EXAM 3 REVIEW:

common symptoms to assess for in patients with neurological disorders/dysfunction:

pain, seizures, dizziness/vertigo, visual disturbances, and muscle weakness

nursing management for the patient with an ALOC

#1 priority is: establish an adequate airway for breathing (epiglottis and tongue may relax, occluding the oropharynx or pt. may aspirate

-maintain fluid balance/nutrition

-oral care

-maintain skin/joint integrity

-preserve corneal integrity

-maintain body temperature

-prevent urinary retention

-promote bowel function

-monitor for complications

potential complications for people with ALOC:

-respiratory distress/failure

-pneumonia

-aspiration

-pressure injury

-thromboembolism

-contractures

Increased ICP

WHAT: increased pressure in the skull

-often caused by head injury

-decreases cerebral perfusion

-medical emergency

S/S: early--> ALOC, restlessness, headache, weakness, and pupil changes

late--> Cushing's triad (bradycardia, HTN, and bradypnea), and a wide pulse pressure

INTERVENTIONS: neutral/midline head positioning, elevated HOB, diuretics given (mannitol), and continuous monitoring for complications

preoperative/postoperative management for patients having intracranial surgery:

PREOP:

-give anticonvulsant such as phenytoin before surgery to reduce the risk of seizures

-dexamethasone given to reduce cerebral edema

-diuretics given

-anxiety meds may b given before as well

-assess LOC

-reduce anxiety/provide emotional support

POSTOP:

- monitor/manage BP

-reduce cerebral edema

-relieve pain/prevent seizures

-monitor for complications (ICP, bleeding, hypovolemic shock, infections)

nursing management during and after a seizure:

DURING seizure:

-observe/record sequence of signs

-prevent injury by protecting the head with a pad, moving objects out of the way, and turning pt. to the side

-loosen clothing

-provide privacy

-time seizure

-stay with patient

AFTER seizure:

-keep patient on one side

-reorient patient

-guide patient into bed/chair if on floor

types of headaches + interventions

primary headaches: no organic cause --> migraines, tension-type, and cluster headaches

-focus is on knowing triggers (for migraines), prevention, and relief of pain

secondary headaches: symptom associated with other causes such as brain tumor

-focus is on treating the cause (stroke, etc.)

ischemic stroke

WHAT: a type of stroke that occurs when the flow of blood to the brain is blocked (due to a blood clot)

S/S: numbness/weakness of the face/arm/leg, confusion/ALOC, visual disturbances, trouble speaking/understanding speech, dizziness, difficulty walking, and sudden headache

INTERVENTIONS: prevention is the best approach (no smoking, physical activity, healthy diet, etc.), administration of anticoagulants, thrombolytic therapy, carotid artery stunting, improving mobility/assisting with nutrition, and monitoring/managing complications

hemorrhagic stroke

WHAT: occurs when a blood vessel in the brain ruptures

-HTN is number one cause

S/S: sudden/severe headache, N/V, and neurological deficits (similar to ischemic stroke s/s)

INTERVENTIONS: prevention (managing HTN), treat any complications (ICP etc.), increase cerebral perfusion, and relieve anxiety

closed (blunt) brain injury

occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura

open (penetrating) brain injury

Skull is fractured, and dura mater is breached (ex: gunshot wound)

contusion

the brain is bruised and damaged in a specific area because of severe blunt force/trauma (can cause structural damage to brain)

concussion

a bruise like injury of the brain that causes TEMPORARY loss of neurological function with NO apparent structural damage to the brain

epidural hematoma

WHAT: a collection of blood in the space between the skull and dura mater

-often caused by falls

S/S: brief loss of consciousness, elevated ICP, and neurological deficits

INTERVENTIONS: treatment focuses on preserving brain homeostasis and preventing secondary brain injury (stabilization of cardio. and respiratory function); burr holes, craniotomy, reduce ICP, and remove bleeding/clots

meningitis

WHAT: inflammation of the meninges (can be bacterial or viral)

S/S: headache along with fever/chills, nuchal rigidity, positive Kernig's sign (when pt. is lying flat with thigh flexed, the leg cannot be extended), positive brudzinski's sign (when neck is flexed, hips/knees flex as well), photophobia, and a rash

INTERVENTIONS: early administration of IV antibiotics, meningococcal vaccine, dexamethasone, treat dehydration/seizures/shock, assess for early signs of shock/respiratory failure, and giving antipyretics

brain abscess

WHAT: collection of pus anywhere within the brain

S/S: headache that is worse in the morning, ALOC, increased ICP, and fever

INTERVENTIONS: control increased ICP, IV ABX's, corticosteroids, ongoing neuro assessment, and aspiration of pus

