with moderate Alzheimer disease, caregivers should provide a controlled environment for safe wandering (eg, throw rugs and clutter removed, exterior doors secured), and the client should wear an identification/location device (eg, bracelet). All medications should be out of reach or locked away. Hazards (eg, gas appliances, rugs, toxic chemicals) should be removed. Grab bars should be installed in showers and tubs.
A patient diagnosed with a hemorrhagic stroke reports of a sudden, severe headache (9 out of 10 pain). Prioritize the next actions: -this isn't an "emergency" so notifying the HCP is not the first thing -first thing is always assessment when it comes to prioritizing options given -assess NEURO then notify HCP -A headache may indicate that the intracranial bleed is worsening. The nurse should first perform a neuro assessment and then immediately notify the physician. Treatment is time-sensitive, so the nurse should work fast. when asked to prioritize a set of nursing diagnosis leave the "at risk" stuff last
Hemiplegia, a total paralysis of one side of the body...never pull on them Passive exercises performed with the assistance of another person. Passive exercises performed with the assistance of another person. Too much activity causes an increase in blood pressure, cerebral blood flow, and ICP. Thus spacing out activity should be done. Weber test is for hearing Romberg is for balance Tonometry measures intraocular pressure. Rinne test is conducted to evaluate the patient for conductive or sensorineural hearing loss. Tuning fork used. Contraindications for an MRI include most pacemakers, cerebral aneurysm clips, and metal implants. Early signs of increased intracranial pressure include headache, nausea, vomiting, decreased level of consciousness, hypertension, and blurred vision. • Late signs of intracranial pressure include alteration in pupil size and reactivity, decorticate or decerebrate posturing, and the Cushing's Triad: widening pulse pressure, bradycardia, and a change in respirations. Frontal craniotomy -HOB 30deg -antiinflammatory steroids IV -fluid restriction 2L per day is okay so no high ml/hr such as 150ml per hour - Administering oxygen at 2 liters per minute is an appropriate order. Oxygen is needed to prevent hypoxia that could lead to cerebral edema. -DO NOT CLUSTER activities
The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? 1. Give the antihypertensive medication [4%] 2. Monitor the blood pressure [61%] 3. Notify the health care provider [6%] 4. Question the prescription [27%] correct: 2 An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status (Option 2).
ICP: Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The head of the bed should be maintained at 30 degrees. Clients should have minimal stimuli, including no bright lights or multiple visitors, as stimulation can increase ICP.
The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply. Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs: N - Neurological examination. Focal deficits include numbness and decreased strength. S - Significant traumatic mechanism of injury A - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2). I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1). D - Distracting injury. Another significant injury could distract the client from spinal pain. S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present (Option 5).
MG -Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. -fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. -nticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal -Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk) -All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles
The facial nerve, cranial nerve VII, is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth. 7 is movement of the face 5 is sensation
MS -progressive, demyelinating disease -*fatigue*, incoordination, balance impairment, muscle weakness, and muscle spasticity -Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required -Range-of-motion, strengthening, and stretching exercises help limit spasticity and contractures -Rather than increasing the duration, clients should balance exercise with rest. -Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation -Wheelchairs are advised ONLY if exercise and gait training are not successful
parkinson -NO soups aspiration issue -must be small frequent easy to chew foods and liquids must be thickened parkinson pt will have a *small* based gait that is why we teach them the wide base gait approach biggest issue with Parkinson is aspiration risk! CVA: dysphasia:: pockets food on weak side unknowingly: thicken their food Myasthenia gravis - affects a person's ability to swallow. -The nurse should assess this ability before administering oral medications.
