Sensorimotor exam

Cerebral angiography

- Views vascular structure of brain -Used to assess cause of strokes, seizures, headaches and motor weakness i. Procedure 1. Allergy to dye? Taking any anticoagulants? (inject dye into femoral artery) 2. Renal function (BUN/Creatinine) 3. Need consent 4. Patient education about procedure 5. NPO 4-6 hours before 6. Use femoral artery **post procedure - movement is restricted, monitor vascular status (important due to accessing an artery), VS, I & O, assess insertion site, check peripheral pulse (radial for upper

Spinal cord complications - Autonomic Hyperreflexia or Autonomic Dysreflexia (sympathetic (fight or flight) stimulation with inadequate compensatory response from the parasympathetic (rest) system

1. Abrupt rise BP 2. Pounding h/a, n, v, blurred vision 3. Vasodilation above the injury (skin flushing, profuse sweating) 4. Vasoconstriction below the injury (cool/pale skin, and piloerection (goose bumps) 5. Medical emergency

Parkinson's nursing interventions -Rigidity

1. Administer meds 2. Teach side effects 3. Promote exercise, ambulation's, ROM 4. Massage or hot packs 5. Encourage patient to hold hands behind their back, grasped together - this is to help improve their gate and posture

Spinal cord complications - i. Complication Triggers spinal cord injuries

1. Bladder distention 80%, bowel distention, pressure ulcers, constricted clothing, menstruation, UTI, sexual activity, gastritis, labor colonoscopy. 2. Care: elevate HOB to sitting position, loosen clothing, monitor BP, empty bladder, check for bowel impaction, notify MD, administer rapid onset/short duration meds (nifedipine, captopril, hydralazine)

spinal cord injury - Steps 1-5

1. Immobilize (back board)/stabilizing (neck brace and back board) 2. Oxygen - supporting vital functions. 3. Monitoring cardiac rhythm BP 4. Establishing an IV (use NS) 5. Radiology for spinal CT

Parkinson's nursing interventions - Nutrition

1. Increase roughage in diet 2. Multivitamins 3. Cut food in small pieces 4. Increase fluid intake 5. Small frequent meals

Myasthenic crisis: manifestations

1. Increased pulse and respirations (shallow) 2. Absence of cough and swallowing reflex 3. Anoxia, SOB 4. Rise in BP 5. Cyanosis 6. Bowel and bladder incontinence

Nursing management during seizure:

1. Institute seizure precautions a. Keep side rails up, padded b. Have suction and O2 available 2. Patient/family education a. Support coping with chronic illness; social stigma b. Health promotion: rest; decrease stress c. Stress medication compliance 3. Discuss operation of machinery/vehicles; most states have their own laws - usually 1-2 years seizure free on medication 4. Discuss factors that could trigger seizures 5. Minimize alcohol use 6. Stress importance of wearing med alert identification

CVA

***remember: a right CVA will have Left sided weakness and a left CVA will have right sided weakness.

CSF analysis:

Normal CSF is colorless, clear and without blood or bacteria. Glucose normal is 40-80; protein is 16-45.

Tonic-clonic

Tonic phase: muscles become rigid

Sensory function

With eyes closed touch with sharp/dull objects; identify objects when placed in hand.

Down syndrome pathophysiology

a. Extra chromosome on 21st pair b. Characterized by: i. Intellectual disability ii. Distinct facial features iii. 60% have congenital heart defects iv. Respiratory infections v. Chronic myelogenous leukemia vi. **weak immune response to infection

Down syndrome physical characteristics

a. Face has flat appearance. b. Head is smaller that average c. Ears are smaller and lower set i. Mouth is small and lips are thin d. Tongue sticks out related to small mouth i. Small teeth ii. Neck appears slightly short and loose folds of skin are seen at the back sides e. Fontanels are larger than normal i. Arms and legs are short in relation to body ii. Protruding abdomen iii. Hands are broad and flat with short fingers, little finger slants inward f. ** seizures across palms (simian crease ) single transverse palmar crease i. Feet are broad with short toes and a larger than normal space between big toe and other toes

