Exam 2: Neurological Disorders

Acetylcholine (ACh)

________ is the neurotransmitter responsible for activating the parasympathetic system.

• rest and digest

• decreasing HR

• bronchoconstriction

• stimulating digestion

The parasympathetic nervous system is responsible for ________.

Norepinephrine (NE)

________ is the neurotransmitter responsible for the fight or flight response (sympathetic activation).

• increasing HR

• bronchodilation

• vasoconstriction

The sympathetic nervous system is responsible for ________.

Parkinson’s Disease

Dopamine deficiency is responsible for what neurological condition?

A. Bradykinesia (slowed movements)

B. Tremor

D. Muscle rigidity (involuntary muscle stiffening or tightening)

A patient experiencing Parkinson’s Disease in response to low dopamine levels may present with ________. (SATA)

A. Bradykinesia (slowed movements)

B. Tremor

C. Hyperreflexia (exaggerated or overactive reflexes)

D. Muscle rigidity (involuntary muscle stiffening or tightening)

Afferent (sensory)

________ neurons carry sensory information to the spinal cord and brain.

Efferent (motor)

________ neurons carry information away from the CNS to the PNS to produce a motor response.

Dorsal (Posterior) Roots = sensory

Ventral (Anterior) Roots = motor

What is the difference between dorsal and ventral roots?

0 = no movement; paralysis

1 = flicker or trace of muscle contraction; no joint movement

2 = movemement w/o gravity

3 = movement against gravity only

4 = movement against reduced resistance (some weakness)

5 = full strength against full resistance

Describe the muscle strength scale.

GCS is based on 3 categories: eye opening, verbal, and motor responses.

Eye Opening;

1 = no eye opening

2 = open in response to pain

3 = open in response to speech

4 = spontaneous

Verbal Response:

1 = no verbal response

2 = incomprehensible sounds

3 = inappropriate words

4 = confused

5 = oriented

Motor Response:

1 = no motor response

2 = abnormal extension (decerebrate)

3 = abnormal flexion (decorticate)

4 = withdrawing from pain

5 = moves in response to localized pain

6 = obeys commands

Total Scoring:

13 - 15 = mild / minimal brain injury

9-12 = moderate brain injury

≤ 8 = severe brain injury / coma

This card contains the grading for Glasgow Coma Scale (GCS). You can either try to describe it without looking, or you can flip the card and study the grading scale.

blood flow to part of the brain becomes blocked, depriving the brain cells of oxygen, causing cell death

Ischemic stroke occurs when ________.

• thrombus

• embolus

• a-fib

• atherosclerosis

Causes of ischemic stroke = ________

restore blood flow to the affected part of the brain before tissue dies

The goal os treatment for ischemic stroke is to ________.

FAST

F = facial droop
A = arm (and leg) weakness
S = speech difficulty
T = time to call 911…need for immediate help

What is the acronym commonly used to remember stroke symptoms?

Left-Hemisphere Stroke:

• affects right side of body

• aphasia (difficulty forming and/or understanding language, reading, or writing)

• slow/cautious behavior

Right-Hemisphere Stroke:

• affects left side of body

• impulsivity + poor judgment

• distractibility

• impaired spatial awareness

• issues with visual perception and memory

What are the differences between left vs. right ischemic strokes?

Broca’s Area:

• Speech production

• Frontal lobe

• Expressive aphasia

Wernicke’s Area:

• Speech comprehension

• Temporal lobe

• Receptive aphasia

What are the differences between Broca’s and Wernicke’s areas?

CT Scan — helps differentiate between ischemic and hemorrhagic

_______ is the first test performed for a patient suspected of having a stroke. Why?

“LAST KNOWN WELL TIME” is used to determine the eligibility of thrombolytic therapy. Thrombolytic therapy must be administered within the first 3 hrs of symptom onset. After this, the risk of intracranial bleeding increases and brain damage becomes irreversible.

What is the importance of the saying “LAST KNOWN WELL TIME”?

• tPA (clot buster - thrombolytic therapy)

• Mechanical Thrombectomy — use of catheter to physically remove a clot

• Antiplatelets + anticoagulants

• Antihypertensives (uncontrolled HTN is the most common cause of stroke)

• Statins — reduce cholesterol

• Hyperglycemia management

• Supportive care + rehabilitation

What tx may be initiated for ischemic stroke?

