NEUROLOGICAL DISORDERS OF THE ADULT PT--NCLEX REVIEW

ANTISEIZURE MEDICATIONS: A.) *HYDRANTOINS: Fosphenytoin, Phenytoin* -2.) Side & Adverse Effects:

- *Gingivial hyperplasia (reddened gums that bleed easily)* -Slurred speech -Confusion -Sedation & drowsiness -N & V -Blurred vision & Nystagmus (rapid involuntary movements of the eyes) -HA's - *Blood Dyscrasias: Decreased platelet count and decreased WBC count* -Elevated blood glucose level -Alopecia or hirsutism -Rash or pruritus

ANTISEIZURE MEDICATIONS: B.) BARBITUATES: Amobarbital, Mephobarbital, Phenobarbital: -2.) Side & Adverse Effects:

- *Sedation, ataxia (lack of muscle control or coordination of voluntary movements), and dizziness during initial tx* -Mood changes -Hypotension - *Respiratory depression* -Tolerance to the medication

ANTISEIZURE MEDICATIONS: F.) IMINOSTILBENES -1.) Description:

- *Used to treat seizure disorders that have NOT responded to other anticonvulsants* - *Are also used to treat trigeminal neuralgia*

ANTIPARKINSONIAN MEDICATIONS: 1.) Description:

-Restore the balance of neurotransmitters acetylcholine and dopamine in the CNS, decreasing the S/S of Parkinson's dx to maximize the pts functional abilities -These meds include the Dopaminergics-which stimulate the dopamine receptors; the Anticholinergics-which block the cholinergic receptors; and the Catechol-O-Methyltransferase inhibitors-which inhibit the metabolism of dopamine in the periphery

NEUROLOGICAL ASSESSMENT: 3.) Assessment of LOC:

#2) Assessment of Cranial Nerves (look in notes*) -Assess the pts behavior to determine LOC (e.g. alertness, confusion, delirium, unconsciousness, stupor, coma), assessment becomes increasingly invasive as the pt is less responsive -Speak to the pt -Assess appropriateness of behavior & conversation -Lightly touch the pt (as culturally appropriate) ** *LOC IS THE MOST SENSITIVE INDICATOR OF NEUROLOGICAL STATUS* **

SEIZURES 4.) Interventions:

** *IF THE PT IS HAVING A SEIZURE, MAINTAIN A PATENT AIRWAY. DO NOT FORCE THE JAWS OPEN OR PLACE ANYTHING IN THE PTS MOUTH* ** -NOTE: -->the time & duration of the seizure -->The type, character, and progression of the movements during the seizure -Assess behavior at the onset of the seizure: If the pt has experienced an aura, if a change in facial expression occurred, or if a sound or cry occurred from the pt -If the pt is standing, sitting, place the pt on the floor & protect the head & body -Support airway, breathing & circulation -Administer -->O2 -->IV meds AP to stop the seizure -Prepare to suction secretions -Turn the pt to the side to allow secretions to drain while maintaining the airway -Prevent injury during the seizure -Remain w/the pt -DO NOT restrain the pt -Loosen restrictive clothing -Monitor: -->For incontinence -->Behavior following the seizure, such as the state of of consciousness, motor ability, and speech ability -Provide privacy -Document the characteristics of the seizure -Instruct the pt: -->About the importance of life-long med and the need for follow-up determination of medication blood levels -->To AVOID Alcohol, excessive stress, fatigue, and strobe lights -Encourage the pt to: -->Contact available community resources, such as the Epilepsy Foundation of America -->To wear a MedicAlert bracelet

ANTIMYASTHENIC MEDICATIONS: 4.) *Interventions:*

- *Assess neuromuscular status, including: reflexes, muscle strength & gait* - *Montior the pt for S/S of medication overdose (Cholinergic crisis) and underdose (Myasthenic crisis)* -Instruct the pt to: -->Take meds on time to maintain therapeutic blood level, thus preventing weakness, b/c weakness can impair the pts ability to breathe & swallow -->Take the med w/a small amount of food to prevent GI sx's --> *Eat a meal 45-60 mins after taking meds to decrease the risk for aspiration* -->Wear a MedicAlert bracelet -Note that Antimyasthenic therapy is lifelong therapy - *Evaluate for medication effectiveness, which is based on the improvement of neuromuscular sx's or strength w/out cholinergic S/S* - *When administering Edrophonium, have emergency resuscitation equipment on hand and Atropine sulfate available for cholinergic crisis*

AUTONOMIC DYSREFLEXIA: 2.) Interventions--Priority Nursing Actions:

-1.) Raise the HOB and ask that the HCP be notified -2.) Loosen tight clothing on the pt -3.) Check for bladder distention or other noxious stimulus -4.)Administer an antihypertensive medication -5.) Document the occurrence, tx & response *Immediate Nursing actions are: to contact the HCP, sit the pt up in bed in a High-fowler's position, and remove the noxious stimulus. The nurse would loosen any tight clothing & then check for bladder distention. If the pt has a urinary catheter, the nurse would check for kinks in the tubing. The nurse also would check for fecal impaction and disimpact the pt if necessary. The nurse assesses the environment to ensure that it is not too cool or too drafty and also monitors VS, paritcularly the BP, EVERY 15 mins. Antihypertensive meds may be prescribed by the HCP to minimize cerebral HPTN. Finally, the nurse documents the occurrence, txs and pt response*

STROKE (BRAIN ATTACK): 1.) Description:

-A stroke or brain attack manifests as a sudden focal neurological deficit & is caused by cerebrovascular dx -Cerebral Anoxia: lasting longer than 10 mins causes: cerebral infarction w/irreversible change -Cerebral edema & congestion cause further dysfxn -Diagnosis is determined by: a CT scan, Electroencephalography, Cerebral arteriography, and MRI. In most facilities, the type of stroke needs to be determined w/in a certain time frame after arrival in order for timely tx to be initiated -Transient Ischemic Attack: may be a warning sign of an impending stroke -The permanent disability cannot be determined until the cerebral edema subsides -The order in which fxn may return is: facial, swallowing, lower limbs, speech & arms -Carotid Endarterectomy: is a surgical intervention used in stroke management; it is targeted at stroke prevention, especially in pts w/symptomatic carotid stensosis

AUTONOMIC DYSREFLEXIA: 1.) *Description:*

-AKA Autonomic Hyperreflexia -It generally occurs after the period of spinal shock is resolved and occurs w/lesions or injuries above T6 and in cervical lesions -It is commonly caused by visceral distention from a distended bladder or impacted rectum -It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke -Autonomic Dysreflexia is characterized by: severe HPTN, bradycardia, severe HA, nasal stuffiness, and flushing -The cause is a noxious stimulus, most often a distended bladder or constipation

ANTIMYASTHENIC MEDICATIONS: 3.) *Side & Adverse Effects/Signs of Cholinergic Crisis*:

-Abdominal cramps -N/V/D -Pupillary miosis (excessive constriction of the pupil) -Hypotension & dizziness -Increased bronchial secretions -Increased tearing & salivation -Increased perspiration -Bronchospasm, wheezing, and bradycardia

INCREASED INTRACRANIAL PRESSURE (ICP): 2..) Assessment:

-Altered LOC, which is the MOST sensitive & EARLIEST indication of increasing ICP -HA -Abnormal respirations -Rise in BP w/widening pulse pressure -Slowing of pulse -Elevated temperature -Vomiting -Pupil changes -Late signs of increased ICP include: increased systolic BP, widened pulse pressure, & slowed HR -Other Late signs include: changes in motor fxn from weakness to hemiplegia, a positive Babinski reflex, decorticate or decerebrate posturing & seizures

ANTIPARKINSONIAN MEDICATIONS: A.) DOPAMINERGIC MEDICATIONS: -2.) Medications:

-Amantadine -Apomorphine -Bromocriptine -Carbidopa-Levodopa -Pramipexole -Rasagiline -Ropinirole -Selegiline hydrochloride

ANTIMYASTHENIC MEDICATIONS: 2.) *Medications:*

-Ambenonium chloride -Edrophonium chloride -Neostigmine broide -Pyridostigmine

NEUROLOGICAL ASSESSMENT: 6.) Assessment of Temperature:

-An elevated temperature increases the metabolic rate of the brain -An elevation in temperature may indicate a dysfxn of the hypothalamus or brainstem -A slow rise in temperature may indicate infection

