NURS 353 final exam (neuro, pt.1)

transient ischemic attack characteristics

occlusion of a small artery that resolves quickly (24 hrs) with min. residual deficit
usually very small artery/arteriole => affects small portion of brain tissue
usually <5 min, always <24 hrs

frontal lobe CVA characteristics

1. altered speech

2. altered emotional behavior

3. alteration of complex intellectual abilities

parietal lobe CVA characteristics

1. altered pain/cold/pressure sensation

2. altered cognition of size/shape/texture

3. altered understanding of location & intensity of stimuli

4. lessened awareness of body parts

temporal lobe CVA characteristics

1. altered hearing/taste/smell

2. altered interpretations of sounds

occipital lobe CVA characteristics

altered visual perception

left hemisphere CVA characteristics

1. right sided paralysis/weakness

2. right visual field deficit

3. expressive, receptive, or global aphasia

4. altered intellectual functioning

5. slow, cautious behavior

right sided CVA characteristics

1. left sided paralysis/weakness

2. left visual field deficit

3. spatial/perceptual deficits

4. increased distractibility 

5. impulsive behavior, poor judgement

6. lack of awareness of deficits

why is periodontal disease relevant to CVA

direct link between body inflammation & gum disease
=> can increase risk of plaque buildup in blood vessels

what does BEFAST stand for

1. B: balance issues

2. E: eyesight changes

3. F: face drooping

4. A: arm weakness

5. S: speech difficulty

6. T: time to call 911

hemiplegia

one sided paralysis

hemiparesis

one sided weakness

dysarthria

speech difficulty d/t weakness of MUSCLES that control speech (not difficulty understanding or creating speech)

expressive aphasia (Broca’s)

loss of ability to produce language

receptive aphasia (Wernicke’s)

loss of ability to understand written or spoken language

hemianopsia

loss of half of visual field

window of opportunity for tPA

<3 hrs - 6 hrs

contraindications for tPA admin

missed WOO
recent trauma/surgery/other CVA
GI/GU bleed
BP 185/110+
INR > 1.7

clot retrieval for CVA procedure

microcatheter is guided beyond thrombus, thrombus is aspirated into catheter

CVA clot retrieval nursing interventions

t-PA interventions PLUS
keep flat for 4 - 6 hours to prevent dislodging of clot at femoral access site
monitor pulse distal to access site (pulse, movement, temperature)

functional independence measure (FIM)

way to quantify ability to care for self based on current mobility, social, cognitive functioning

aneurysm

weakened spot in vessel that fills w/ blood

coiling of an aneurysm

platinum wire is coiled w/in to prevent collapse & prevent blood from accumulating & clotting

most common cause of head injury / TBI

falls

classifications for level of damage of TBI

open v closed
diffuse v focal
epidural v subdural v intracerebral

epidural TBI/hemorrhage characteristics

above dura, under skull
rupture of artery (medical emergency)

subdural TBI/hemorrhage characteristics

between dura & brain tissue
usually venous (rupture of vein)
acute, subacute, chronic
=> chronic in elderly & people on anticoagulants

intracerebral TBI/hemorrhage characteristics

w/in brain tissue
caused by focus injury or systemic issues (ex HTN)

s/s of epidural hematoma

1. loss of consciousness

2. focal neuro deficits

3. pupil dilation

4. paralysis of extremity

concussion characteristics

damage is global & microscopic
homogenous impairment of brain cells => underperformance
no visible bleeding

s/s concussion

confusion
irritability
disorientation
headache

contusion characteristics

damage is localized & macroscopic
leads to structural damage that kills cells
creates areas of localized damage

s/s of contusion

1. increased ICP d/t bleeding

2. blurred vision

3. disorientation

4. unsteady gait, slurred speech

5. vomiting

6. coma

ways to medically control ICP

intracranial bolt
mechanical ventilation

goals of mechanical ventilation for ICP

prevent hypoxemia (can cause lactic acidosis => vasodilation => increased ICP)

prevent hypercapnia (can cause cerebral vessels to dilate & increase ICP)

