Medsurg Exam III

Neurological Assessment

Cerebral Lobes

Frontal

Parietal

Temporal

Occipital

Front Lobe Function

Located in the front area of the brain and is largely responsible for motor movement and personality.

• Motor cortex. voluntary movement

• Broca’s expressive speech center - dominant hemisphere

• Personality

• Behaviors: social, sexual, judgement, and problem solving

Parietal Lobe

Found behind the frontal lobes

Controls sensation and perception - sight, taste, hearing, smell, touch

Plays a role in social relationship such as body position

Integration of sensory input, such as visual input

• Being able to assess size, shae, and orientation in space of both visible stimuli and objects you see.

Temporal Lobe

Located on the sides of the brain

Auditory sensation and perception

• Being able to hear and understand speech, it gives the ability to understand and give meaning to language

• Being able to control unconscious and apparently automatic reactions such as appetite, thirst, and hunger.

Long term memory

Wernicke’s receptive speech center

• Allows for the production of speech

Occipital Lobe

Located at the back of the brain, and is responsible for vision

Perception of color and shapes

Glascow Coma Scale

Used to assess level of consciousness, identifying patients responsiveness and orientation to person, place, or time.

the GCS assigns a score for eye-opening, best motor response, and verbal response.

• Highest possible score: 15

• With a score of 8 or less indicating severe neurological issues.

Components of the Glasgow Coma Scale

Best Eye Opening

Best Motor Response

Best Verbal Response

Best Eye Opening

Spontaneous - 4, responds no neccessary to command

To speech - 3, Opens eye only to verbal stimuli

To pain - 2, opens eyes only to painful stimuli

None - 1, doesn’t open eyes

Best Motor Response

Obeys commands - 6, obeys commands

localized - 5, purposeful movement to pain

withrdraws (flexion) - 4, withdraws from painful stimuli

abnormal flexion - 3, flexion in response to pain

abnormal extension - 2, extension in response to pain

flaccid - 1, no response to pain

Best Verbal Response

Oriented - 5, Orientated to person, place, and time

Diagnostic Tests

1. CT (computed tomography) or CTA (CT angiography)

2. Magnetic Resonance Imaging (MRI) or MR angiography (MRA)

3. Lumbar Puncture (LP)

4. Electroencephalography (EEG) & Biopsy

CT or CTA

Uses cross-sectional images that are viewed as cuts or slices that allow the provider to view the brain, spine, and orbits in a quick, NONINVASIVE manner.

Used to assess for bleeding, edema or masses

It is a required screening test for someone with suspected ischemic stroke - CT is used to rule out hemorrhagic stroke which is a contraindication to thrombolytc therapy.

Nursing Implication - CT or CTA

Provide patient education for the procedure

Mention that it is noninvasive and painless

Ensuring a patent IV line is in place

Checking for allergies such as shellfish or dyes, because contrast ontaines iodine

Monitoring BUN and creatinine to assess kidney function before contrast because it is toxic to the kidney and can impair renal function

Assess for diabetes DM and use of metformin in the management of type 2 diabetes, if yes - hold metformin 48 hours before to avoid renal impairment

Providing post procedure care

• Administering IV fluids or increasing intake of oral fluids to clear contrast mediun from the system

• Monitoring if allergic reactions occur due to the contrast.

Magnetic Resonance Imaging (MRI) or MRA

Type of MRI that uses radio-wave signal characteristics of flowing blood to get images of the body’s blood vessels.

MRA - Used to determine the presence of aneurysms, clots, dissections, or vessel stenosis.

• Diagnosis of tumors, infections, and bleedings

• Diagnosis of cerebrovascular accident (CVA)

Nursing Implications of MRI and MRA

Patient education prior about the procedure

It is noninvasive and painless

Non Iodine contrast - there is no need to worry about kidney damage

Ensure that the patient doesn’t have any metal objects

• Check patient for any cardiac implantable electronic device, mechanical metallic heart valve(s), metallic foreign bodies, implantable neurostimulation systems, etc.

• Assess the patient for claustrophobia and anxiety (long-test and causes lots of noises) - patient may require sedation.

