Altered Neurological Function

http://nursinglectures.blogspot.com

nursinglectures.blogspot.com

To determine if client will be able to do his ADLs

Test for cerebral function

LOC – most important single indication of cerebral function

Level I: Conscious – normal awareness (oriented)

Level II: Lethargy, Somnolence, or Obstundation – responds with confusion; falls asleep when left alone; responds briskly to painful stimuli

Level III: Stupor – minimal physical & mental activity; reacts by reflex &/or making unintelligible sounds

Level IV: Semi-coma – no spontaneous movement withdrawal from painful stimuli; verbal response is limited to groaning; cough & swallowing reflex may occur; incontinence

Level V: Coma – no spontaneous movement; reflexes are very minimal to absent

Assessment tool designed to note trends in response to stimuli

Score Eye opening Verbal Response Motor

6 x x Obeys command

5 x oriented & converses Localizes pain

4 simultaneously opens confused, converses Withdraws fr. pain

3 verbal command Inappropriate Decorticate

2 Pain Incomprehensible Decerebrate

1 NO RESPONSE (GCS = 3)

Scores: >11 = 86% chance of moderate disability or recovery

9+ = conscious

8 = 50/50condition

7↓ = lethargic

<7 = indicative of comatose client

3-4 = 85% chance of dying or vegetative state

O lfactory (S) = test smell using odorous substances

Hyperosmia – acute sense of smell

Parosmia – abnormal sense of smell

Anosmia – loss of sense of smell anosmia

O ptic (S) = Snellen’s (3-6y/o =20/20vision)

O cculomotor (M) eye movements = 6 gaze directions ( √ diplopia &

T rochlear (M) strabismus, nystagmus)

T rigeminal (B) (S) = facial sensations using pins/cottons

A bducens (M) (M) = chewing & corneal reflex using cotton (+) blinking

F acial (B) -> (S) = anterior tongue; (M) = facial expressions ( √ for Bell’s Palsy)

A coustic (S) = hearing (tinnitus & vertigo) & balance -> Romberg’s test (+) means ataxia is present;

G lossopharyngeal (B) -> (S) = posterior tongue; (M) = swallowing: √gag reflex

V agus (B) -> √ gag reflex

S pinal accessory (M) = head & shoulder movement

H ypoglossal (M) = tongue movement

Muscle strength

Akinesia, hemiplegia, hemiparesis, paraplegia, quadriplegia

5-point Scale

5/5 = normal (full strength & ROM against gravity & applied resistance/pressure)

4/5 = full ROM but weakness upon against pressure

3/5 = move actively against gravity alone

2/5 = able to move with support

1/5 = contraction is palpable & visible; trace/flicker movements occur

0/5 = undetectable contraction & movement

Muscle tone:

Hypotonicity – soft, flabby, flaccid

Hypertonicity – rigid, spastic

Muscle coordination – Finger-to-nose test, heel Down Opposite Shin

Babinski– normal for infants til 2y/o

Brudzinski’s sign- flexion of hips & knees upon forward flexion of the neck

Kernig’s sign – resistance or pain upon straightening the knees as the legs, hips, & knees are flexed

Grading: 0 = absent

+1= diminished

+2 = normal

+3 = brisker than ave.

+4 = hyperactive

Orientation

Language / communication

Aphasia – defect in using & interpreting symbols of language

Receptive / sensory

Motor / expressive

Dysarthria / anarthria – imperfect articulation causing difficulty in speaking due to crani al nerve dysfunction

Attention span – serial 3s / 7s

Memory

Immediate recall - 5-8digits then reverse 4-6digits

Recent memory

Remote memory

ability to keep its body temperature within certain boundaries, even when temperature surrounding is very different

Thermo-regulatory center = hypothalamus

Physiologic adaptation:

Vasodilatation and sweating are the primary modes to lose excess body

Skin - assists in homeostasis by reacting differently to hot and cold conditions so that the inner body temperature remains more or less constant

Heat loss

Sweating is the only physiological way to lose heat - heat loss by evaporation

Vasodilatation occurs, this is the process of relaxation of smooth muscle in arteriole walls allowing increased blood flow through the artery. This redirects blood into the superficial capillaries in the skin increasing heat loss by radiation and conduction

Heat production

Piloerection - lifting the hair follicle upright; makes our hairs stand on end which acts as an insulating layer, trapping heat

Vasoconstriction - blood is rerouted away from the skin and tow ards the warmer core of the body; this prevents blood from loosing heat to the surroundings and also prevents the core temperature dropping further