MVC neck brace pt -In trauma patients, the first action is to secure the neck to prevent any injury to the cervical spine. -If the patient is breathing, the level of consciousness should be determined next by asking simple questions such as name and birthday while checking the pupils for responsiveness. -Vital signs should be obtained after the patient is situated and assessment has begun. A patient admitted to the medical ward has a fever of 103˚ F, nuchal rigidity, pain on extension of the legs, and opisthotonos. Based on these findings, prioritize these nursing diagnoses: 1. Altered comfort: pain 2. Altered cerebral perfusion 3. Anxiety 4. High risk for injury answer: 2, 1, 3, 4 In meningitis, there is inflammation of the meninges of the brain and spinal cord. Patients have altered cerebral perfusion related to an increased intracranial pressure (ICP) and inflammatory process.
When transferring a client from bed to chair the following are recommended for client safety: Clients should wear nonskid shoes (first step) Make sure the bed and chair (wheelchair) brakes are locked Use a transfer belt. A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety. Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side. (Option 3) The nurse using proper body mechanics would pivot on the foot distal to the chair. (Option 2) The nurse should provide a wide body stance for more stability. Keeping the feet close together would not be good body mechanics and could cause injury.
Myasthenia gravis is an autoimmune disease manifesting mainly as muscle weakness and ptosis. The muscle weakness increases with activity, and by the end of the day, ptosis is present. These are expected findings for this condition, and so this client is not a priority. However, clients with myasthenic crisis can have respiratory failure, which, if it occurs, would be a priority. typical parkinsonian tremor occurs at rest and not during purposeful movement,
Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury). The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used.Appropriate interventions to aid communication include asking short, simple, "yes" or "no" questions; using hand gestures or pictures to demonstrate activities; and patiently allowing the client time to understand each instruction.
Safety is the immediate priority in a client experiencing a seizure. Nursing interventions include: Remain at the client's bedside while noting duration and symptoms of the seizure Call for help so that other team members can assist with care of the client (Option 1) Protect client from hitting hard surfaces by padding the side rails Turn client on the side if possible to allow for drainage of secretions and prevent the tongue from occluding the airway (Option 5) Loosen clothing around the neck and chest to promote ventilation Use suction equipment after the seizure subsides as needed to maintain a patent airway (Option 4)
Huntingsons disease -autosomal dominant hereditary disease - progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. *Chorea (involuntary, tic-like movement) is a hallmark sign*. The onset age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis -HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counselin - Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease).
Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: Use distraction and redirection (eg, going for a walk) to manage agitation (Option 3). Speak slowly and use simple words and yes-or-no questions. Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling") (Option 4). Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices (Option 2) NO open ended questions
The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? 1."I got short of breath this morning when I worked out." 2."I have cut down on smoking to 1/2 pack per day." 3."I haven't been feeling well, so I have been sleeping a lot." 4."I took an acetaminophen in the waiting room for this bad headache." correct 4 -arteriovenous malformation (AVM) is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. -tx depends on the location of the AVM, but blood pressure control is crucial. -high risk for having an intracranial bleed as the veins can easily rupture - Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage (Option 3) Reports of not feeling well and sleeping a lot may be related to the headache and possible hemorrhage, but this alone would not prompt a call to the health care provider.
The goals of emergency care for the client with suspected substance abuse who exhibits signs of central nervous system depression (eg, altered level of consciousness, bradypnea, hypotension, bradycardia) are to promote adequate ventilation and oxygenation and preserve hemodynamic stability. Interventions are prioritized according to the ABCs (ie, airway, breathing, circulation). Initial actions involve maintaining patency of the client's airway, including appropriate positioning, oropharyngeal suctioning, and artificial airway placement (if needed). Respiratory depression occurring after the ingestion of an unknown substance (eg, depressants [opioids, benzodiazepines, barbiturates]) should initially be treated with administration of reversal agents (eg, naloxone, flumazenil).
Cushing's triad/reflex indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes).
The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response? 1. Consumes 600 mL liquid over 4 hours [2%] 2. Insertion site dressing saturated with clear fluid [74%] 3. Observed lying in the right-sided Sim's position [9%] 4. Reports a headache rated 6/10 [13%] After a lumbar puncture, cerebrospinal fluid leakage from the puncture site requires health care provider notification for a blood patch. A headache after the procedure is an expected finding. The client should lie flat and increase fluid intake afterwards. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required.
