Adult Health II: Exam #1 (Neuro & Critical Care)

Skull & Spinal Radiography

- x-ray reveals fractures, bone erosion, dislocation, etc.

CT

- cross-sectional images to revel tumors, internal bleeding/clotting, bone fractures, abnormalities (cancer), etc.

Non-Contrast CT

first step for stroke

Contrast CT

- better & more detailed

Nursing Education

* pt NPO for 4 hrs prior

- radiation harmful to fetus

* monitor BUN & creatinine

MRI

- cross-sectional image to reveal torn ligaments, bones, organs, joints, & tissue

- magnetic imaging

Nursing Education

* ask to remove metals or ask about implants (pacemaker)

LP/Spinal Tap

- CSF removed to detect cancers/malignancies, infections (meningitis, syphillis), etc.

Nursing Care

- pt must be in knee-chest position w/ neck flexed & head on pillow

- use 20-22 g inserted in L3/4 or L4/5

Cerebral Angiography

- visual cerebral blood vessels to reveal defects, narrowing, or obstruction of arteries

Nursing Education

* pt NPO for 6 hrs prior

- may have metallic taste/feel warm

* assess BUN & creatinine

Electroencephalography (EEG)

- assess electrical activity of brain (seizure activity, sleep disorders, behavior changes)

Nursing Education

- pt hair must be clean

- pt needs to be sleep deprived

* avoid stimulants (caffeine, etc) before test

Caloric Testing

- assess vestibular system by instilling warm/cold water into ear canal

Nursing Education

- abnormal result = NO rapid eye movement

ICP Monitoring

- device inserted into cranial cavity to record pressure

- shows waveform w/ pts who have head injury

- irrigate system to maintain potency & recalibrate

ex: intraventricular, subarachnoid screw/bolt, epidural sensor

Contrast Dye

Nursing Education

- withhold Metformin 48hrs prior to& 48 hrs after

- ask if allergic to iodine or shellfish

- ask about renal function (could lead to contrast-induced AKI)

Meningitis Pathophysiology

- inflammation of the meninges that affects the subarachnoid fluid space

Causes --> bacteria (most contagious; Neisseria meningitidis), viruses, fungi, parasites, amoeba, trauma, or meds

transmission --> high pop density (college dorms, prison)

* DROPLET PRECAUTIONS *

Meningitis Clinical Presentation Infants

- anorexia, vomiting, diarrhea

- irritability

- macular rash

- respiratory symptoms

Meningitis Clinical Presentation Adults

- fever

* severe headache

- stiff neck

- seizures

* photosensitivity

- N/V

Meningitis Diagnosis

* LP = most effective

* CSF proteins --> C & S = elevated

- blood or nasopharynx cultures

Glasgow Coma Scale

Nursing Assessment = notify provider of any significant changes

Prioritize Hypothesis

- lower = 3 pts (deep coma or death)

- highest = 15 pts (fully awake)

- score < 8 pts = severe head injury & coma

- score 9-12 pts = moderate head injury

- score > 13 pts = minor head injury

Migraines

Causes = genetics (#1), trauma, environment, foods/additives

Clinical Presentation = reoccurring headaches persisting for at least 72 hrs

- photophobia

- N/V

- unilateral pain

- stress

- anxiety

- phonophobia

Migraine Phases

1. Prodromal

2. Aura

3. Headache

4. Postdromal

Aura

- can tell it is coming

- visual field loss

- visual/sensory/motor disturbances

- tunnel vision

- blindness

- heavy limbs

- speech disturbances

- tingling

Cluster Headache

Causes = stress (#1), allergens, environment, tobacco/alcohol, meds

Clinical Presentation

- severe pain (excruciating & non-fluctuating) on one side of head & behind eye

- lacrimation, nasal congestion, eyelid/facial swelling

- 15 mins to several hours, several times a day

Tension Headache

Causes = stress (#1), posture, depression

Clinical Presentation

- mild or moderate pain (dull/band-like pressure) on both sides of head

- muscle tightness in shoulder, back, neck

- 4-6 hrs

Primary Headaches

migraine, tension, cluster

Secondary Headaches

Cause = underlying causes

ex: trauma, infection (meningitis), intracranial disorders, psychiatric

Seizure Pathophysiology

- abnormal, sudden, excessive discharge of electrical activity in the brain

Types

- generalized = tonic-clonic, absence, myoclonic, atonic, akinetic

- partial = simple or complex

Seizure Nursing Assessment

- seizure hx (type, occurrence, prodromal signs, aura, loss of motor activity)