Seizures & Epilepsy nursinglectures.blogspot.com

Paroxysmal uncontrolled abnormal discharge of electrical activity in the brain

Malfunction of hypersensitive neurons in cerebral cortex & limbic centers

A symptom rather disease in itself

Classification according to etiology

Primary / Unknown – assessment finding does not reveal a definite cause

Secondary / Symptomatic – causes

Hyperpyrexia

CNS infection

Cerebral hypoxia &/or trauma

Toxic agents / poison; metabolic intoxication

Brain defects

Degenerative diseases

anaphylaxis

Generalized – usually begins bilaterally without local onset, EEG abnormalities

Grand Mal / Generalized Tonic-Clonic Seizure

Precede by an aura (strange feeling of sensation)

Loss of consciousness

Tonic phase – entire body stiffens in rigid contractions, fixed jaw, clenched fists, temporary interruption of respiration (30-60s duration)

Clonic phase – rhythmic jerky contraction & relaxation of muscles (esp. extremities), may bite lip 7 tongue, may be followed by fatigue, confusion, depression, amnesia

Petit Mal / Absence seizure

No actual convulsive movement

Vacant stare

Childhood or early adolescence

No recall of attack

Partial / Focal Seizure – most common; depends on brain part involved

Jacksonian / Simple Partial Motor Seizure

Tonic-clonic convulsive movement in a localized body region opposite of lesion

Usually without loss of consciousness

nursinglectures.blogspot.com Hypothermia, hypoglycemia, hypoxia, toxic substances Firing of neurons in increasing frequency & amplitude Threshold of intensity of electrical discharges Firing spreads to adjacent neurons Brain stem Cortex & basal ganglia Muscle contraction & loss of consciousness Slowing of neuronal firing Intermittent contraction-relaxation phase seizures

Priorities: airway & safety

Provide privacy

Ensure patent airway

Side-lying position

Padded tongue depressor

Prevent injury

Raise padded side rails

Do not leave client alone (stay with client until fully conscious)

D not attempt to restrain

Protect the head (slip a small pillow under; place on lap)

Reorient client to surroundings upon waking

Note position of eyeball & head at the beginning of attack

Note duration of unconsciousness

Observe for fecal or urinary involvement

A brain disorder accompanied by periodic convulsions and loss of consciousness

Causes:

Head trauma – most common cause (closed head injuries)

Brain tumors

Risk factors:

CVA

CNS infections

Toxic substances interfering with brain metabolism (O 2 & glucose supply) – lead, alcohol & substance abuse

Genetic pre-disposition (cerebral dysrhythmia, monozygotic twins)

Detailed Hx

Neurologic assessment

Mental status exam

EEG (electroencephalogram) – determines existence & type of epilepsy

Hair shampoo (Prior & after the test)

Hold meds (sedatives, tranquilizers, stimulants) & foods with caffeine 2-3days prior

Skull x-rays – reveals skull configuration

Remove metallic objects

Computerized Tomography (CT) scan – visualization of brain & its structures in successive layers; IV contrast medium may be used

Secure consent

NPO at least 4hrs prior

√ for seafood allergy

C/I: pregnant, obese, claustrophobic, unstable v/s , a llergy to the dye

MRI

Positron-emission Tomography (PET) – visualization of physiologic functions; client is given doses of strong radioactive tracers

Secure consent

NPO 4hrs prior

If diabetic client, CBG < 150mg/dL

Agitated clients may require sedation

Pharmacologic management - to control or minimize seizure

IV

Phenobarbital (Sodium luminal)

Phenytoin (Dilantin)– slow cardiac arrhythmias & prevent seizures

Diazepam (Valium) – muscle relaxant

Oral – maintenance dose

Carbamazepine (Tegretol)- anti-convulsant

Dilantin

Nursing – refer to seizure management

Help client identify precipitating factors (stress, lack of sleep, alcohol use)

No alcoholic beverages

Take meds religiously

Caution in swimming, horse-back riding, & driving

Provide support to clients to accept condition & live a life as normal as possible

Psychosocial counseling

Carry IDs stating client is epileptic

Surgery – last resort; client does not respond to meds

Cortical resection of anterior temporal lobe – safest & most effective

Criteria: failure of medical approach & localization of a focus of abnormal electrical discharge

Client must be awake the whole time

Brain tumor surgery

Status epilepticus – continuous seizures or rapid succession lasting for at least 30mins

A medical emergency

Client may remain comatose & have repetitive seizure for hours

Precipitating factor: abrupt withdrawal of anti-convulsant meds

Lorazepam (Ativan) slow IV – med of choice given until seizures stop (Valium or Dilantin may be used instead)

Ventilation equipment must be ready

General anesthesia may be used or Vecuronium bromide (Norcuron –neuromuscular blocker)

Client must be on continuous EEG monitoring

http://nursinglectures.blogspot.com

Altered Neurological Function

3 comments

Notes on slide 1

5 Favorites