primary areas of compromise for pt with TBI

airway & breathing pattern
cerebral tissue perfusion
fluid balance

secondary areas of compromise for pt with TBI

infection
post concussion syndrome
infection

s/s pf post concussion syndrome

1. headache, dizziness

2. lethargy, fatigue

3. irritability, emotional lability

4. poor concentration, decreased attention span

5. memory & intellectual impairment

normal
- ICP
- CPP
- MAP

ICP: 7 -15 mmHg
CPP: 60 - 80 mmHg
MAP: 65 - 100 mmHg

early s/s of increased ICP

1. changes in LOC

2. pupillary changes

3. impaired ocular movements

4. weakness in one extremity/side

5. impaired speech

6. constant headache that

   1. increases in intensity

   2. is aggravated by movement/straining

7. pain, puking

late s/s of increased ICP

1. deterioration of LOC

2. altered respiratory pattern

3. loss of brainstem reflexes (pupillary response, gag/swallowing reflex, corneal)

4. cushing’s triad (before herniation)

5. hemiplegia or flaccidity

6. posturing (decorticate or decerebrate)

cushing’s triad

HTN & widening pulse pressure
bradycardia
bradypnea

characteristics of decorticate posturing

sign of damage to corticospinal tract
better than decerebrate posturing, can progress to decerebrate or alternate

pt is exhibiting:
- adducted & flexed arms
- unclenched hands
- unilaterally or bilaterally

decorticate posturing

pt is exhibiting:
- arms adducted, extended, and pronated
- flexed wrists
- muscles are tightened & held rigid

decerebrate posturing

decerebrate posturing characteristics

damage to brainstem
worse than decorticate!!

nursing interventions to prevent CPP compromise

elevate HOB, maintain neutral position
preoxygenate & hyperventilate before suctioning
space nursing interventions to prevent patient fatigue
continually assess abdominal distention & level of cognition

what to avoid to maximize CPP in pt w/ increased ICP

1. valsalva maneuver

2. coughing w/ mouth closed

3. ask pt to exhale when being moved/turned

4. extreme hip extension

5. enemas, suppositories

6. isometric exercises that increase SBP

   1. contracting muscles w/o moving joint

7. high levels of PEEP

8. emotional distress & frequent arousal from sleep

nursing interventions to promote proper airway clearance in increased ICP

elevate HOB
admin O2 and suctioning PRN (never suction nares)
assess lungs, O2 sat, nasal drainage

nursing interventions to prevent fluid imbalance w/ increased ICP

good oral hygiene
assess VS, I&O, skin turgor, mucus membranes, serum & urine osmolality, IVF

if giving mannitol, what is it important to monitor for

CHF and pulmonary edema

nursing assessments to identify compromised bowel/bladder function during increased ICP

1. urinary output Q2 - 4 hrs

2. urine for specific gravity & glucose presence

3. bowel sounds, abdominal distention

4. stool for occult blood

nursing interventions to prevent infection during increased ICP

1. aseptic technique when managing intraventricular catheter/direct ICP monitoring

2. assess

   1. character of CSF drainage (report cloudiness/blood)

   2. s/s of meningitis

   3. temp, labs

   4. urine

   5. lungs

s/s of meningitis

fever, chills
nuchal rigidity
increasing, persistent headache

what to keep in mind when measuring BP of patient w/ increased ICP

high range is normal & essential for maintaining adequate CPP

medications for increased ICP

1. mannitol: osmotic diuretic

2. corticosteroids: reduce cerebral edema

3. dilantin: prophylaxis of seizure activity 

4. antibiotics

5. anti-anxiety meds

complications of increased ICP

1. brain stem herniation

2. respiratory distress/failure

3. aspiration, pneumonia, pressure ulcer, DVT, contractures

4. seizures

5. diabetes insipidus, SIADH

what is a seizure

uncontrolled, abnormal, recurring electrical discharges in brain

causes of a seizure

1. idiopathic

2. cerebrovascular disease, head injury/seizure, brain tumor

3. CNS infection

4. renal failure, hypoglycemia, HTN

5. hypoxemia, fever

6. drug/ETOH withdrawal

7. allergies

classifications of a seizure

generalized
partial/focal
- simple partial
- complex partial

generalized seizure

involves entire brain

partial/focal seizure

begins in one part of the brain

simple partial seizure

consciousness remains intact throughout seizure

complex partial seizure

seizure causes impairment w/o LOC

manifestations of a seizure

1. LOC

2. excessive movement (not necessarily convulsions)