Carotid Endarterectomy

________ is a preventative surgery used to remove plaque from the carotid artery, especially for those w/ severe carotid stenosis.

swallow test

Before giving a stroke client food, drink, or PO meds, a ________ should be performed.

• Aspiration prevention (upright, chin tuck, thickened liquids, puree diet)

• Mobility (turn q2h, ROM, positioning, physical activity as tolerated)

• Skin integrity (frequent repositioning, padding, bowel + bladder care)

• ADLs (encourage independence while maintaining safety)

• Neuro checks + vitals (changes in LOC, strength, sensation, oxygenation)

• Safe med administration

What are the nursing interventions for ischemic stroke?

a blood vessel in the brain ruptures, causing bleeding into the brain tissues, ventricles, or subarachnoid space

Hemorrhagic stroke occurs when ________.

• HTN (most common)

• aneurysm

• AVM

• anticoagulants

What are the causes of hemorrhagic stroke?

• “Worst headache of my life”

• Vomiting

• Seizures

• Decreased LOC

What are the common symptoms of hemorrhagic stroke?

• stop bleeding

• prevent rebleeding

• control intracranial pressure (ICP)

• maintain oxygenation

What are the goals for treating a person w/ hemorrhagic stroke?

Craniotomy — remove hematoma

Aneurysm Clipping — prevents rupture

Endovascular Coils — occlude aneurysms

What surgical interventions may be implemented for a patient w/ hemorrhagic stroke?

• Bedrest + HOB at least 30 degrees

• Oxygenation

• Hydration

• Seizure precautions

• Reorientation

• Low stimulating environment

What are the nursing interventions for a client with hemorrhagic stroke?

• Protect head

• Remove loose objects from bed

• Turn to side (recovery position)

• Loosen clothing

• Time the seizure

• Note what occured before the seizure happened

What should a nurse do for a client DURING a seizure?

• Side-lying position (recovery position)

• Maintain airway

• Reorient patient

• Neuro assessment

What should a nurse do AFTER a seizure?

• suction available

• oxygen available

• padded side rails

• bed in lowest position

• avoid loose items in bed

Seizure precautions include ________.

A seizure lasting 5 minutes or longer, or a seizure without recovery.

What is status epilepticus?

• Airway

• Oxygen

• IV access

• IV diazepam, lorazepam, or fosphenytoin

Emergency seizure treatment includes ________.

• Fever

• Nuchal rigidity (severe neck stiffness that makes it painful or impossible to comfortably flex your chin toward your chest)

• Altered LOC

• Headache

• Photophobia (light sensitivity)

• Seizures

• Positive Kernig and Brudzinski signs

What are the S/S of meningitis?

Kernig: pain w/ knee extension

Brudzinski: neck flexion causes knee/hip flexion

What are the differences between Kernig’s + Brudzinski’s Signs?

• Neisseria meningitidis

• Streptococcus pneumoniae

Bacterial meningitis is most often caused by what two bacterial species?

• Antibiotics (ceftriaxone, rifampin, ciprofloxacin)

• Dexamethasone — reduces inflammation

• Droplet precautions

• Meningococcal vaccine at age 11-12 + booster at 16

What are the interventions and treatments for bacterial meningitis?

Levodopa-Carbidopa (Sinemet)

________ is the combination medication used to slow the progression of Parkinson’s Disease by increasing dopamine levels in the brain.

Deep Brain Stimulation (DBS)

________ may be used for treating a patient with severe Parkinson’s Disease, in which a device is implanted into the brain, delivering electrical impulses to stimulate specific brain parts.

• Fall precautions

• Encourage exercise

• Constipation management

• Soft diet if experiencing dysphagia

• Promote ADLs

Nursing care for a patient w/ Parkinson’s Disease includes ________.

• Falls (about ½ of TBIs)

• Motor Vehicle Accidents

• Struck by objects

• Assaults

Traumatic Brain Injury (TBI) is most commonly caused by ________.

Primary Brain Injury:

• occurs immediately

• skull fracture, concussion, hematoma

Secondary Brain Injury:

• occurs later

• cerebral edema, hypoxia, increased ICP

What are the differences between Primary and Secondary TBIs?

3 Components inside the Skull:

• brain tissue

• blood

• CSF

If one of these components increases, another component must decreases…otherwise ICP rises

Describe the Monro-Kellie Hypothesis.