- occurring during postictal states (headache, LOC, sleepiness, impaired speech or thinking)

Seizure Nursing Interventions

* Assess ABCs & LOC

* remain w/ the client (NEVER leave alone)

- time & duration (document)

- assess behavior at onset of seizure (if aura, what kind)

- call an ACT/rapid

- if standing or sitting --> lay on floor, left side, protect head

* protect airway from injury --> do NOT stick anything in mouth & have O2/suction ready

-do NOT restrain (loosen restrictive clothing)

- note the type, character, & progression of the movements during the sz

- monitor for incontinence

* IV access & admin medication IV push

* seizure precautions (fall/aspiration)

- monitor behavior following sz (LOC, motor ability, speech)

Seizure DC Teaching

- avoid alcohol, excessive stress, fatigue, & strobe lights

- community resources (Epilepsy Foundation of America)

- encourage the client to wear medical alert bracelet

* instruct client about importance of lifelong medication & need for follow-up to determine medication blood levels

Seizure Medications

* 1st line = benzodiazepines

- carbamazepine = 3-14

- clonazepam = 20-80

- divalproex = 50-100

- ethosuximide = 40-100

- lorazepam = 50-240

- phenobarbital = 15-40

- phenytoin = 10-20

others = gabapentin, lacosamide, lamotrigine, levetiracetam, oxcarbazepin, pregabalin, tiagabine, topiramate, zonisamide, vigabatrin

Flumazenil

* reverse effects of Benzos

- do NOT give to pt w/ IICP or status epileptics (cause seizure)

Phenytoin

- give slowly to prevent hypotension or cardiac dysrhythmias

- can decrease effectiveness of BC

Seizure Medication Education

** do NOT dc --> status epilepticus may occur

- take w/ food

- avoid alcohol, OTC meds, antacids

- wear medical alert bracelet

- caution = performing activities w/ alertness

* toxicity --> follow-up w/ periodic blood studies

- monitor serum glucose levels

- urine = may have harmless pink-red or red-brown color

* REPORT --> sore throat, bruising, nosebleeds (indicate blood dyscrasia)

- inform HCP of bleeding gums, N/V, blurred vision, slurred speech, dizziness

Transient Ischemic Attack (TIA) Pathophysiology

- a mini stroke

- caused by inadequate blood flow due to stenosis (narrowing of blood vessels) or an occlusion (most commonly clot)

* resolves completely

TIA Manifestations

- slurred speech

- dizziness

- headache

- blurred/double vision

- weakness

- aphasia

- dysphagia

- ataxia

- increased BP

FAST --> facial drooping, arm weakness, speech disturbance, time to call 911

TIA Risk Factors

- HTN, CVD, DM, HLD

- physical inactivity, obesity

- smoking, excessive alcohol intake

- low SES

TIA DC Education

* pt at risk for stroke or TIA for next 48 hrs

- decrease risk for aspiration (due to dysphagia)

- educate how to recognize manifestations

- encourage regular exercise to lose weight

- smoking cessation, decrease alcohol intake

- reinforce diet & medication for DM

Ischemic Stroke

- sudden loss of brain blood flow --> O2 deprivation

Causes

- embolism

- stenosis

- plaque buildup in arteries (atherosclerosis)

Hemorrhagic Stroke

- blood vessels leak or rupture --> increased pressure in brain

Causes

- small cerebral arteries that have been damaged overtime by HTN

- hemorrhages or aneurysms --> lead to brain death

Stroke Modifiable Risk Factors

- HTN, HLD

- smoking

- physical inactivity, obesity, unbalance diet

- drugs

- sleep apnea

- oral contraceptives

Stroke Non-Modifiable Risk Factors

- age, sex

- genetics, family hx

- sickle cell

- race, ethnicity

Stroke Manifestations

BE FAST

- balance = dizzy, loss of balance/coordination

- eyes = difficulty seeing

- face = severe headache, numbness, facial drooping

- arms = numbness on one side of arms & legs

- speech = aphasia, slurred, confused, difficulty understanding

- time = call 911

Neuro = mental status change & seizure

Stroke Diagnosis

* CT = primary test (non-contrast to differentiate b/t ischemia & hemorrhagic) -- w/in 25 mins

