Studied by 56 peoplewhat is normal ICP
0-15
what factors influence ICP
brain tissue, blood, CSF
how does CO2 affect ICP
it is a vasodilator so it increases ICP
how does a brain tumor affect ICP
it occupies space so it increases ICP
what does untreated increased ICP lead to
brain herniation and death
what are the S/S of increased ICP
change in LOC, cushings triad, decreased eye reflexes, hemiparesis and hemiplegia, HA, projectile vomiting without nausea
what are some nursing interventions for increased ICP
elevate HOB, hyperventilation, suctioning, NG tube
how does mannitol work
hypertonic fluid/osmotic diuretic for plasma expansion and pulling fluid out of cells to decrease ICP
how dose lasix work
reduces blood volume and rate of CSF production
if a patient is experiencing increased ICP due to increased CO2, what nursing action can be taken
hyperventilate the patient
how does O2 affect ICP
decreases ICP
what does a glasgow coma score of 3 indicate
brain dead
what does a glasgow coma score of 8 or less indicate
coma
what nursing interventions are required for a patient with a glasgow coma score less than 8
monitor ICP
what does a glasgow coma score of 15 indicate
normal
what areas are assessed with the glasgow coma scale
verbal, motor, and eye-opening response
what is decadron
corticosteroid used to treat arthritis and test for cushings syndrome
what is excedrin used to treat
headaches and migraines
what is levadopa used to treat
parkinsons
how does levadopa treat parkinsons
increases dopamine in the brain
what is meningitis
inflammation of the brain and spinal cord that increases CSF production and increased ICP
what is the cause of meningitis
bacterial or viral upper respiratory infection
what are the early S/S of meningitis
fever, nuchal rigidity, HA
what are the severe S/S of meningitis
change in LOC, hemiparesis, abscess, hydrocephalus, waterhouse-friderichsen syndrome
what is waterhouse-friderichsen syndrome
petechiae, PIC, adrenal hemorrhage
what diagnostic test is used to diagnose meningitis
lumbar puncture
what are the nursing interventions for meningitis
low stimulating environment, high protein and calorie diet, ROM, warm baths, monitor vitals and ICP
what is a brain abscess
accumulation of pus in the brain
what diagnostics are used for a brain abscess
CT, MRI
what is the treatment for a brain abscess
antibiotics, incisions/drainage or removal of abscess
what are the S/S of a tension headache
bilateral pressure/tightness, mild-to-moderate severity, photophobia and phonophobia
what is the treatment for tension headaches
ASA, tylenol, ibuprofen
what are the S/S of a migraine
recurring, unilateral, trobbing, worsended with activity, associated with aura
what is the treatment for migraines and cluster headaches
imitrex, ergotamine, midrin, corticosteroids
what are the S/S of a cluster headache
severe, unilateral, abrupt onset, repeated over 2-3 months, facial swelling, lacrimation, rhinnorhea, ptosis
what nursing interventions should be completed after the tonic-clonic phase and during the post ictal phase
turn the patient on their side
when does suctioning and oxygen therapy begin
post-ictal phase
what should you not do for a patient having a seizure
restrain or put anything in the patients mouth
what is the primary seizure medication
tensilon
what is the therapeutic blood level for tensilon
10-20 mcg/ml
how does one monitor tensilon levels
monitor with blood draws prior to morning med
how do you administer tensilon through an IV
dilute and give slowly to prevent hypotension and cardiac dysrhythmias
what are the side effects of tensilon
gingival hyperplasia, slurred speech, confusion, blood dycrasias, hyperglycemia, alopecia, hirsutism
what patient education should be provided to a patient on tensilon
perform good oral hygeine
what is an important assessment question for a patient who arrives to the ER with stroke S/S
when was the patient last seen normal
what is the priority action for a pt with stroke S/S
stat CT to determine if its ischemic or hemorrhage
what is a hemorrhagic stroke
bleeding caused by rupture of a blood vessel resulting in the death of cells
what are the causes of hemorrhagic stroke
HTN and aneurysms
what is the tell-tale sign of a hemorrhagic stroke
worst headache of my life
what is an ischemic stroke
inadequate blood flow to part of the brain from an occlusion of an artery
what is a thrombotic stroke
clot formation due to narrowing of the arteries from plaque
what is an embolic stroke
