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  • 1. MedSurg NCTC NeuroQuestionAnswerTwo divisions of the nervous systerm  Central (CNS) Peripheral (PNS)  Sensory Neurons  Transmit impulses to the CNS  Motor Neurons  Transmit impulses from the CNS  Three parts of the Brain  Cerebrum cerebebellum brain stem  Cranial Nerve I  Olfactory nerve: sense of smell  Cranial Nerve II  Optic nerve: sight  Cranial Nerve III  Oculomotor nerve: Contraction of iris and eye muscles  Cranial Nerve IV  Trochlear nerve: eye movement  Cranial Nerve V  Trigeminal nerve: sensory nerve to face, chewing  Cranial Nerve VI  Abducens nerve: eye movement  Cranial Nerve VII  Facial nerve: facial expression, taste, secretions of salivary and lacrimal glands  Cranial Nerve VIII  Vestibulocochlear (or auditory) nerve: hearing, balance  Cranial Nerve IX  Glossopharyngeal nerve: taste, sensory fibers of the pharynx and tongue, swallowing, secretions of parotid gland  Cranial Nerve X  Vagus nerve: Motor fibers to glands producing digestive enzymes, heart rate, muscles of speech, gastrointestinal motility, respiration, swallowing, coughing, vomiting reflex.  Cranial Nerve XI  Accessory (or spinal accessory) nerve: head and shoulder movement.  Cranial Nerve XII  Hypoglossal nerve: movement of the tongue  Cranial Contents:  84% brain, blood 4% CSF 12%  Decorticate posturing  one or both arms are fully flexed on the chest  Decerebrate posturing  one or both arms are stiffly extended.  Conscious  the client responds immediately, fully, and appropriately to visual, auditory, and other stimulation.  Somnolent or lethargic  The client is drowsy or sleepy at inappropriate times but can be aroused, only to fall asleep again. Response to questions are delayed or inappropriate. Speech in incoherent. The client responds slowly to verbal commands, responds to painful stimuli  Stuporous  The client is aroused only by vigorous and continuous stimulation usually by manipulation or strong auditiory or visual stimuli...one or two word answers, or motor activity or purposeful behavior directed toward avoiding further stimulation.  Semicomatose  The client is unresponsive except to superficial, relatively mild painful stimuli to which the client makes some purposeful motor response to evade stimulation.  Comatose  The client responds only to very painful stimuli by fragmentary , delayed reflex withdrawl; in deeper stages, he or she loses all responsiveness. There is no spontaneous movement and the respiratory rate is irregular.  Glasgow Coma Scale  a tool for assessing a client's response to stimuli. A score of 10 or less indicates a need for emergency attention. A score of 7 is generally interpreted as coma. 3 categories eye opening, verbal response, and motor response gives points from 1-4  C.T Scan - Computer Tomography  uses x-rays and computer analysis to produce three dimensional views of thin cross sections of the body * if using contrast requires consent  MRI - Magnetic Resonance Imaging  Is based on the magnetic behavior of protons in body tissues. it uses radio frequency waves to produce images of tissues of hight fat and water content such a soft tissue, veins, arteries and the brain and spinal cord no radiation.  Positron Emission Tomography  uses radioactive substances to examine metabolic activity of body structures.  Single Photon Emission Computed Tomography  provides information about the brain's function, cerebral blood flow and status of receptors for neurotransmitters. Early identification on lesions  Lumbar Pucture  Examination of CSF for pressure, pathogenic microorganisms and blood cells  Contrast Studies -cerebral angiography -  detects distortion of cerebral angiography  Electroencephalogram  records the electrical impulses generated by the brain.  Increased Intracranial pressure  Brain 84% Blood 4% CSF 12%  Foramen magnum -  the opening in the lower part of the skull through which the upper part of the spinal cord connects with the brain. The only hole in the brain. ...too much pressure the brain with herniate ....DRT dead right there.  IICP - signs and symptoms  Decreasing LOC Confusion, restlessness Headache - especially one that is more severe in the morning, increases with activities that elevate ICP such as coughing sneezing or straining at stool. vomiting with no nausea  Cushings Triad  pulse rises then falls widening pulse pressure irregular respiratory rate  Cheyne-Stokes respirations -  shallow rapid breathing followed by periods of apnea.  