Encephalitis

WHAT: inflammation of the brain usually caused by a virus

S/S: fever, headache, confusion, ALOC, hemiparesis, hallucinations, and Parkinson-like movements

INTERVENTIONS: assess neurological function, acyclovir for herpes-simplex encephalitis, antifungals for fungal infections, and comfort/supportive measures

Creutzfeldt-Jakob disease (CJD) and variant CJD (vCJD)

WHAT: infectious, degenerative neurological disorder ("mad cow") from ingesting meat infected with prions

S/S: rapid cognitive decline, blurry vision, twitching and mm stiffness, difficulty walking, sleep disturbances, and behavior changes

INTERVENTIONS: (no effective treatment) --> progressive and fatal

multiple sclerosis

WHAT: progressive immune-related demyelination disease of the CNS (relapsing and remitting)

S/S: fatigue, muscle spasms, asymmetric weakness, numbness, difficulty in coordination, loss of balance, voice impairment, pain and visual disturbances

INTERVENTIONS: prednisone, interferons, prevention of aspiration, avoid strenuous activity/prevent fatigue, bowel/bladder control (voiding schedule, etc.),

myasthenia gravis

WHAT: a chronic autoimmune disease that affects the neuromuscular junction

-antibodies destroy Acetylcholine receptors at junction

S/S: voice impairment (happens earlier than in MS), ptosis (drooping eyelids), dysphagia, dyspnea, blurry vision, mm fatigue that improves with rest, and symmetric mm weakness

INTERVENTIONS: symptom management + anti cholinesterase/immunosuppressive meds (prednisone) , IVIG, and plasmapheresis

Guillain-Barre syndrome

WHAT: autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response, and sudden ascending muscle weakness

S/S: ascending weakness, paralysis, pain, absent DTR's, bulbar weakness, and cardiovascular issues (tachycardia/Brady, hypo/hypertension)

INTERVENTIONS: ongoing assessment for respiratory failure/cardiac dysrhythmias, or DVTs, plasmapheresis, IVIG, enhance physical mobility, and IV nutrition

(have mechanical ventilator/intubation at bedside)

myasthenia crisis vs. cholinergic crisis

Myasthenic crisis: Severe worsening of myasthenia gravis → respiratory failure due to not enough acetylcholine at neuromuscular junction

-causes severe mm weakness, and respiratory distress

-happens when patient does not take their meds

Cholinergic crisis: Excess acetylcholine at neuromuscular junction, usually from too much anticholinesterase medication

-also leads to respiratory distress

(TENSILON TEST --> if patient's symptoms improve, it is MG crisis, if not--> cholinergic crisis)

Trigeminal Neuralgia

WHAT: a condition characterized by sudden, intense, severe lightning-like pain due to an inflammation of the fifth cranial nerve

S/S: pain to face from any kind of stimulation such as washing face, brushing teeth, or even the wind

INTERVENTIONS: anti seizure meds are used off-label, surgery to remove nerve/decompress nerve, avoidance of triggers, reduce pain, and enhance hygiene

Bell's palsy

WHAT: temporary paralysis of the seventh cranial nerve that causes paralysis only on the affected side of the face

(most patients completely recover in 3-5 weeks)

S/S: unilateral facial weakness, drooping, and paralysis

INTERVENTIONS: corticosteroid therapy, provide supportive care, and protect eye (cover the eye)

spinal cord injury

WHAT: trauma to the spinal cord, vertebral column, supporting soft tissue, or intervertebral discs

S/S: depends on level of injury

cervical injury- usually quadriplegia

thoracic injury- lower extremity paralysis

lumbar injury- bladder + lower extremities effected

INTERVENTIONS: high-dose IV corticosteroids, oxygen therapy, and skeletal fracture reduction/traction and/or surgery

spinal shock and neurogenic shock

spinal shock = loss of reflexes, flaccid paralysis below level of injury, and sensory deficits (NO HYPOTENSION)

neurogenic shock = results in HYPOTENSION + bradycardia, dysregulated temperature, and dependent edema

meds for neurogenic shock= prednisone to decrease swelling, and IV fluids/vasopressors to increase BP

Autonomic Dysreflexia

WHAT: a medical emergency that occurs in people with spinal cord injuries at T6 or above triggering an uncontrolled sympathetic response

S/S: severe HTN (up to 300 systolic), pounding headache, diaphoresis above level of injury, bradycardia, flushing, nasal congestion, blurry vision, and anxiety

INTERVENTIONS: determine trigger + remove the trigger (distended/full bladder, blocked catheter, tight clothing, constipation/impaction, etc.); sit patient upright, and give antihypertensives

management of MG crisis

-patient education on s/s (severe muscle weakness, etc.)