A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion. lients may experience confusion after a seizure during the postictal phase. The client should be observed for safety and abnormalities documented before and during this phase.
The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately? 1. Diminished gag reflex after endotracheal tube removal [15%] 2. Increased agitation level and pulling at linens [28%] 3. Left arm drift during bilateral arm extension [53%] 4. Responds to verbal commands with eyes closed [2%] correct: 3 A carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status postoperatively can be challenging, as the effects of anesthesia degrade the neurologic examination. Nurses should use the FAST acronym to assess for stroke: Facial drooping: Numbness or droopiness on one side of the face Arm weakness: Weakness or drifting of one arm when raised to shoulder level (Option 3) Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others Time: Notation of the time of symptom onset, which is critical for guiding treatment (Option 1) Diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. (Option 2) Individuals recovering from anesthesia may have alterations in mood or affect (eg, agitation, anxiety, tearfulness) that will resolve as anesthesia wears off. (Option 4) Drowsiness and somnolence during purposeful interactions (ie, following commands) are expected after anesthesia. Educational objective: Following a carotid endarterectomy, the client should be monitored for alterations in mental status that are unexpected in the context of typical postanesthesia symptoms (eg, diminished gag reflex, altered affect, drowsiness). The FAST assessment (Facial drooping, Arm weakness or drift, Speech difficulties, Time) assists with identifying alterations that may indicate stroke.
An essential aspect of discharging a client with a head injury is ensuring that a responsible adult will check on the client as the level of consciousness can change (Option 5). Brain edema or increased intracranial pressure (IICP) may not be evident immediately. The client should return to the emergency department or notify the primary care provider if any of the following signs/symptoms are present in the next 2-3 days: Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion) Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics Visual changes (eg, blurring) Motor problems (eg, difficulty walking, slurred speech) (Option 3) Sensory disturbances Seizures Nausea/vomiting or bradycardia (indicates IICP) The client is also to abstain from alcohol, check before taking medications that can affect level of consciousness (eg, muscle relaxants, opioids), and avoid driving or operating heavy machinery (Option 1).
The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating [16%] 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait [31%] 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL [11%] 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL [41%] correct is 4 bc a brain tumor grows slowly and edema is expected. Patients get steroids and stuff. The closed injury pt has an acute onset and he can detreoriate faster!
*The single most important factor in preventing strokes is controlling hypertension.* Risk factors for stroke - idiabetes, high cholesterol, hypertension, smoking, obesity (particularly in the abdomen), older age, and genetic susceptibility.
absence seizures -typically occur in children -Daydreaming episodes or brief (<10 seconds) staring spells -Absence of warning and postictal phases -Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity) -Unresponsiveness during the seizure -No memory of the seizure
Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position. if its a neuro question and "vomiting" is in the questions assume the worse! ICP!! Research has FAILED to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is related to the development of AD.
alzheimer disease -over age 65 usually diagnosed -familial, environmental, lifestyle -children of clients with early onset AD (got it when 60 or less) have a 50%!!! chance of getting it. -For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD. Trauma to the brain has been associated with the development of AD in the future. -Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD -Injury-prevention modifications include: Arrange furniture to allow for free movement to prevent falls (Option 1). Place frequently used items within easy, visible reach of the client (Option 2). Place locks on stairwells and outside doors to decrease the client's risk of falls and becoming lost during periods of wandering (Option 3). Label the doors to the bathroom and other commonly used rooms to assist with environment interpretation and promote independent functioning (Option 4). (Option 5) Providing a night light in the sleeping area can prevent falls, aid in orientation, and decrease illusions.
Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel ------literally anything any vertebrae above t6 generic rule: in neuro never lower the HOB unless the pt is post lumbar since they have to be flat. most of the time all the questions will have ICP or Auto dysref in mind.
alzheimers -During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. -another is to feed them 20 mins early then after. so half half it.
DI is often related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, hypovolemia, increased serum osmolality, and decreased urine specific gravity.
any client with suspected meningitis the FIRST thing to do is to put them in droplet precaution isolation -Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. -Viral meningitis and other types of bacterial meningitis (ie, other than meningococcal meningitis) usually do not require droplet precautions. -but again the question has to be very specific that the pt DOES NOT have bacterial meningitis. if it doesn't and simply states miningititis assume the WORST! *Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out* KNOW THIS KNOW THIS KNOW THIS
A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? MG pt c fever and increasing difficulty swallowing
atropine is a cardiac drug remember we need an EEG to confirm the bradycardia AND the client must show signs of low cardiac output
bells palsy -ere is flaccidity of the affected side with drooling. This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow saliva. Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly), but the condition is not emergent. Trigeminal neuralgia (tic douloureux) -presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening.Excessive weight loss Depression Social isolation Paresthesia and loss of corneal reflex (after surgery)....No impairment of sensory or motor function...Administer prescribed medications, such as carbamazepine. Give baclofen with food, if ordered. Obtain specimens for laboratory testing, as ordered, such as carbamazepine and phenytoin drug levels. Obtain baseline complete blood and platelet counts when beginning carbamazepine therapy. Institute safety precautions, as indicated, related to the sedative effects of prescribed medications. Provide nutritional management. Help the patient identify possible triggers related to food, such as texture and temperature. Frequently monitor weight.
epidural hematoma -THE DURA is being skinned away from the skull! -The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. -HALLMARK: The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.
left hemiparesis -respond to call lights in a timely fashion -put the client on a toileting schedule to prevent incontinence since the client cannot get up independently -assist with toileting at least every 2 hours and monitor for skin breakdown. -Elevating the client's left arm and repositioning the client every two hours are important to prevent complications from immobility. -risk factor for pressure ulcer development. The patient should be repositioned as frequently as possible (at least every two hours) and should also be encouraged to move independently in bed to prevent complications of immobility such as pneumonia and constipation. -Patients who cannot lift themselves with repositioning and who must be lifted up in bed due to sliding down (when in semi-Fowler's) are at high risk for friction and shearing injuries, which are risk factors for skin breakdown. Always use a draw sheet. - The affected arm should be elevated above the level of the heart to promote venous return and reduce edema.
light pupil reaction - A normal consensual pupil response is a crossed reflex in which light directed at one eye causes contraction of the pupil in both eyes. -A direct reaction occurs when the illuminated pupil constricts. -Accommodation and pupillary convergence occur when the patient stares at an object 3-4 feet away, then the object is moved toward the patient's nose. Pupils should constrict as the object moves toward the patient's nose. Pupil responses are uniform.
he neck should be supple and able to be flexed toward the chest. Nuchal rigidity requires follow-up due to possible meningeal irritation related to infection (eg, meningitis) Normal pupils are 3-5 mm in diameter Oculocephalic reflex (doll's eyes) is an expected finding indicating an intact brainstem. It is tested by rotating the head and watching for the eyes to move simultaneously in the opposite direction. The test is not performed if spinal trauma is suspected.
presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in infants up to age 1, but in an adult may indicate a brain or spinal cord lesion.
Cranial nerve 8 damage -auditory and balance precaution! -Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. -place items near the pt since cranial nerve 9 and 10....DYSPHAGIA
pt with a stroke comes in ED c slurred speech, facial drooping, and right arms weakness. began an hour ago..initial plan -STAT CT scan of head! this is priority and probably the first thing to do -Perform neuro assessment -initiate alteplase within the next 3 hours there are two types of strokes...embolic and hemmorghic. thats why the client must have an immediate CT scan or MRI of the head to determine the type and location of the stroke. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm or platelet count less than 100K). It must be administered within *4.5 hours* from onset of symptoms (Option 5).
