Module 9 + 10
What is the sympathetic nervous system?
"Fight or flight" Blood pressure/heart rate increase Main neurotransmitters = Norepi and Epi
What is the parasympathetic nervous system?
"Rest and digest" Blood pressure/heart rate decrease + digestive increases.
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"You must avoid coughing, sneezing, and blowing your nose."
What do you do with a pt with a head injury?
Assume there is spine injury Preserve homeostasis Treat IICP THREE CARDINAL SIGNS BRAIN DEATH Coma + absence of brain stem reflexes + apnoea Supportive measures (nutrition + airway + fluid + skin integrity)
What reasons would a pt receive a LP?
CSF pressure reading Injecting contrast Culture
Why is IV mannitol used before craniotomy with burr holes?
Decrease fluid in brain
What therapeutic effect do you expect to see with mannitol use in a pt with IICP?
Decreased ICP
Pt sustained head injury in an accident. Nurse notes the pt is always thirsty and passing urine constantly. Which condition is suspected?
Decreased antidiuretic hormone DI
What disorder is caused by the deficiency of antidiuretic hormone?
Decreased antidiuretic hormone DI
Which info would you include in the teaching for pt diagnosed with epilepsy taking phenytoin?
Floss regularly Gingival hyperplasia
How can brain injuries be classified?
Focal Diffuse
How are seizures classified?
Focal - One hemisphere (do not lose conciousness - can have weird taste in mouth) Generalized - Bilateral (lose consciousness - febrile - tonic/clonic) Epilepsy
What test would you expect to be ordered for a pt with suspected intracranial aneurysm?
Magnetic resonance angiography Assesses blood flow
A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?
Severe exploding headache
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
What is a migraine?
Severe headaches often accompanied with nausea and vomiting With aura: lights and visual disturbances With tension Affect women more than men + onset around puberty
The pt with which NIHSS score would receive priority care? 1 for limb ataxia 3 for facial palsy 0 for LOC
3 for facial palsy Complete facial paralysis
What is the normal intracranial pressure range?
0-15 mm Hg
How do you stage reflexes?
0: Absent 1+: Present but decreased or hypoactive 2+: Normal 3+: Increased or brisk but not pathologic - No clonus 4+:Hyperactive with clonus Clonus = Involuntary muscle movements or contractions
What are the two major parts of the nervous system?
1) The CNS (Central Nervous System) 2) The PNS (Peripheral Nervous System Control motor, sensory, autonomic, cognitive, and behavioral activities
What is the NIH stroke scale?
11 item assessment Each item gets 0-4 score (0 meaning no signs of stroke - 4 being serious signs) Max score is 42 1. LOC 2. Gaze 3. Visual 4. Facial palsy 5. Motor arm 6. Motor leg 7. Limb ataxia 8. Sensory 9. Language 10. Dysarthria 11. Extinction and Inattention
What is the 5 point scale for muscle strength?
5 - is full power and strength 4 - active movement against gravity and resistance 3 - active movement against gravity 2 - active movement with gravity eliminated 1 - flicker or trace of movement 0- no movement at all
What is the Glasgow Coma Scale?
A brain injury severity scale that assesses depth and duration of impaired consciousness and coma Scored between 3 and 15 Below 8 = coma and indicates need for endotracheal tube and mechanical vent 3 is BAD 15 is GOOD
What is a myoclonic seizure?
A brief jerking or stiffening of the extremities which may be symmetrical or asymmetrical Like when feel like you're falling in bed :0
What is a tonic clonic seizure?
A generalized seizure in which the patient loses conciousness and gets stiff / shakes Grand mal Experienced during febrile seizure
What is spinal shock?
A sudden depression of reflex activity below the level of spinal injury S/S: Muscular flaccidity and lack of sensation and reflexes
What assessment findings indicate a stroke? Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started 2 hours ago
ALL!
What nursing intervention is a priority for a pt in a motorcycle accident with a neck injury? ABC
Airway
What are the types of dementia?
Alzheimers Vascular (post stroke) Dementia with Lewy Bodies (proteins invading the brain) Frontotemporal (damage to brain) HIV or AIDS related dementia
What is a traumatic brain injury (TBI)?