ANTIPARKINSONIAN MEDICATIONS: B.) ANTICHOLINERGIC MEDICATIONS: -1.) Description:

-Anticholinergic meds block the cholinergic receptors in the CNS, thereby suppressing acetylchoine activity -They reduce the tremors & drooling but have a minimal effect on the bradykinesia, rigidity, and balance abnormalities - *They are contraindicated in pts w/Glaucoma* -The pt w/Chronic Obstructive Lung Dx can develop dry, thick mucous secretions

ANTIMYASTHENIC MEDICATIONS: 1.) Description:

-Antimyasthenic meds also called, *Anticholinesterase medications, relieve muscle weakness assoc. w/myasthenia gravis by blocking acetylcholine breakdown at the neuromuscular jxn -These are used to treat or diagnose myasthenia gravis or to distinguish cholinergic crisis from myasthenic crisis -Neostigmine bromide, pyridostigmine, and ambenonium chloride-are used to control myasthenic sx's -Edrophonium is used to diagnose myasthenia gravis and to distinguish cholinergic crisis from myasthenic crisis

ANTISEIZURE MEDICATIONS: 1.) Description:

-Antiseizure meds are used to depress abnormal neuronal D/C's and prevent the spread of seizures to adjacent neurons -These should be used w/caution in pts taking: Anticoagulants, Acetylsalicylic acid, Sulfonamides, Cimetidine, and Antipsychotic meds -Absorption is decreased w/the use of: Antacids, Calcium preparations, and Antineoplastic meds

STROKE (BRAIN ATTACK): 8.) *Interventions in the Chronic Phase of Stroke:*

-Approach the pt from the UNAFFECTED side -Place the pts personal objects w/in the visual field -Provide eye care for visual deficits -Place a patch over the affected eye if the pt has diplopia -Increase mobility as tolerated -Encourage: -->Fluid intake & a high-fiber diet -->The pt to express his/her feelings -->Independence in ADL's -->The pt & family to contact available community resources -Administer Stool softeners AP -Assess the need for assitive devices such as: a cane, walker, splint, or braces -Teach transfer technique from bed to chair & from chair to bed -Provide gait training -Initiate PT & OT for assessment and the need for adaptive equipment or other supports for self-care & mobility -Refer pt to a speech & language pathologist AP

ANTIPARKINSONIAN MEDICATIONS: A.) DOPAMINERGIC MEDICATIONS: -3.) *Side & Adverse Effects:*

-Dyskinesia -Involuntary body movements -Chest pain -N & V -Urinary retention -Constipation -Sleep disturbances, insomnia, or periods of sedation -Orthostatic hypotension & dizziness -Confusion -Mood changes, especially depression -Hallucinations -Dry mouth

THE UNCONSCIOUS PT: 3.) *Interventions:*

-Assess: -->Patency of airway and keep airway & emergency equipment readily available -->Respiratory & circulatory status -->Lung sounds for the accumulation of secretions; suction as needed -->For edema -->Neurological status, including: LOC, pupillary rxns, and motor & sensory fxn, using a coma scale -->Bowel sounds -->The eyes for the presence of a corneal reflex & irritation, and instill artificial tears or cover the eyes w/eye patches -Monitor: -->BP, pulse & heart sounds -->For dehydration -->I&O and daily weight -->Elimination patterns -->For constipation, impaction, and paralytic ileus -->The status of skin integrity -->Drainage from the ears or nose for the presence of CSF -DO NOT leave the pt unattended if unstable -Maintain: -->A patent airway and ventilation b/c a high CO2 level increases ICP -->NPO status until consciousness returns -->Nutrition AP (IV or enteral feedings) and monitor fluid & electrolyte balance (when consciousness returns-->check the gag & swallow reflex before resuming a diet -->Urinary output to prevent stasis, infection & calculus formation -Place the pt in a Semi-Fowler's position* -Change position of the pt EVERY 2 hours, avoiding injury when turning -AVOID Trendelenburg's position -Use side rails unless contraindicated or according to agency protocol -Initiate measures to prevent skin breakdown -Provide frequent mouth care -Remove dentures and contact lenses -Assume that the unconscious pt can hear -AVOID restraints -Initiate seizure precautions if necessary -Provide range-of-motion exercises to prevent contractures -Use a footboard or high-topped sneakers to prevent footdrop -Use splints to prevent wrist deformities -Initiate physical therapy as appropriate

ANTIPARKINSONIAN MEDICATIONS: A.) DOPAMINERGIC MEDICATIONS: -4.) *Interventions:*

-Assess: -->VS -->For risk of injury -->For S/S of parkinsonism such as: rigidity, tremors, akinesia, bradykinesia, a stooped forward posture, shuffling gait, and masked faces -Instruct the pt: -->To take the medication w/food if N/V occurs -->To report side & adverse effects & sx's of dyskinesia -->To change positions slowly to minimize orthostatic hypotension -->Not to discontinue the medication abruptly -->To AVOID alcohol -Monitor: -->For signs of dyskinesia -->The pt for improvement in S/S of parkinsonism -Inform the pt that urine or persipiration may be discolored and that this is HARMLESS but may stain the clothing* -Advise the pt w/DM that glucose testing SHOULD NOT be done by urine testing b/c the results will not be reliable - *Instruct the pt taking Carbidopa-Levidopa to divide the total daily prescribed protein intake among all meals of the day; high-protein diets interfere w/medication availability in the CNS* - *When administering Carbidopa-Levidopa-->instruct the pt to avoid excessive vitamin B6 intake to prevent medication rxns*

TRAUMATIC HEAD INJURY: 1.) Hematoma: -b.) *Assessment:*

-Assessment findings depend on the injury -Clinical manifestations usually result from increased ICP -Changing neurological signs in the pt -Changes in LOC -Airway & breathing pattern changes -VS change, reflecting increased ICP -HA, N&V -Visual disturbances, pupillary changes, and papilledema -Nuchal rigidity (not tested until spinal cord injury is ruled out) -CSF drainage from the ears or nose -Weakness and paralysis -Posturing -Decreased sensation or absence of feeling -Reflex activity changes -Seizure activity ** *CSF CAN BE DISTINGUISHED FROM OTHER FLUIDS BY PRESENCE OF CONCENTRIC RINGS (BLOODY FLUID SURROUNDED BY YELLOWISH STAIN; HALO SIGN) WHEN THE FLUID IS PLACED ON A WHITE STERILE BACKGROUND, SUCH AS A GAUZE PAD. CSF ALSO TESTS POSITIVE FOR GLUCOSE WHEN TESTED USING A STRIP TEST* **

STROKE (BRAIN ATTACK): 3.) Risk Factors:

-Athersclerosis -HPTN -Anticoagulation therapy -DM -Stress -Obesity -Oral contraceptives

ANTISEIZURE MEDICATIONS: B.) BARBITUATES: Amobarbital, Mephobarbital, Phenobarbital: -1.) Description:

-Barbituates are used for Tonic-Clonic seizures and Acute episodes of seizures caused by Status Epilepticus -Barbituates may also be used as adjuncts to anesthesia

ANTISEIZURE MEDICATIONS: C.) BENZODIAZEPINES: Clonazepam, Cloraxepate, Diazepam, Lorazepam -1.) Description:

-Benzodiazepines are used to treat Absence Seizures -Diazepam & Lorazepam are used to treast Status epilepticus, anxiety, and skeletal muscle spasms -Clorazepate is used as adjunctive therapy for Partial seizures

ANTIPARKINSONIAN MEDICATIONS: B.) ANTICHOLINERGIC MEDICATIONS: -2.) Medications:

-Benztropine mesylate -Trihexyphenidyl hydrochloride

ANTIPARKINSONIAN MEDICATIONS: B.) ANTICHOLINERGIC MEDICATIONS: -3.) *Side & Adverse Effects:*

-Blurred vision -Dryness of the nose, mouth, throat, and respiratory secretions -Increased pulse rate, palpitations, and dysrhythmias -Constipation -Urinary retention -Restlessness, confusion, depression, & hallucinations -Photophobia

SPINAL CORD INJURY: 2) Most Frequently Involved Vertebrae:

-Cervical: C5, C6, C7 -Thoracic: T12 -Lumbar: L1

SPINAL CORD INJURY: 3.) Transection of the Cord:

-Complete transection of the cord: The spinal cord is severed completely w/total loss of sensation, movement, and reflex activity below the level of injury -Partial Transection of the Cord: -->The spinal cord is damaged or severed partially -->The sx's depend on the extent & location of the damage -->If the cord has not suffered irreparable damage-->early tx is needed to prevent partial damage from developing into total & permanent damage

SPINAL CORD INJURY: 4.) Assessment of Spinal Cord Injuries:

-Dependent on the level of the cord injury -Level of spinal cord injury: Lowest spinal cord segment w/intact motor & sensory fxn -Respiratory status changes -Motor & sensory changes below the level of injury -Total sensory loss & motor paralysis below the level of injury -Loss of reflexes below the level of injury -Loss of bladder & bowel control -Urinary retention and bladder distention -Presence of sweat, which does NOT occur on paralyzed areas EFFECTS OF SPINAL CORD INJURY: -Tetraplegia (Quadriplegia): -->Injury occurring b/w C1 & C8 -->Paralysis involving all 4 extremities -Paraplegia: -->Injury occurring b/w T1 & L4 -->Paralysis involving only the lower extremities

ANTIPARKINSONIAN MEDICATIONS: A.) DOPAMINERGIC MEDICATIONS: -1.) Description:

-Dopaminergic meds stimulate the dopamine receptors and increase the amount of dopamine available in the CNS or enhance neurotransmission of dopamine -Dopaminergic meds are contraindicated in pts w/: cardiac, renal or psychiatric disorders ** *CARBIDOPA-LEVIDOPA TAKEN W/A MONOAMINE OXIDASE INHIBITOR (MAOI) ANTIDEPRESSANT CAN CAUSE A HYPERTENSIVE CRISIS* **

ANTISEIZURE MEDICATIONS: F.) IMINOSTILBENES -2.) Side & Adverse Effects:

-Drowsiness -Dizziness -N & V, Dry mouth - Constipation & Diarrhea -Rash -Visual abnormalities -Blood dyscrasias, Agranulocytosis -HA

SPINAL CORD INJURY: 8.) Emergency Interventions:

-Emergency management is critical b/c improper movement can cause further damage and loss of neurological fxn -Assess the respiratory pattern & maintain a patent airway - *Prevent head flexion, rotation & extension* -During immobilization-->maintain traction and alignment on the head by placing hands on both sides of the head by the ears -Maintain an extended position -Logroll the pt -No part of the body should be twisted or turned and th pt is NOT allowed to assume a sitting position -In the ED, a pt who has sustained a cervical fracture should be placed IMMEDIATELY in skeletal traction via skull tongs or halo traction to immobilize the cervical spine and reduce the fracture & dislocation ** *ALWAYS SUSPECT SPINAL CORD INJURY WHEN TRAUMA OCCURS UNTIL THIS INJURY IS RULED OUT. IMMOBILIZE THE PT ON A SPINAL BACKBOARD W/THE HEAD IN A NEUTRAL POSITION TO PREVENT AN INCOMPLETE INJURY FROM BECOMING COMPLETE* **

CRANIOTOMY: 2.) *Preoperative Interventions:*

-Explain the procedure to the pt & family -Prepare to shave the pts head as prescribed (usually done in the OR) & cover the head w/an appropriate covering -Stabilize the pt before surgery

OSMOTIC DIURETICS: 2.) Side & Adverse Effects:

-F&E imbalances -Pulmonary edema from the rapid shifts of fluid -N/V -HA -Tachycardia from the rapid fluid loss -Hyponatremia and dehydration

CEREBRAL ANEURYSM: 2.) Assessment:

-HA & Pain -Irritability -Visual changes -Tinnitus -Hemiparesis (partial paralysis affecting 1 side of the body) -Nuchal rigidity -Seizures

TRAUMATIC HEAD INJURY: 1.) Description:

-Head injury is trauma to the skull, resulting in mild to extensive damage to the brain -Immediate complications include: cerebral bleeding, hematomas, uncontrolled increased ICP, infections & seizures -Changes in personality or behavior, cranial nerve deficits, and any other residual deficits depend on the area of the brain damage and the extent of the damage

ANTISEIZURE MEDICATIONS: A.) *HYDRANTOINS: Fosphenytoin, Phenytoin* -1.) Description:

-Hydrantoins are used to treat: partial & generalized tonic-clonic seizures -Phenytoin is also used to treat dysrhythmias

INCREASED INTRACRANIAL PRESSURE (ICP): 1.) Description:

-Increased ICP may be caused by: trauma, hemorrhage, growths of tumors, hydrocephalus, edema or inflammation -Increased ICP can impede circulation to the brain, impede the absorption of CSF, affect the fxning of nerve cells, and lead to brainstem compression & death

ANTISEIZURE MEDICATIONS: 2.) Interventions for pts on Antiseizure Medications:

-Initiate seizure precautions -Monitor: -->Urinary output -->Liver & renal fxn tests & medication blood serum levels -->For signs of medication toxicity, which would include: CNS depression, ataxia, N/V, drowsiness, dizziness, restlessness & visual disturbances -If a seizure occurs-->assess seizure activity including: location and duration -Protect the pt from hazards in the environment during a seizure

SPINAL CORD INJURY: 5.) Cervical Injuries:

-Injury at C2-C3 is usually fatal -C4 is the major innervation to the diaphragm by the phrenic nerve -Involvement above C4 causes respiratory difficulty and paralysis of all 4 extremities -The pt may have movement in the shoulders if the injury is at C5 thru C8, and may also have decreased respiratory reserve

SPINAL CORD INJURY: 7.) Lumbar & Sacral Level Injuries:

-Loss of movement & sensation of the lower extreities may occur -S2 & S3 center on micturition; therefore, below this level the bladder will contract but not empty (neurogenic bladder) -Injury above S2 in males allows them to have an erection, but they are unable to ejaculate b/c of sympathetic nerve damage -Injury b/w S2 & S4 damages the sympathetic & parasympathetic response, preventing erection or ejaculation

SPINAL CORD INJURY: 6.) Thoracic Level Injuries:

-Loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury -Leg paralysis (paraplegia) may occur -Autonomic Dysreflexia w/lesions or injuries above T6 and in cervical lesions may occur -Visceral distention from noxious stimuli such as distended bladder or an impacted rectum may cause rxns such as: sweating, bradycardia, HPTN, nasal stuffiness, and goose flesh (bumps_=)

CEREBRAL ANEURYSM: 3.) *Interventions:*

-Maintain a patent airway (suction ONLY w/an HCP's prescription) -Administer O2 AP -Monitor VS & for HPTN or dysrhythmias -AVOID taking temperatures via the rectum -Initiate aneurysm precautions

STROKE (BRAIN ATTACK): 7.) Interventions During the Acute Phase of Stroke:

-Maintain: -->A patent airway and adminster O2 AP -->A quiet environent -->F&E balance -Monitor: -->VS -->*For increased ICP b/c the pt is most at risk during the 1st 72 hrs following the stroke* -->LOC, pupillary response, motor & sensory response, cranial nerve fxn, and reflexes -Usually a BP of 150/100 mmHg is maintained to ensure cerebral perfusion* - *Suction secretions to prevent aspiration AP, but NEVER suction nasally or for longer than 10 seconds to prevent increased ICP* - *Position the pt on the side to prevent aspiration, w/the HOC elevated 15-30 degrees AP* -Insert a urinary catheter AP -Administer IV fluids AP -*Prepare to administer Anticoagulants, Antiplatelets, Diuretics, Antihypertensives, & Antiseizure meds AP depending on the type of stroke that has been diagnosed* -Establish a form of communication*

CEREBRAL ANEURYSM: 4.) Aneurysm Precautions:

-Maintain: -->the pt on bed rest in a semi-Fowlers or a side-lying position -->A darkened room (subdued lighting and AVOID direct bright, artificial lights) w/out stimulation (a private room is optimal) -->Fluid restrictions -->Normothermia -Provide: -->A quiet environemtn (AVOID activities or startling noises); a telephone in the room is not usually allowed -->Diet AP; AVOID stimulants in the diet -->Sedation -->Pain control -->Deep vein thrombosis (DVT) Prophylaxis AP -Reading, watching TV, and listening to music are permitted, provided that they do not overstimulate the pt -Limit visitors -Prevent: -->Any activities that initiate the Valsalva maneuver (straining at stool, couging); provide stool softeners to prevent straining -->HPTN -Administer: -->Care gently (such as the bath, back rub, ROM) -->Prophylactic Antiseizure medications -Limit invasive procedures