CVA WILL cause permanent neuro crap TIA will NOT a pt with a hx of TIA more than likely to get a CVA in the future bacterial meningitis have at least the following symptoms: nuchal rigidity, fever, HA, alt. mental status *acute bacterial meningitis= DROPLET PRECAUTION*
pt with closed head injury and has halo on pillow...not an emergency but hcp should be contacted ASAP and monitor *dialysis disequilibrium syndrome (DDS)* Headache, nausea, pupillary changes, and confusion are signs. -complication of hemodialysis, when the concentration of BUN is being reduced more rapidly than the urea nitrogen level in the cerebrospinal fluid and brain tissue. causing temporary cerebral edema during and after hemodialysis. -
anyone with an aneurysm prevent ICP elevation -NO ENEMAS -NO straining -Red. stimulation bc they are on seizure precaution
review -MG -strokes aka hemmor, emobolic, aneurysm -bells palsy -huntingston -trigeminal neurologia -carotid endarectomy
MG -Myasthenia gravis is a chronic neurologic autoimmune disease in which acetylcholine receptors are blocked, causing muscle weakness. Infection, undermedication, and stress can lead to a myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. -It is treated with pyridostigmine (Mestinon), which increases the amount of acetylcholine -Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention.
ruptured cerebral aneurysm aka "silent killers" -usually asymptomatic unless they rupture; -may go undetected for many years before rupturing without warning signs. -HALLMARK sign: abrupt onset of "the worst headache of my life" -changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck -emergency!! needs sx!!!
Homonymous hemianopsia -loss of one half of the field of vision on the same side in both eyes. - turn their heads and scan the area that has a visual deficit to reduce the risk of injury and self-neglect. -Food and fluids should be kept within the client's field of vision to encourage intake as appropriate. -higher risk for neglecting that side or being unable to eat food placed on the left side of a plate. high risk of injury
serial neurological assessments include -Glasglow -pupils (PERRLA) -motor -strength and movement in all four extremities -Vital signs- Cushing triad bc we are always assessing for ICP Neurovascular assessment, commonly known as the 5 Ps, consists of paresthesia, pain, pallor, paralysis, and pulselessness.
Symptoms of meningitis -fever, opisthotonos (abnormal positioning with arched back and head flexed backward), nuchal rigidity, and Brudzinski's sign and Kernig's sign, all of which are signs of meningeal irritation. A seizure at onset of symptom is NOT a characteristic for meningitis that is more for epilepsy A patient with expressive aphasia is unable to communicate using either verbal or written language A head injury in general can result in a decreased LOC which could be masked by a long nap. It is important to monitor the patient frequently to assess for unusual sleepiness, which might indicate increasing ICP. Sleeping is allowed, but the spouse should check on the patient frequently and make sure they can be aroused.
snellen= vision On the intensive care unit, a patient with head trauma is on continuous mechanical ventilation. The patient develops increased intracranial pressure. Which among the following interventions should the nurse implement first? -*hyperventilate first* aka tell provider for orders to hyperventilate -Carbon dioxide has a potent vasodilating effect and this can increase cerebral blood flow, leading to higher ICP. Cerebral hypoxia may result if the high ICP puts too much pressure on the brain. The provider should be called to get orders to hyperventilate the patient. Hyperventilation is the first-line intervention to decrease ICP because it decreases carbon dioxide levels. -If suctioning is required, hyperventilation is done prior to suctioning.
The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? 3,4,6
status epilepticus -BAD BAD DEADLY does not resolve -Grunting and a dazed appearance are 2 common signs. -Stopping seizure activity is the first nursing priority. - IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. -Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. -Finding the cause of the seizure is important and should be done as soon as seizing has stopped.
*Clients experiencing receptive aphasia, impaired comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lobe. The nurse would not speak louder as this does not aid comprehension. The nurse should speak clearly, ask "yes" or "no" questions, and use gestures and pictures to increase understanding*
strokes