10 (based on lecture) — some sources say 5-15

Normal ICP = ________

CCP = MAP - ICP

• normal CCP = 70-100 mmHg

Cerebral Perfusion Pressure (CCP) = ______ - ______

CCP = 69 - 16 = 53

BP = 104/52

MAP = 69

ICP = 16

CCP = _____

• Bradycardia (HR < 60 BPM)

• Widening pulse pressure (increased systolic pressure w/ low or stable diastolic pressure)

• Irregular respirations (abnormal erratic breathing)

Cushing’s Triad indicates 3 medical signs of increased ICP, which are ________.

• HOB 30-45 degrees

• Neutral neck alignment

• Calm environment

• Avoid excessive suctioning

• Stool softeners

• Monitor for neuro changes (neuro checks)

What are the nursing interventions for a patient w/ increased ICP?

• Mannitol — osmotic diuretic that quickly reduces ICP by drawing free water from the brain parenchyma into vascular space

• 3% hypertonic solution — hyperosmolar agent that helps optimize serum sodium levels

• Propofol — fast-acting anesthetic used post-intubation to help reduce cerebral blood flow and reduce ICP

What medications may be used to treat elevated ICP?

External Ventricular Drain (EVD)

________ is a temporary, lifesaving bedside or operating room procedure used to relieve dangerous pressure in the brain. It works by inserting a thin tube (catheter) into the brain’s fluid-filled ventricles to drain excess cerebrospinal fluid (CSF) and monitor intracranial pressure (ICP).

It is important to use aseptic technique due to risk of infection.

What should a nurse known about EVD?

Diabetes Insipidus (DI)

Pituitary damage resulting from brain injury may lead to ________.

• Increased urine output

• Diluted urine

• Dehydration

• Hypernatremia

What are the S/S of Diabetes Insipidus?

• Monitor I&Os

• Monitor sodium

• Replace fluids

What are the nursing considerations for DI?

• Bruising behind ear (battle scar)

• Raccoon eyes

• CSF leakage from nose and/or ear

What are the S/S of basilar skull fractures?

meningitis

When caring for a client with basilar skull fracture, the nurse should monitor for ________.

False, the nurse should avoid inserting an NG tube because there is a risk of the tube entering the cranial cavity rather than the esophagus.

True or False

When caring for a patient suspected of having a Basilar Skull Fracture, the nurse should insert an NG tube as ordered by the provider.

blood collects between the skull and the outer membrane covering the brain (the dura mater), usually due to a fractured skull and torn artery.

Epidural hematoma occurs when ________.

a loss of consciousness followed by lucid intervals followed by coma

A patient with an epidural hematoma may present with ________.

falls (especially in older adults)

Subdural hematoma most often occurs due to ________.

• changes in LOC

• headache

• pupillary changes

S/S of subdural hematoma include ________.

contusion, laceration, or compression of the spinal cord

A spinal cord injury results from ________.

phrenic nerve

High cervical spine injury may affect the ________, causing respiratory failure.

areflexia, resulting in a loss of function below the injury

Spinal shock is caused by ________.

• Flaccid paralysis

• No reflexes

• Hypotension

• Bradycardia

• Ileus — disruption of intestinal motility

S/S of spinal shock include ________.

a loss of autonomic nervous system function below the level of the injury

Neurogenic shock refers to ________.

• Bradycardia

• Hypotension

• Decreased CO

• Venous pooling in extremities

• Vasodilation

Whata re the S/S of neurogenic shock?

Autonomic Dysreflexia

________ occurs after spinal shock has resolved. It is a medical emergency in which the autonomic nervous system overreacts to a stimulus below the level of the injury, causing widespread vasoconstriction.

T-6 or above

Autonomic dysreflexia occurs only in fractures ________.

• retinal hemorrhage

• hemorrhagic stroke

• MI

• seizures

Autonomic dysreflexia requires immediate medical intervention to prevent ________.

full bladder

• other causes: constipation, skin irritation, pressure injury, thermal stimuli

The most common trigger of autonomic dysreflexia is ________.

• Priority is sitting patient upright…then:

  • Check bladder

  • Check bowel

  • Check skin

Nursing interventions for autonomic dysreflexia?

• Pin-site care

• Assess infection

• Never loosen pins

• Keep wrench available

Halo Traction is an orthopedic procedure used to gently stretch and straighten severe, stiff spinal deformities like scoliosis or kyphosis. What are the nursing interventions for a patient undergoing halo traction?

• LOC

• Pupils

• Motor response

• Vitals

• Drainage

After a craniotomy, the nurse should monitor…….?