head injury  compresses the brain - big changes quickly the pop off valve is the foramen magnum (big hole at the bottom of the skull) Brain stem - heart rate, respirations, LOC - no going back  ○ Glasgow Coma scale  § 3-15 § 7 is comatose  □ Eye opening □ Speak □ Move independently □ response to pain  Vomiting  especially without nausea is a neurological issue  Papilledema  § optic nerve swollen □ vision change □ pupil response □ fixed and dilated □ unequal pupils □ check for prosthetic eyes if no pupillary response  * Tests that determine underlying cause of IICP:  ○ CT scan 10-15 min ○ MRI ○ Lumbar puncture ○ Intracranial pressure monitor ○ Do a good assessment -can tell how they are doing by a good neuro assessment  * Meningitis:  ○ headache --light sensitive (photophobia) quiet cool dark area ○ stiff neck - nucle rigidity ○ fever ○ rash on trunk ○ mental alterations - can be wild Seizures  Meningococcal:  faster onset; diagnosed by spinal tap cloudy fluid make sure we do a CT before the spinal tap, antibiotics, anticonvulsants, pain, low stimulus environment.  Spinal tap  roll into a ball shoulder and hips inline so the vertebre make more space. Check fluid then send to the lab numbered tubes first one they disregard RBS from the tap, usually to a head ct first before the tap in case of a bleed in the brain.  Cerebral Vasculitis:  Inflammation of the blood vessels in the brain can result in irreversible coma, long lasting neurological problems hearing and vision. Can be fatal  Encephalitis Patho & Etio  many different causes usually vector borne. Most common is west nile. find source; mosquito control.  Gillian Barre Syndrome Patho & Etio  Auto immune - commonly follows a viral infection usually a respiratory or vaccines effects the myelin sheet  Assessment: Gillian Barre Syndrome  weakness numbness tingling effects the arms and legs. Starts at the bottom and works their way up. Gradual onset with a slow and recovery will be the reverse. Can take up to a year depending on the severity of the problem.  Brain Abscess Patho & Etio:  Infections; caused sinus, teeth ear, surgery, tongue piercing,  Assessment: Brain Abscess  headaches, vomiting, fever, seizures, LOC, difficulty walking, pt may be compensating for some time if the abscess is severe.  Medical Mgmt: Brain Abscess  Antibiotics, surgery, may need life support * Nursing Mgmt: measure I &O, LOC, Monitor for intracranial pressure,  Multiple Sclerosis Patho & Etio:  Destruction of the myelin sheath chronic and progressive with exacerbations and remissions but keep getting worse. Onset 20 to 40 years affects men and women approximately equally in more northern climates.  * Capizole - new drug foe MS  ○ flushing ○ heart palpitations ○ anxiety ○ dyspnea ○ raised burning welt possible ○ lasts 15 min or less  * Nursing Mgmt: MS  Keep immune system up, supportive care for pt and family, many different drugs for symptoms, no cure but meds to help with lessening exacerbations.  Myasthenia Gravis Patho & Etio:  thymus gland issues - drooping of eyelids, difficulty chewing and swallowing, different muscle groups effected. May see improvement with rest  *Myasthenia Gravis Medical & Surgical Mgmt:  diagnostic Tensilon will see improvement for 5 min. * Nursing Mgmt: Monitor respiratory, allow for periods of rest,  Amyotrophic Lateral Sclerosis Lou Gerick's disease Patho & Etio:  lack of muscle control degeneration of the myelin sheath, degeneration of muscle neurons and spinal cord. Potentially fatal, can be very aware that their mind is here but their body is failing.  Amyotrophic Lateral Sclerosis Lou Gerick's disease** Assessment:  progressive wasting of extremities, then respiratory, swallowing, speech, emotional inability to appropriately respond, watch for respiratory issues and failure.  Cranial Nerve Disorders Trigeminal Neuralgia Patho & Etio:  affects the 5th cranial nerve pain with chewing might be from compression from the nerve, will be reoccurring, sudden severe burning pain. can think of nothing but pain. May not be able to communicate effectively until their pain is treated.  Trigeminal Neuralgia * Medical Mgmt:  Treated with narcotics, watch for respiratory depression. may take lots of meds to get their pain under control but may not be able to make it go away completely. Anticonvulsants seem to help settle down the nerves some.  Trigeminal Neuralgia * Surgical Mgmt:  Sever the sensory route, may lose control of that side of their face, really look carefully before taking this step  Trigeminal Neuralgia * Nursing Process:  any little thing can set off a reaction, protect this person's face from cool breezes, fans, washing their face, eating cold things, cold drinks, any stimulation may set off this reaction. Sometimes it may resolve as quickly as it started.  Bell’s Palsy Patho & Etio:  7th nerve * drooping of the face and eyelid, usually see more of the eye than a stroke ( with stroke you will see more lip ), Decreased sensation, usually not a headache, limited to the face (stroke is the whole body)  Bell’s Palsy *  Assessment:  symptoms develop in a few hours to one or two days. Most cases recover but if still have symptoms after three months it may be permanent. eye damage, trouble swallowing, need ointment on the eye at night and tape close.  Temporomandibular Disorder Patho & Etio:  The meniscus of cartilaginous disk between the condyle and the temporal bone becomes displaced.  Temporomandibular Disorder * Assessment:  pain, headache, muscle spasm, clicking, lock jaw, chewing and talking problems, could be swallowing problems. Nutrition, cold or hot food may be irritating.  Extrapyramidal Disorders - Huntington's and Parkinson's disease most common Parkinson's  Patho: affects the dopamine receptors stiffness, tremors, rigidity, hips and knees slightly flexed, short shuffling steps, stooped posture, arms flexed at elbows and wrists. Progressive disorder, watch for falls, pill rolling( early sign)  Parkinson's Medical Management:  prolong their independence for as long as possible. Rehab: maintain the highest level of function available train them and their caregivers for their needs and care.  Huntington's Disease Patho -  hereditary disorder, genetically passed symptoms usually show up when the pt is in their 40-50's  S/S no early symptoms - Huntington's Disease  hallucinations, emotional disturbances, impaired judgment, fast changes, speech and swallowing difficulty, twisting of the body, bowel and bladder control depletes, people wither down to almost nothing, contortions odd body positioning,  Nursing mgnt: Huntington's Disease  try to prevent complications, support them nutritionally , try to keep safe, emotional support try to maintain the highest level of functioning.  Seizures - Partial  won't lose consciousness, may have some uncontrolled jerking movement of a body part usually last lest than a minute. May have sensory manifestations.  Generalized - Grand Mal  Tonic clonic movements, whole body involved, may have sensation before called an aura. Sudden excessive jerking, may have a preictal phase vague emotional stage, after may have post ictal phase, pt very tired needs to sleep,  Status Epilepticus -  Series of tonic clonic seizures blood to brain, breathing, must be stopped, valium, may have to paralyze them and put on a vent, Cerebyx or dilantin to keep from seizing. Tergitol, Zarontin, Depakene, often seen if they don't take their meds  Brain Tumors, -  some more common in children, some more common in adults, about 50% of all tumors are malignant what causes? abnormal growth of cells, viral immunosuppression, infection, trauma, genetic, radiation,  Brain Tumors Assessment  headache worse in morning, vomiting without nausea, LOC, speech, paralysis, double vision, seizures,  Central Nervous System  * consists of the Brain and Spinal Cord  * Peripheral nervous system  * consists of the 12 pairs of cranial nerves & 31 pairs of spinal nerves  * Brain stem  * Controls awareness/alertness through reticular activating system * made up of medulla, pons & midbrain: * -*  Medula  anterior to cerebellum * regulates HR, resps, BP, coughing, sneezing and swallowing  Pons  - anterior to medulla, relays messages to upper brain centers  Midbrain  * extends from pons to hypothalamus * regulates movement of eyes, auditory reflexes, righting reflexes-to keep head upright  * Cerebellum  * posterior to medulla and pons * Coordinates involuntary aspects of voluntary movement, maintains balance, posture, spatial orientation  * Cerebrum  * Controls higher functions and activities, conscious mental processes, sensations, emotions, and voluntary movements  Forebrain  Includes the frontal, parietal, occipital, & temporal lobes & central portion of brain  sympathetic division: Fight or flight  * bronchodilator * increased HR and Resp * decreased gastric motility * run by neurotransmitters called catecholamines: epi & nor-epi  parasympathetic division: Rest & Digest  * opposite of fight or flight-dominant during non-stressful times * Bronchi-constricted or normal * decreased HR and resp, or normal * increased gastric motility  How do you perform a Babinski reflex, also known as a plantar reflex, and what does it indicate?  * Stroke lateral side of the bottom of foot-if positive-great toe pulls towards nose and other toes flare * normal response is for toes to curl when foot stroked * positive response indicates abnormalities  * What is an EEG and what prep is necessary?  * A graphic representation of electrical activity of brain cells * shampoo hair thoroughly so that electrodes will adhere to scalp * withhold seizure meds, anticonvulsants, sedatives and tranquilizers for 24-48 hours prior to EEG * restrict caffeine  How would you do Neuro checks on a head trauma pt?  * assess LOC: is pt somnolent, lethargic, stuperous, semi-comatose, comatose * assess mental status: ask them to say their name, date and place, include a question with a commonly known answer- * assess pupil response: * assess extremity strengt  subarachnoid bleed  * S/S-sudden onset, severe HA, stiff neck, decreased LOC, photophobia  * What is a coup and contrecoup injury?  * Coup injury is a closed head injury caused by hitting an unmoving object-the brain hits on the inside of the skull * Contrecoup injury is when an object hits the head and the brain bounces off the opposite side of the skull.  What is ICP, and how important is this?  * Intracranial pressure-components that exert pressure in the cranium-normal 0-15 mm Hg * anything above 15 mm Hg creates potential life threatening problems * 3 things control ICP: brain, blood & CSF  The Monroe Kellie hypothesi  states that in order for ICP to remain normal one must decrease if one increases.  Why did you take care not to twist an mva pts back during transfer?  * Twisting the spinal column in the presence of injury can decrease the blood supply to the spinal column changing the components that control ICP, this leads to increased ICP  Glasgow Coma Scale what is normal?  * Measures eye opening, best motor and best verbal response * each assessment receives a score * normal score: 15 * ask open ended questions  What S/S occur with increased ICP?  * LOC-most reliable indicator of mental status - earliest changes seen * pupillary changes are second * altered motor function * Posturing * change in temp * as pressure on hypothalamus increases body unable to control temp  Biots respiration  2 shallow breaths followed by a period of apnea  * What are some of the effects of spinal cord injury?  * Damage can be complete or incomplete * above C4 interrupts respirations-can be fatal * C5 and below spares diaphragm so able to maintain respirations but still have respiratory compromise  spinal shock  reflexes below level of injury temporarily stops-extremities are flaccid-becomes spastic as shock resolves (pg. 439) loss of sensation below the level of injury increases the risk of other injuries  * autonomic dysreflexia  * most dangerous problem, may occur as spinal shock subsides * exaggerated response to painful or noxious stimuli, distended bladder, constipation, renal calculi, ejaculation or uterine contractions, enemas, position change  * autonomic dysreflexia S/S  * severe vasoconstriction leads to severe hypertension * vasodilation occurs above injury: flushing, sweating * vagus nerve stimulated causing bradycardia * Treat cause to correct  Contact lenses and a head injury patient  You remove them and place them in a safe container.  What would you do if the pt did not have an intact corneal reflex?  Lubricate eyes regularly with saline  * Why would you space out the care for a spinal cord pt instead of doing his bath, PROM, oral care and dressing changes all at one time?  * you want to prevent autonomic dysreflexia  Decadron  a corticosteroid- decreases brain swelling  Dilantin  decreases possibility of sezures  Mannitol IV  used to decrease intracranial pressure  * Patient’s with neurological impairment often become easily agitated and combative. What medication can be given to help with this problem?  * Haldol  * What problems are associated with Haldol?  * Can cause extrapyramidal symptoms such as Tardive dyskinesia and Dystonia * Give Cogentin to control this problem  Kernig’s sign-  flex leg at hip then extend knee * may cause pain in hamstring  Brudzinski’s sign  when neck flexed, hip flexion occurs  What medical treatment is used for bacterial meningitis?  * Antimicrobials for bacterial meningitis * anticonvulsants for seizure activity  * What medical treatment is used for Viral meningitis?  requires supportive care  What causes Parkinson’s?  * idiopathic-no known cause  * What are the early s/s of Parkinson's disease?  * Tremor, rigidity * bradykinesia-extremely slow movements * loss of dexterity & power in affected limbs, aching, handwriting changes, drooling, lack of facial expression, rhythmic head nodding, pill rolling  * Why would physical therapy be used for Parkinson's?  * To help control symptoms of disease * PT includes massage, heat, exercise and gait retraining  Levodopa  * crosses the blood brain barrier-converted to dopamine to supplement the levels of dopamine in the brain to improve motor movement  What medication is used in combination with Levodopa and why?  * Sinemet- converts dopamine in the brain and is used in combo so that lower dosages can be used to achieve therapeutic levels  What are the 2 major causes of CVA?  * hemorrhage * blood vessel ruptures causing bleeding into brain leading to increased intracranial pressure * ischemia * embolic & thrombotic strokes-obstructs blood flow to brain cells and they become ischemic and die  * What part of the brain are often affected by CVA?  * cerebrum * right hemisphere controls left side * left hemisphere controls right side * brain stem * controls vital functions-resp, HR, LOC  What s/s might a person with CVA experience?  * Depends on type, location, and extent of injury * Hemorrhagic * Sudden onset * Severe HA- described as the “worst HA of my life” * Photophobia * Stiff neck * Loss of consciousness * Vomiting * Seizures  * Embolic CVA S/S  * Depends on the area of the brain that becomes ischemic * Unilateral numbness, weakness or paralysis * Visual problems * Confusion or memory loss * HA * Dysphagia * Memory loss * Thrombotic S/S same, but more gradual  What is affected by left brain damage?  * Right sided paralysis * Aphasia * Slow cautious behavior * Memory deficits * Reasoning * Logic * Ability to analyze  What is affected by right brain damage?  * Left sided paralysis * Spatial-perceptual deficits * Quick impulsive behavior * Memory deficits * Emotions * Loss of creativity * Imagination  What is a TIA?  * Transient Ischemic Attack * Temporary blockage of a cerebral vessel * 85% blockage causes symptoms of a TIA * TIA’s are warning signs of an impending stroke  What tests are done to determine if the CVA is caused by a clot or bleed?  * CT scan * MRI * Cardiac ultrasound * Cerebral and carotid angiogram * EKG * PET scan  clot busters  * Streptokinase * tPA * Activase  “clot busters” what makes a candidate  You must start this medication within three hours of the onset of symptoms. Stroke must be from a clot, no recent surgeries, no medications that contraindicate it.  Mannitol  for cerebral edema  Corticosteroids  for increased ICP reduce inflammation, suppresses immune system, monitor glucose levels. watch for GI bleeds.  Nimodipine or Nimotop  a CCB used to decrease cerebral spasm (for hemorrhagic stroke)  Dilantin  decrease the incidence of seizures makes birth control pills inactive, and causes birth defects.  Heparin  anticoagulation  What drugs are used to prevent TIA or CVA’s?  * ASA * Ticlid * Warfarin Sodium * Lovenox-must inject in the “love handles” **using a 25 g, 5/8” needle  What options are available for patients who are S/P stroke?  * Physical Therapy * Occupational Therapy * Speech Therapy * Home Health * Rehab hospitals  Hemianopsia  loss of vision  Agnosia  inability to recognize objects  Aphasia  inability to speak, read, write, use language, or comprehend words  Dysphagia  difficulty swallowing  Dyspraxia  difficulty initiating voluntary movements  Hemiplegia  half of the body is paralyzed  What can the nurse do to help communicate to either type of aphasia?  * speak slowly & clearly * use gestures * listen attentively when pt tries to speak * use alphabet board or pictures * use simple questions that require only yes or no answers  PT is going to assist your patient with right sided weakness. How does the patient need to hold the cane?  * With the left hand, 6” lateral to the left foot **Opposite the side of weakness!!  What is Guillain-Barre’ Syndrome?  * rapid progression (1-3 weeks)-myelin sheath destroyed along peripheral nervous system * an autoimmune response to a viral infection  What lab tests might be performed for Guillain-Barre’ Syndrome?  