- ASAP = CT, CT angiography, MRI

- ultrasound to determine occlusion

- ECG & chest x-ray to detect cardiac abnormalities

Stroke Safety

* NPO until swallow test --> consult SLP

- fall precautions

- bleeding precautions

Stroke Education

- manifestations of stroke

- medication regimen

- assistive devices/rehab

- community resources

- modifiable risk factors

tPa

indication = Ischemic Stroke

time window = < 4.5 hrs (cannot give if no witnessed time change)

side effects = significant risk of bleeding (intracranial, internal, site), drop in BP, N/V, & dizziness

tPA Exclusive Criteria

- head trauma/prior stroke in prev. 3 months

* subarachnoid HEMORRHAGE

- arterial puncture in prev 7 days

- hx of previous intracranial hemorrhage

- intracranial neoplasm, AVM, or aneurysm

- recent intracranial or intraspinal surgery

* BP > 185 or > 110

- active internal bleeding

- CT demonstrates multilobar infarction (hypo density > 1/3 cerebral hemisphere)

Acute Bleeding Diathesis

- platelets < 100,000/mm^3

- heparin w/in 48hrs w/ abnormally elevated aPTT

- current anticoagulant w/ INR > 1.7 or PT > 15 sec

- current direct thrombin inhibitors or direct factor Xa inhibitors w/ elevated sensitive lab tests (e.g. aPTT, INR, platelet count, ECT, TT, or appropriate factor Xa activity assays_

* BG < 50 mg/dL (2.7 mmol/L)

Stroke Aspiration Precautions

- NPO until completion of swallowing eval to decrease risk of choking or aspirating --> then pick appropriate diet

- assess for changes in neurological status (LOC) to prevent aspiration

- assist in upright position when eating, promote small bites, no straws, check cheeks for food pocketing

Stroke Anticoagulants (Warfarin)

* do NOT give for hemorrhagic stroke

- common in pt w/ AFIB

- monitor PT/INR (4x 1st week) --> normal = 2-3

- onset = 24-72 hrs

- peak = 5-7 days

* antidote = vitamin K

Cerebral Edema Pathophysiology

- swelling of the brain that causes increase ICP

- restricts blood & spinal fluid from entering or leaving the brain

Vasogenic Cerebral Edema

- interruption of blood brain barrier (something wrong w/ vessel)

- common in = strokes, brain tumors, high altitude

Cellular/Cytotoxic Cerebral Edema

- influx of Na+ & then water into cells --> brain cells lose ability to maintain normal fluid balance, leading to edema

- common in: TBIs & strokes

Interstitial Cerebral Edema

- CSF moves from intraventricular space into interstitial space of brain --> fluid increases pressure in interstitial

- common in = hydrocephalus & meningitis

Osmotic Cerebral Edema

- brain cells take water from circulating plasma

- common in = DKA & hyponatremia

Cerebral Edema Nursing Assessment

Manifestations

- sensory & mental status alterations

- visual changes

- weakness

- seizures

- headache (early manifestation)

- confusion, lethargic

- dizziness

- N/V

Diagnosis --> CT & MRI

Assess --> changes in LOC & mental status

Head Injury Pathophysiology

- any damage to the head due to a traumatic event

- does not always result in a brain injury but can

Traumatic Brain Injury (TBI)

concussion or subdural hematoma --> temporary or permanent alteration in neurological function

Concussion

- mild

- may or may not cause temporary loss of consciousness, headache, confusion, difficulty concentrating, N/V, dizziness, blurred vision, & amnesia

Subdural Hematoma

- may be asymptomatic

- change in consciousness, alteration in pupillary response, hemiparesis, HTN, bradycardia, bradypnea, coma

Common Causes of Head Injury in Older Adults

* hitting head during FALL --> decreased visual acuity, weakness, chronic HTN, poly pharmacy (increased dizziness), lack of safety devices (stair rails, shower bars), throw rugs, electrical cords, floor clutter