• Ensure the patient receives adequate hydration post procedure

Lumbar Puncture (LP)

Common procedure done to obtain a sample of cerebrospinal fluid (CSF) for the analysis and to measure intracranial pressure.

• Increased pressure can indicate CSF obstruction or overproduction.

• Presence of abnormalities in glucose or protein as well as a cloudy color = infection.

Presence of breakdown products of RBCs, known as xanthochromia or frank blood can indicate subarachnoid hemorrhage or a traumatic tap.

Lumbar Puncture can also be used for spinal anesthesia and intrathecal medication or to remove CSF from the spinal cord to reduce pressure.

Pt positioning during Lumbar Puncture

Requires the patient to be positioned laterally (on the side) in bed, drawing the knees up toward the tress. Or the patient can be leaning cross a bedside table with the back arched.

• the procedure occurs with a puncture of a spinal need into the L3 to L4 space of the spinal column below the level of the spinal cord.

Nursing Implication of LP

Provide education for the patient about the procedure

Providing preprocedure care:

• Ensuring that antiplatelet or anticoagulation medication are held prior to the test to reduce risk of bleeding.

• Checking coagulation studies prior to test

• Informed consent is obtained

• Post LP Care

  • Ensuring flat bedrest for 4-6 hours after the test to help prevent CSF leakage, which can cause severe headrest

  • Encouraging fluids post procedure to decrease headache intensity if present.

EEG & Biopsy

EEG is an inexpensive, nonvasive procedure that uses 8 to 24 scalp electrodes to trace the spontaneous electrical activity in the brain.

Diagnostic test for seizure activity

Used during sleep study.

Nursing Implication for EEG

No caffeine 8-12 hours prior

Wash hair, no hair products

Brain Biopsies

Tissue sample to identify tumor type infection, or abscess

Types:

Needle

Stereotactic

Open

Needle

drilling a small hole in the skull and a needle is inserted to obtain tissue

Stereotactic

Uses specialized computer imaging that utilizes a 3D coordinate system to pinpoint area

Open

Performed OR, removing portion of bone from the skull.

Brain Disorders

Headaches

Also referred to as cephalalgia

There are two types of headaches: primary and secondary

Epidemiology of Headaches - clinical manifestation

Common Manifestations of pain, accounting for more missed days of work and school, and more visits to healthcare providers.

• 20-40% of the US population reports having migraines (women>men, greater than 2:1)

• WHO mentiones that it is in the top 10 ranking for disabling conditions, ranking headaches in the top 5 for women

Primary Headache

Not associated with underlying causes

Typically is a migraine, tension, or cluster.

Secondary Headache

Caused by an underlying pathology

Typical presentation: sudden onset, severe pain

Due to infection (meningitis), neoplasm (tumor), vascular (blood vessel aneurysm or rupture)

Secondary Headache Diagnosis

CBC and Blood Culture to detect infection

CRP and ESR (C-reactive protein, erythrocyte sedimentation rate) - checks for inflammation

CT and MRI (check for masses, cysts, vessel, and osseous skull abnormalities)

EEG used to check for seizures, tumors, inflammation, and brain injury.

Sleep studies (check for fatigue & sleep apnea)

Brain Tumors

Tumors that originate in the brain and range from slow-growing, benign tumors to highly malignant, aggressive tumor

Types of Brain tumors:

• Primary Brain Tumors

• Metastatic Brain Tumors

Primary Brain Tumors

Originiate from brain cells, brain meninges (membranes covering the brain), nerves, and glands.

• Male individuals typically having a higher number

Can be both malignant and benign meningioma

Malignant Tumors

Grade I/II - Due to Glioma

Grade III - Anaplastic Glioma

Grade IV - Glioblastoma Multiforme

Oligodendrogliomas

Gliomas

Generally originiate in the cerebrum - glial cells provides the physical structure of the brain and supports endothelial cells of the blood-brain barrier.

Glial cells provide nutrients and ionic balance that are involved with repair and scarring process.

Gliomas are typically developed along the curved areas of the brain, making the frontal lobes more susceptible, typically found in patients between the ages of 20 and 50 years old, they are slow growing tumors.