lumbar puncture shows increased protein in CSF  What is Myasthenia Gravis?  * A chronic, progressive disease with a defect in the neuromuscular junction (causes electrical impulses to be impaired to muscle)  What meds might be used for Myasthenia Gravis?  * Anticholinesterase drugs-Neostigmine-increases availability of acetylcholine at the neuromuscular junction * Corticosteroids-used when anticholinesterase drugs don’t work  myasthenic crisis?  * Myesthenic crisis-sudden exacerbation of myasthenia symptoms-difficulty breathing and swallowing, resp arrest * precipitated by infection  * cholinergic crisis-  sudden extreme weakness and resp impairment precipitated by overdose of anticholinesterase drugs  What is Amyotrophic Lateral Sclerosis?  Lou Gehrig’s disease * rapid progression of degeneration of the anterior horn cells and corticospinal tracts of the motor neuron causing spasticity, hyperreflexia , weakness, atrophy, cramps and muscle twitching, * maintains intellectual ability  * Describe Post Polio Syndrome.  * Pt’s with this syndrome experience progressive muscle weakness years after having Polio * care is supportive-help pt to adapt to symptoms and maintain maximum function * Must maintain strict bed rest while feeling weak  What meds are commonly used with MS?  prednisone, interferon 1B, baclofen, Tegretol, Symmetrel  What are the S/S of MS?  * Weakness * Vision changes * Nystagmus-involuntary eye movements * Tingling in extremities * Difficulty with coordination * Bowel/bladder dysfunction * Spasticity * Depression  What can cause an exacerbation of MS?  * Illnesses * flu, URI, **UTI  Describe the medical treatment for MS.  * Treat symptomatically * Supportive care * Solumedrol for exacerbations * Interferon 1B and 1A to prevent progression * Baclofen for spasticity  What meds are used for a pt with a seizure disorder?  * Dilantin * Cerebrex * Neurontin * Topamax  Seizure discharge teaching  * Must take meds for the rest of their life * NEVER suddenly stop taking your meds-contact physician first * When taking Phenytoin, you must have good oral hygiene  What is the first step you the nurse must do to dislodge a foreign object from the ear?  * Gentle flush with sterile NS May need to use mineral oil or alcohol if an insect is present  What S/S occurs with external otitis? Treatment?  * Pain that increases when auricle pulled * Dizziness, fever, drainage * Topical ATB, ASA or codeine for pain * Also known as “swimmer’s ear”  What is otitis media and how is it treated?  * Infection of the middle ear * Treated with ATB * If chronic-tubes, myrongotomy  What is Meniere’s disease?  * Disorder of the labyrinth, possibly caused by fluid in the inner ear  What S/S does a pt with Meniere’s disease experience?  * Acute attack-unilateral hearing loss, vertigo * Attacks usually become more frequent and closer together as it progresses * Tinnitus is most common c/o associated w/inner ear problems  How is Menieres disease treated?  * Meds for an acute attack are-atropine, Valium, antihistamines and vasodilators * Surgical tx-drain fluid from the inner ear or cut the acoustic nerve that controls balance * Ototoxic ablation-instilling ATB that are toxic to the inner ear  battery acid splashed in his right eye. He is in severe pain. What is your first intervention?  * Flush the eye with saline continuously for 30 minutes or until the burning stops  How will the doctor check for damage to the cornea?  * With a Woods Lamp  What is the difference between central cataracts and peripheral cataracts?  * Central-good peripheral vision * Peripheral-good central vision  What medical treatment may be appropriate for a cataract pt in the early stages? Late?  * Early-mydriatics * Late-cataract extraction with intraocular lens implant  * Mydriatics  -dilation  Cycloplegics  paralyze muscles necessary for accomodation so eye won’t move during surgery  What nursing interventions post-op are necessary to keep intraocular pressure in the operative eye normal?  * HOB up 45 * Lie on unaffected side * Antiemetics to prevent or tx N/V * Administer eye drops as ordered * Instruct pt no lifting >5-10 lbs * Don’t bend forward until released by Dr. * Report severe pain immed.-usually sign of increased IOP  What observations do you need to make if you witness a seizure?  * Respiratory * Airway * S/S of hypoxia * Length of time seizure is lasting * What body parts are involved * LOC * Incontinence   <br />