Med Surg week 7 (Neuro assessment and seizures)

peripheral nervous system consists of

12 pairs of cranial nerves

31 pairs of spinal nerves

autonomic nervous sysetem

cranial nerves and the mneumonic

Oh, oh, oh, to touch and feel very good velvet, such heaven!

olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, hypoglossal

central nervous system consists of

brain and spinal cord

the autonomic nervous system of the PNS consists of

sympathetic fibers and parasympathetic fibers

neurons are the…

basic unit of the brain, transports impulses/messages

motor vs sensory neurons

motor neurons impact mobility

sensory neurons impact perception and retain/processing of information

myelin sheaths

white lipid covering that enhance the speed of nerve impulse conduction along an axon

cerebral spinal fluid action, produced by

circulates/cushions brain and spinal cord

produced by choroid plexus

CSF circulation

circulates through subarachnoid space and is reabsorbed via arachoid villi to the suprasaggital sulcus

neuroglial cells action

position, structure, and nutrition for neurons

also help regulate the blood brain barrier

blood brain barrier

endothelial cells of cerebral capillaries keep substances in blood and out of CSF circulation/brain tissue

what cross the BBB

oxygen, Co2, glucose, water, alcohol, anesthesia

what does NOT cross the BBB?

larger molecules like albumin/any substance bound to it, some antibiotics

cerebral circulation

internal cartoid branches to 2 anterior cerebral arties and 2 middle cerebral arteies

r/l vertebral arteries join to make the basilar artery

the basiliar artery branches off into the two posterior cerebral arteries to form circle of willis

layers of brain

cerebral cortex, pia mater, subarachoind space (CSF!), arachnoid space, dura mater, cranium, scalp

3 main areas of the brain

frorebrain, cerebellum, brainstem

forebrain

most advanced

divides into cerebrum, diencephalon, thalamus, hypothalamus, epithalamus

cerebrum recieves info from the ____. Its three main functions are…

receives info via the thalamus

intelligene, creativity, memory

thalamus

in the diencephalon, switch board of CNS for sensory and LOC

epithalamus job

emotion, smooth movement, voluntary motor function

hypothalamus job

under ANS control to regulate temperature and cognition

Cerebral cortex

of the forebrain

composed of gray matter to control higher functioning, processes peripheral NS, feelings/thoughts

brain stem is composed of the

midbrain, pons, RAS, and medulla

responsible for basic life functions such as breathing, heart rate, and arousal

reticular formation system(RAS)

part of brain stem, controls alert/awareness

cerebellum function

recieves info about muscle, joints, tendons to regulate balance

anterior, posterior, and middle artery are joined together by small comunicating arteries to form a

ring at the based of brain called circle of willis

spinal cord regulates

mobility, organ function, sensory perception

transmits info to/ from brain

descending tracts of spinal cord- originate in…carries…

begin in brain and end in spinal cord

carries autonomic/involuntary movement

ascending tracts of spinal cord- originate in…carries…

begin in spinal cord and end in brain

carries sensation pain, temperature, light tough/pressure and awareness of movement

sympathetic NS- carries, cells originate, location

urgent stress response= fight/flight

cells originate in grat matter

nerves located T1-L2/3

what is the flight/fight response

increased HR, RR, inhihbits GI and repro

parasympathic nervous system

cells from S2-S4 and cranial nerves 3, 7 ,9, 10

can slow body down when needed

involves sensory and motor function= irritation, stretching of an organ, decrease in O2, pain perception

what is a bodily therapy that can control PNS

biofeedback

nursing assessment of neuro

fam hx/genetic risk= epilesy, stroke, mirgraines

personal hx= SUD, occupation, smoking, appearance, education

memory, attention, language/copying, cognition, cranial nerves, sensory function, relfex activity, cerebellar function (balance)

mental status assessment consists of

LOC and orientation/cognition

LOC

aawareness of self/environment

includes= A&O, amount of stimulation needed to arouse

ask= person(HCP), place(home address), time(year/month)

when should you NOT assess LOC?

if a pt was just medicated or if hypoglycemic

less than levels of alertness

lethargic= fades in/out, drowsy, slowed

stuporous= pt can only be awakened w vigorous or painful stim (sternal rub)

comatose= no arousal

What information from sensory assessment is key to baseline?

what is their preferred hand dominance

what does cognition assess

memory and attention

use cognition box= directions, reading comprehension, ease of ability to find words

glascow coma scale- what are the main areas w scoring and highest score?

eye opening (4) verbal response (5), motor response (6)

highest score is 15 (lower the score the lower the neuro functioning)

what other assessments are done with GCS? explain them

pupillary response- size are equal, reactivity to light, constriction

muscle strengths- hands/feet

when should we assess size of pupils?

before using flashlight when testing for constriction

decortication, score?

arms, wrists, fingers are flexed

internal rotation and plantar flexion of legs

score= 3

what could decorticate positioning mean?