Glasgow Comma scale

a. GCS is measure of LOC b. GCS scores range from 3 to 15 i. (priority intervention for this patient would be assessment of airway, breathing and circulation) ii. 3 = brain death iii. Can't evaluate eye opening with swollen eyes (give a 1 and make a note) iv. Can't even evaluate verbal response with facial trauma or if on a vent (give a 1 and make a note) v. **scoring is important to know - understand total and what it indicares range 3-15

Neuro assessment:

a. History - very important to get this. i. Circumstances of injury on admission ii. Pertinent family and social history iii. Chief complaint? Symptoms? (paralysis, weakness, paresis, h/a) iv. PMH (HTN, alcohol use, smoker, CAD, seizures, hx of falls/accidents, surgeries) v. Current medications vi. Vision, hearing vii. ADL's

Brain abscess - expected findings.

a. History of an infection b. ***constant or intermittent headache not relieved by meds and increased with straining (most common symptom) c. Drowsy, confused, mental slowness, possible seizures, fever, bradycardia, possible IICP d. S and S can process rapidly leading to death or they can be benign. It all depends on the site of the abscess.

Guillain Barre - clinical manifestations

a. Most clients have symmetric weakness beginning in lower extremities b. Ascends body to include upper extremities, torso, and cranial nerves c. Sensory involvement causes severe pain (nighttime), paresthesia and numbness d. Client cannot close eyes e. **paralysis of intercostals and diaphragmatic muscle can result in respiratory failure. f. Autonomic nervous system involvement: blood pressure fluctutations; cardiac dysrhythmias, paralytic illness, SIADH, urinary retention, bowel dysfunction g. Dysphagia h. Poor speech i. Weakness usually plateaus or starts to improve in the fourth week with slow return of muscle strength.

Multiple Sclerosis - medical management

a. No cure b. Focus is on retaining optimum functioning, limiting disability. c. Corticosteroids d. Chemo: Cytoxan, methotrexate e. Antispasmodics/muscle relaxants to treat muscle spasms (bacloflen, Zanaflex) f. Urinary retention; Urecholine g. Urinary frequency; Ditropan

Brain abscess

a. Occurs almost always secondary to an infection (ear, sinus, lung, heart, teeth, skin or pelvic organs) b. **usually caused by staph, strep or pneumococci. c. *** occurs almost always from secondary infection ear/sinus/lung/heart/skin/pelvic organs. d. Most common in older kids and young adults, but can occur at any age e. It's a localized inflammation of the brain and exudates form. f. Brain tissues becomes edematous and necrotic. g. After several weeks, the abscess falls off and may rupture the ventricles h. Common in the temporal lobe and cerebellum

Multiple sclerosis - nursing management

a. PT, ROM - daily muscle strengthening b. Stool softeners, high fiber diet c. Refer to support groups d. Educations i. Avoid extremes in heat (sx can increase) ii. Avoid exposure to infection iii. Avoid stress iv. Avoid fatigue/overexertion. v. Get plenty of rest

Early warning signs of cerebral palsy

a. Poor head control b. Excessive startling c. Stiffness, floppiness, or unusual muscle tone; arm or leg tremors, seldom moves voluntarily. d. Difficulty motor development e. Delayed motor development f. Poor posture g. Slowness to reach development milestones h. Seizures i. *important to recognize early and promote optimum development.

Amyotrophic Lateral Sclerosis (ALS) - also known as Lou Gehrig's disease

a. Progressive degenerative neurologic disease characterized by weakness and wasting of muscles without sensory or cognitive changes. b. Physiologic problems involve swallowing managing secretions, communication, respiratory muscle dysfunction. c. Males affected 3x more than females. d. Death usually occurs in 2-5 years due to respiratory failure.

Alzheimer's - nursing interventions

a. Provide environmental stimulation through contact with people, provide a clock and calendar, present change gradually, allow for rest periods, use reptition. b. Be concrete. c. Limit information d. Prevent overstimulation and provide structure e. Promote independence in ADL f. Be consistent g. Promote bowel and bladder continence by offering rest room breaks q 2hr daytime, limit fluids at hs. h. Administer cholinesterase inhibitors such as Aricept, reminyl and Exelon. Maintains functionally for a few more months. i. Provide ID band j. ***monitor patient to reduce restlessness k. Involve activities l. Promote good nutrition; hygiene m. Interprofessional collaboration (legal-advance directives, power of attorney) n. Consult social services

Alzheimer's

a. Stage 2: very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease) b. The person may feel as if he or she is having memory lapses- forgetting familiar words or the location of everyday objects.