3. loss of muscle tone

4. disturbance of behavior, mood, sensation/perception

nursing interventions during a seizure

maintain & protect airway
limit seizure duration w/ meds
protect against injury
observe seizure activity & monitor neuro/cardiac/resp

nursing interventions post seizure

reorient pt & treat any injury
maintain seizure precautions
meds & education PRN

status epilepticus

 emergency seizure lasting longer than 5 mins w/o waking between

s/s pf diabetes insipidus

1. polyuria & polydipsia

2. low urine specific gravity

3. dehydration

causes of diabetes insipidus

increased ICP
surgical ablation/irradiation of posterior pituitary gland
CNS infection

tx of diabetes insipidus

replace fluid loss
replace ADH

s/s of SIADH

fluid retention w/o edema
dilutional hyponatremia

causes of SIADH

1. increased ICP

2. bronchogenic carcinoma => paraneoplastic syndrome where ADH is secreted by tumor cells

3. severe pneumonia

4. hemothorax

treatment for SIADH

restrict fluid intake (1,200 - 1,800 mL / day)
replace sodium (hypertonic saline)

two common areas for spinal cord injury d/t greater ROM of spinal column

C5 - C7
T12 - L1

C5 - C7 spinal cord injury will result in what

tetraplegia (neck & down)

T12 - L1 spinal cord injury will result in what

paraplegia (below waist)

nursing interventions for acute spinal cord injury

maintain airway
maintain BP 90/60+ with IV fluids, vasopressors, elevate feet
stabilize spine until diagnosis
evaluate w/ ASIA impairment scale (level & completeness of injury)
admin meds

nursing interventions for spinal cord injury recovery

C&DB, Q2hr turn & reposition, bladder training
suctioning, control room temp
assess core temp Q4 hrs for 3 days after initial injury
monitor for post-void residual w/ bladder scan
prevent immobility complications (ctr, DVT, pressure injury)

autonomic dysreflexia

 autonomic nervous system reaction to overstimulation

cause of autonomic dysreflexia

spinal cord injuries above T6 + exacerbating factor
ex kinked catheter, distended bowel/bladder

onset s/s of autonomic dysreflexia

1. severe HTN, bradycardia

2. throbbing headache

3. profuse diaphoresis & flushing

4. nasal congestion, blurred vision

5. nausea

interventions for autonomic dysreflexia

1. elevate HOB to 90 degrees

2. continuously check BP & admin antihypertensive PRN

3. remove/treat possible causes

4. monitor Q3-4 hrs after symptoms subside

benefits of halo traction

immobilize cervical fractures
skeletal traction

nursing care for halo traction

1. wrench taped to front for emergency access

2. fall risk!!

3. never grasp rods to help patient to reposition

4. pin care & skin assessment for areas under jacket

CT scan purpose

creates detailed tissue & bone images that can detect hemorrhages, tumors, fractures, abscesses, hydrocephalus, edema, or ventricular/vascular anomalies (lesions)

cerebral angiogram

contrast dye is injected into an artery to assess vasculature in the brain to identify narrowing/blocked/ruptured vessels

lumbar puncture important contraindication r/t lecture

cannot be done with increased ICP d/t tumor/space occupying mass

PET scan purpose

observes blood flow & metabolic activity

EEG

electroencephalogram, measures electrical activity of the brain

direct ICP monitoring

ICU intervention that identifies pressure changes & allows prompt initiation of tx

benefits of direct ICP monitoring

1. access to CSF for sampling

2. evaluate tx response

3. early ID

max & min GCS score

max = 15
min = 3

FOUR score

full outline of unresponsiveness (GCS-like score for intubated pt)

carotid endarterectomy

removal of atherosclerotic plaque from carotid arteries

carotid stenting

opens carotid arteries for people w/ high surgical risk

indications for carotid endarterectomy & stenting

TIA, mild CVA, 70 - 99% carotid blockage

two types of intracranial surgery discussed in class

craniectomy & cranioplasty

craniectomy v cranioplasty

craniectomy: removal of part of skull to allow room for swelling
cranioplasty: repair of skull using a metal/plastic plate

indications for intracranial surgery

1. reduce ICP

2. remove tumor/foreign body

3. evacuate a blood clot

4. control hemorrhage

supratentorial v infratentorial intracranial surgery approach

supratentorial: area above tentorium cerebelli (membrane that separates brain from the cerebellum)
infratentorial: area below tentorium cerebelli (membrane that separates brain from the cerebellum)