- increased incidence of SDH --> natural atrophy of brain tissue allows more room for bleeding inside cranial vault

- abuse from caregivers

Head Injury Nursing Assessment Conscious

subjective

- mechanism of injury

- time of injury

- pain level, location, & characterstics

- any manifestations/symtpoms that began at or immediately following the injury

- hx of prior head trauma

- hx of head surgeries

objective

- thorough head exam for signs of injury

- full neuro assessment (reflexes, sensation, strength, visual acuity)

- determine GCS score to assess severity

Head Injury Nursing Assessment Unconscious

- thorough head exam for signs of injury (lacerations, edema, ecchymosis)

- neurological exam

- determine clients Glasgow Coma Scale (GCS) score to help assess injury severity (< 8 = severe injury)

- Assessment: unarousable, primitive or no response other than painful stimuli, altered respirations, decreased cranial nerve & reflex activity

- Interventions = assess airway, VS, watch for CO2

expected vs unexpected

Nursing Care of Unconscious Head Injury

* assess latency of airway --> maintain & have emergency equipment readily available

- monitor BP, pulse, & heart sounds

- assess respiratory & circulatory status

* do NOT leave client unattended if unstable

- maintain patent airway & ventilation (high CO2 = increases ICP)

* assess lung sounds for accumulation of secretions --> suction as needed

* assess neurological status --> LOC, pupillary reactions, motor/sensory function, using coma scale (GCS)

- place client in semi-fowler's position

- change position of client q2 hrs, avoiding injury when turning

- use side-rails unless contraindicated or protocol

- assess for edema

- monitor dehydration

- monitor I/Os & daily weight

* maintain NPO until conscious (check gag & swallow reflex)

- maintain nutrition as prescribed (IV or enteral), monitor fluid/electrolye balance

- monitor status of skin integrity & prevent skin breakdown

- provide freq mouth care

- remove dentures & contact lenses

- assess eyes for presence of corneal reflex & irritation & instill artificial tears

* monitor drainage from ears or nose for the presence of CSF

- assume the unconscious pt can hear

- avoid restraints

- initiate seizure precautions if necessary

- provide ROM exercises to prevent contractures

- initiate PT as appropriate

- use footboard or high-topped sneakers to prevent foot drop & use splints to prevent wrist deformities

Cerebral Aneurysm Pathophysiology

- dilation of the walls of a weakening cerebral artery --> ruptures & increases ICP

Unruptured CA Manifestations

typically asymptomatic until rupture or leak

Ruptured CA Manifestations

-sudden, severe headache due to small amount of leaking blood (considered subarachnoid hemorrhage)

- similar to stroke manifestations (hemiparesis) = N/V, stiff neck, blurred or double vision, sensitivity to light, seizure, loss of consciousness, confusion, & tinnitus

Leaking CA Manifestations

- extremely severe headaches that may last several days & up to 2 weeks

Cerebral Aneurysm Nursing Intervention

- patent airway, O2, VS (HTN & dysrhythmias), avoid rectal temperature

- surgical interventions: microsurgical clipping, artery bypass & occlusion

- end-vascular interventions: coiling, flow diversion w/ stents

Parkinson's Disease Pathophysiology

- degenerative, progressive condition caused by gradual loss of cells in the substantial nigra --> stops producing dopamine & NE

Parkinson's Disease Manifestations

- shaking

- stiffness

- freezing in place

- loss of balance

- shuffling gait

- stooped posture

Parkinson's Stage 1

- manifestations are mild

- client can provide self-care duties w/out assistance

- tremors & other involuntary movements occur unilaterally

- changes in walking & facial expressions

Parkinson's Stage 2

- tremors affect both sides of the body & interfere with/ self-care activities

- change in posture

- balance is uncoordinated

- clients develop difficulty walking

- activities of daily living become more difficult to complete

Parkinson's Stage 3

- mid-stage w/ mild to moderate disability

- client experiences loss of balance & slow movements

- motor manifestations continue to worsen

Parkinson's Stage 4

- manifestations severely disabling

- self-care activities require assistance due to severe tremors & stiffness

- client can walk but may need to ambulate w/ a can or walker to maintain safety & prevent falls

