Neuro

Question 1

What is the most important aspect of the neuro exam?

Answer 1

Level of consciousness

Question 2

What is assessed during a mental status exam?

Answer 2

1) Awareness of surroundings and alertness.
2) Orientation to person, place and time.
3) Short and long term memory.

Question 3

What is often the first sign of a neuro problem?

Answer 3

Change in LOC

Question 4

When is the Glasgow Coma Scale used?

Answer 4

To determine LOC in clients with altered mental status or the potential to develop altered consciousness (think trauma).

Question 5

What is the highest (best) score on the Glasgow Coma Scale?

Answer 5

15

Question 6

If Glasgow score is less than 8…..

Answer 6

Your patient you must intubate!

Question 7

What are the symptoms of Cushing’s triad?

Answer 7

1) HYPER-tension with widening pulse pressure (high systolic)
2) BRADY-cardia
3) BRADY-pnea
* think HYPER BRADY BRADY

Question 8

Is Cushing’s triad an early or late sign of increased ICP?

Answer 8

Late. It’s an emergency!

Question 9

Is the Babinski reflex normal in adults?

Answer 9

No

Question 10

What does the presence of the Babinski reflex indicate?

Answer 10

A CNS problem affecting an upper motor neuron.

Question 11

What might cause a Babinski reflex?

Answer 11

Tumors, brain lesions, spinal cord lesions, meningitis, MS, Lou Gehrig’s disease.

Question 12

How do you grade reflex response?

Answer 12

0 = no response (absent)
1+ = present but slugish
2+ = Active or expected (normal)
3+ = More brisk than expected, but not necessarily pathological
4+ = brisk, hyperactive with intermittent or transient clonus (abnormal reflex movements of foot induced by sudden dorsiflexion)

Question 13

How are reflex responses documented?

Answer 13

Number of assessment over highest number of scale.

Ex: 2+/4+

Question 14

What is the normal foot reflex in an adult called?

Answer 14

Plantar reflex

Question 15

Why are lumbar punctures performed?

Answer 15

To obtain CSF for testing, measure readings with an a manometer, reduce CSF pressure, administer drugs intrathecally (into spinal canal).

Question 16

How are patients positioned for lumbar puncture?

Answer 16

Side lying in fetal position or over bedside table. Back must have a lot of arch and patient must be very still.

Question 17

What is the preferred position for 4-6 hours post lumbar puncture?

Answer 17

Prone

Question 18

What should be increased after a lumbar puncture?

Answer 18

Fluids, to replace lost CSF

Question 19

What is the most common complication of lumbar puncture?

Answer 19

Headache that worsens with sitting/standing and decreases with lying down.

Question 20

How is headache post lumbar puncture treated?

Answer 20

Bed rest, fluids, pain meds and blood patch.

Question 21

What is the most serious complication of a lumbar puncture?

Answer 21

Brain herniation. This occurs when a puncture is made in a patient with increased ICP. The puncture creates a pressure gradient, drawing the high pressure in the brain downwards, which herniates the brain and brain stem. This is FATAL in 99% of cases.

Question 22

When is lumbar puncture absolutely contraindicated?

Answer 22

In patients with increased ICP.

Question 23

What must be assessed prior to lumbar puncture?

Answer 23

ICP, check for lesions around puncture site before procedure to reduce risk of bacterial meningitis. Alert physician to any possibility of increased ICP or lesions near site.

Question 24

What is the earliest sign of increasing ICP?

Answer 24

LOC changes, slowed or slurred speech, changes in attention span, delay in verbal response, increase in drowsiness, restlessness, confusion

Question 25

What are late signs of increasing ICP?

Answer 25

Marked changes in LOC progressing to stupor or coma, Cushing's triad, slow, full and bounding pulse, irregular respirations, decerebrate/decorticate posturing

Question 26

What is the worst form of posturing?

Answer 26

Decerebrate (all 4 extremities in rigid extension)

Question 27

Anytime a patient with a head injury complains of headache, assume what?

Answer 27

Increasing ICP

Question 28

What are complications of increased ICP?

Answer 28

Brain herniation, DI and SIADH

Question 29

Problems with ___ are always secondary to other problems?

Answer 29

ADH. Think head injuries.

Question 30

What is the treatment for increased ICP?

Answer 30

1) Maintain cerebral perfusion (oxygenation) 2) Reduce cerebral edema by: reducing amount of CSF or reducing blood volume in the brain. 3) Keep temperature below 100.4 (38 C) (may use cooling blanket if hypothalamus not working) 4) Elevate the HOB 5) Keep head midline so jugular veins can drain. Neutral position.

Question 31

What should be assessed during treatment for increased ICP?

Answer 31

1) Monitor vitals for Cushing's triad and increased temperature 2) Watch ICP monitor with turning. ICP pressure increases with intervention but should decrease within 15 minutes. 3) Monitor Glasgow coma scale 4) Monitor fluids to prevent fluid volume excess.

Question 32

What should be avoided during treatment for increased ICP?

Answer 32

7) Avoid restraints, bowel/bladder distention, hip flexion, valsalva, isometrics, sneezing/nose blowing 8) Limit suctioning 9) Space interventions

Question 33

What can be used to treat hypotension in the client with increased ICP?

Answer 33

Isotonic solutions and inotropic agents like dobutamine and norepinephrine (short term).

Question 34

What can be used to decrease cerebral edema by decreasing metabolic demands of the brain?

Answer 34

Hypothermia

Question 35

____ induced coma is used to decrease cerebral metabolism.

Answer 35

Barbituate (phenobarbital, thiopental, propofol)

Question 36

What is the osmotic diuretic most commonly prescribed to reduce cerebral edema?

Answer 36

Mannitol

Question 37

What else can be used as an osmotic diuretic?

Answer 37

Hypertonic saline.

Question 38

If a tumor is the cause of increased ICP, what medication may be used to decrease cerebral edema?

Answer 38

Steroids

Question 39

What are the two most common forms of ICP monitoring devices?

Answer 39

Ventricular catheter and subarachnoid screws.

Question 40

With ICP monitoring devices, what is the greatest risk?

Answer 40

Infection. No loose connections! Keep dressings dry!

Question 41

What is the most serious type of skull fracture?

Answer 41

Basilar fracture

Question 42

Where do you see bleeding with a basilar skull fracture?

Answer 42

EENT (eyes, ears, nose, throat)

Question 43

What is Battle's sign?

Answer 43

Bruising over the mastoid (bone behind ear).

Question 44

What is an epidural hematoma?

Answer 44

A rupture or laceration of the middle meningeal artery. Signs include initial loss of consciousness, recovery period, then neuro changes leading to coma. Emergency!

Question 45

What is the treatment for epidural hematoma?

Answer 45

Burr holes to remove clot.

Question 46

What is a subdural hematoma?

Answer 46

Collection of blood (usually a venous bleed) between the dura and the brain. Chronic (slow) bleeds are tricky as they mimic other disorders.

Question 47

What kind of injury can put a patient at risk for autonomic dysreflexia?

Answer 47

A spinal injury ABOVE T6.

Question 48

What is the FIRST treatment for autonomic dysreflexia?

Answer 48

Sit patient up to lower blood pressure. THEN treat the cause (bladder, bowel, skin irritant, etc)

Question 49

What are S/S of autonomic dysreflexia?

Answer 49

Severe hypertension, severe headache, bradycardia, nasal stuffiness, flushing, sweating (esp on forehead), blurred vision, nausea, and anxiety.

Question 50

Why are patients with increased ICP placed on fluid restriction?

Answer 50

Less volume, less pressure!