An injury to the brain sustained by physical trauma or external force Falls
What is brain death?
An irreversible loss of all brain functions, including the brain stem
What are sensory issues?
Anesthesia - absence of pain Hypesthesia - decreased touch Hyperesthesia - increased touch (and other senses) Analgesia - inability to feel pain Hypoalgesia - decreased pain Hyperalgesia - increased pain Vibratory sensation Sensitivity to position
What is Cranial Nerve VI?
Abducens - controls outward eye movement Test - Extraocular eye movements by following movements of penlight Deficiency - Dilation of pupils with loss of light reflex on one side + impaired ocular movement + diplopia (double vision) + gaze palsies (cant move both eyes together) + ptosis of eyelids (sagging eyelid)
What is tactile discrimination?
Ability to tell what you're touching JUST by touching it
How is persistent vegetative state diagnosed?
Absence of awareness of self and surroundings Inability to interact with others No reproducible voluntary behavior Incontinent
What is apnoea?
Absence of breathing Muscles and soft tissues in the throat relax and collapse sufficiently to cause a total blockage of the airway
What is cerebral edema?
Accumulation of water or fluid on the brain Increases ICP and volume of brain tissue Leads to autoregulation - decreased production and flow of CSF
What is delirium?
Acute confusional state Caused by: Meds + metabolic issues + electrolyte imbalance + surgery + dehydration
What is dopamine?
Affects behavior, attention, emotion, fine motor skills Dysfunction in Parkinson's disease
What is serotonin?
Affects mood, hunger, sleep, arousal and pain
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?
Airway
What is ADH?
Anti-diuretic hormone Decreased production of ADH can result from: Disruption of the hypothalamus or pituitary Interruption of the blood supply to these parts of the brain Increased ICP or edema causing herniation of the brain and compression of the pituitary
Client admitted with tonic clonic seizures after his seizures have been well controlled by phenytoin for 6 months. The client says "I am so upset. I didnt think I would have anymore seizures." Which response is best?
Are you worried about having more seizures?
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?
Assist the client to the floor, in a side-lying position, and protect him with linens
What meds do you give for seizures?
Ativan is used for immediate help Anticonvulsants used to prevent the NEXT seizure Anticonvulsants = -Dilantin (gingival hyperplasia) -Keppra (not as many side effects) -Valproic acid -Gabapentin (not the best) Need blood work before anticonvulsants for liver func. and kidney func. Avoid alcohol Carbamazepine Clonazepam Divalproex Ethosuximide Phenobarbital Phenytoin Primidone Valproic acid
What phase of a unilateral throbbing HA with nausea and light/sound intolerance involves double vision?
Aura phase = visual changes
How do you treat a HA?
Avoid triggers HA journal Calm + dark + quiet + manage stress + heat or cold Abortive medication: Sumatriptan (Imitrex) Naratriptan (Amerge) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Zlmotriptan (Axert) Ergot alkaloids - contains small amounts of caffeine + causes vasoconstriction
What potential issue can occur early on for a pt with paraplegia secondary to spinal injury?
Bladder control issues
What is an absence seizure?
Blanking out staring and not moving at all Can be misdiagnosed (need to rule out other options) Periods of time they do not remember Can be triggered Treated with anticonvulsants Phenobarbital - addicting + LOC change
What is a subarachnoid hemorrhage?
Bleeding into the subarachnoid space Sudden onset HA described as "the worst headache of my life"
What is a subdural hematoma?
Blood collection under the dura Requires immediate craniotomy and control of ICP Venous Acute Subdural: 24-48 hours Subacute Subdural: 48 hours -2 weeks Chronic Subdural: Weeks to months
What is a closed brain injury?
Blunt force trauma Acceleration/deceleration injury that occurs when the head accelerates and then rapidly decelerates damaging brain tissue
What are the signs of spinal shock (neurogenic shock)?
Bradycardia Hypotension Urine retention
What is a battle sign?
Bruising behind the ear (over mastoid process) Indicates skull fracture that could cause brain injury if not treated
What is a ventriculostomy?
Cath inserted into ventricles of the brain Nondominant hemisphere Receives continuous ICP readings Allows CSF to drain (can also drain blood) Can give intraventricular meds Complications - infection + meningitis + ventricular collapse + occlusion
How is brain death diagnosed?