SPINAL & NEUROGENIC SHOCK: 3.) Interventions:

-Monitor: -->For signs of shock following a spinal cord injury -->For hypotension & bradycardia -->For reflex activity -->For bowel & urinary retention -->For the return of reflexes -Assess bowel sounds -Provide supportive measures AP, based on the presence of sx's

TRAUMATIC HEAD INJURY: 1.) Hematoma: -c.) *Interventions:*

-Monitor: -->Respiratory status & maintain a patent airway b/c increased CO2 levels increase cerebral edema -->Neurological status and VS, including temperature -->For Increased ICP -->For pain & restlessness -->For drainage from the nose or ears b/c this fluid may be CSF -->For signs of infection -Maintain head elevation to reduce venous pressure -Prevent neck flexion -Initiate: -->Normothermia measures for increased temperature -->Seizure precautions -Assess cranial nerve fxn, reflexes & motor & sensory fxn -Morphine sulfate may be prescribed to decrease agitation & control restlessness caused by pain for the head-injured pt on a ventilator; administer w/CAUTION b/c it is a respiratory depressant & may increase ICP - *DO NOT attempt to clean the nose, suction or allow the pt to blow his/her nose if drainage occurs* - *DO NOT clean the ear if drainage is noted, but apply a loose, dry sterile dressing* - *Check drainage for the presence of CSF* - *Notify the HCP if drainage from the ears or nose is noted and if the drainage tests positive for CSF -Instruct the pt to avoid coughing b/c this increases ICP* -Prevent complications of immobility -Inform the pt & family about the possible behavior changes that may occur, including those that are expected & those that need to be reported

INCREASED INTRACRANIAL PRESSURE (ICP): 3.) *Interventions:*

-Monitor: -->Respiratory status & prevent hypoxia -->Electrolyte levels & acid-base balance -->I&O -AVOID the administration of morphine sulfate to prevent the occurrence of hypoxia -Maintain: -->Mechanical ventilation AP; maintaining the PaCO2 at 30-35 mmHg will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, & therefore decreased ICP -->Body temperature -Prevent shivering which can increase ICP -Decrease environmental stimuli -Limit fluid intake to 1200 mL/day -Instruct the pt to Avoid: -->Straining activities, such as coughing & sneezing -->Valsalva's maneuver (straining to poop etc) ** *FOR THE PT W/INCREASED ICP, ELEVATE THE HOB 30-40 DEGREES, AVOID THE TRENDELENBURG POSITION & PREVENT FLEXION OF THE NECK & HIPS* **

ANTIPARKINSONIAN MEDICATIONS: B.) ANTICHOLINERGIC MEDICATIONS: -4.) *Interventions:*

-Monitor: -->VS -->For involuntary movements -Assess: -->For risk of injury -->The pts bowel & urinary fxn and monitor for urinary retention, constipation, and paralytic ileus -Encourage the pt to AVOID: alcohol, smoking, caffeine, and acetylsalicylic acid to decrease gastric acidity -Instruct the pt to: -->Consult the HCP before taking any nonprescription meds -->Minimize dry mouth by increasing fluid intake & using ice chips, hard candy, or gum -->Prevent constipation by increasing fluids & fiber in the diet -->Use sunglasses in direct sunlight b/c of possible photophobia -->Have routine eye examinations to assess intraocular pressure ** *IF AN ANTICHOLINERGIC MED IS DISCONTINUED ABRUPTLY, THE S/S OF PARKINSONISM, SUCH AS: RIGIDITY, TREMORS, AKINESIA, BRADYKINESIA, STOOPED FORWARD POSTURE, SHUFFLING GAIT & MASKED FACE, MAY BE INTENSIFIED* **

OSMOTIC DIURETICS: 3.) *Interventions:*

-Monitor: -->VS -->Weight -->Urine output -->Electrolyte levels -->Lung & heart sounds for signs of pulmonary edema -->For signs of dehydration -->Neurological status -->For increased intraocular pressure --> *For crystallization in the vial of mannitol before administering the medication; if crystallization is noted, DO NOT administer the med from that vial* -Assess for signs of decreasing ICP if appropriate -Change the pts position SLOWLY to prevent orthostatic hypotension

CRANIOTOMY: 3.) Postoperative Interventions:

-Monitor: -->VS & neurological status EVERY 30-60 mins -->For increased ICP -->For decreased LOC, motor weakness, or paralysis, aphasia, visual changes, and personality changes -->The head dressing frequently for signs of drainage -->The drain, which may be in place for 24 hours; maintain suction on the drain AP -->Electrolyte levels -->For dysrhythmias, which may occur as a result of F&E imbalance -Maintain: -->Mechanical ventilation and slight hyperventilation for the 1st 24-48 hrs AP to prevent increased ICP -->Fluid restriction at 1500 mL/day AP -Assess the HCP's prescription regarding the pt positioning -AVOID extreme hip or neck flexion, and maintain the head in a midline neutral position -Provide: -->A quiet environment -->ROM exercises EVERY 8 hours -Mark any area of drainage at least once each nursing shift for baseline comparison -Measure drainage from the drain EVERY 8 hours, & record the amount & color -Notify the HCP: -->If drainage is more than the normal amount of 30-50 mL/shift -->Immediately of excessive amounts of drainage or a saturated head dressing -Record strict measurement of hourly intake and output -Apply ice packs or cool compresses AP; expect periorbital edema & ecchymosis of 1 or both eyes -Place antiembolism stockings on the pt AP -Administer: -->Antiseizure meds, Antacids, Corticosteroids, & Antibx's AP -->Analgesics such as: codeine sulfate or acetaminophen AP for pain

OSMOTIC DIURETICS: 1.)Description:

-Osmotic diuretics increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water & electrolytes -They are used for: oliguria & to prevent kidney failure, decrease ICP, and decrease intraocular pressure in pts w/narrow-angle glaucoma -Mannitol is used w/chemotherapy to induce diuresis

CRANIOTOMY: 4.) Postoperative Positioning Following a Craniotomy:

-Positions prescribed following a craniotomy vary w/the type of surgery and the specific postoperative HCP's prescription -ALWAYS check the HCP's prescription regarding pt positioning -Incorrect positioning may cause serious & possibly fatal complications 1.) REMOVAL OF A BONE FLAP FOR DECOMPRESSION: -To facilitate brain expansion, the pt should be turned from the back to the nonoperative side, but not to the side on which the operation was performed 2.) POSTERIOR FOSSA SURGERY: -To protect the operative site form pressure & minimize tension on the suture line, position the pt on the side w/a pillow under the head for support, and not on the back 3.) INFRATENTORIAL SURGERY: -Infratentorial surgery involves surgery below the tentorium of the brain -The HCP may prescribe a flat position w/out head elevation or may prescribed that the HOB be elevated at 30-45 degrees -DO NOT elevate the HOB in the acute phase of care following surgery w/out an HCP's prescription 4.) SUPRATENTORIAL SURGERY: -Supratentorial surgery involves surgery above the tentorium of the brain -The HCP may prescribe that the HOB be elevated at 30 degrees to promote venous outflow thru the jugular veins -DO NOT lower the HOB in the acute phase of care following surgery w/out an HCP's prescription

NEUROLOGICAL ASSESSMENT: 8.) Assessment of Posturing:

-Posturing indicates a deterioration of the condition 1.) Flexor (Decorticate posturing): -Pt flexes 1 or both arms on the chest & may extend the legs stiffly -Flexor posturing indicates a nonfxning cortex 2.) Extensor (Decerebrate posturing): -Pt stiffly extends 1 or both arms and possibly the legs -Extensor posturing indicates a brainstem lesion 3.) Flaccid Posturing -Pt displays no motor response in any extremity

ANTISEIZURE MEDICATIONS: C.) BENZODIAZEPINES: Clonazepam, Cloraxepate, Diazepam, Lorazepam -2.) Side & Adverse Effects:

-Sedation, drowsiness, dizziness, blurred vision - *For IV injection-->administer SLOWLY to prevent bradycardia -Medication tolerance & dependency -Blood dyscrasias: decreased platelet count & decrease WBC count -Hepatotoxicity ** *FLUMAZENIL REVERSES THE EFFECTS OF BENZODIAZEPINES. IT SHOULD NOT BE ADMINISTERED TO PTS W/INCREASED ICP OR STATUS EPILEPTICUS WHO WERE TREATED W/BENZODIAZEPINES B/C THESE PROBLEMS MAY RECUR W/REVERSAL* **

SEIZURES 3.) *Assessment:*

-Seizure hx -Type of seizure -Occurrences before, during & after the seizure -Prodromal signs, such as mood changes, irritability, & insomnia -Aura: Sensation that warns the pt of the impending seizure -Loss of motor activity or bowel & bladder fxn or loss of consciousness during the seizure -Occurrences during the postictal state, such as: HA, loss of consciousness, sleepiness, & impaired speech or thinking

SEIZURES: 1.) Description:

-Seizures are abnormal, sudden, excessive D/C of electrical activity w/in the brain -Epilepsy: is a disorder characterized by chronic seizure activity & indicates brain or CNS irritation -Causes include: genetic factors, trauma, tumors, circulatory or metabolic disorders, toxicity & infections -Status Epilepticus: involves a rapid succession of epileptic spasms w/out intervals of consciousness; it is a potential complication that can occur w/any type of seizure, & brain damage may result

SPINAL & NEUROGENIC SHOCK: 1.) Description:

-Spinal Shock: A complete but temporary loss of motor, sensory, reflex, and autonomic fxn that occurs immediately after injury as the cord's response to the injury It usually lasts less than 48 hours but can continue for several weeks -Neurogenic Shock: Occurs most commonly in pts w/injuries above T6 and usually is experienced soon after the injury. Massive vasodilation occurs, leading to pooling of the blood in blood vessels, tissue hypoperfusion, and impaired cellular metabolism

CRANIOTOMY: 1.) Description:

-Surgical procedure that involves incision thru the cranium to remove accumulated blood or a tumor -Complications of the procedure include: increased ICP from cerebral edema, hemorrhage, or obstruction of the normal flow of CSF -Additonal complications include: hematomas, hypovolemic shock, hydrocephalus, respiratory & neurogenic complications, pulmonary edema, and wound infections - *Complications r/t F & E imabalances include: DI & Inappropriate Secretion of Antidiuretic Hormone (SIADH)* -Stereotactic Radiosurgery (SRS) may be an alternative to traditional surgery and is usually used to treat tumors, & arteriovenous malformations

ANTISEIZURE MEDICATIONS: 3.) Pt Education-Antiseizure Medications:

-Take the prescribed med in the prescribed dose and frequency -Take w/food to decrease GI irriation, but AVOID milk (Ca++) and antacids which impair absorption -If taking liquid medication, shake well before ingesting -DO NOT discontinue the meds -AVOID: -->Alcohol -->OTC meds -Wear a MedicAlert bracelet -Use caution when performing activities that require alertness -Maintain: -->Good oral hygiene & use a soft toothbrush -->Preventive dental checkups -->Follow-up health care visits w/periodic blood studies r/t determining toxicity -Monitor serum glucose levels (DM) -Urine may be a harmless pink-red or red-brown color -Report sx's of: sore throat, bruising and nosebleeds which may indicate a blood dyscrasia -Inform the HCP if side & adverse effects occur, such as: bleeding gums, N/V, blurred vision, slurred speech, rash or dizziness

STROKE (BRAIN ATTACK): 8.) *Interventions in the Chronic Phase of Stroke:* -b.) Hemianopsia:

-The pt has blindness in half of the visual field - Homonymous hemianopsia: is blindness in the same visual field of both eyes -Encourage the pt to turn the head to scan the complete range of vision; otherwise, he/she does not see half of the visual field

STROKE (BRAIN ATTACK): 8.) *Interventions in the Chronic Phase of Stroke:* -a.) Neglect Syndrome:

-The pt is unaware of the existence of his/her paralyzed side (unilateral neglect), which places the pt @ risk for injury -Teach the pt to touch & use both sides of the body

NEUROLOGICAL ASSESSMENT: 13) *Glasgow Coma Scale:*

-The scale is a method of assessing a pts neurological condition -The scoring system is based on a scale of 3-15 points -A score lower than 8 indicates that coma is present GLASGOW COMA SCALE: SCORE: -The lowest possible score is 3 points (deep coma or death) -The highest possible score is 15 points (fully awake) MOTOR RESPONSE POINTS: -Obeys a simple response=6 -Localizes painful stimuli=5 -Normal flexion (w/drawal)=4 -Abnormal flexion (decorticate posturing)=3 -Extensor response (decerebrate posturing)=2 -No Motor response to pain=1 VERBAL RESPONSE POINTS: -Oriented=5 -Confused conversation=4 -Inappropriate words=3 -Responds w/incomprehensible sounds=2 -No verbal response=1 EYE-OPENING POINTS: -Spontaneous=4 -In response to sound=3 -In response to pain=2 -No response, even to painful stimuli=1

THE UNCONSCIOUS PT: 1.) Description:

-The unconscious pt is in a state of depressed cerebral fxning w/unresponsiveness to stimulation of sensory & motor fxn -Some causes include: head trauma, cerebral toxins, shock, hemorrhage, tumor & infection

STROKE (BRAIN ATTACK): 2.) Causes:

-Thrombosis -Embolism -Thrombatic & embolic strokes are classified as ischemic strokes -Hemorrhage from rupture of a vessel; classified as a Hemorrhagic stroke -Manifestation so of different types of strokes are similar and therefore it is critical to determine the type of stroke occurring; the type CANNOT be determined solely based on manifestations & the correct and appropriate tx for the stroke must be initiated

NEUROLOGICAL ASSESSMENT: 1.) Assessment of Risk Factors:

-Trauma -Hemorrhage -Tumors -Infection -Toxicity -Metabolic disorders -Hypoxic conditions -HPTN -Cigarette smoking -Stress -Aging process -Chemicals, either ingestion or environmental exposure

SPINAL CORD INJURY: 1.) Description:

-Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons -The injury can involve: contusion, laceration, or compression of the cord -Spinal cord edema develops; necrosis of the spinal cord can develop as a result of compromised capillary ciruclation & venous return -Loss of motor fxn, sensation, reflex activity & bowel & bladder control may resutl -The MOST COMMON causes include: motor vehicle crashes, falls, sporting & industrial accidents, & gunshot or stab wounds -Complications r/ the injury include: respiratory failure, *Autonomic dysreflexia*, spinal shock, further cord damage, & death

ANTISEIZURE MEDICATIONS: A.) *HYDRANTOINS: Fosphenytoin, Phenytoin* -3.) *Interventions:*

-Tube feedings may interfere w/the absorption of the enteral form of phenytoin & diminish the effectiveness of the medication; therefore, feedings should be scheduled as far as possible away from the time of phenytoin administration -Monitor: -->Therapeutic serum levels to assess for toxicity *(Therapeutic serum range for phenytoin=10-20 mcg/mL)* -->For signs of toxicity -When administering phenytoin IV: --> Dilute in normal saline b/c dextrose causes the med to precipitate -->Infuse w/an inline filter and no faster than 25-50 mg/min; otherwise, a decrease in BP and cardiac dysrhythmias could occur -Assess for ataxia (staggering gait) -Instruct the pt to consult w/the HCP before taking other meds to ensure compatibility w/anticonvulsants ** *PHENYTOIN MUST BE GIVEN SLOWLY TO PREVENT HYPOTENSION & CARDIAC DYSRHYTHMIAS. ALSO, IT MAY DECREASE THE EFFECTIVENESS OF SOME BIRTH CONTROL PILLS & MAY CAUSE TERATOGENIC EFFECTS IF TAKEN DURING PREGNANCY* **

THE UNCONSCIOUS PT: 2.) Assessment:

-Unarousable -Primitive or no response to painful stimuli -Altered respirations -Decreased cranial nerve and reflex activity

NEUROLOGICAL ASSESSMENT: 7.) Assessment of Pupils:

-Unilateral pupil dilation-->indicates compression of cranial nerve III (oculomotor) -Midposition fixed pupils-->indicates midbrain injury -Pinpoint fixed pupils-->indicate pontine damage

NEUROLOGICAL ASSESSMENT: 9.) Assessment of Reflexes:

1.) BABINSKI REFLEX: -Dorsiflexion of the big toe, and fanning of the other toes; elicited by firmly stroking the lateral aspect of the sole of the foot -Is a pathological or abnormal reflex in anyone older than 2 years and represents the presence of CNS dx 2.) CORNEAL (BLINK) REFLEX: -Involuntary closure of the eyelids in response to stimulation of the cornea -Loss of the blink reflex indicates a dysfxn of cranial nerve V (trigeminal) 3.) GAG REFLEX: -Contraction of pharyngeal muscle, elicited by touching the back of the throat -Loss of the gag reflex indicates a dysfxn of cranial nerves IX & X (Glossopharyngeal & Vagus)

TRAUMATIC HEAD INJURY: 2.) Types of Head Injuries:

1.) CONCUSSION: -Concussion is a jarring of the brain w/in the skull; there may or may not be a loss of consciousness 2.) CONTUSION: -Contusion is a bruising type of injury to the brain tissue -Contusion may occur along w/other neurological injuries, such as w/subdural or extradural collections of blood 3.) SKULL FRACTURES: -Linear -Depressed -Compound -Comminuted 4.) EPIDURAL HEMATOMA: -The MOST SERIOUS type of hematoma, epidural hematoma forms rapidly & results from arterial bleeding -The hematoma forms b/w the dura & skull from a tear in the meningeal artery -It is often assoc. w/temporary loss of consciousness, followed by a lucid period that then rapidly progresses to coma -Epidural hematoma is a surgical emergency 5.) SUBDURAL HEMATOMA: -Subdural hematoma forms slowly & results from a venous bleed -It occurs under the dura as a result of tears in the veins crossing the subdural space 6.) INTRACEREBRAL HEMORRHAGE: -Intracerebral hemorrhage occurs when a blood vessel w/in the brain ruptures, allowing blood to leak inside the brain 7.) SUBARACHNOID HEMORRHAGE: -A subarachnoid hemorrhage is bleeding into the subarachnoid space. It may occur as a result of head trauma or spontaneously, such as from a ruptured cerebral aneurysm

NEUROLOGICAL ASSESSMENT: 5.) Assessment of Respirations:

1.) Cheyne-Stokes: -Rhythmic w/periods of apnea -Can indicate a metabolic dysfxn or dysfxn in the cerebral hemisphere or basal ganglia 2.) Neurogenic Hyperventilation: -Regular rapid & deep sustained respirations -Indicates a dysfxn in the low midbrain & middle pons 3.) Apneustic: -Irregular respirations w/pauses at the end of inspiration & expiration -Indicates a dysfxn in the middle or caudal pons 4.) Ataxic: -Totally irregular in rhythm & depth -Indicates a dysfxn in the medulla 5.) Cluster: -Clusters of breath w/irregularly spaced pauses -Indicates a dysfxn in the medulla & pons

NEUROLOGICAL ASSESSMENT: 11.) Assessment of the Autonomic System:

1.) Sympathetic Fxns, Adrenergic Responses: -Increased pulse & BP -Dilated pupils -Decreased peristalsis -Increased perspiration 2.) Parasympathetic Fxn, Cholinergic Responses: -Decreased pulse & BP -Constricted pupils -Increased salivation -Increased peristalsis -Dilated blood vessels -Bladder contraction

A nurse is performing a neurological check on a pt who is 1 day post-craniotomy notices that the pts right eye does not turn laterally. Which of the following cranial nerves should the nurse suspect is damaged? a.) Cranial nerve II b) Cranial nerve V c) Cranial nerve VI d.) Cranial nerve VII

ANSWER=C (CN VI) RATIONALE: -CN's III, IV & VI deal w/movement of the eye -The *abducens* nerve (CN VI) fxns specifically as a motor nerve innervating the lateral rectus muscle of the eye. A medial deviation or an inability to laterally deviate the eye would indicate damage to this nerve INCORRECT: -The optic nerve (CN II) is a sensory nerven responsible for vision -The Trigeminal nerve (CN V) provides sensation to the face & innervation of the muscles of mastication -The Facial nerve (CNVII) innervates the muscles of expression & taste from the anterior part of the tongue

TRAUMATIC HEAD INJURY: 1.) Hematoma: -a.) Description:

A collection of blood in the tissues that can occur as a result of a subarachnoid hemorrhage or an intracerebral hemorrhage

STROKE (BRAIN ATTACK): 5.) Assessment Findings in a Stroke:

AGNOSIA: -The inability to recognize familiar objects or persons APRAXIA: -Called dyspraxia if the condition is mild -Characterized by: loss of ability to execute or carry out skilled movements or gestures, despite having the desire & physcial ability to perform them HEMIANOPSIA: -Blindness in half the visual field HOMONYMOUS HEMIANOPSIA: -Loss of half of the field of view on the same side in both eyes NEGLECT SYNDROME (UNILATERAL NEGLECT): -Pt unaware of the existence of his/her paralyzed side PROPRIOCEPTION ALTERATIONS: -Altered position sense that places the pt at increased risk for injury -Pyramid Pont: *W/visual problems, the pt must turn the head to scan the complete range of vision* OTHER ASSESSMENT INFO/FINDINGS: -Assessment findings depends on the area of the brain affected; stroke scales such as the NIH Stroke Scale may be used -Lesions in the cerebral hemisphere result in manifestations on the contralateral side, which is the side of the body opposite the stroke -*Airway patency is ALWAYS a priority* -Pulse ( may be slow & bounding) -Respirations (Cheyne-Stokes) -BP (HPTN) -HA, N&V -Facial drooping -Nuchal rigidity -Visual changes -Ataxia (loss of full control of bodily movements) -Dysarthria (difficult or unclear articulation of speech) -Dysphagia -Speech changes -Decreased sensation to pressure, heat & cold -Bowel & bladder dysfxns -Paralysis

A pt is admitted or a severe head injury and develops dry mucous membranes. The urine output is 400 mL/hr for the last 8-hr shift. Prioritize the nurses next actions: 1.) Notify the physician 2.) Complete a neurological assessment 3.) Assess the pts urine specific gravity and blood Na+ levels 4.) Start IV fluids & administer nasal desmopressin (DDAVP)

ANSWER=2, 1, 3, 4 RATIONALE: -After sustaining a head injury, a UO of 400 mL/hr would be suspicious for DI. DI is the failure to produce an antidiuretic hormone due to damage to the pituitary gland from increased ICP. W/a recent head injury, the nurse should 1st perform a neuro exam -Notify the HCP is appropriate in order for the nurse to obtain orders for additional tests -The nurse should then gather more info by assessing for low specific gravity & elevated serum osmolarity, as ordered by the HCP -The HCP may order tx's including IV fluids for dehydration & DDAVP to replace vasopressin

On the ICU, a pt w/head trauma is on continuous mechanical ventilation The pt develops increased ICP. Which among the following interventions should the nurse implement FIRST?: a.) Call the HCP anticipating orders to hyperventilate the pt b) Increase the O2 concentration c.) Position in Trendelenburg d.) Suction the ET tube

ANSWER=A RATIONALE: -CO2 has a potent *vasodilating* effect & 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 HCP should be called to get orders to hyperventilate the pt. *Hyperventilation* is the 1st-line intervention to decrease ICP b/c it decreases CO2 levels -High O2 levels may decrease ICP, but too much O2 can cause pulmonary fibrosis & seizures. Hyperventilation should be the FIRST intervention

(*CARD SHOULD BE IN RENAL/URINARY NCLEX STUDY DECK)* A dialysis nurse is treating a pt w/newly diagnosed acute renal failure who is receiving dialysis for the 1st time. Which common complication must the nurse look out for?: a.) Bradycardia, tingling, weakness b) HA, Nausea, confusion c.) Hypotension, wheezes, increased temperature d.) Increased respirations, hypotension, back pain

ANSWER=B RATIONALE: -HA, nausea & confusion are S/S of Dialysis Disequilibrium Syndrome (DDS) -This is a complication of hemodialysis when the concentration of blood urea nitrogen level in the blood (BUN) is being reduced more rapidly than the urea nitrogen level in the CSF and brain tissue. B/c of the slow transport of urea across the BBB, it creates a large urea concentration gradient, which results in reverse osmosis, causing temporary cerebral edema during and after hemodialysis. Pupillary changes, HA, nausea, along w/changes in mental status suggest this condition -The other S/S are not indicative of DDS