Review IICP - S & S of IICP

a. Temporary IICP: cough, sneeze, straining with BMs (Valsalva) i. Contrast dye with CT or angiography can irritate the cerebral blood vessels causing temporary IICP b. We need to detect S & S quickly and prevent by teaching to avoid trauma/accidents (helmets, seatbelts, say no to drugs/alcohol, driving safety) c. Changes in vital signs would be: i. Increase - temperature and blood pressure ii. Decrease - pulse and respirations iii. Cushings traid - increase BP and decrease pulse, decrease respirations and increase temp.

ALS - diagnostic tests

a. Testing rules out other conditions that may mimic early ALS such as hyperthyroidism, compression of spinal cord, infections, neoplasms b. EMG to differentiate neuropathy from myopathy c. Muscle biopsy shows atrophy and loss of muscle fiber d. Serum creatine kinase if elevated (non-specific) e. **pulmonary function tests: to determine degree of respiratory involvement

Myelomeningocele

a. The meningeal membrane that covers the spinal cord and part of the spinal cord protrude thru a cleft, forming a sac or cyst which is clearly visible on the skin. b. Sac contains tissue, CSF, nerves, and part of the spinal cord. c. The spinal cord is usually damaged at that level of the defect. d. Amount of disability depends on where the spina bifidia is and the amount of nerve damage involved. e. The opening is surgically repaired shortly after birth f. 80% have hydrocephalus. g. Diagnostic - meningocele (light shines through); myelomeningocele ( light will not shine through)

TIA vs CVA

a. Transient ischemic attack b. Symptoms last seconds, minutes or hours c. Symptoms must resolve in 24 hours. d. Symptoms related to sire of involvement. e. Visual, motor, sensory disturbances f. Diagnosed with carotid doppler.

Guillain Barre - medical management

a. Usual timeline i. Following the first symptom the condition tends to progressively worsen for about two weeks. ii. Symptoms reach a plateau and remain steady for two to four weeks iii. Recovery begins, usually lasting six to 12 months. iv. No cure but can speed up recovery and reduce severity with plasmapheresis.

Manifestations of IICP

i. Lethargy to coma (change in LOC) ii. Behavioral changes iii. Headache iv. N/V v. Change in speech pattern vi. Aphasia vii. Pupillary changes-papilledema viii. Cranial nerve dysfunction ix. Seizures x. Abnormal posturing xi. **Cushing's triad - elevated BP, decreased pulse and decreased respirations.

Hydrocephalus surgery shunt care - Pre-shunt care

i. Monitor for skin breakdown ii. Move head, neck and shoulders with body iii. Monitor for seizures and respiratory problems iv. Potential for vomiting- want to minimize - vomiting increases ICP v. Small frequent feedings vi. Don't move during and after feedings vii. Feed slowly viii. Place on side or infant seat after feeding

Motor functioning:

i. Muscle tone, movement, and strength ii. Compare L and R for equality/symmetry. Any tremors or twitching

Diagnosis of myasthenia gravis:

i. Often misdiagnosed (chronic fatigue, neurosis) 1. Physical examination and history 2. EMG: reduced action potential 3. Antiacetylcholine receptor antibody serum levels; increased in 80% MG clients; used to follow course of treatment 4. **serum assay of circulating acetylcholine receptor antibodies: if increased is diagnostic of MG

meningitis - Pathophysiology

i. Organisms that reach the brain disseminate quickly thru the meninges and into the ventricles causing. 1. Congestion of the meningeal vessels 2. Edema of brain tissue 3. IICP 4. Generalized inflammation with WBC exudate formation. 5. Possibly hydrocephalus if the exudate blocks the ventricular passages. 6. Coats nerve sheaths.

Hydrocephalus

a. Excessive accumulation of CSF in ventricles of brain b. Most common in neonates; can occur in adults r/t injury or disease c. In children, head is enlarged d. **Prognosis is improved/guarded with early diagnosis and treatment

Seizures: Postictal

refers to the time after a seizure when the patient recovers; amount of time varies for each patient; may be some lethargy, confusion, inability to follow commands, or speak clearly.