Cause of irreversibility Absence of brain stem reflexes Absent / diminished response to pain Absent respirations with PCo2 of 60 or more THREE CARDINAL SIGNS Coma + absence of brain stem reflexes + apnoea
What are things to remember about a hemorrhagic stroke?
Caused by bleeding + aneurysm + head trauma + Arteriovenous malformations (AVMs) Subarachnoid hemorrhage is mostly caused by a ruptured aneurysm - feels like the worst headache ever ICP increases
What is neurogenic shock?
Caused by spinal cord injury, usually as a result of a traumatic accident or injury or meds Shock state resulting from loss of sympathetic tone causing relative hypovolemia Dry + warm skin Hypotension Bradycardia Syncope
What are target cells?
Cells that have receptors for a particular hormone
The brain and the spinal cord are included in which part of the nervous system?
Central nervous system CNS
What is a headache?
Cephalgia It is a symptom Triggers: Tyramine Nitrates Monosodium glutamate Season changes Hormones Bright lights Odors Sleep issues OPQRST
What is a halo sign?
Cerebrospinal fluid from nose/ear will form a clear "halo" around the blood on a cloth
Pt hospitalized for brain injury + skull fracture Which members of the staff can provide care to this pt?
Charge RN NOT UAP
What are neurotransmitters?
Chemical messengers Hormones Acetylcholine, norepinephrine, dopamine, and serotonin Imbalance = neuro dysfunction
What is dementia?
Chronic disorder of the mental processes Most common dementia: Alzheimer's disease Can still experience delirium
What are burr holes?
Circular openings made in the skull Can determine intercranial swelling + injury + size and location of ventricles Can drain abcessess and hematomas
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
Close eyes and stand erect
What is an epidural hematoma?
Collection of blood between the dura and the skull Brief loss of consciousness Return to lucid state Hematoma expands Reduced LOC again Reduce ICP Remove clot Stop Bleed Burr holes Craniotomy
What is full consciousness?
Consciousness in which you know and are able to report your mental state
What intervention would you include for an older client with dementia? Consistency with activities Detailed explanation Be firm with them
Consistency with activities
Nurses notes shortened muscles over a joint that is preventing full extension, what is this called?
Contracture
What is the somatic nervous system?
Controls the body's skeletal muscles S = skeleton
What is a cluster HA?
Cyclical pattern or a cluster period Intense pain in or around one eye - unilateral Strike quickly, usually without warning
What is secondary brain injury?
Damage evolves over ensuing days and hours after the initial injury
What is a stroke?
Damage to the brain from interruption of its blood supply Cerebrovascular disorder Ischemic - blockage (most common) Hemorrhagic - bleeding
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
Decerebrate
How do you treat increased ICP?
Decrease cerebral edema + lower CSF volume + decrease cerebral blood volume Give diuretics + restrict fluid + drain CSF + control fever + maintain BP Elevate HOB + decrease coughing + avoid vasal maneuvers + O2 + monitor BP and temp every 30 mins
After conducting a falls risk assessment education session for the staff, what action by staff would need review for corrective action? Using fall risk assessment form Assessing room for fall risk Inquiring about fall history Delegating fall assessments to UAP
Delegating fall assessments to UAP
What condition would you expect in an older person with new onset decreased LOC + fatigue + hallucinations?
Delirium
Which assessments would the nurse include for a pt with spine injury wearing a jacket brace?
Developing cast syndrome Ausc bowel sounds Assess skin
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern?
Difficulty swallowing
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
Diminished responsiveness Changes in LOC
What is a primary brain injury?
Direct contact to head/brain during the instant of initial injury
What are things to remember about an ischemic stroke?
Disruption of the blood supply caused by an obstruction - usually a blood clot •Large artery thrombosis •Small penetrating artery thrombosis •Cardiogenic embolism •Cryptogenic Covid-19: Higher incidence of ischemic strokes due to abnormal blood clotting
How do you treat cerebral edema?
Diuretics + hypertonic saline (dehydrate) + foley + assess hydration status + steroids for brain tumor + fluid restrict
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?
Ecchymosis over the mastoid
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:
Evaluation of the corneal reflex response
What is the FAST acronym?