potential lesions in the corticospinal pathway

Decerebration

abnormal movement, rigidity w extension of arms/legs

pronation of arms

plantar flexion

opisthotonus= body spasms, bowed forward

score of 2

motor response GCS

pt dosen’t respond to comands, either localizes (5), withdraws (4) OR…

abnormal flexion= decorticare posturing is a score of 3

abnormal extension= decerebrate posturing is a score of 2

Pupillary assessment= PEARRLA

pupil size, light, accomodation

light reactions= brisk, slugish, fixed, dilates, pinpoint

Lab assessment fo neuro abnormalities

BMP- Glucose, Calcium, Sodium, Potassium, Chloride, CO2, BUN Creatinine

ABG= pH

skull and spine xrays for assessing neuro system investigates

fractures, calcifications, erosions, structural abn

Cerebral angiography (arteriography) for assessing neuro system investigates

perfusion to the brain

potential brain bleeds/ruptured BV

CT scan for assessing neuro system investigates

bone and CSF abnormalities

MRI for assessing neuro system investigates

nerve roots/srtucutres

what other more rare assessments can we go for abn of neuro system

PET scans

single photo emission CT (SPECT)= crosses BBB

MEG= expensive, see brain singnals in action

electromyography (EMG)

identifies nerve/muscle disorders as well as spinal cord disease

lumbar puncture

insertion of spinal needle into subarachnoid space (3rd/4th lumbar vertebrae) to assess CSF for inf, bleeding, cancer, cranial pressure disorders

contraindicated in pt w increased ICP or skin infection near puncture site

lumbar puncture nursing interventions

stand at hob, ensure consent is given, answer questions

ask provider for calming meds, ensure admin of local anesthetic

position pt to fetal side lying (to seperate vertebrae for inc access to nerve roots)

ensure an empty bladder

teach pt to STAY STILL and alert if feel shooting pain/numb/tingling

monitor for s/s of comp= inc ICP, CSF leak, herniation, inf, hematoma

spinal h/a from lumbar pincture

due to the brain taking a while to replenish CSF
hard to treat

s/s of inc ICP

h/a, n/v, altered LOC, vision changes/blurred vision

follow up care from a lumbar puncture

lie flat, ensure bed rest

drink fluids

obtain VS within 1st hour, neuro checks Q1 hr for 3-4 hrs

assess site

CSF appearance

clear like water

EEG (Electroencephalography)

records electrical activity of cerebral hemispheres showing freq/amp

sleep deprivation may be required, pt cant drive home after

anticonvulsants can be witdtheld 12-24 hrs before

EEG (Electroencephalography) nursing maagement

ensure pt has not fasted (hypo can alter results), ensure hair is clean

ensure a quiet room w no visitors

pt can be in bed or in chair

lie still w eyes closed at first, then engage in activity like…

hyperventilation= show vasoconstriction/alkalosis which can initate seizure

bright light

sleep dep.

nursing post care of EEG

wash hair asap!

what is a seizure? what can it result in?

abnormal, sudden, excessive, uncontrolled electrical discharge of neurons w/in brain

can result in alternation of consciousness/sensory ability/behavior

epilepsy

two or more seizures

chronic disorder w recurrent, unprovoked seizure activity

can be caused by anormality in electrical neuronal activity/imbalance in neurotransmitters (GABA)

examaples of causes of seizures

fever

alcohol withdrawl

brain tumor

head injury

generalized tonic clonic seizures

lasts 2-5 minutes, stiffening, muscle rigidity, immediate LOC

postictal state of tonic clonic seizures

a period of confusion, disorientation, and fatigue that follows a seizure, lasting from minutes to hours.

partial/focal seizures

one part of the cerebral hempisphere, either complex or simple partial

complex partial seizures

may lose consciousness for few mins

amnesia after

simple partial seizures

less responsive to treatment

seen in adults

remain conscious, see aura

unclassified seizures can occur for

no reason

primary/idiopathic epilepsy

not associated w an identifiable brain lesion

secondary seizures

result from underlying brain lesion, most commonly a major trauma

many diseases/disorders associated w s/s of seizure

seizure risks

metabolic disorders

acute alochol withdrawl

electrolyte disturbances (Na2+, K+. hypoglycemia)

heart disease

high fever

stroke

substance abuse

head injury

seizure diagnoses

EEG

CT scan/MRI

rule out underlying causes, documentation before/after seizures

carbamazepine

tegratol

monitor WBC, can decrease

Diazepam and or Lorazepam

take at same time daily, follow up on labs

seizures given in hospital to stop (iv or rectal)

divalproex

depacote

monitor theraputic level

gabapentin

neurontin

for neuropathy

Lamotrigine

lamactyl

titrate doses, do not stop abruptly

monitor for SJS

Levetiracetam

Keppra

do not stop abruptly

Phenobarbitol

barbituate

decreases the effectiveness of hormonal contraceptives and interacts dangerously with alcohol

Phenytoin

Dylantin

IV/PO

don’t give with warfarin→ pt will bleed more

general anti epileptic therapy interventions

evaluate most current blood level of medication (theraputic range)

be aware of drug/drug interactions

maintain theraputic blood levels for max effectiveness

document/report adverse reactions

seizure precautions

airway= oxygen, suction equipment

IV access (ensure flushed Q shift)

side rails up, padded rails (some cases)

Do not force anything into mouth, (NO TONGE BLADE)

turn pt on side

protect from environment= clear, free of clutter

nursing management w seizure occuring

vs, o2 sat

document start/end time, ensure safety, NO RESTRAINTS

after 5 mins get ativan to stop seizure

other meds= lorazepam, diazepam, diastat, IV phenytoin

status epilepticus criteria

ER- prolonged seizures lasting more than 5 mins OR repeated seizures over course of 30 mins

status epilepticus managment

establish airway- suction PRN

ABGs

ensure safe environment= clear clutter

IV push lorazepam, diazepam, rectal dizepam

loading dose IV phenytoin

vagus nerve stimulation

device subcutaneously surgically implanted near collarbone in L chest wall to the vagus nerve to precent simple/complex seizures

other surgical mangement for seizures

anterior temporal lobe resection

partial corpus callostomy= cut brain fiber connecting 2 halves of brain

Patient/family education

alternative employment, refer to social services

vocational rehab

anti epileptic drugs may not be stopped even if seizures stop

no driving for 6 mos after a seizure