Status epilepticus

1. Life threatening emergency 2. Characterized by continuous cycles of tonic clonic activity with short or no periods of rest between them 3. Patient is in danger of developing hypoxia, hyperthermia, hypoglycemia, and exhaustion if seizure activity is not arrested. 4. O2 consumption outpaces the O2 and nutrient delivery. 5. Protect airway and provide O2 6. Benzodiazepines (Ativan and valium) are given rapidly to terminate the seizures 7. A loading dose of an anticonvulsant is also administered. 8. Dilantin (phenytoin) is given IV; mix in NS- never D5W (precipitates); max rate is 50mg/min causes hypotension and cardiac dysrhythmias; can cause gum disease when taken po; takes 7-10 days to reach therapeutic levels, therapeutic level is 10-20 mcg/ml 9. Educate for phenytoin. a. Maintain the state b. Does not prevent an aura from occurring c. Take daily d. Do not stop even if feeling better

Parkinson's nursing interventions - Communication

1. Listen carefully 2. Encourage vocal exercises 3. Speech therapy, OT

Nursing care during a seizure

1. Need to act quickly 2. Never leave the patient alone 3. Assure patient has patent airway 4. Do not restrain the patient 5. Loosen restrictive clothing 6. Protect from injury 7. Nothing is forced into the patients clenched mouth 8. After the seizures, assess the airway; administer O2 if necessary; assess for injury; reorient; provide rest.

Cholinergic crisis - too much meds

1. Occurs with overdosage of medications (anticholinesterase drugs) used to treat MG 2. Develops GI symptoms, sever muscle weakness, vertigo, respiratory distress, sweating, increased salivation, bradycardia

Parkinson's nursing interventions - Bradykinesia

1. Sit in a straight upright chair a. Modify clothing (wide zippers, Velcro) 2. Ensure safety 3. Remove scatter rugs, clutter 4. Use handrails 5. Teach patient to think about lifting their feet when walking

Myasthenic crisis: not getting enough then get tensilon to circulate.

1. Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration 2. Under medicated with anticholinesterase drugs 3. Progression of disease 4. Emotional upset 5. Systemic infections (pneumonia) 6. Fever 7. Stress

Spinal cord complications -Spinal cord - education

1. Tell patients which lesions above T6 that these episodes can occur for many years after injury, but are temporary once stimulus is removed a. Goal is prevent episodes 2. Injury affects motor and sensory function at the level of the injury and below.

Clonic phase:

1. rhythmic muscle jerking 2. Impaired LOC; tonic followed by clonic; possible tongue biting/urinary and fecal incontinence; air moving across vocal cords creates a "cry"; may become cyanosis if diaphragm is contracted too long; postictal state present. 3. Turn client's head to the side to prevent aspiration 4. Don't: restrain extremities, take vital signs or try to place airway into the mouth. 5. Priority action turn client's head to the side (prevent aspiration)

Cranial nerves

12 pairs of nerves that carry messages to and from the brain i. Assessment of proper functioning: ex swallowing, shoulder shrug, hearing etc.

Traction: skeletal; halo

Halo pins will be held in head to lock them in place. **pin site care is performed to prevent infection. Done several times a day 2. No weight with this traction 3. Secured with vest 4. Pins locked into place and not maneuvering traction stays on all times

CVA - nursing management

a. **VS especially temperature b. Elevate HOB c. **neurochecks d. Maintain nutritional status (prevent aspiration) e. IV fluids, I and O f. Monitor labs ( H and H, PTT, PT, INR) g. Assess respiratory status h. Keep suction available i. O2 j. Cough and deep breathe k. TEDS l. Seizure precautions m. ROM, PT, OT i. Upstairs with the good leg first to provide support, review ambulation with cane. n. Evaluate communication o. **R CVA: patient may deny/ignore the L side or have trouble judging position and distance. p. L CVA; patient may behave and act impulsively q. Reposition r. Assess bowel and bladder functioning s. Quiet environment t. Safety u. Psychological support v. **initiate stroke protocol: i. Oxygen > 95% ii. Use NIH stroke scale to assess patient iii. CT without contrast iv. Infuse TPA w. 1st 72 hours important to prevent complications x. Cranial 9 Glasgow coma i. Swallowing - causes impairment chewing/swallowing. ii. High fowlers while eating to prevent aspiration.

