Medsurg 1 (CH 5) - Neurological Disorders PT 1

LOC assessments

- Alert --> able to concentrate, spontaneous eye movements

- Lethargic --> responsive to voice unable to concentrate/awake

- obtuned --> responsive to touch, AOx1-2

- stuporous --> responsive to sternal rub, unable to awake

- coma --> unable to arise for a long time period

mental status assessments

- appearence

- behavior

- speech

- thought process

- mood

- cognitive ability

behavior observations

- posture/gait

- facial expressions

- eyes

- affect

mental status vs LOC assessments

- LOC = glassglow coma scale, determining state of arrousal

- mental status = direct relationshiop, LOC assumes mental status level. affect of a person

Glassglow coma scale assessments

determines LOC based on 3 subclasses (eyes, speech, motor)

- lowest score = 3 (deep coma state)

- highest score = 15 (fully alert state)

- <8 score = high comatose risk

glassglow coma scale EYE grading

EYES: grading 4-1

- 4 = sponatneous

- 3 = to speech

- 2 = to pain

- 1 = nonresponsive

glassglow coma scale SPEECH grading

SPEECH: grading 5-1

- 5 = AO

- 4 = confused

- 3 = inappropriate responses

- 2 = incomprehensable

- 1 = non-responsive

glassglow coma scale MOTOR grading

MOTOR: grading 6-1

- 6 = obeys commands

- 5 = localized pain to commands

- 4 = withdraws from pain to

- 3 = decorticate

- 2 = decerebrate (mental status is reverting back to fetal responses EMERGENCY)

- 1 = non-responsive

Mini-Mental State Examination (MMSE)

mental status assessment grading out of 30 based on 5 subclasses

- lower the score = severe impaired mental state

- orientation (AOx0-4)

- registration (immediate memory)

- attention/calculation

- recall (short-term memory)

- language and visual skills

national institute of health stroke scale (NIHSS)

mental status assessment to determine neurlogical function for suspected stroke

- determines severity

- LOC

- facial drooping

- arm/leg strength

- speech/language abilities

- AO grading

altered LOC causes

- traumatic brain injuries

- stroke

- infections (MENINGITIS/ENCEPHELITIS)

- metabolic disturbance

- overdose

nursing priorities for altered LOC assessments

- ENSURE AIRWAY

- neuro checks frequently

- determine baseline altered LOC/mental status

- baseline vitals

- safety assessments

CT scan education

- series of X-ray images on different angles/areas of the body. shows cross-sectional imaging of body

- lay fat on a table

- doughnut shaped machine scans body/rotates around you

- takes 10-15MIN

nursing priorities for CT scans

- reduce anxiety

- educate to remain as still as possible

- education radiation risk

primary use for CT scans

- trauma injuries

- bone fractures

- tumors/growths

- heart disease

- vascular disease

- biopsy

- infections

MRI pt education

magnetic scanning of the body,

- can be very claustraphorbic for some people/LOUD

- must not have any metal at all

- takes 45MIN-1HR

primary use for MRI

- aneurysm

- MS

- stroke

- spinal disorders

- tumors

- blood vessel issues

- join/tendon anxiety

nursing priorities for MRIs

- minimize anxiety

- assess for any metal in or on body

- educate to remain as still as possible

- assess problems addressed on MRI

X-RAY pt education

quick/painless procedure uses X-Rays to look at dense images in the body (AKA: bones, growths, swallowed items, poop)

- takes 10-15MIN

primary use for X-RAYs

- bone fractures

- orthoitis/osteoporosis

- infections

- growths/cancer

- swallowed items

- digestive tract issues

nursing priorities for X-RAYs

- minimize pt anxiety

- educate importance or procedure

- educate risk of radiation exposure

ultrasound pt education

use of a small remote uses high frequency sound waves to look at imagines of the body

- use of gel/lube is applied to skin to get clearer image of inside body and protect the skin

- takes 30MIN-1HR

primary use for ultrasounds

- gallbladder issues

- lumps/growths

- pregnancy

- genital/prostate issues

- biopsies

- blood flow issues

- joint inflammation

PET scan pt education

use of radioactive drugs/dye is inserted into the blood stream in order to show scans of organ/tissue functioning

- tracker can be ingested or via IV

- takes 1 1/2 - 2HRs

primary use for PET scans

- cancer

- heart disease

- CAD

- alzhiemers (pinpoint origin)

- seizures (pinpoint origin)

- epilepsy (pinpoint origin)

- parkinsons

- stroke

nursing priorities for PET scans

- do not eat 4-6hrs before procedure

- assess swallowing/aspiration risk

- assess IV patency

- allergy assessments

- pt positioning: supine (lying on their back) with arms above their head

ICP education

increased intracranial pressure (normal limits = 0 - 10)

- buildup of pressure in the skull damaging the brain

- 15> upper limits (very dangerous)

CAUSES:

- stroke (ischemia)