Face drooping Arm weakness Speech difficulty Time to call 911 Stroke assessment
What is Cranial Nerve VII?
Facial - controls sense of taste and contraction of facial expression muscles Test - Puff out cheeks, raise eyebrows, close eyes tightly, smile, and frown Deficiency - Facial dysfunction + weakness/paralysis + hemifacial spasm + diminished taste + facial pain
What is a DI? Diabetes insipidus
Failure of ADH resulting in dilute urine in large amounts Admin fluids + electrolytes + administration of a synthetic vasopressin (desmopressin DDAVP).
What can trigger a migraine?
Fatigue Sleep issues Hormonal issues
What is decorticate posturing?
Flexion of the arm and legs pulled toward the core of the body DeCOREricate
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?
Form understandable words and comprehend spoken words
What is a basilar fracture?
Fracture at the base of the skull
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Administering prescribed antipyretics Elevating the head of the bed to 90 degrees Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Frequent oral care
Frequent oral care (would be on fluid restrict so would have dry mucous membranes) Elevating the head of the bed to 90 degrees Administering prescribed antipyretics (control fever because fever can lead to increased ICP)
What cells nourish and protect the neurons?
Glial cells If glial cells absent / diminished - the neurons are not able to fully function
What is Cranial Nerve IX?
Glossopharyngeal - motor and sensory nerve for throat and taste Test - Taste, throat sensations, swallowing movements, gag reflex (tongue depressor), and saliva secretion Deficiency - Pain on base on tongue + difficulty swallowing + loss of gag reflex + palatal/pharyngeal/laryngeal paralysis
What intervention does the nurse include for a pt admitted with R sided cerebrovascular accident (CVA)? Apply elastic stockings Use bed cradle ROM exercises Hand roll to support L arm (contractures)
Hand roll to support L arm (contractures) L side of body affected with R side attack
What position do you place a pt with spinal injury and autonomic dysreflexia?
High fowler
What is Cranial Nerve XII?
Hypoglossal - motor nerve for tongue movement Test - Tongue movements + tongue midline Deficiency - Abnormal tongue movement + weakness/paralysis of tongue + difficulty talking/chewing/swallowing
What is cerebral perfusion pressure?
ICP - MAP = CPP Normal CPP = 70-100 CPP <50 = pt with irreversible neuro damage If ICP = MAP than cerebral circulation has ceased (nothing moving)
Pt with a brain tumor (astrocytoma) complains of HA and begins to cry during exam while lying in supine What factor is the cause of the HA?
IICP caused by the tumor The IICP is causing the HA
What is a brain herniation?
Increased intracranial pressure pushes the brain out of position Leading to irreversible brain anoxia and brain death
What conditions can precipitate delirium?
Infection Dehydration Urine retention Meds
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
Intracerebral hematoma
What is a diffuse brain injury?
Involves widespread areas of the brain
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?
Keep the client's neck in a neutral position (no flexing)
What are signs of increased ICP?
LOC changes Confusion Irregular resp Headache Restless Drowsy Decorticate/decerebrate Flaccidity Coma
What is the cushings triad?
Late sign of increased ICP Brain increases arterial pressure to try and fix blood flow back to the brain Wide PP Bradycardia Elevated systolic BP Can cause brain herniation and death
What is autonomic dysreflexia?
Life-threatening emergency in spinal cord injury SNS response is exaggerated Hypertensive emergency Occurs AFTER spinal shock has resolved Symptoms: Severe headache Diaphoresis Nausea Nasal congestion Bradycardia Triggering stimuli: Bladder distention Distended rectum Constipation Skin stimulation
What is lethargy?
Limited spontaneous movement or speech - may not be oriented to time, place, or person
What is confusion?
Loss of ability to think rapidly and clearly - impaired judgement and decision making
What is a persistent vegetative state?
Loss of cognitive function and awareness of self and surroundings Eyes will open spontaneously without awareness Sleep wake cycle intact Brain stem intact Enteral feeding needed
What is atonic seizure?
Loss of muscle tone and falls to the ground Known as "drop attacks" Risk for injury Wear helmet + gait belt
What clinical finding is consistent with IICP?