Down syndrome/trisomy 21

a. 1 in 700 births b. Associated with older moms (>35to = 1 in 384; > 45yo = 1 in30) c. Risk also increases for men > than 50

Cerebral palsy

a. A non-progressive disorder that results from damage to or a defect in part of the brain that controls motor function (postural and balance difficulties) b. Caused by brain injury pre (70-80%) peri, or postnatally. c. Injury occurs before CNS reaches maturity. d. Cant be cured e. Prognosis varies f. Normal life expectancy possible g. Early death from respiratory involvement

Medications to treat migraines

a. Abortive therapy i. Alleviate pain during the aura phase ii. Drug therapy iii. Mild HA 1. NSAIDs, acetaminophen 2. Caffeine iv. Severe HA 1. Ergotamine preparations (cafergot-caffeine based) Triptans (Imitrex, Maxalt, axert, zomig, trexmia) v. Preventative RX 1. Beta blockers such as propranolol; calcium channel blockers- verapamil; tricyclic antidepressants (amitriptyline) anti-seizure meds (Depakote, Neurontin, Topamax) (educate to take even when feeling well) decrease HR and BP 2. don't relieve pain during aura phase 3. help prevent vascular changes for someone having migraines - take even if well

Guillain Barre:

a. Acute inflammatory demyelinating disorder of peripheral nervous system characterized by acute onset of motor paralysis(usually ascending) (starts at toes and works its way up) b. Cause is unknown but precipitating events, include GI or respiratory infection prior surgery, or viral immunizations c. 80-90% of clients have spontaneous recovery with little or no disabilities d. 4-6% mortality rate and up to 10% have permanent disabling weakness e. Characterized by progressive ascending flaccid paralysis of extremities with paresthesia and numbness. f. **20% require mechanical ventilation due to respiratory involvement.

Bell's Palsy

a. Affects 7th cranial nerve (facial) i. *impulses are blocked due to inflammation around the nerve b. Cause is unknown, but thought to be related to herpes virus c. Occurs between age of 20-60 equally in males and females d. Majority of person recover fully in few weeks to months - important to know - expected outcome i. Some persons have residual paralysis. e. May recur on the same or opposite side f. # of nursing interventions they will have: artificial tears - 4 times a day to help with dryness cause they cant close their eyes. Teach patient to manually close eyes throughout the days. Brief closing not long period of time

Review posturing

a. Any damage to CNS can lead to pathologic motor responses in comatose patients b. Decorticate - indicates a lesion that involves large portion of sensorimotor cortex. (Core - pulling everything into their core) c. Decerebrate - lesions at level of the brain stem; very grave prognosis (grave - extension of arms; internal rotation/plantar flexion of legs) d. Both can occur concurrently (one on each side) will be accompanied by deep coma, rapid breathing and dilated pupils.

Medical management of CVA: Remember "time is brain"

a. Brain ages 3-6 years for each hour treatment is delayed b. Need to know type of CVA before treating!!! c. **systemic thrombolytic (TPA) - must meet strict criteria. Must give within 3 hours of onset of s/s d. **anticoagulants (assuming not a bleed): lovenox, heparin e. **antiplatelets: ASA, ticlid, Plavix, persantine (post CVA) f. Antihypertensives, analgesics, diuretics (mannitol) g. Catherter directed thrombolytic therapy - may use if systemic tx not effective h. Endarterectomy i. Craniotomy j. Wire coils in aneurysms- seals the area

Nursing interventions: pre op care Myelomeningocele

a. Cleanse/moisten sac with NS b. Keep it covered with NS dressing c. No ointment, powders, etc. to area i. Keep infant on their side or stomach ii. Elevate HOB to prevent contamination with urine and feces. iii. Provides emotional support to parents d. Provide for bonding (no pressure allowed on sac) i. Maintain infant's temperature. ii. Measure head circumference daily iii. Passive ROM to prevent contractures iv. Monitor for s&s of meningitis v. Ensure nutrition and hydration vi. Monitor I & O

