Chapter 47&48 CNS Disorders

Basic neurological assessment

LOC, VS, Pupil response to light, extremity strength/movement, sensation.

Mannitol (Osmitrol)

*class*: osmotic diuretic *Indication* increased ICP, oliguric renal failure, edema, intraocular pressure *Action*: inhibits reabsorption of water and electrolytes by increasing osmotic pressure, excreted by kidneys

signs and symptoms of meningitis

- Nuchal rigidity (stiff neck) - Positive Kernig and Brudzinski signs - Fever - Photophobia - Petechial rash on the skin and mucous membranes - Encephalopathy

diagnostic testing for meningitis

- lumbar puncture(viral- clear fluid)(bacterial- cloudy) -culture and sensitivity -CBC

Nursing Interventions for meningitis

-antimicrobials -seizure precautions -Antipyretics -pain management -quiet dark room -education

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Parkinson's disease

A disorder of the central nervous system that affects movement, often including tremors. signs and symptoms -muscular rigidity -pill rolling tremor -shuffling and freezing gait

Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness.

A. Assessing the left leg. airway and breathing are established so the nurse's next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation. Inadequate circulating volume compromises systemic tissue perfusion.

subdermal hematoma

Accumulation of blood beneath dura mater but outside the brain causing pressure fluctuating LOC and slurred speech

diagnostic testing for encephalitis

CT MRI Lumbar puncture EEG CSF(yellow colored)

Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive homan's sign D. Negative Kernig's sign

Correct Answer: A. Positive Kernig's sign A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space.

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. ineffective airway clearance C. Impaired urinary elimination D. Risk for injury

Correct Answer: B. Ineffective airway clearance In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.

Correct Answer: C. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium. Hypertension is the most common cause of hemorrhagic stroke. Long standing hypertension produces degeneration of media, breakage of the elastic lamina, and fragmentation of smooth muscles of arteries.

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

Correct Answer: C. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to the physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.

Glascow Coma Scale

EYE OPENING 4 - spontaneous 3 - open to speech 2 - open to pain 1 - no response VERBAL 5 - alert and oriented 4 - disoriented conversation 3 - inappropriate words 2 - nonsensical sounds 1 - no response MOTOR 6 - spontaneous 5 - localizes pain 4 - withdraws to pain 3 - decorticate posturing 2 - decerebrate posturing 1 - no movement

causes of meningitis

Either viral or bacterial. Bacterial is transmitted through the Respiratory system and more severe. Viral is less severe

signs and symptoms of encephalitis

Headache Nausea Vomiting ataxia( lack of muscle coordination) decreased LOC Tremors Abnormal sleep patterns Hemiperalysis( one-sided weakness)

Brudzinski's sign

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

Kernig's sign

Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

Stages of Alzheimer's Disease

Stage 1. No apparent symptoms increased forgetfulness Stage 2. progressive memory loss Stage 3. complete dependency and loss of bladder and bowel control.

Encepholopathy

a defect in brain functions

Huntington's disease

a hereditary disease marked by degeneration of the brain cells and causing chorea and progressive dementia. signs and symptoms -dementia -inappropriate behavior -paranoia -dysphagia

parasympathetic nervous system (PEACEFUL)

a set of nerves that helps the body return to a normal resting state

sympathetic nervous system (STRESS RESPONSE)

a set of nerves that prepares the body for action in challenging or threatening situations( fight or flight)

Nursing Interventions for encephalitis

antipyretics anticonvulsants anti inflammatory drugs stool softener

symptoms of subdural hematoma

head trauma, loss consciousness, grogginess, irritability, amnesia, seizures, numbness, headache, dizziness, weakness/lethargy, nausea/vomiting, personality changes, slurred speech, ataxia, altered breathing, blurred vision, deviated gaze

Encephalitis + causes

inflammation of the brain The most common cause is by viruses( bug bites, HIV)

Meningitis

inflammation of the meninges of the brain and spinal cord

intercranial pressure

the amount of pressure inside the skull interventions -elevate HOB 30 Degrees - neck in a neutral position -maintain normal body temp -prevent volume overload -keep pt immobilized

Automic Dysreflexia

~ Injury at or above T6 ~ Exaggerated autonomic reflex response ~ Massive sympathetic discharge and release of catecholines ~ Triggered usually by bowel or bladder distention

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child. B. Allowing the child to play in the bathtub. C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.

Correct Answer: C. Keeping extraneous noise to a minimum A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. Maintain a quiet environment and keep the lights dim. Prevents stimulation that can cause or precipitate an episode of convulsion.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started. B. Maintain enteric precautions. C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. D. Maintain neutropenic precautions.

Correct Answer: C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Antibiotics are given to treat the underlying causes of inflammation and thus prevent the occurrence of seizure activity.

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive

Correct Answer: C. Raise the head of the bed The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation.

Correct Answer: C. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident