Exam 5 - Neuro Flashcards

Question

What would you assess for when a patient is having a seizure?

Answer 1

History - need to know description of the type of seizure activity, events surrounding the seizure assists in determining best plan. –How often the seizure occurs –A description of each seizure –Whether more than 1 type of seizure occurs –Sequence of seizure progression –How long seizure last –When last seizure took place –seizure preceded by an aura –If the client knows that a seizure has taken place –What the client does after the seizure –how long it takes for the client to return to pre-seizure status –whether the client becomes incontinent of bowel or bladder during the seizure

Answer 2

* Eye fluttering * head & eye deviation to 1 side or another * changes in pupil size * movement & progression of motor activity * lip smacking or other automatisms * alterations in LOC

Answer 3

* apnea * cyanosis * copious salivation * incontinence of urine & stool * tongue or lip biting

Answer 4

* EEG study measures the electrical activity of the brain and records alpha, beta, delta, & theta brain waves. * Types of seizures have distinct patterns. * EEG can pinpoint the focus or source of the seizure also.

Answer 5

* High risk for injury RT seizure activity * Ineffective individual coping RT perceived social stigma, potential changes in employment or leisure activity & chronic nature of disease. * Ineffective airway clearance RT tracheobronchial obstruction during or after seizure * Self esteem disturbance RT diagnosis of disease with social stigma * Fear RT possibility of having a seizure at work or in another public place

Answer 6

* Have oxygen & suctioning equipment close by * Have a heparin or saline lock in place * Side rails up & bed in low position * padding side rails - controversial issue * * PLEASE NOTE- padded tongue blade _DOES NOT_ belong at the bedside and _never_ should be inserted into the patient’s mouth

Answer 7

* Protect from injury * DO NOT force anything into the mouth * Turn the client to the side * Loosen any restrictive clothing * Maintain the client’s airway & suction PRN * Do not restrain the patient, guide the patients movements * At the end of the seizure: 1. take vital signs 2. perform neuro checks 3. keep on side and allow to rest 4. document the seizure

Answer 8

* Nurse administers the medications on time to maintain therapeutic blood levels & maximal effectiveness. * Nurse instructs patients to avoid drugs & foods that might interfere with the absorption or metabolism of the anticonvulsant.

Answer 9

* Therapeutic blood level = 8-12 mcg/ml\ * Give with meals * Monitor for S/E - diplopia, blurred vision, N/V, leukopenia which is checked q 3-6 mo. * Can cause SIADH * Contraindication if glaucoma, cardiac or renal, or hepatic disease

Answer 10

* used in absence seizures * Theraputic level = 30-100 mcg/ml * Monitor CBC & LFT q 4-6 mo * Contraindicated in renal & liver disease * Monitor S/E - N/V, anorexia, lethargy, blood dyscrasia

Answer 11

* Metabolism is inhibited by warfarin, chloramphenicol, INH, & carbamazepine, & digoxin * **Please note - phenytoin & dilantin are not exactly the ‘ same. Can’t interchange becusing the dosing and the efficacy are different** * Check CBC & Ca++ levels * Monitor for S/E: _gingival hyperplasia_, gastric distress, _hirsutis__m_, anemia, ataxia, & nystagmus * Elevated Blood levels –20-30: nystagmus –30-40: ataxia – \> 40 - dec. LOC * For IV administration, flush IV line with NS before & after. Give slowly, no more than 50 mg/ml

Answer 12

* Monitor for CBC & AST * Monitor for S/E: N/V, lethargy, impaired PT & PTT, hair loss, leukopenia, & liver toxicity. * Increases serum phenobarbital levels, & alters serum phenytoin levels. * Monitor for drowsiness, blood dyscrasia, ataxia, nystagmus, gastric distress

Answer 13

* A vagal nerve stimulating device is surgically placed below the pt. Left clavicle in the sterncleidomastoid mm. * Vagus nerve dissected free from carotid artery & jugular vein. * Each month, the amplitude, frequency, & stimulation time of the device are adjusted.

Answer 14

* High fat, low carbohydrate diet mimic the ketogenic effects of fasting * **Effective for tonic-clonic, absence, complex partial seizures**

Answer 15

* Prevent injury during bathing & toileting * grab bars in the bathtub or shower area * signal device if client needs help * mechanism to easily enter a locked BR door from the outside * Know about medications * Medic alert bracelet or necklace * Consult MD before taking other meds., OTC meds. * No ETOH

Answer 16

* Seizures that are continuous or in rapid succession, without regaining consciousness, lasting at least 30 minutes. Causes: * sudden withdrawal from anticonvulsant meds * infections * acute ETOH withdrawal * head trauma * cerebral edema * metabolic disturbances

Answer 17

* THIS IS A NEURO EMERGENCY !! * Present with generalized tonic-clonic seizures * must be tx to prevent irreversible brain damage & possibly death from anoxia, cardiac dysrrhythmias, or lactic acidosis * Nursing Management * Notify MD immediately * Get ready for emergent intubation * Will give benzodiazepenes to stop motor movement

Answer 18

* Fosphenytoin (cerebyx) –IV * Lorazepam (ativan) to stop seizures * Phenobarbital may also be used * May insert NG tube to prevent vomiting & aspiration * Monitor cardiac functioning & BP * Prevent hyperthermia * Observe for S/E & toxicity of meds. * Monitor drug levels closely for 1st 3 days.

Answer 19

* An inflammation of the arachnoid & pia mater of the brain & the spinal cord. * Bacterial or viral organisms most common * Not as common, fungal & protozoal organisms * Mode of transmission vary depending on organism * –direct contact - ie, droplet contact * –occurs in areas of high population - dorms, crowded living areas, prisons * Frequently - predisposed - fx of skull, brain or spinal surgery, sinus or URI, nasal sprays with sinusitis * Organism enters the CNS via the blood stream at eh blood-brain barrier. * Otorrhea (ear discharge) or rhinorrhea (nasal discharge) may lead to meningitis owing to the direct communication of CSF with the environment.

Answer 20

* Seen most frequently in fall & winter, when URI commonly occur * Organisms most common: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningtidis, & Staphylococcus aureus * Body recognizes protein within bacteria as an Ag and triggers inflammatory response. * An exudate consisting of bacteria, fibrin, & leukocytes is formed in the subarachnoid space. Accumulates in the CSF * CSF becomes thickened and may interfere with the normal flow of CSF around the brain & spinal cord -\> hydrocephalus (abnormal accumulation of CSF within the brain) * **Exudate, more inflammation -\> inc. ICP (this does not occur in viral meningitis** * **Exudate deposited over brain, cranial nerve, & spinal nerve roots**

Answer 21

Meningeal cells become edematous because cell membranes can no longer regulate flow of fluid into or out of the cell. * Rapid vasodilation of the cerebral vessels occurs -\> engorgement, rupture, or thrombosis of the vessel walls. * **Brain tissue may infarct -\> greater inc. in ICP** * May lead to 2nd infection

Answer 22

* Referred to as “Aseptic meningitis” * Herpes simplex, herpes zoster, mumps, measles can cause * herpes simplex alters cellular metabolism * other viruses alter production of enzymes or neruotransmitters * No exudate occurs and CSF culture negative * Inflammation occurs over the cerebral cortex, white matter, & meninges

Answer 23

Look out for headaches when doing a lumbar puncture, tell them to drink a lot of water, caffeine beverages, tell them to lie down as much as possible…

Answer 24

Assess for Neurological changes: * LOC * Pupil reaction & eye movements (CN 2,3,4,6) * Orientation of person, place, time * Motor response

Answer 25

* severe HA tachycardia * generalized muscle aches & pain * N/V * Tachycardia * fever(bacterial) * chills * often mistaken as flu * Distinction - HA is severe and unrelenting * Red, macular rash with meningococcal meningitis * Viral - abdominal & chest pain–severe HA tachycardia * generalized muscle aches & pain –N/V Tachycardia * fever(bacterial) chills –\*\* often mistaken as flu * Distinction - HA is severe and unrelenting * **Red, macular rash with meningococcal meningitis** * Viral - abdominal & chest pain

Answer 26

Eyes: C/O of photophobia * Check for nystagmus * Exudate, inflammation, & vascular engorgement, dysfunction of CN III, IV, & VI may be evident. * CN VII & CN VIII are also involved - facial paresis and difficulty hearing. * CN VIII - dizziness –Early stage- motor exam §normal –Later §hemiparesis, hemiplegia, decreased muscle tone

Answer 27

* nuchal rigidity * Positive Kernig’s sign * Positive Brudzinski’s sign * Nuchal rigidity is manifested by a stiff neck & soreness, particularly when neck is flexed.