Anaplastic Glioma

Grade III tumors cells out of control, lacking differentiation and/or orientation to one another and to surrounding vessels.

Glioblastoma Multiforme

Grade IV astrocytoma and is the most aggressive and lethal type of tumor, especially when located in or near the brainstem.

Oligodendrogliomas

Arises from oligodendrocytes, or oligodendroglia and their main functions are to provide support and insulation to axons in the CNS, equivalent to the function performed by Schwann cells in the PNS and they are slow-growing tumors that generally don’t spread to surrounding tissue.

Typically found in middle-aged patients.

Benign Tumor Types

Meningioma

Acoustic Neuromas

Schwannomas

Pituitary Tumors

Meningioma

Most common form of brain cancer - 90% are typically benign but cause significant damage based on its location.

Acoustic Neuromas

CN VIII, which are slow-growing benign tumors that generally don’t invade other tissues, however compression on other cranial nerves and tissue (cerebellum and brainstem) can manifest in severe complication.

• They are also known as schwannomas, and they originate from the protective covering around nerve fibers (CN VIII) at the anatomical location of the cerebellopontine angle.

Pituitary Tumors

Generally found in the anterior lobe of the pituitary.

Most common of which is the adenoma and the clinical manifestations are pituitary adenomas related to hypersecretion of hormones by the pituitary gland including acromegaly from hypersecretion of growth hormone, amenorrhea-galactorrhea from prolactin hypersecretion.

Brain tumor Management

Chemotherapy

Gliadel Wafers

Radiation Therapy

Cyberknife

Chemotherapy

Cross the BBB (blood brain barrier):

• Temozolomide ( radiosensitizer)

• Carmustine, Lomustine, Methotrexate

Temozolomide ( radiosensitizer)

Used to treat brain cancer, it inteferes with the growth of cancer cells, which are then destroyed by the body.

Carmustine

Chemotherapy medication that works by damaging the DNA cancer cells to stop them from growing and dividing.

Giladel Wafers

Impregnated with chemotherapy and put in the surgical bed at the time of surgical resection

Side effects to be aware of:

• Neutropenia (susceptibility to infection), nausea, vomiting, fatigue, mucositis, hair loss, sterility.

Radiation Therapy

Concentrated on the affected area and it destroys both tumor and normal cells by damaging cellular DNA.

Side effects includes:

• fatigue, redenning of the skin (sunburn appearance), headache, swelling, visual changes, nuerological disturbances, hearing loss, and facial numbness.

CyberKnife

A technology that is used to direction radiation to the tumor, avoiding healthy brain tissue

Seizure

An uncontrolled, sudden, excessive discharge of electrical activity which results in a range of manifestations from changes in behaviors to loss of consciousness.

Types of Seizures:

• Epilepsy

• Cryptogenic Seizure

Nursing Assessment for Seizures

Check for Airway and breathing

• Maintaining airway patency during seizure and postictal state

• Decreased level of consciousness

Vital Signs

• Oxygen Sat and RR during a seizure.

• HR and BP may increase during a seizure

Tonic movements (muscle activity characterized by a sudden, sustained increase in muscle tone and stiffness)

Clonic Movement (rhythmic, rapid, and repetitive contraction and relaxation of a muscle, typically resulting in unstoppable shaking or jerking)

Loss of Consciousness

Aura (being fully conscious and alert - warning sign before a larger seizure)

Automatisms (involuntary, stereotyped, and repetitive behavior performed without conscious self-control, intention, or awareness)

Loss of Motor Tone

Nursing Interventions during Seizure

Setting up suction equipment at the patient’s bedside - important to provide assistance with airway.

Have oxygen available at the patient’s bedside

• During the postictal phase, the pt may require supplemental oxygen to maintain the oxygenation saturation.

Safety Measures

• ensuring bed is at lowest position, suction at bedside, and oral airway is at the bedside.

• For someone who just experienced a seizure, protection includes not forcing any object into the mouth (for fear of biting tongue, breaking teeth, causing injurt, etc), loosening of restrictive clothing, and turning the patient to the side (preferably the left to reduce the risk of aspiration)

Place an IV catheter per orders

• IV access may be needed to stop the seizure activity.