A pt diagnosed w/a hemorrhagic stroke reports of a sudden, severe HA (9 out of 10 pain). *PRIORITIZE* the next actions: 1.) Administer Acetaminophen or apply a cold pack to the pts head 2.) Perform a neuro assessment 3.) Notify the HCP 4.) Notify the Charge nurse a.) 1, 3, 2, 4 b.) 2, 3, 1, 4 c.) 4, 2, 3, 1, d.) 4, 3, 2, 1

ANSWER=B (2, 3, 1, 4) RATIONALE: -A HA may indicate that the IC bleed is worsening. The nurse should 1st perform a neuro assessment and then immediately notify the HCP. Tx is time-sensitive so the nurse should work fast - -The HCP will decide whether a cold pack or acetaminophen is appropriate -The charge nurse should be updated on the situation AFTER the physician has been notified and time-sensitive tx given

The home health nurse observes the nurse aide transfer a pt w/hemiplegia from a sitting position on the bed to the wheelchair. Which of the following actions needs correction by the home health nurse? The nurse aide... a.) Assists the pt to stand by bracing the affected knee & foot b.) Moves the pt toward the unaffected side c.) Pulls the pt up to a standing position by grasping the pts arms d.) Tells the pt to lean forward before standing

ANSWER=C RATIONALE: -Should subluxation and pain can result from pulling the pts paralyzed arm. The pts unaffected arm or hand must be allowed to reach for the wheelchair's arm and to brace themselves that way. The unaffected arm should be supported but NOT pulled -The other options are CORRECT and indicate proper techniques that promote safety and comfort -Allow the pt to lean foward shifts the center of gravity and enables the pt to rise from the bed properly -Moving the pt toward the unaffected side permits the strong arm & leg to accomplish the transfer safely. Bracing the knee and foot assists in balance during the transfer

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? a.) Document the findings b.) Reinforce the dressing c.) Notify the HCP d.) Mark the area of drainage w/a pen and monitor for further drainage

ANSWER=C RATIONALE: CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes presence of this type of drainage, the HCP needs to be notified. The remaining options are inappropriate nursing actions

A pt 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?: (SATA) a.) Infuse IV fluids at 175 mL/hr b) Keep the HOB flat c.) Maintain elevation of the HOB at 30-45 degrees w/a large pillow under the pts head & shoulders d.) Monitor the neurological status & VS every 4 hours e.) Place a small pillow under the neck f.) Prevent stiffness of the pts neck by flexing it every 2 hours

ANSWERS= B&E RATIONALE: -An infratentorial craniotomy has the incision made at the nape of the neck; the site of surgery is below the tentorium into the infratentorial compartment -The correct position for an infratentorial approach is to keep the HOB flat & place a small pillow under the nape of the neck to promote venous return and reduce ICP -Elevating the HOB at 30-45 degrees is for the supratentorial approach -Post-craniotomy pts must be monitored for neuro & VS every 30 mins -Flexing the neck of this particular pt could disrupt the suture line -Post-craniotomy pts are at risk for cerebral edema and increased ICP. Fluids at 175 mL/hr could lead to fluid overload

A nurse is caring for a pt who has left hemiparesis after a stroke. To avoid the risk of disuse syndrome, the nurse should do which of the following?(SATA): a.) Assist w/passive & active ROM b) Encourage the pt to use his right side to perform ADL's c.) Place the pt in a supine position d.) Position the pts affected arm w/the hand slightly below the elbow & wrist e) Use boots to prevent foot drop

ANSWERS=A & E RATIONALE: -The nurse should assist w/passive & active ROM and w/using boots to prevent footdrop -Use of boots (foot positioning aids) can reduce the risk of footdrop -Passive & active ROM (as tolerated) of the affected areas will help the pt to preserve fxn & mobility -The pt 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 fxn

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. a.) Head midline b.) Neck in neutral position c.) HOB elevated 30-45 degrees d.) Head turned to the side when flat in bed e.) Neck & jaw flexed forward when opening the mouth

ANSWERS=A, B, & C RATIONALE: Use of proper positions promotes venous drainage from the cranium to keep ICP from elevating. The head of the pt at risk for or w/increased ICP should be positioned so that it is in neutral midline position. The HOB should be raised 30-45 degrees. The nurse should avoid flexing or extending the pts neck or turning the pts head from side to side

A definitive diagnosis of Alzheimers dx (AD) requires histopathologic examination, which is rarely done. What tests could the nurse order to rule out other disorders?:(SATA) a.) CT scan b) MRI of the brain c) Oral cholecystography d.) Positron emission tomography (PET) scan e.) Screening for Vitamin B12 deficiency f.) Tensilon test

ANSWERS=A, B, D, & E RATIONALE: -While lab tests are not helpful in confirming the diagnosis of AD, some tests are indicated to exclude contributing secondary causes -The DSM-5 recommends MRI of the brain to rule of cerebrovascular dx, chronic subdural hematoma, cerebral neoplasm, and regional brain atrophy suggesting dementia -PET scan measures the metabolic activity of the cerebral cortex & may help confirm early diagnosis -CT scan may show more brain atrophy that occurs in normal aging -Vitamin B12 deficiency can cause reversible memory & attention problems -Tensilon confirms the diagnosis of myasthenia gravis -Oral cholecystography confirms the presence of gallstones

A nurse caring for a 50 yr old newly diagnosed w/Parkinson's Dx would want to educate the pt & their family about which of the following sx's?: (SATA) a.) A mask-like expression b.) A shuffling gait c.) A wide-based gait d.) Difficulty swallowing e.) Fluctuating muscle weakness f.) Muscle rigidity g.) Optic neuritis

ANSWERS=A, B, D, & F RATIONALE: -Muscle rigidity and mask-like (blank) expression, a shuffling gait, and difficulty swallowing are all classic signs of Parkinson's dx -The nurse will want to teach the pt & family to monitor for the development of dysphagia, a dangerous sx of Parkinsons that can lead to choking or aspiration pneumonia -A pt w/Parkinson's will have a small-based gait

A nurse is caring for a pt diagnosed w/myasthenia gravis. When caring for this pt, which of the following interventions are appropriate?: (SATA) a.) Administer meds when the pt is awake to promote rest b.) Have suction available at all times c.) Monitor VS and watch for signs of myasthenia crisis: bradycardia, hypotension, and cyanosis d.)Monitor VS and watch for signs of myasthenia crisis: tachycardia, HPTN, & restlessness e.) Schedule periods of rest into the day f.) When swallowing is difficult, provide liquids instead

ANSWERS=B, D, & E RATIONALE: -The hallmark sx of MG is fluctuating muscle weakness that worsens w/effort or exercise & improves w/rest. Medical management of MG depends on the administration of cholinesterase inhibitors such as pyridostigmine & corticosteroids given at specific times to avoid exacerbation's -May pts experience weakness of the facial, masticatory, speech & neck muscles. Often times pts will get tired while chewing foods and need to rest or will have difficulty swallowing food due to the weakness. Its always necessary to have suction set up for these pts -Pts must be monitored for signs of myasthenia crisis, a life-threatening complication in which the breathing muscles become too weak. Signs are an increase in HR, BP, RR, cyanosis, increased secretions, or urinary and bowel incontinence -Periods of rest are important for these pts as they are at risk for extreme fatigue so care should NOT be clustered INCORRECT: -If swallowing or chewing becomes difficult, soft food should be given, but liquid food can increase the risk of aspiration -Medication should not be given when the pts are awake, but should be given according to a strict schedule

A pt is scheduled for a lumbar puncture. Which of the following statements indicates the pt understands the procedure?: (SATA) a.) A dye will be injected into my CSF to help diagnose the cause of my problem b.) Electrical activity in my brain will be recorded c.) Fluid will be removed from my spinal canal d.) I must lay flat after the procedure for at least 4 hours e.) I will have to be in the prone position for the lumbar puncture f.) My nerve impulses will be measured

ANSWERS=C & D RATIONALES: -LP involves the insertion of a needle into the subarachnoid space & the removal of CSF for diagnostic or therapeutic purposes -To prevent injury the pt must NOT MOVE during the insertion of the needle into the spinal canal. The pt will need to lie on his/her side, curling forward so that the knees are flexed toward the chest w/the chin touching the knees