Low LOC
What are preventative measures for HA?
Low dose beta blockers + antidepressants + antiseizure meds + HRT + magnesium + NSAIDs Regular eating and sleeping Avoid MSG + chocolate + alcohol + vasodilators + histamines Control stress
What are the nursing managements for a hemorrhagic stroke?
Low stimulation + stress + dim lights + restrict visitors Prevent increase in ICP + BP + bleeding Bedrest HOB 30 degrees Vasal maneuvers Stool softener + mild laxatives Seizure precautions
What is glutamate?
Major excitatory neurotransmitter
What are complications post transsphenoidal hypophysectomy?
Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus - it is treated with vasopressin Pneumocephalus (air in the intracranial cavity)
What condition in a pt with brain injury is contraindicated for MRI with contrast?
Metal in body
What is obtundation?
Mild to moderate reduction in arousal - falls asleep unless stimulated verbally or tactilely
What are the nursing managements for an ischemic stroke?
Monitor VS and neuro LOC Motor func Speech Pupil I+O O2 CATSCAN! Within 25 minutes Determine what kind of stroke it is!! Where is the clot? Can you give TPA? TPA can only be given in small window!!!
What is a febrile seizure?
Most common RAPID CHANGES TO TEMP Determine source of fever + control + meds
What helps increase conduction speed in the neuron?
Myelin Anything that interferes with myelin - the client will exhibit motor / function challenges
Can you give a lumbar puncture with increased ICP?
NO Can cause brainstem herniation
What are post-op nursing considerations after a transsphenoidal hypophysectomy?
NO: Coughing + blowing nose + straws + pressure on surgical site + bending + straining Raise HOB + check nasal packing frequently for blood Biggest complaint = dry mouth (frequent mouth care - but do not brush teeth until incision on palate is healed) Nasal packing is removed after 3-5 days
What is the basic unit of the nervous system?
Neuron
A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?
Noncontrast computed tomography
What are the risk factors for stroke?
Nonmodifiable: 55 yo or older Males Black Modifiable: •Hypertension •Cardiovascular disease •Elevated cholesterol •Obesity •Diabetes •Oral contraceptive use •Smoking/tobacco, drug, and alcohol abuse
What action do you take when caring for a client who had a craniotomy and is transferring to the ICU from PACU? Monitor temp TCDB Notify HCP of yellow/bloody drainage Admin opiods with irritability
Notify HCP of yellow/bloody drainage
What are the symptoms of an ischemic stroke?
Numbness/weakness of face + arm + leg (especially to one side) hemiparesis + hemiplegia Facial drooping Change in mental status Aphasia - Difficulty understanding/expressing speech Difficulty walking + dizziness + loss of balance and coordination Sudden + severe HA Perceptual disturbance Dysarthria - makes it difficult to form and pronounce words Hemianopsia GLUCOSE CHECK: rule out hypoglycemia
What is an open brain injury?
Object penetrates the brain or trauma is so severe that the scalp and skull are opened
What action do you take first with a pt admitted for seizures?
Obtain history of seizures
What is Cranial Nerve III?
Oculomotor - controls eye movement (pupillary control) Test - Pupils and pupillary response (PERRLA) using a pen light, check for accommodation Deficiency - Assess for extraocular movements and nonreactive pupils
What is Cranial Nerve I?
Olfactory - controls sense of smell Test - Have patient smell something and identify it Deficiency - Diminished taste of food or anosmia
What are different types of fractures?
Open Closed Frontal Temporal Occipital Linear Depressed Comminuted - 2 places
What would a glasgow coma scale of 8 indicate?
Opens eyes to painful stimuli Incomprehensible sounds Flexes to pain 8 or less = coma
What is Cranial Nerve II?
Optic - controls vision Test - Peripheral vision Deficiency - Homonymous hemianopsia (or hemianopia) only seeing one side right or left
What class is mannitol?
Osmotic Decreases sodium absorption
What hormones are secreted by the posterior pituitary gland?
Oxytocin Antidiuretic (vasopressin)
What is the POUND acronym?
P - Pulsating O - hOurs U - Unilateral N - Nauseating D - Disabling
What is a tension HA?
Pain is mild to moderate Steady tight band around the head or on both the sides and back of the head
What is stupor?