Parkinson's Stage 5

- most advanced & debilitating

- client are wheelchair or bed bound

- require maximum assistance w/ self-care activities

Parkinson's Nursing Interventions

Fall Precautions = assistive devices, non-slip socks, bed/chair alarm (reduce wandering)

Nutrition = aspiration precautions, appropriate diet, small bites, eat upright, thickened liquids, soft foods, high-fiber, fluids

Safety = locks on doors, use signs, remove rugs & wires, adequate lighting

Calm Environment = calming music, reduce loud noises

- adherence to medication & treatment

- plan of care focuses on self-care activities, safety, social activities

- promote resources/support groups

- promote physical, occupational, speech therapy

Carbidopa-Levodopa

- Parkinson's medication

- acts as natural chemical, dopamine, in the brain

Adverse Effects

- irregularities in BP

- dyskinesia

- confusion

- dry mouth

- constipation

- hallucinations

- headaches

Increased Intracranial Pressure (IICP) Manifestations

- Change in LOC

- headache

- seizure

- eyes = papilledema, pupillary changes, impaired eye movement

- postural = decerebrate, decorticate, flaccid

- decreased motor function

- vomiting

- change speech

- increased systolic BP

- decreased pulse

- altered respirations

IICP Assessment

* LOC (most sensitive & earliest indication)

- headache

- abnormal respirations

* increase BP w/ widening pulse pressure

- elevated temp

- vomiting

- pupil changes

- bradycardia

- Late Signs = increased systolic BP, widened pulse pressure, low HR, motor function changes from weakness or hemiplegia, positive babinski reflex, decorticate or decerebrate, seizures, positive glucose testing

* be alert for Cushing's triad

*assess for CSF leakage

IICP Risks

- decreased cerebral perfusion

- hypoxia

- seizure activity

* CSF leakage

- risk for shunt failure or infection following VP shunt placement

IICP Generate Solutions

- monitor respiratory status & maintain ventilation

- maintain body temp & prevent shivering

- decrease environmental stimuli

- monitor fluid & electrolyte balance, acid-base balance, & I/Os --> limit fluid intake to 1200 mL/day

- instruct client to avoid coughing, sneezing, & valsalva's maneuver

* elevate HOB 30 degrees (avoid trendelenburg)

- prevent fixation of neck & hips

- administer prescribed medications = anti-seizure medications, antipyretics, muscle relaxants, antihypertensives, corticosteroids, IV fluids, hyper osmotic agents (mannitol)

IICP Nursing Interventions

- monitor CO2 levels as prescribes

- avoid administration of morphine sulfate to prevent hypoxia

- monitor renal function w/ mannitol therapy

- expect & monitor for diuresis

- VP Shunt = position supine, position from back to non-operative side, monitor for shunt failure, monitor for signs of infection

Spinal Shock

- complete but temporary loss of motor, sensory, reflex, autonomic function

- occurs immediately after cord's response to injury

Manifestations

- loss of sensory/motor function & reflexes below the injury

- hypotension

- hypothermia

- urinary retention

- fecal incontinence

Neurogenic Shock

- common in injuries above T6 (experienced soon after injury)

- vasodilation leading to pooling of blood in vessels, tissue hypo perfusion, & impaired cellular metabolism

Spinal Cord Injury Assessment

* assess level of spinal cord injury (lowest spinal cord segment w/ intact motor & sensory function)

- assess motor & sensory changes below level of injury

- assess total sensory loss & motor paralysis below the level of injury

- assess for loss of bladder/bowel control, urinary retention, & bladder distention

- assess VS

* assess respiratory status (changes), especially w/ C4 injuries

- monitor ABGs & ventilator status if ventilated

- monitor for respiratory infection

- monitor for dysrhythmias, hemorrhage or bleeding, shock, DVT, & orthostatic hypotension

* assess neurological status

- assess motor ability (squeeze hands, spread fingers, move toes, turn feet)

- assess for absence of sensation

* monitor for Autonomic Dysreflexia, Spinal Shock

* assess pain

- assess fluid & electrolyte balance

- assess skin integrity

- assess psychological status, including. feelings of anger, depression, loss, & sexual concerns