-patient education on taking medications (can happen if they do not take meds)

-ensure adequate ventilation

what are the differences in symptoms between MG and MS?

MG- symptoms are primarily muscle weakness that worsens with activity

MS- has similar muscle weakness/spasms along with neurological dysfunction --> numbness, tingling, cognitive changes, and bladder dysfunction

A spinal injury at the lumbar vertebrae and above will lead to ______

bladder involvement

primary interventions for all SCI's:

focus on mobility, skin integrity, breathing, and nutrition

a subdural hematoma is usually caused by ______

normal brain shrinkage

basilar skull fracture signs:

Raccoon eyes (periorbital edema), CSF leakage, bleeding, and bruising on lower jaw/behind eyes (battle sign)

S/S of a brain injury:

altered LOC, abnormal pupils, neurologic changes (sensation, movement, reflexes), changes in vitals, headache, and seizures

normal ICP is

5-10 mmHg

verbal response (GCS)

5 - oriented

4 - confused

3 - inappropriate words

2 - incomprehensible sounds

1 - none

Motor response (GCS)

6-obeys commands

5-localizes pain

4-withdraws from pain

3-abnormal flexion

2-abnormal extension

1-none

Eye opening Response (GCS)

4- opens eyes spontaneously

3- opens to speech

2- opens to pain

1- does not open eyes

normal cerebral perfusion pressure

60-80 mmHg

if a patient's CPP is less than 50, what does that indicate?

permanent neurological damage

how can you maintain a person's cerebral perfusion?

reduce ICP pressure, avoid extreme head rotation, and keep HOB flat or only 30 degrees

cranial nerve 1 (olfactory)

I

Function: Smell

Assessment: Ask the patient to close their eyes and identify familiar smells (e.g., coffee, vanilla) in each nostril separately

cranial nerve 2 (optic)

II

Function: Vision (visual acuity, visual fields)

Assessment:

Visual acuity: Use Snellen chart

cranial nerve 3 (oculomotor)

III

Function: Eye movement (up, down, medial), eyelid elevation, pupil constriction, lens shape for near vision

Assessment:

Pupillary response to light and accommodation

Extraocular movements (up, down, medial)

Observe eyelid drooping (ptosis)

cranial nerve 4 (trochlear)

IV

Function: Eye movement (superior oblique muscle → down and inward)

Assessment: Ask the patient to look down and in (common test: reading or walking downstairs

cranial nerve 5 (trigeminal)

V

Function:

Sensory: Face, sinuses, teeth

Motor: Muscles of mastication

Assessment:

Sensory: Light touch, pain, temperature on forehead, cheeks, jaw

cranial nerve 6 (abducens)

VI

Function: Eye movement (lateral rectus → outward/lateral)

Assessment: Ask patient to look laterally (side to side)

cranial nerve 7 (facial)

VII

Function:

Motor: Facial expression

Assessment:

Ask patient to smile, frown, puff cheeks, raise eyebrows, close eyes tightly

cranial nerve 8 (vestibulocochlear)

VIII

Function: Hearing and balance

Assessment:

Hearing: Whisper test, tuning fork (Rinne and Weber tests)

Balance: Observe gait, Romberg test

cranial nerve 9 (glossopharyngeal)

IX

Function:

Motor: Swallowing, gag reflex

Assessment:

Gag reflex (tested with IX and X together)

Swallowing ability

cranial nerve 10 (vagus)

X

Function:

Motor: Palate, pharynx, larynx (speech and swallowing)

Assessment:

Ask patient to say “ah” and watch uvula for midline elevation

Assess speech for hoarseness

cranial nerve 11 (accessory)

XI

Function: Shoulder and neck movement (sternocleidomastoid, trapezius)

Assessment:

Ask patient to shrug shoulders against resistance

Turn head against resistance

cranial nerve 12 (hypoglossal)

XII

Function: Tongue movement (speech, swallowing)

Assessment:

Ask patient to stick out tongue (should be midline)

Move tongue side to side

GCS of 8, _______

intubate

what is the best/highest score you can get on the GCS scale?

15

how to recognize a CSF leak and what to do:

-if there is clear, watery drainage from the nose or ear that has a salty taste

-postnasal drip

-headache worse at night

-halo sign (clear ring around blood on gauze)

actions: notify HCP, HOB elevated, avoid coughing or straining, and protect the site