Partial or almost complete unconsciousness
The cranial nerves, spinal nerves, and autonomic nervous system are included in which part of the nervous system?
Peripheral nervous system PNS
What action is essential for a pt with hemianopsia as a result of L ischemic stroke? Place objects in visual field Teach ROM exercises Instill artificial tears in eyes Reduce time spent on L side
Place objects in visual field
What are the stages of seizures?
Pre-ictal: before Ictal: during Post-ictal: after
What do you do for seizures as a nurse?
Prevent injury Protect head Pad side rails Low bed Non restrictive clothing Do not place anything in clients mouth O2 Suction IV access
What is a lumbar puncture?
Procedure of taking fluid from the spine in the lower back through a hollow needle - usually done for neuro diagnostics Should be watery and colorless Bloody CSF = subarachnoid hemorrhage Milky/cloudy = infection (like meningitis) Could start off bloody due to initial trauma of the test but becomes clearer as more drains
What prescription would the nurse question when a clients sodium is 123? Add table salt Fluid restrict Assess neuro Provide 0.45% NaCL IV Normal: 125-145
Provide 0.45% NaCL IV Hypotonic solution - would make the issue worse
Which interventions would the nurse implement when caring for a pt with diabetes insipidus after a head injury?
Provide fluids Assess neuro Monitor for constipation + weight loss + hypotension + tachy
What finding for a pt with afib is most important to report to HCP? Irregular HR RA weakness Pt reporting palpitations Pt reporting lightheadedness
RA weakness Sign of atrial clot formation + may embolize and cause stroke
What assessment is priority before administration of TPA?
Signs of bleeding
What action do you take for a pt with possible skull fracture as a result of trauma?
Signs of brain injury ASSESS PT
The PNS can be broken up into...
Somatic nervous system Autonomic nervous system
Which mechanism of action explains how diuretics reduce BP?
Reduce circulating blood vol
What is status epilepticus?
Reoccurring epilepsy Seizure lasting upwards of 30 minutes OR 2 seizures with no break GOLD STANDARD = ATIVAN AT HOME = DIAZEPAM Rectal Dia-Stat (diazepam) Nasal diazepam can also be prescribed Neurologic emergency!!!
What is the autonomic nervous system?
Responsible for control of the unconscious bodily functions - breathing, the heartbeat, and digestive processes Broken up 3 more times - sympathetic + parasympathetic + enteric
What is the primary nursing objective for pt with dementia, delirium, and other neuro issues?
SAFETY
What actions are appropriate during the tonic-clonic stage of seizure?
SAFETY Protect head
What is important to include in the teaching for a pt with tonic clonic seizures?
Safety while having seizures Prevent physical trauma
How do you treat autonomic dysreflexia?
Seated HOB raised (45°) Assess Empty bladder Examine rectum for fecal mass Examine skin for stimuli Vasodilator (IV + nitro) Hydralazine (IV) Nifedipine (Bite + swallow)
What finding in a pt being treated after motor vehicle accident indicates immediate intervention? Facial edema Septal deviation O2 89% Bilateral periorbital bruise Clear nasal drainage
Septal deviation O2 89% Bilateral periorbital bruise Clear nasal drainage
What are the symptoms of an hemorrhagic stroke?
Severe HA Vomiting Early + sudden LOC changes Nuchal rigidity + tinnitus + photophobia + seizure
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Severe TBI
What is a focal brain injury?
Specific and occurs in a precise location of the brain
What is Cranial Nerve XI?
Spinal Accessory - motor nerve for shoulder and head movement Test - Shrugging shoulders against resistance and turning head side to side and up and down Deficiency - Drooping of shoulder + limited movement + weakness/paralysis of head rotation/flexion/extension/shoulder elevation
What is coma?
State of profound unconsciousness
How do you assess motor function?
Strength + tone Gait and balance Romberg test - stand straight with eyes closed Finger to nose test - coordination Heel to shin test (trace in straight line)
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
What can increase ICP?
Suctioning + straining + turning + vomiting + coughing + bearing down If constipated administer stool softeners, high fiber diet, ambulate often If nauseous administers antiemetics (Zofran) Cough give suppressant
What is a craniotomy?