clot comes from somewhere else in the body and gets stuck in an artery that is too small
what is the cause of an embolic stroke
a-fib
what is the treatment for an ischemic stroke
tPa
what is the treatment for transient ischemic attacks
plavix, aspirin (ASA), and coumadin
how do plavix and aspirin work
prevent platelet aggregation
what is the action of coumadin
anticoagulant
primary nursing diagnosis for tPa use
risk for bleeding
what are surgical interventions to prevent hemmorhagic strokes
clipping or coiling of an aneurysm, endartectomy
S/S of right sided stroke
reckless, impulsive, moves quickly
what are the S/S of a left sided stroke
language skills deficit, very cautious
what occurs in a wernicke deficit
receptive aphasia resulting in difficulty understanding
what occurs in a brocas deficit
expressive aphasia resulting in difficulty speaking and writing
what is the patho of parkinsons
deterioration of the basal ganglia
what are the S/S of parkinsons
tremors, pin-rolling, rigidity, bradykinesia
what is the treatment of parkinsons
levodopa
what are the S/S of levodopa overdose
akinesia (freezing and slow) and athetosis (writhing movement of the neck
what are nursing interventions for parkinsons
small frequent meals, declutter environment, simplify clothing
what is the patho of myasthenia gravis
autoimmune disease that attacks acetylcholine receptors
what are the S/S of myasthenia gravis
progressive weakness, ptosis, voice fading, respiratory problems
what are the causes of myasthenia gravis
stress, infection, extreme temps, hypokalemia
what is the treatment of myasthenia gravis
tensilon, neostigmine, atropine
what is the action of tensilon and neostigmine
cholinesterase inhibitor which increases acetylcholine
what is the action of atropine
blocks acetylcholine
what are the nursing interventions for myasthenia gravis
respiratory support, mechanical soft diet
what is the patho of multiple sclerosis
deterioration of the myelin sheath
what are the S/S of multiple sclerosis
muscle spasticity and stiffness, weakness and paralysis, diplopia, tinnitus, hermits sign (electric shock)
what is the treatment for multiple sclerosis
corticosteroids, immunomodulators, megavitamin therapy, baclofen pump
what is the patho of huntingtons disease
excess of dopamine
what are the S/S of huntingtons disease
involuntary movements (chorea), impaired speech and swallowing, deteriorating gait, intellectual decline
what are the nursing interventions of huntingtons disease
high calorie diet to accommodate chorea
what is the patho of ALS
progressive loss of motor neurons
what are the S/S of ALS
weakness of extremities, dysarthria, dysphagia, respiratory dysfunction
what is the prognosis of ALS
death in 2-6 years from respiratory infection secondary to compromised respiratory function
what is a cholinergic crisis
too much acetylcholinesterase drug that does not respond to tensilon
what med do you give for a cholinergic crisis
atropine
what is a myasthenic crisis
acute exacerbation that responds to tensilon and neostigmine
what is the patho of guillan-barre syndrome
post infectious polyneuropathy resulting in paralysis from the loss of myelin, inflammation of nerves, and loss of neurotransmission
what are the S/S of guillane-barre syndrome
paralysis from the lower extremities up, paresthesia, autonomic dysfunction, SIADH, respiratory failure
what is the treatment of guillane-barre syndrome
plasmapheresis, immunoglobin
what are nursing interventions for guillane-barre syndrome
assess and maintain airway and circulation, foley, passive ROM and repositioning, eye ointment and safety
what is the patho of bells palsy
facial paralysis involving cranial nerve 7
what are the nursing interventions for bells palsy
facial exercises and sling, protect eye from dryness, oral care, chew on unaffected side
what is the patho of trigeminal neuralgia
sensory disorder involving cranial nerve 5
what are the S/S of trigeminal neuralgia
severe, recurrent, sharp pain along nerve distribution in the tongue, gums, nose, and cheeks
what are common triggers for trigeminal neuralgia
cold, washing face, chewing, foods/fluids of extreme temp
what medications can be given for trigeminal neuralgia
elavil, baclofen, tegretol, valium, dilantin
how does alcohol injection help trigeminal neuralgia
produces anesthesia
how does a rhizotomy effect trigeminal neuralgia
severance of sensory root nerves
how does the jannetta procedure help trigeminal neuralgia
relocates artery that is compressing the trigeminal nerve
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