INCREASED INTRACRANIAL PRESSURE (ICP): 4.) Medications for Increased ICP:

ANTISEIZURE: -Seizures increase metabolic requirements and cererbral blood flow & volume, thus increasing ICP -Meds may be given prophylactically to prevent seizures ANTIPYRETICS & MUSCLE RELAXANTS: -Temperature reduction decreases metabolism, cerebral blood flow, and thus ICP -Antipyretics prevent temp elevations -Muscle relaxants prevent shivering BP MEDICATION: -BP medication may be required to maintain cerebral perfusion at a normal level -NOtify the HCP if the BP range is lower than <100 or higher than >150 mmHg systolic CORTICOSTEROIDS: -Corticosteroids stabilize the cell membrane & reduce leakiness of the blood-brain barrier -Corticosteroids decrease cerebral edema -A histamine blocker may be administered to counteract the excess gastric secretion that occurs w/corticosteroids -Pts must be w/drawn slowly from corticosteroid therapy to reduce the risk of adrenal crisis IV FLUIDS: -Fluids are administered IV via an infusion pump to control the amount administered -Infusions are monitored closely b/c of the risk of prolonged additional cerebral edema & fluid overload HYPEROSMOTIC AGENT: -A hyperosmotic agent increases intravascular pressure by drawing fluid from the interstitial spaces & from the brain cells -Monitor renal fxn -Diuresis is expected

STROKE (BRAIN ATTACK): 5.) Assessment Findings (continued):

APHASIA (loss of ability to understand or express speech): -1.) Expressive: -->Damage occurs in Broca's area of the frontal brain -->The pt understands what is said but is unable to communicate verbally -2.)Receptive: -->Injury involves Wernicke's area in the temporoparietal area -->The pt is unable to understand the spoken & often the written word -3.) Global or Mixed: -->Language dysfxn occurs in expression and reception *INTERVENTIONS FOR APHASIA:* -Provide repetitive directions -Break tasks down 1 step at a time -Repeat names of objects frequently used -Allow time for the pt to communciate -Use a picture board, communication board, or computer technology

ANTISEIZURE MEDICATIONS: D.) SUCCINIMIDES: Ethosuximide, Methsuximide -1.) Description & Side and Adverse Effects:

Are used to treat Absence seizures S&A Effects: -Anorexia, N/V -Blood dyscrasias

CEREBRAL ANEURYSM: 1.) Description:

Dilation of the walls of a weakened cerebral artery; can lead to rupture

INCREASED INTRACRANIAL PRESSURE (ICP): 5.) Surgical Intervention for Chronic Increased ICP--Ventriculoperitoneal Shunt:

Directs CSF from the ventricles into the peritoneum POSTOPERATIVE INTERVENTIONS: -Position the pt supine & turn from the back to the NONOPERATIVE side -Monitor for signs of: -->Increasing ICP resulting from shunt failure -->infection

NEUROLOGICAL ASSESSMENT: 10.) Assessment of Meningeal Irritation:

GENERAL FINDINGS: -Irritability -Nuchal rigidity -Severe, unrelenting HA's -Generalized muscle aches and pains -N/V -Fever & chills -Tachycardia -Photophobia -Nystagmus -Abnormal pupil rxn & eye movement BRUDZINKSKI'S SIGN: -Involuntary flexion of the hip & knee when the neck is passively flexed; indicated meningeal irritation KERNIG'S SIGN: -Loss of the ability of a supine pt to straighten the leg completely when it is fully flexed at the knee and hip; indicates meningeal irritation MOTOR RESPONSE: -Hemiparesis, hemiplegia, & decreased muscle tone -Cranial nerve dysfxn, especially cranial nerves III, IV, VI, VII, & VIII (Oculomotor, Trochlear, Abducens, Facial, & Acoustic) MEMORY CHANGES: -Short attention span -Personality & behavioral changes -Bewilderment

SEIZURES 2..) Types of Seizures:

GENERALIZED SEIZURES: 1.) TONIC-CLONIC: -Tonic-clonic seizures may begin w/an aura -The tonic phase involves the stiffening or rigidity of the muscles of the arms and legs & usually last 10-20 seconds, followed by loss of consciousness -The clonic phase consists of hyperventilation and jerking of the extremities and usually lasts about 30 seconds -Full recovery from the seizure may take several hours 2.) ABSENCE: -A brief seizure that lasts seconds and the individual may or may not lose consciousness -No loss or change in muscle tone occurs -Seizures may occur several times during a day -The victim appears to be daydreaming -This type of seizure is MORE COMMON in children 3.) MYOCLONIC: -Myoclonic seizures present as a brief generalized jerking or stiffening of extremities -The victim may fall from the seizure 4.) ATONIC OR AKINETIC (DROP ATTACKS): -An atonic seizure is a sudden momentary loss of muscle tone -The victim may fall as a result of the seizure PARTIAL SEIZURES: 1.) SIMPLE PARTIAL: -The simple partial seizure produces sensory sx's accompanied by motor sx's that are localized or confined to a specific area -The pt remains conscious and may report an aura 2.) COMPLEX PARTIAL: -The complex partial seizure is a psychomotor seizure -The area of the brain most usually involved is the Temporal lobe -The seizure is characterized by periods of altered behavior of which the pt is not aware -The pt loses consciousness for a few seconds

NEUROLOGICAL ASSESSMENT: 4) Assessment of VS:

Monitor for BP & pulse changes, which may indicate increased ICP

SPINAL & NEUROGENIC SHOCK: 2.) Assessment:

NEUROGENIC SHOCK: -Hypotension -Bradycardia SPINAL SHOCK: -Flaccid paralysis -Loss of reflex activity below the level of the injury -Bradycardia -Hypotension -Paralytic ileus AUTONOMIC DYSREFLEXIA: -Sudden onset, severe throbbing HA -Severe HPTN and bradycardia -Flushing above the level of the injury -Pale extremities below the level of injury -Nasal stuffiness -Nausea -Dilated pupils or blurred vision -Sweating -Piloerection (goose bumps) -Restlessness and a feeling of apprehension

STROKE (BRAIN ATTACK): 4..) Manifestations of Right Brain & Left Brain Stroke:

RIGHT-BRAIN DAMAGE (stroke on right-side of the brain): -Impaired judgement -Impaired time concepts -Impulsive, safety problems -Left-sided neglect -Paralyzed left side: hemiplegia -Rapid performance, short attention span -Spatial-perceptual deficits -Tends to deny or minimize problems LEFT-BRAIN DAMAGE (stroke on left-side of the brain): -Aware of deficits: depression, anxiety -Impaired comprehension r/t language, math -Impaired right/left discrimination -Impaired speech/language aphasias -Paralyzed right-side: hemiplegia -Slow performance, cautious ** *A CRITICAL FACTOR IN THE EARLY INTERVENTION & TX OF STROKE IS THE ACCURATE IDENTIFICATION OF STROKE MANIFESTATIONS & ESTABLISHING THE ONSET OF MANIFESTATIONS. STROKE SCREENING SCALES MAY BE USED TO IDENTIFY STROKE MANIFESTATIONS QUICKLY. IDENTIFICATION OF THE TYPE OF STROKE OCCURRING IS CRITICAL IN DETERMINING THE APPROPRIATE TX, & THIS IS USUALLY DONE USING IMAGING SUCH AS A CT SCAN* **

STROKE (BRAIN ATTACK): 6.) Clinical Manifestations of Stroke Based on Type:

THROMBOTIC STROKE: -Typically, there is no decreased LOC w/in the 1st 24 hrs -Sx's get progressively worse as the infarction and edema increase EMBOLIC STROKE: -Sudden, severe sx's -Warning signs are less common -Pt remains conscious & may have a HA HEMORRHAGIC STROKE: -Sudden onset of sx's -Sx's progress over minutes to hours due to ongoing bleeding

NEUROLOGICAL ASSESSMENT: 12.) Assessment of Sensory Fxn:

Touch, pressure, pain

ANTISEIZURE MEDICATIONS: E.) VALPROATES: Valproic Acid, Divalproex Sodium -1.) Description & Side and Adverse Effects:

Used to treat Tonic-Clonic, Partial, and Myoclonic Seizures S&A Effects: -Transient N/V & indigestion -Sedation, drowsiness, and dizziness -Pancreatitis -Blood dyscrasias -Hepatotoxicity