Document specific of seizure activity

• date, time, and duration of the seizure; clear description of the seizure, sequence of the seizure progression, and precital and postictal observation.

Pt education (seizure)

Medication regimen

• Control of seizure activity is determined by therapeutic levels of prescribed antiseizure medications.

Medic Alert Bracelet

• Important for pts with seizures to wear a Medic Alert braclet in event of seizure activity and it facilitates prompt interventions in the event of a seizure.

Driving Restrictions

• Important for pt to research driving restrictions.

Parkinson’s Disease

Progressive, neurodegenerative disease of the CNS manifesting primarily in motor dysfunction

• Caused due to idiopathic origin (unknown), environmental toxins - pesticides and herbicides, brain injury, brain tumors, and use of antipsychotic medication.

PD is typically found in men more and generally begins the ages of 40 and 70 years.

in US it is typically prevalent within Amish communities.

Pathophysiology of Parkinson’s Disease

It is a motor system disorder, which involves the substantia nigra. this is responsible for transmitting signals to allow for dopamine and GABA release, and it allows for motor functions to occur, along with regulating muscle tone and posture.

Motor activity is the result of the release of dopamine and Ach

Due to the a mutation defect in the gene, there is a deterotiation of the substantia nigra and it decreases the amount of dopamine in the brain.

Clinical Manifestations of Parkinsons

1. Resting tremors

2. Muscle Rigidity

3. Bradykinesia

4. Postural instability

Bradykinesia

Slowness of voluntary movement

• “limbs feel heavy”

• everything becomes a lot of work

• causes a masked face - slow blinking

Resting Tremor

Usually shows in hand as steady, rhythmic shaking

Disappears with movement

tremors can also affect legs, jaws, or lips it is worse when stressed or anxious

Rigidity

Muscle stiffness and resistance to passive movement

Postural Instability

Due to weakness of the body, which can also lead to falls

It is a loss of balance

Progressive Stages of Motor Dysfunction

Initial Phase:

• Presents with unexplained unilateral weakness and upper extremity tremors.

Later Phase:

• Slow shuffling gate

• Postural Instability

• Stooped Posture

• Rigidity

• Generalized tremor

• Maslike face

Parkinson’s Diagnosis Factors

When there are two or more observable symptoms with asymmetry on presentation:

• Bradykinesia

• Resting Tremor

• Rigidity

• Postural Instability

No defintive test to confirm PD

ch 37: Spinal Cord Disorders

Spinal Column

Responsible for the spinal cord and the nerve pathways that carry info between the brain and rest of the body.

parts of the spine

Butterfly of the Spinal Cord

Gray Matter of the Spinal Cord and is surrounded by white matter

• This is the processing center bu recieving and integrating information.

Gray Matter

• contains motor neurons that control movements

White matter

• contains the conduction tracts for nerve impulses and the tracts of the nerve fibers consists of axons, which are going to carry impulses away from the cell body.

Herniated Disc

Vertebral disk rupture or tearing that causes leaking into the vertebral area resulting in back pain

Epidemiology of Herniated Disc

As people age, the disk between the vertebrae degenerates and weakens, so the disk becomes more inflexible and more prone to tearing or rupturing with movement.

• a herniation occurs when the leaking out of the interior nucleus disk contents into the vertebral areas

Tends to occur more in men.

Risk Factors of Herniated Disc

Age + gender

Smoking, obesity, and occupations.

Clinical Manifestation

Presents with pain caused by the inflammatory process and compression to nerve roots.

Radiculopathy (a nerve root compression) which can result in numbness in the affected extremity as well as pain, weakness, and inability to control motor m

ovements in the affected area.

Diagnosis of Herniated Disc

History and Physical, with focused neurological examination to test:

• reflex

• Muscle strength

• patients ability to feel touch and vibration to localize the affected lvel

Tests used:

• Imaging studies such as - x-ray, CT scans, MRIs, and myelograms.

Additional neurological tests used:

• EMG and nerve conduction studies

• These are used to pinpoint the location of nerve damage.