Meningitis - medical management

i. ** treatment according to causative pathogen as found by LP (lumbar puncture) ii. Bedrest iii. IV fluids, analgesics for pain and fever iv. Anticonvulsants (increase ICP or seizure) v. Corticosteroids, mannitol (decrease inflammation/fluid) vi. Pathogen specific, antibiotics - meningococcus - penicillin or cephalosporins; rifampin or cipro; pneumococcal - PCN, cephalosporins and also vancomycin vii. Antipyretics, antiemetics, analgesics viii. **Respiratory isolation for up to 48 hours antibiotics are begun or CSF report comes back with bacterial vs viral dx. (droplet precautions up to 48 hours after antibiotics started report comes back noting which type)

Mental status

i. ***Level of consciousness 1. Alert- awake and responsive 2. Lethargic - drowsy, sleepy, but easily aroused 3. Stuporous - only arousable with vigorous or painful stimuli 4. Comatose - unconscious and cannot be aroused 5. ** if a sudden change of consciousness would require a neuroassessment then notify the neurologist of findings a. Ex report patient at this time A/O x4 then change note time and change ** LOC is most sensitive indicator of neuro status

Cerebellar Exam

i. Assess balance and coordination. ii. Gait iii. Touching nose with finger iv. Thumb to finger test

Spinal injury - medical and nursing management

i. At the scene, rapid assessment, immobilize and stabilize the patient ii. Support the vital functions iv. Surgery: to decompress the spinal column, insert rods for stabilization or correct deformities vi. Ng tube; foley vii. Log roll for body alignment

Reflexes

i. Babinski 1. Adult: abnormal - toes fan out : normal toes curl 2. Infants up to 6 months - toes fan out ii. Others (patellar, Achilles, bicep) iii. Check for hypo/hyper and symmetrical vs asymmetrical.

Meningitis - CSF results

i. Bacterial - cloudy, increased WBC's, increased proeting, decreased glucose, elevated CSF pressure > 20 (more harmful; all are greatly abnormal) ii. Viral - clear, increased WBCs, slightly elevated protein, normal glucose, variable CSF pressure. (Some are abnormal and some are not) iii. Know the differences to answer questions

Head trauma: major cause of death in people ages 1-35

i. Base of skull (basilar fracture): serous; cranial nerves and nerve pathways can be damaged; IICP; brain abscess; meningitis. ii. Complication - hemorrhage/infection - respiratory compromise - can have spinal cord injury

Diagnostic tests

i. CT ii. Neurochecks-obtain a accurate baseline preoperative (neurologic assessment) iii. ABG's iv. Lumbar puncture is not done with suspected IICP

Parkinson's dopaminergic drugs

i. Carbidopa/levodopa (Sinemet) ii. Levodopa is converted into dopamine iii. Levodopa is always given in combination with carbidopa iv. **this combination ensures that as much levodopa gets to the brain as possible (with least amount of side effects0 v. Dose is individualized vi. **side effects: confusion; constipation; diarrhea ; dizziness; drowsiness; dry mouth, headache; increased sweating; loss of appetite; nausea; taste changes; trouble sleeping; urinary tract infection. Vomiting; hypotension vii. Places more at risk for falls - educate fall risk/preventive measures viii. Shouldn't be taken on an empty stomach. Take with food

meningitis - Expected findings.

i. Changes in LOC ii. Disorientation iii. Photophobia - sensitivity to light iv. Nystagmus v. Hemiparesis vi. CN dysfunction vii. Personality changes viii. N/V ix. Fever and chills x. Red macular rash xi. Nuchal rigidity (stiffness in neck) xii. Headache xiii. + Brudzinski's and Kernig's sign

Parkinson's - manifestation's - Autonomic nervous system

i. Constipation and urinary hesitation or frequency ii. Orthostatic hypotension, dizziness with position change iii. Eczema, seborrhea iv. *depression and dementia; confusion, disorientation, memory loss, slowed thinking. v. * inability to change position while sleeping, sleep disturbance vi. * masks like facies, drooling