Answer 28

* Exudate -\> hydrocephalus & cerebral edema * Left untreated, inc. ICP leads to herniation & death * Seizure activity may be caused by irritation of the cerebral cortex. Because of abnormal stimulation of the hypothalamic area, excessive amounts of ADH are produced. * Results in water retention & dilution of serum Na+ attributable to inc. excretion of Na+ by the kidneys. * **SIADH further inc. ICP.**

Answer 29

**Assess:** **–color & temperature of the extremities --\> can indicate emboli** **–peripheral pulses** **–identifies any indicators of abnormal bleeding** Septic emboli in the blood may block circulation in small vessels of the hands & feet, leading to gangrene. * Vascular involvement of the cerebral arteries & veins can cause seizures & hemiparesis.

Answer 30

Most important is accurate monitoring & recording of their neurologic status, VS, & vascular assessment. * Neuro checks & VS at least q 4 h * Assess for S/S of ICP * Cranial nerve assessment esp. III, IV, VI, VII, VIII * deficit of CN VI may indicate development of hydrocephalus * Assess for urinary incontinence * vascular assessment - at least q shift or more * must recognize gangrene early because evolves quickly

Answer 31

**Want to avoid life-threatening complications:** * Start with broad spectrum antibiotic such as ampicillin * Once cultures identify the organism , change therapy **Nursing:** * Check for drug allergies * Administer drug within 1-2 hours of ordering * Administer subsequent doses on time * Monitor & document responses to therapy

Answer 32

* necessary for bacterial meningitis for first 24 h after starting antibiotics * Viral meningitis - precautions with stool & urine only * Pneumococcal meningitis - respiratory isolation usually for first 24 hr after antibiotics started * Place on seizure precautions

Answer 33

* Is an inflammatory of the brain parenchyma (brain tissue) & often the meninges. * Often caused by a virus, but can also be caused by bacteria, fungus, or parasites. * Mosquito - St. Louis encephalitis, west nile * Herpes virus, poliovirus, coxsackie virus * Viral invasion leads to hemorrhage, edema, necrosis, & dev. Of small lacunae within cerebral hemispheres.

Answer 34

* A surgical procedure that involves an incision through the cranium to remove accumulated blood or a tumor. * **Complications:** * Increased intracranial pressure * Cerebral edema * hemorrhage * obstruction of normal flow of CSF * Fluid & electrolyte impairments * DI * SIADH

Answer 35

**Preoperative Care:** –Informed consent –Explain procedure to patient & family –Prepare to shave the head and cover as prescribed **Post operative care:** –Positioning –other care

Answer 36

* Very important to follow MD orders - incorrect positioning can cause permanent harm or death **Removal of a bone flap for decompression** * To facilitate brain expansion, the client should be turned from the back to the unoperative side, but not to the side operated on. **Posterior fossa surgery** * To protect the operative side from pressure, and minimize tension on the suture line, position the client on the side, with a pillow under the head for support, and not on the back. **Infratentorial surgery** * Involves surgery below the patient’s tentorium * MD may order a flat position without head elevation or may order the HOB to be elevated at 30-45 degrees * _Do not elevate the HOB during the acute phase of care following surgery without a MD’s order._ **Supratentorial surgery:** * Involves surgery above the brain’s tentorium. * MD may order the HOB elevated at 30 degree to promote venous outflow through the jugular vein. * _Do not lower HOB in the acute phase of care following surgery without MD’s order._

Answer 37

* Monitor vital signs & neurologic status every 30 min -1 hour * Monitor for ICP * Monitor for dec. LOC, motor weakness or paralysis, aphasia, visual changes, or personality changes. * Maintain mechanical ventilation & slight hyperventilation for the first 24-48 hours as prescribed to prevent increased ICP. * Assess the MD’s orders regarding patient positioning. * Avoid extreme hip or neck flexion & maintain the head in a midline neutral position. * Provide a quiet environment. * Monitor the head dressing frequently for signs of drainage. * Mark the area of drainage once each shift for baseline comparison * Monitor the Hemovac or Jackson-Pratt drain, which may be in place for 24 hours. * Maintain suction on the Hemovac or drain. * **Measure drainage from the Hemovac or drain every 8 hours and record the amount and color.** * Notify the MD immediately of excessive amounts of drainage or a saturated head dressing. * Record strict measurement of hourly I & O * Monitor electrolytes values * Monitor for dysrhythmias, which may occur as a result of fluid & electrolyte imbalance. * Apply ice packs or cool compresses as prescribed for periorbital edema & ecchymosis of one or both eyes, which is not an unusual occurrence. * Provide ROM exercises every 8 hours * Place TED hose on the patient. * Administer anticonvulsants, antacids, corticosteroids, and antibiotics as prescribed * Administer analgesics such as codeine and acetaminophen as prescribed

Exam 5 - Neuro Flashcards

(64 cards)