Neurosensory and neurologic Flashcards
(43 cards)
Closed traumatic brain injury
Result of Blunt trauma
More serious than open due to chance of increased ICP in closed vault
The most important indicator of increased ICP
Changes in level of responsiveness
Even subtle changes such as restlessness, irritability, or confusion may indicate increased ICP
Symptoms of increased ICP
Changes in level of responsiveness
Changes in vital signs (bradypnea or resp irregularities, changes in pulse, rising BP, rising temperature)
Headache
Vomiting (usually projectile)
Pupillary changes
Seizures
Ataxia
Abnormal posturing (decerebrate or decorticate)
Cerebral spinal fluid leaking through nose or ear
Head injury patients should keep their head of bed elevated to
30- 45 degrees to aid in venous return from the neck and decrease cerebral volume
Head injury patients should have neurological vital signs taken every
1-2 hours
What should you do if client with head injury develops a fever
Immediately take action to reduce temperature through medication, or cooling blankets because increased temperature increases the cerebral blood flow drastically.
Avoid client shivering
When an intracranial monitoring system is being used to lower and maintain ICP pressure- at what level ICP should be reported immediately?
Elevations of ICP over 20 mm Hg should be reported stat
Why should nurses avoid narcotics in patients with head injuries?
They mask the level of responsiveness which is needed to assess early signs of increased ICP pressure
Post traumatic syndrome symptoms
Headache vertigo emotional instability, inability to concentrate, impaired memory
This is a possible after effect of a head injury
Most common sites for spinal cord injuries are
C5, C6, C7, T12, and L1
When can permanent impairment be determined in a spinal cord injury?
When the spinal cord edema has subsided- usually by 1 week
Hypotension and bradycardia will occur with any injury above (—) because sympathetic outflow is affected
T6
Spinal shock
A complete loss of all reflex, motor, sensory, and autonomic activity below the lesion
Medical emergency that occurs immediately after the injury
Characterized by hypotension and bradycardia. Complete paralysis and lack of sensation below lesion. Bladder and bowel distention
It is imperative to reverse spinal shock as quickly as possible bc permanent paralysis can occur is spinal cord is compressed for 12-24 hours
Autonomic dysreflexia
Exaggerated autonomic responses to stimuli that usually occurs in clients with lesions at or above T6.
Medical emergency that usually occurs after the period of spinal shock has finished and is usually triggered by a noxious stimulus such as bowel or bladder distention.
Characterized by elevated BP, pounding headache, sweating, nasal congestion, Goode bumps, bradycardia, bladder and bowel distention
Acute Paralytic ileus
Lack of gastric activity after spinal cord injury
Assess bowel sounds frequently and initiate gastric suction to reduce distention, and prevent aspiration and vomiting.
Spinal cord injury related to UTI
A common cause of death after a spinal cord injury is a UTI.
Brain tumors
Neoplasms occurring in the brain
Primary tumors can arise in any tissue of brain
Secondary tumors are result of metastasis from other areas (mostly lungs)
Multiple sclerosis
Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses
Symptoms usually begin in upper extremities with weakness progressing to spastic paralysis.
More common in women
Myasthenia gravis
Disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body
Autoimmune disorder characterized by pretense of acetylcholine receptor antibodies
Usually affects women ages10-40 and men ages 50-70.
Nursing assessment of myasthenia gravis
Diplopia (double vision)
Ptosis (eyelid drooping)
Mask like effects (sleepy appearance due to facial muscle involvement)
Weakness improved by rest- worsened by activity
Keep tracheostomy kit available at bedside incase of myasthenic crisis
Be alert for changes in resp status- most severe involvement may result in resp failure
Edrophonium (tension) test can indicate what for myasthenia gravis patients?
A positive Tensilon test indicates myasthenic crisis
A negative test indicates cholonergic crisis
Parkinson’s disease
Chronic progressive debilitating neurological disease of the basal ganglia and substantia nigra, affecting motor ability and characterized by tremor at rest, pill rolling movement, increased muscle tone (rigidity), slowness in initiating movement (bradykineshia), and postural instability
Medication for Parkinson’s diseases
Levodopa
Guillain-Barré syndrome
Clinical syndrome of unknown Orgin involving peripheral and cranial nerves
Usually preceded by a viral resp or GI infection 1-4 weeks prior to the onset of neurological deficits
Constant monitoring is needed for these pts to prevent the life threatening problem of acute resp failure
Full recovery usually occurs within several months to a year after the onset of symptoms