Speech

i. Dysarthria - ineffective articulation ii. Expressive aphasia - inability to express self-using motor aspects of speech iii. Receptive aphasia - inability to comprehend spoken words iv. Global aphasia - neither express or comprehend language

Tensilon Test - determines if they have MG

i. Edrophonium chloride (tensilon) is administered ii. **Baseline muscle strength tested then injection given. Within 30-40 seconds, most myasthenic patients show a marked improvement in muscle tone that lasts several minutes. iii. * may be used to distinguish between myasthenic crisis and cholinergic crisis. 1. Atropine sulfate have on hand if complication occurs. Cholinergic crisis if too much acetylcholine - med atropine sulfate.

Head trauma - medical management

i. Goal: ID and treat cause of IICP and cerebral edema ii. Steroids (methylprednisolone (Medrol) - to decrease the edema iii. Diuretics (mannitol, Lasix, and fluid restriction) iv. Dilantin v. Barbiturates (Nembutal) to decrease ICP pressure vi. Airway management: intubation 1st priority vii. Surgery to repair fx or laceration viii. Intracranial surgery for debriding or repairing effects of head trauma, aneurysms, abscesses, or brain tumors. ix. Small hematomas will reabsorb spontaneously x. Craniotomy for epidural hematomas and larger subdural hematomas xi. Intracerebral hematomas - less successful r/t widespread tissue damage

Meningitis - nursing assessment

i. History of respiratory infection, sinus infections, immunosuppression ii. Recent ventriculoperitoneal shunt placement or cochlear implant surgery (individual with hydrocephalus) iii. C/O h/a, chills, malaise, vomiting, stiff neck, fever iv. Change in LOC and orientation

meningitis - risk factors

i. Inflammation of the meninges or brain covering. ii. Entry is via the bloodstream at the blood-brain barrier. iii. May be direct route or via skull fractures. Exercise will develop. iv. Viral is most common - ex mumps/measles. v. Fungi-Cryptococcal. Can be caused by sinusitis. vi. Bacterial -mortality rate +25%. Most commonly caused by Neisseria meningitis and streptococcus pneumoniae. (most harmful) vii. Kids are affected more because of their frequent UTI's and ear infections. viii. Bacterial meningitis is a medial emergency. If not tx, can be fatal.

Parkinson's - manifestation's - Abnormal posture

i. Involuntary flexion of head and shoulders stooped leaning forward position. ii. **equilibrium problems causing falls, and short, accelerated steps. (shuffling gait) iii. Reduced arm swing on the affected side of the body iv. Risk for aspiration

Hydrocephalus surgery shunt care -Post shunt care

i. Place on opposite side of body where shunt is with head level with body, unless ordered otherwise. ii. I and O > 30ml/hr normal iii. Frequent neuro-checks - (if sleepy and difficult to arouse, requires immediate attention) iv. Check pupils should be PERL v. Monitor for vomiting vi. Monitor for signs of infection (meningitis) vii. Monitor shunt site for infection viii. Pain meds (check neuro status before, during and after meds) ix. **normal BP and HR for child x. Normal BP child - systolic and diastolic 1. 0-6 months 65-90 45-65 2. 6-12 months 80-100 55-65 3. Child HR 100-160

Head trauma - nursing interventions - post op

i. Post op care 1. Monitor neuro status 2. Monitor respiratory status - ventilator 3. Assess for S&S of IICP 4. Incisional care 5. Assess for complications: infections, hemorrhage, respiratory compromise, IICP.

Head trauma - nursing interventions - pre op

i. Preop Care: intracranial surgery 1. Assessment: VS, LOC, neurochecks, respiratory status, S&S of IICP, speech, bleeding from nose/ears, racoon eyes or Battle's sign (ecchymosis by supramastoid) - basilar skull fracture 2. Allow verbalization of fears 3. If head needs to be shaved, will be done in OR 4. Reinforce info about surgery and post op care 5. ***shouldn't receive any sedatives or narcotics. Can reduce respirations and won't be able to sign for consent r/t condition.