Spinal Cord Injuries

Unexpected catastrophic event that results in the loss of function such as mobility or sensation.

Spinal cord trauma can be due to direct injury to the cord or indirect injury to surrounding bones, tissues, and blood vessels,

Risk Factors of Spinal Cord Injuries

Typically occurs in males between the ages of 29 and 43.

Activities such as participating in high-risk physical activities such as speeding and drinking while under the influence of alcohol, substance use, and not using protective gear in sports or recreational activities.

Most common places for spinal cord injuries

C4-C6

T12

Clinical Manifestation of Spinal Cord Injury

The level of injury predicts what part of the body is affected:

Cervical injuries

• Quadriplegia

• C4 and above → inability to breathe, phrenic nerve innervates the diaphragm at this level

Thoracic Injuries

• Paraplegia with trunk and leg involvement, normal arm and and movement

• T6-T12: paraplegia with fair ability to control balance and trunk, little or no voluntary bowel or bladder control.

Lumbar and Sacral Injuries:

• Leg control, bowel and bladder function, sexual function (functional losses)

Other Effects

• Hypotension

• Chronic Pain

• Decreased temperature control

Conservative Treatment for Spinal Cord Injuries

Once spinal cord damage occurs, it is not reverisble

Acute Stage

• Treatment is focused on maintaining airway patency, adequate breathing and oxygenation, preventing spinal shock, restoring and maintaining blood pressure, preventing further cord damage, spinal immobilization, and avoiding possible complications.

Rapid vital signs!!

Nursing Assessment of Spinal Cord Injuries

Respiratory Function

• Check for hypoventilation (intercostal muscle paralysis)

• C4 and higher (no diaphragmatic innervation)

Vital Signs

• Loss of sympathetic input

• Spinal shock

• Neurogenic Shock

• Respiratory or cardiac arrest

• Autonomic dysrexia

Patients are unable to regulate their temperature , and hypothermia can occur due to the loss of control of blood vessels.

Nursing Intervention for Spinal Cord Injuries

Maintain suction equipment at patient’s bedside (with decreased cough effectiveness - the patient may require suctioning to clear the airway)

Facilitate cough effectiveness

Maintain spinal immobilization and stabilization

Passive ROM

Reposition and maintain good alignment

• prevent pressure injuries and decreasing risk of DVT due to immobility

Perform routine pin site care

Patient Education for Spinal Cord Injury

Ensure information about respiratory distress

Clinical manifestations of autonomic dysreflexia

Skin care/management

• prevent skin breakdown

Amyotrophic Lateral Sclerosis

Also known as Lou Gehrig’s disease where there is rapid degradation of the motor nerves.

• It is a fatal CNS (brain and spinal cord) disease that affects voluntary muscle control and it leads to muscle atrophy.

• It is more prevelant in males.

Clinical Manifestation of ALS

Cause is unknown.

Clinical manifestation typically appear in males between ages of 55 and 75.

Early Symptoms:

• Muscle cramps or stiffness

• Muscle weakness in one part of the body

• Difficulty swallowing (dysphagia)

• Slurred speech

As the disease progresses it can affect the diaphragm, and an artificial airway is needed

Complications of ALS

Aspiration of fluid or food due to dysphagia

Respiratory failure

Pneumonia

Pressure injuries

DVT

PE

Constipation

Contractures

Depression

Weight loss

Loss of the ability to care for self.

Nursing Assessment

Check the airway

• Motor weakness involves muscle of the face, mouth, and neck, maintaining an intact airway is compromised.

• Airway comprise is greater as the patient demonstrates weakened cough and impaired swallowing

Check O2 saturation

Motor Strength

• Muscle weakness increases as the disease progressing due to neuronal degeneration and cell death

Ability to swallow

• increased risk of aspiration

Skin

• immobility promotes skin breakdown due to the compresison of soft tissue between a bony prominence and an external surface.

Coping skills

• assess effectiveness of current skills and identify support syste,

Nursing Intervention ALS

Check for ROM

Administer Medications to treat clinincal manifestations

• alleviate muscle cramps, pain, constipation, fatigue, depression, etc.