- increased edema

- decreased cerebral perfusion

- brain tissue death

causes of ICP

- trauma to head

- metabollic reasons

epilepsy education

reacurring seizures <24HRs APART commonly caused by chronic underlying conditions

CAUSES:

- cerebral vascular disease

- childhood fevers

- MENINGITIS

- brain tumor

- head trauma

- HYPOGLYCEMIA (metabollic changes)

- hypoxemia

epilepsy s/s

- loss of consciousness

- muscle stiffness/jerking

- staring spells

- confusion

- unusal sensory changes (touch, auditory, smell, visual)

nursing priorities for epilepsy

- safety assessment's

- maintain airway

- pos-seizure education

- determine underlying triggers for episodes

focal seizure classification

potential onset symptoms --> start on one side of brain (symptoms SOMETIMES affect awareness)

- focal-aware seizures

- Focal-impaired awareness seizures

focal-aware seizures s/s

- person is conscious/appears awake

- specific body part twitching

- fear/anxiety

- sensory changes

focal-impaired awareness seizures s/s

- alerted conciousness, appears awake but is not responsive

- confusion

- sensory changes

- difficultly responding

- memory loss

- repetitive movements

- lip-smacking

generalized seizure classification

starts on both sides of the brain, loss of consciousness, severe symptoms typical of what people expect seizures to look like --> (ALWAYS LOSS OF CONSCIOUSNESS)

- lasts >2min

- > 5min = status epilipticus

- recovery phase lasts hrs, sleepiness = hrs

types:

- tonic clonic seizure

- abscence seizure

- myoclonic seizure

- atonic seizure

tonic clonic seizures s/s

- stiffening and jerking movements

- loss of consciousness

- moaning/painful sounds

- frophing at the mouth

absence seizures s/s

- brief staring spells

- rapid facial movements/blinking

- short/onset symptoms

myoclonic seizures s/s

- sudden uncontrolled muscle jerking

- can occur in clusters

- frequent falls

atonic seizures s/s

- sudden brief shocks of muscle jerks

- unable to move

- sudden falls/droping objects

nursing priorities for seizures

RECOVERY POSITION: promotes drainage + ensures airway

- bend the arm nearest you, raising it above head.

- other arm goes across their chest

- Bend your knee farthest from you

- mouth pointing downward

- clear surroundings

- Prepare to administer O2

- respiratory assessments post-seizure

- documentation

seizure education

uncontrolled neurological impulses causing a change in LOC, memory, behavior, and feelings

CAUSES:

- cerebral vascular disease

- Childhood fevers

- MENINGITIS

- brain tumor

- head trauma

- HYPOGLYCEMIA (metabolic changes)

- hypoxemia

status epilipticus education

continuous seizure state >5MIN --> MEDICAL EMERGENCY

- PRIORITIZE stopping the seizure

- WHY STOP? =

status epileptics nursing priorities

- ABCs --> MAINTAIN AIRWAY

stopping the seizure:

- IV vavlium/ativan

- IV phenytonin

- pt positioning promoting drainage

- anticipate invasive airway methods

diagnostic priorities for seizure care

- EEG 24HRS WITHIN SEIZURE + repeat

- MRI/CT/PET scan/MRA

- labs ruling out metabolic issues

EEG education

Multiple electronic wires are connected over the entire head via gel/pads to look at electrical activity in the brain

- takes 1HR

- must remain completely still

- flashing lights/buzzers = risk seizure precautions

EEG pre procedure care

- shampoo/wash hair before

- NO caffeine 24- 48hrs

- withhold non-compatible meds 24- 48hrs before

Medications not compatible w/ EEGs:

- vaccines

- Profanolol (general anesthesia)

- IV benedryl

- hormone meds

phenytoin priority care

- CNS effects w/ toxicity = ataxia, hystammus, blurry vision

- gingivitis in children

- SJ syndrome monitoring

- therapuetic range 10-20mcg

- IV care = 50mg MAX dose/ 25mg MAX dose in elderly

primary headaches

no underlying condition/cause

- migraines

- tension

- cluster

secondary headaches

arise from underlying structural, systemic, or infectious causes and may be life-threatening

(INFECTIOUS MOST COMMON)

- neck

- sinus

- TMJ

migraines

an intense constant headache surrounding the entire head

manifestations:

- N/V

- sensitivity to light/noise

- head throbbing

- dizziness

- neck pain/stiffness

tension headaches

dull aching pain, band of tightness across the head

manifestations:

- dull aching pain

- tightness in forehead/temples

cluster headaches

sharp headache in one side of head affecting the eye

manifestations:

- watering of eye

- N/V

-facial flushing

- onset symptoms

- sensitivity to light/sound

- can be treated with "triptin medications" and high flow oxygen

primary/secondary headache nursing care

- low stimulating environment

- medication therapy

- reduce light and sound triggers

- cool compress for head

- prioritize determining triggers for headaches

SECONDARY: prioritize determining cause of the headache

TMJ headache

pain is at temples, in front of ears

sinus headache

pain is usually behind the forehead and/or cheekbones

neck headache

Pain is at the top and/or back of head