Poor muscle tone (hypotonia) and loose jointedness (hyperflexibily)

i. Reflexes tend to be weaker ii. Cry is weak iii. Final height for males is 5 feet, females are a few inches shorter

Spinal cord injury - respiratory function

i. Respiratory function after SCI varies with level of injury (cervical) 1. Injury above C3 - immediate cessation of breathing 2. C3-C4 markedly decreased inspiratory volumes. 3. C5- T1 can initiate breaths normally, but may experience hypoventilation - may need O2 (O2 with non rebreather) can't use arms or rest of body. 4. Most common site of injury a. T5,6,7 and 12 b. L1 5. Higher the injury the more complicated with breathing 6. C5 focus on how area below will be paralyzed - person can raise his or her arms and bend elbows. Likely to have some or total paralysis of wrists, hands, trunk, and legs. Can speak and use diaphragm but breathing will be weakened.

Parkinson's - manifestation's: Akinesia

i. Slowed or delayed movement that affects chewing, speaking, eating ii. May freeze: loss of voluntary movement Bradykinesia: slowed movement

Meningitis - bacterial meningitis vaccine (worst one)

i. The CDC recommends the meningococcal vaccine for: 1. All children and adolescents age 11 through 18 2. College freshman living in dormitories. 3. Military recruits 4. Scientists routinely exposed to meningococcal bacteria 5. Anyone traveling to or living in a part of the world where the disease is common, such as Africa 6. Anyone with a damaged spleen or who has had his or her spleen removed. 7. Anyone who has terminal complement component deficiency (an immune system disorder) 8. Anyone who has ever had a severe (life threatening) allergic reaction to a previous dose of meningococcal vaccine 9. Anyone who has a severe (life threatening) allergy to ay vaccine component. Tell your doctor if you have any severe allergies 10. 2 doses

Plasmapheresis:

i. This treatment also known as plasma exchange - is a type of "blood cleaning" in which damaging antibodies are removed from your blood. Plasmapheresis consists of removing the liquid portion of your blood (plasma) and separating It from the actual blood cells. The bloods cells are then put back into your body, which manufactures more plasma to make up for what was removed. It's not clear why this treatment works, but scientists believe that plasmapheresis rids plasma of certain antibodies that contribute to the immune system attack on the peripheral nerves. 1. Av shunt placed if needed frequently. Assess patency hear the bruit feel the thrill. Monitor for infection of a new shunt.

**Eyes

i. Upward and outward slant ii. Fold of skin on the inner side of the eye (epicanthal fold) iii. Eye slit is narrow and short iv. Small, white patches can be seen on the edge of the iris (brushfield's spots) v. Mild to moderate intellectual disability (IQ usually 25-50)

Treatment of IICP

i. Urea IV ii. Mannitol IV - 1st line of IV- used to decrease fluid (watch for dehydration) (monitor labs - serum osmolality/electrolytes iii. Hypertonic glucose IV (25-50%) iv. Decadron (dexamethasone) IV v. (all of these meds dehydrate and put excess fluid into the circulation) - labs to monitor; serum osmolarity and electrolytes) vi. Dilantin (phenytoin) - seizures vii. Avoid narcotics or meds that cause respiratory depression ( will not give - respirations are already decreased so don't want to decrease anymore)

Spinal cord injury (SCI)

i. Usually r/t trauma ii. Young adults and adolescents are most affected iii. Risk factors: age, gender, ETOH, and drug abuse iv. Even minor compression or displacement of the spinal column can be serious v. Edema occurs which worsens the compression vi. Injury affects motor and sensory function at the level of the injury and below.

1. Types of strokes: a. Thrombotic - onset is gradual

i. Usually related to ASHD and hypertension ii. Intact LOC iii. May have speech and visual changes iv. Slight HA v. No seizures vi. Deficits may be permanent

Meningitis - nursing interventions

i. administer antibiotics as ordered. ii. I and O iii. Assess skin turgor, mucous membrane, assess VS, neuro checks, seizure activity. Keep room dark, limit sensory stimuli. iv. Keep side rails up v. Don't abruptly move or jar patient vi. Maintain isolation vii. Suction only if necessary (will increase ICP) viii. Administer stool softners ix. No narcotics: 1. Notify anyone who came in close contact with patient they may be treated with prophylactic antibiotics. x. Teach patients with chronic sinusitis importance of medical treatment to prevent meningitis.