Neuro Flashcards
Neuro Assessment
- Know location, how long symptoms have persisted, when they started, and how severe
- Did anything relieve the symptoms?
- General appearance and behavior (slurred speech / drooping face)
- Mental Status
- awareness of surroundings and alertness
- orientation to person, place, and time
- memory (short and long term)
- LOC - most sensitive indicator of neuro status / may be first sign that there’s a problem
- Glasgow Coma Scale
- Pupillary Changes (normal is 2-6mm)
- PERRLA
- hand grips / leg lifts / pushing strength of feet
- strength / follows commands
- Babinski reflex
Glasgow Coma Scale
13-15 is best score
1) Eye Opening
- 4 - spontaneous
- 3 - verbal command
- 2 - to pain
- 1 - no response
2) Motor Response
- 6 - verbal command
- 5 - localized pain
- 4 - flexed / withdraws
- 3 - flexes abnormally
- 2 - extends abnormally
- 1 - no response
3) Verbal Response
- 5 - oriented / talks
- 4 - disoriented / talks
- 3 - inappropriate words
- 2 - incomprehensible sounds
- 1 - no response
PERRLA
pupils equal, round, reactive to light, and accommodation
normal pupil size is 2-6 mm
Babinski reflex
normal in an infant up to 1 year (goes away when they walk)
abnormal in adult
Babinski - toes fan
Plantar - toes curl
If an adult has babinski reflex, then there’s severe problem with CNS that’s affecting upper motor neuron
Possible Causes: tumor or lesion on brain or spinal cord, meningitis, multiple sclerosis, Lou Gehrig’s disease
Deep Tendon Reflex Scale
0 = no response (absent) 1+ = present, sluggish or diminished (hypoactive) 2+ = active or expected response (normal) 3+ = more brisk than expected; slightly hyperactive but not necessarily pathological 4+ = brisk, hyperactive w intermittent or transient clonus
- ankle clonus = abnormal reflex movements of foot induced by sudden dorsiflexion
normal reflex documented as 2+ / 4+
Lumbar Puncture
What’s it used for and how are they positioned?
Used to:
- obtain CSF to analyze for blood, infection, and even tumor cells - Measure pressure readings with a manometer and reduce CSF pressure - administer drugs intrathecally (into spinal canal)
Client positioned propped up over bedside table w head down while arching their back or in fetal position.
inspect surrounding skin at puncture site for any infection
CSF should be…
clear and colorless
look just like water
Lumbar Puncture Post-Procedure
lie flat or prone for 4-8 hours
increase fluids to replace lost spinal fluid and reduce risk of complications
- most common complication = headache
pain of headache increases when client sits up and decreases when they lie down
How do we treat a headache caused by a lumbar puncture?
they need to lie flat
bed rest, fluids, pain meds, blood patch
Lumbar Puncture Complications
brain herniation - if pt has increased ICP, lumbar puncture is CONTRAINDICATED
- needle insertion creates low pressure which makes brain suck downwards (fatal)
infection - if bacteria gets in puncture site, it infects CSF and meningitis can occur
- no punctures near lesions
Early S/sx of Increased ICP
change in LOC (coma or as subtle as change in attention span)
speech may become slurred or slowed
delay in response to verbal suggestion (slow response to commands)
increase in drowsiness
restlessness with no apparent reason
confusion
Late S/sx of Increased ICP
- Marked change in LOC progressing to stupor, then coma
- VS changes
- Cushing’s Triad = immediate intervention to prevent further brain ischemia and restore perfusion - Slow, full, bounding pulse
- Irregular respirations
- change in pattern such as Cheyne Stokes or ataxic respirations - Decerebrate and decorticate posturing
Cushing’s Triad
systolic HTN w widening pulse pressure
Decerebrate Posturing
present with all 4 extremities in riged extension / WORST
Decorticate Posturing
present with arms flexed inward and bent in toward body and legs are extended
Miscellaneous S/sx of Increased ICP
headaches (anytime head injury pt complains of headache = think ICP is increasing
change in pupils and pupil response
- in profound coma = pupils will be fixed and dilated
projectile vomiting can occur bc vomiting center in brain is being stimulated
- if this happens, assume ICP is up
Complications of increased ICP
Brain herniation - obstructs blood flow leading to brain death
DI and SIADH
Treatment for increased ICP
Goal = relieve increased ICP
- reduce cerebral edema - reduce amount of CSF - reduce amount of blood volume in brain
Maintain Cerebral Perfusion:
- oxygenation - decreased O2 and increased CO2 causes vasodilation in brain which
increases ICP
- don’t want hypotension or bradycardia
- isotonic saline and inotropic agents (dobutamine and norepinephrine)
- inotropic agents are emergency meds and not given long term
- keep temp below 100.4 (hypothalamus not working = cooling blanket)
- hypothermia used to treat cerebral edema by decreasing metabolic demands of brain
- antipyretics (anti-fever)
- HOB elevated
- keep head midline so jugular veins can drain
- when turning, if ICP doesn’t go back down after 15 min, turn back
- avoid restraints, bowel/bladder distention, hip flexion, valsalva, isometrics, no sneezing, no nose blowing
- limit suctioning and coughing
- space interventions so they can rest
- monitor Glasgow coma scale and VS for Cushing’s Triad
- Barbiturate-induced coma to decrease cerebral metabolism (phenobarbital, thiopental, propofol)
- Osmotic diuretics (mannitol) - pull fluid from brain cells and filter through kidneys
- Hypertonic saline (3%) - pulls fluid from brain
- steroids (dexamethasone) - when tumor is cause
- fluid restriction (less volume = less pressure)
*** increased volume = increased CO = increased brain perfusion