• Elevate the head of the patient’s bed when eating, drinking, or brushing teeth

  • Difficulty with swallowing

Turn, cough, deep breathing

Turn scheduled every 2 hours

Emotional Support

Renal Failure

Partial or complete inability of the kidney to filter waste products and water from the blood through glomerular and tubular filtration.

Types of Renal Failure

Acute Kidney Injury

Chronic Kidney Disease

Renal Replacement Therapies

Acute Kidney Injury

Sudden, rapid decrease in renal function, which leads to the build up of waste, fluid and electrolyte imbalance.

• It can be reversible if it is managed in a timely manner.

• The injury can be in different places of the kidney

Types of AKI

Pre-renal

Infra renal

Post renal

Prerenal Injury

Most common cause of AKI

It is caused due to an external factor, where there is an issue with perfusion to the kidney, which decreases the function of the kidney

• There is decreased blood flow to the kidney, which prevents it from filtering and it deprives kidney nutrients.

Prerenal Causes

Typically a cardiac issue, external bleeding, dehydration, burns. This all leads to causes of

• Hypovolemia

• Decreased Cardiac Output

• Decreased Peripheral Vascular Resistance

• Vascular Obstruction

While this occurs, the renal system senses poor perfusion and activates the RAAS to maintain BP. If perfusion remains low, there is damage to the renal issue.

Infrarenal AKI

Impaired nephron functioning and causes decreased ability to filter blood, remove waste and this leads to excessive water and lack of maintain electrolyte levels.

Infrarenal Causes

Prolonged ischemia

Nephrotoxic drugs - NSAIDS, aminoglycosideantibiotics (tobramycin, gentamicin, neomycin)

Contrast dye using imaging studies

Chemo drugs

Infection - glomerulonephritis

Hemoglobin released from RBC hemolysis

Myoglobin released from necrotic muscle cells.

Post Renal AKI

Blockage in the urinary tract after the kidney to the urethra, which prevents urine from draining out of the system.

• It will lead to build up of pressure in the kidneys and waste.

Postrenal Causes

Obstruction of the lower urinary tract:

• Ureters

• Bladder

• Urethra

• BPH - men having issues with bladder

• Prostate CA

• Calculi

• Trauma

• Tumors

AKI Management

The goal is to ensure circulating volume, correcting fluid overload, and correcting biochemical abnormalities.
important to ensure adequate hydration.

Medications/Diuretic therapy

• Lasix (loop diueretic)

• Bumetanide (loop diuretic)

• Mannitol (osmotic diuretic)

Treatment of hyperkalemia - increasing cellular uptake of K+

• IV glucose followed by IV regular insulin

• Albuterol

• Bicarbonate

• Hyperkalemia can lead to cardiac arrest

Enhancing K+ elimination

• Sodium polystyrene sulfonate (kayelxalate) binds K+ and eliminates K+ in the stool.

• lasix

• HD

Nursing Assessment AKI

Vital Signs

• Initially check for BP and HR

  • Hypotension and Tachycardia (FVD)

  • Later: Hypertension (FVO)

Nursing Interventions AKI

Manage fluid balance and daily weights

• Measure intake and output

• Provide fluids to ensure volume

• Restrict fluids in FVO

Administer medications as orders

• Diueretics

• Potassium lowering therapy

Mobility and skin care

Patient Education - AKI

Knowledge of the cause and treatment of AKI

Helps manage anxiety

Encourages adherence with treatment

Avoiding nephrotoxic substances

Information about finding rationale for fluid and dietary restrictions.

Chronic Kidney Disease

Significant decrease in renal function and it occurs over a long period of time

It is irreversible

It will lead to buildup of proteinuria, nothing is filtering and it will cause to fluid overload.

The whole kidney structure will be affected

Causes of CKD

Diabetes Mellitus and Hypertension

Diabetes

• Uncontrolled hyperglycemia causes glucose to stick to artery walls (sugar is sticky), so it affects the artery that is supplying.

HTN

• Asymptomatic

• Constant high pressure hitting the arterial wall, so the kidney becomes damaged and there is less blood to nephrons