Surgical opening of the skull Used to remove tumor + relieve IICP + remove blood clot + control bleeding Goes into the: •Supratentorial compartment •Infratentorial compartment •Mouth + nasal sinuses (pituitary gland)
What is a transsphenoidal hypophysectomy?
Surgical removal of the pituitary gland through the palate + sinuses Cannot be done if pt has a sinus infection Corticosteroids may be given before and after surgery because the surgery involves removal of the pituitary which is the source of adrenocorticotropic hormone (ACTH) which regulates the amount of cortisol released from adrenal gland
What is SIADH?
Syndrome of inappropriate antidiuretic hormone Too much ADH Vol overload Fluid restrict + In severe cases careful administration of a 3% hypertonic saline solution
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6
What is thrombolytic therapy? Tissue Plasminogen Activator
TPA Clot buster Give within 3 hours - goal is 60 minutes from onset of symptoms Delays make the patient ineligible for therapies because revascularization of necrotic tissue (which develops after 3 hours) >18 yo Diagnosed ischemic stroke Systolic blood pressure ≤185 Diastolic ≤110 No minor stroke + rapid resolving stroke Has not received heparin in the past 48 hours + does not have elevated PTT Platelets >100,000 Glucose >50 No prior intercranial hemorrhage No major surgery or trauma in last 14 days No stroke + head injury + cranial surgery in last 3 months No gastrointestinal or urinary bleeding in the last 21 days No pregnancy
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?
Take medication as soon as symptoms of the migraine begin
Pt is scheduled for a CT of the brain with contrast. The nurse would report what important finding after looking at the chart?
Takes metformin daily Can cause lactic acidosis with contrast
What explanation would the nurse give about transient ischemic attacks (TIAs)?
Temporary episodes of neuro dysfunction
What is decerebrate posturing?
The arms and legs being extended straight out + hands curled back + the head and neck being arched backwards
How do you respond when the spouse of a client with an intracranial hemorrhage asks why the pt is not receiving anticoag?
The bleeding would increase Dumba s s
What is a diffuse axonal injury (DAI)?
Widespread axon damage in the brain seen with head trauma Client develops immediate coma
When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?
The stroke may have impacted the body's thermoregulation centers.
What are endorphins and dopamine used for?
They are morphine like transmitters Pain reduction and pleasure sensations
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours
15% of strokes are preceded by what?
Transient ischemic attack (TIA) Same s/sx of a full stroke but symptoms resolve within 24 hours TIAs warn of a full stroke Diagnostic workup to prevent further Anticoagulants + Anti-platelet meds
What is Cranial Nerve V?
Trigeminal - controls chewing and face sensations Test - Temporomandibular joint and sharp to dull facial sensation Deficiency - Pain in face or diminished corneal reflex / chewing dysfunction
What are treatment meds for HA?
Triptans: Treat migraines but can cause chest pain contraindicated in ischemic heart disease (sumatriptan (Imitrex) and almotriptan (Axert) Antiepileptics: Turn off the chems that can lead to migraines BLACK BOX! Life threatening liver toxicity and fetal toxic (Divalproex sodium (Depakote) and topiramate (Topamax)
What is Cranial Nerve IV?
Trochlear - controls down and inward eye movement Test - Extraocular eye movements by asking patient to follow movements of penlight Deficiency - Assess for extraocular movements and nonreactive pupils
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
Unequal response
What is acetylcholine?
Usually gives excitatory affect HOWEVER Acetylcholine excited vagus nerve - leads to decrease HR Myasthenia Gravis associated neurotransmitter Parts in the body that use or are affected by acetylcholine are referred to as cholinergic
What is Cranial Nerve X?
Vagus - motor and sensory nerve for throat, larynx, and organs in thoracic and abdominal cavities Test - Open mouth and say "ahh" Deficiency - Voice changes + hoarseness + vocal paralysis + dysphagia
What is Cranial Nerve VIII?
Vestibulocochlear or Acoustic - controls equilibrium, balance, and hearing Test - Whisper test (occlude one ear and whisper two words in the opposite ear) Deficiency - Tinnitus + vertigo + hearing problem
What imaging test would be ordered to rule out cervical spine fracture?
Xray