Spinal Cord Injury Risks

- respiratory failure

* Autonomic Dysreflexia

- spinal shock

- further spinal cord damage

- urinary retention

- impaired skin integrity

- complications related to immobility

Spinal Cord Injury Interventions

* always suspect spinal cord injury when trauma occurs until ruled out

* maintain airway --> prevent head flexion, rotation, or extension

- immobilize the client & maintain traction & alignment

- logroll client

- encourage deep breaths & use of IS

- monitor infection

- monitor for complication related to lack of movement

- maintain bowel program --> high fiber diet

- prevent urinary retention --> initiate bladder control program

- prevent UTIs & calculi

- Q2 turns

- promote rehabilitation & self-care measures

- set realistic goals based on client's potential functioning level

- utilize community resources

Autonomic Dysreflexia Etiological/Causative Factors

- occurs after spinal shock has resolved

- occurs when/ lesions or injury above T6 & cervical lesions

- most commonly caused by = visceral distention from a distended bladder or impacted rectum

- Bladder Triggers --> kinked/clogged foley, bladder spasms, bladder stones, UTIs

- Bowel Triggers --> pooping quickly, stool impacted in rectum, enema or manual removal of stool, gas & gas pain, constipation/diarrhea, Diverticulitis, Crohn's disease, anal fissure, hemorrhoids

- Skin Triggers --> rashes, bedsores, cuts/bruises, tight/lumpy/baggy clothing, itching that cannot be sense or scratched, ingrown toenails

- Others = neurological disease, stroke, brain injury, CNS tumor, MS, Guillian-Barre syndrome, med AE, severe head trauma, subarachnoid hemorrhage, stimulant drugs

Autonomic Dysreflexia Manifestations

- VS: high BP that rises rapidly, slow or fast HR

- severe, pounding headache

- N/V

- blurred or other vision changes

- stuff nose

- cold, dry, pale, clammy skin

- anxiety, apprehension, or uneasiness

- heavy sweating --> red, hot, flushed skin

- goosebumps or hair standing up

- tingling sensations

- narrowed blood vessels

- compare current BP to patient's usual BP

- review hx of spinal cord injury

Autonomic Dysreflexia Nursing Interventions

* neurological emergency

* FIRST --> raise HOB or sit up right & dangling

- remove tight clothing, jewelry, or devices

- monitor BP --> at least 2 hrs after it begins to decrease

* identify cause & fix

- check bladder drainage --> insert foley if no output

- check bowel or stool blockage --> remove blockage

- check skin for wrinkles, constrictions & tight clothing

- continue looking for & removing triggers if symptoms persist

- emergency tx = fast-acting medications (nitrates, hydralazine, labetolol, or nifedipine)

Respiratory Acidosis

Cause = hypoventilation (e.g. COPD)

pH < 7.35

PaCO2 > 45 mmHg

HCO3 = 22-26 mEq/L (normal)

Respiratory Acidosis Manifestations

- headache

- confusion

- drowsiness

- SOB

- hypotension

Respiratory Acidosis Nurse Management

- monitor ABG levels

- encourage deep breathing

Respiratory Alkalosis

Cause = hyperventilation (e.g. anxiety)

pH > 7.45

PaCO2 < 35 mmHg

HCO3 = 22-26 (normal)

Respiratory Alkalosis Manifestations

- dizziness

- tingling in extremeties

- chest pain

- confusion

- dry mouth

Respiratory Alkalosis Nurse Management

- address underlying cause

- coach controlled breathing

Metabolic Acidosis

Cause = increased acid production or bicarbonate loss (e.g. DKA, diarrhea)

pH < 7.35

PaCO2 = 35-45 mmHg (normal)

HCO3 < 22 mEq/L

Metabolic Acidosis Manifestations

* rapid breathing (Kussmaul respirations)

- nausea

- lethargy

- confusion

- abdominal pain

Metabolic Acidosis Nurse Management

- correct underlying cause (i.e. insulin for DKA)

- administer Bicarb

Metabolic Alkalosis

Cause = excess bicarbonate or acid loss (e.g. vomiting, diuretics)

pH > 7.45

PaCO2 = 35-45 mmHg (normal)

HCO3 > 26 mEq/L

Metabolic Alkalosis Manifestations

- muscle twitching

- dizziness

- paresthesia

- confusion

- hypoventilation

Metabolic Alkalosis Nurse Management

- replace electrolytes

- address volume status