neuro Flashcards Preview

NCLEX > neuro > Flashcards

Flashcards in neuro Deck (17)
Loading flashcards...
1

neuro assessment

onset:
when did they start?

description:
location
how long?
how severe?

associated factors:
triggers
aggravating factors
anything relieve?

overall appearance:
general appearance
behavior
obvious signs of neuro deficit (speech/physical)

****degree of consciousness:
LOC (may be 1st sign there is a problem)
mental status (alertness, awareness of surroundings, orientated x4, memory)

Glasgow coma scale: pg 194
used for LOC
eye opening
motor response
verbal response
we like a high number (13-15)

pupillary changes:
pupil size (2-6mm)
PERRLA

hand grips/leg lifts/pushing strength of feet

Babinski reflex:
normal up to 1 year of birth (fanning of toes when stroke the bottom of the foot)
***walking toddler should not have
abnormal in adult
normal = curling of the toes when the bottle of the foot is stroked (plantar reflex)
if adult has babinski reflex (central nervous issue that affects upper motor neuron)

2

deep tender reflex scale

0=no response (absent)
1+ = present, but sluggish or diminished (hypoactive)
2+ = active/expected/normal
3+ = brisk, hyperactive slightly
4+ = brisk, hyperactive, intermittent or transient clonus

**ankle clonus (abnormal reflex movements of foot induced by sudden dorsiflexion

** normal reflex is documented as 2+/4+

3

neuro diagnostic test

lumbar puncture:
lumbar subarachnoid space
used to obtain CSF to analyze for blood, infection, tumor cells, measure pressure readings using manometer, administer drugs intrathecally (into spinal cord)

*** positioned propped up over the bedside table with head down, arched back to open up space between vertebrae, on side in fetal position (chin to chest and knees flexed)

inspect surrounding skin
CSF should be clear and colorless (looks like water)

post procedure:
lie flat or prone for 4-8hours
increase fluids
headache is a common complication (pain increases when sit up and decrease when they lie down)-- treated with bedrest, fluids, pain meds, blood patch

big complication:
brain herniation
infection (can cause meninigitis)

4

early signs of high ICP

change in LOC is earliest
slurred/slow speech
delay in verbal suggestion (slow to respond to commands)
increase in drowsiness
restless
confusion

5

late signs of high ICP

marked change in LOC progressing to stupor then coma
VS change (Cushing's triad--immediate intervention, systolic hypertension with a widening pulse pressure, slow full and bounding pulse, irregular respirations)

6

decerebrate and decorticate posturing

indicates motor response centers of the brain, midbrain, and brainstem compromised

decorticate:
arms flexed inward and bent toward the body
legs extended

decerebrate:
all 4 extremities rigid
WORST
burning cals

7

miscellaneous ICP signs

headaches
****anytime you have a head injury client that complains of headache think high ICP

change in pupils and pupil response (fixed and dilated)
projectile vomiting

8

complications of high ICP

brain herniation (obstructs blood flow leading to anoxia and brain death)
DI
SIADH

9

treatment for high ICP

reduce cerebral edema
reduced CSF
reduce blood volume
maintain oxygenation (decrease O2 cause cerebral vasodilation and high ICP)
don't want hypotension or bradycardia (decreases brain perfusion)
isotonic and inotropic solutions (Dobutamine, norepinephrine)
****high volume = high CO = high brain perfusion
keep temp below 100.4
elevate HOB
keep head midline so jugular vein can drain
watch ICP when turning
avoid restraints, bowel/bladder distension, hip flexion, valsalva, and isometric, no sneezing, no nose blowing
limit suctioning and coughing
space care
monitor GCS
***if GCS if below 8 think intubate
monitor V for Cushing's triad
barbiturate induced coma to decrease cerebral metabolism (phenobarbital, thipental, propofol)
osmotic diuretics (mannitol)--pull from from the brain cells and filter through the kidneys
hypertonic saline (pulls fluid from brain to reduce cerebral edema)
fluid restriction
ICP monitoring devices:
ventricular catheter monitor or subarachnoid screw
risk for infection

10

meningitis

inflammation of the covering of the spinal cord and brain

cause:
viral
bacterial

s/s:
chills
fever
headache
disorientation-coma
n/v
nuchal rigidity (stiff neck)
photophobia
seizures
positive kernig and brudzinki sign
kernig (stiff hamstrings, unable to straighten legs when hips flex 90degrees)
brudzinki (neck stiffness, hips/knees flex when neck is flexed

11

meningitis treatment

corticosteroids
antibiotics (if bacterial)
analgesics
anticonvulsants (if seizures)
droplet precautions
viral (transmitted by feces and requires contact precautions

12

TBI

closed:
brain injured
skull is not broken
dura is not torn

open:
skull is damaged
dura is torn
location is important
basilar (most serious), see bleeding ear, eyes, nose, and throat
battle's sign (bruising over the mastoid (bone behind ear)
raccoon eyes (peri-orbital bruising)
cerebrospinal rhinorrhea (leaking CSF from nose)
check CSF by testing positive for glucose

13

focal injuries

contusions seem with blunt trauma or deceleration and acceleration injuries
brain is bruising and damaged

hematoma:
small & rapid = death
large & gradual = adaptation

14

epidural hematoma

patho:
rupture/laceration of the middle meningeal artery
injury-LOC-recovery period-bleeding into their head-cannot compensate-neuro changes
knocked out-wake up-neuro changes-then coma

treatment:
burr holes to remove the clot
stop the bleeding
control ICP
ask:
did they pass out
did they pass out, wake up, then pass out again
did they just see stars
***emergency

15

subdural hematoma

patho:
collection of blood between the dura and the brain
venous bleed

treatment:
immediate craniotomy to remove clot and control ICP

16

diffuse brain injuries

concussion:
temporary loss of neurologic function with complete recovery
short period of unconsciousness
may just get dizzy
bring back to ED if ***difficult to awaken

17

autonomic dysreflexia

life threatening
upper spinal cord injury (above T6)
exaggerated response to certain stimuli that are harmless to someone without a spinal cord injury

s/s:
severe HTN
headache
bradycardia
nasal stiffness
flushing
sweating (forehead)
blurred vision
nausea
anxiety
sudden onset
if not treated, HTN stroke occurs

Causes:
distended bladder
constipation
impaction
stimuli to skin (pain, pressure, temp)

treatment:
sit up to lower BP
bed bound in semi-fowlers
treat cause
cath
remove any impaction
look for skin pressure, painful stimuli or cold draft/breeze
antihypertensives
teach prevention