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58 Cards in this Set
- Front
- Back
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Neurologic Assessment
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Sensory Assessment
Touch, position Motor Function Bilateral symmetry and equal size, muscle tone, strength and movement Cerebellar Function Cranial Nerves Assessment Gait, Romberg, coordination DTR LOC (response to auditory and/or tactile stimuli) Vital signs Pupillary response to light Strength of hand grip and movement of extremities bilaterally Determine ability to sense touch/pain in extremities |
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Cranial Nerve III
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this nerve is under uncus. swelling pupils uneven.
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Glascow Coma Scale
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3 areas
Gives overview of responsiveness 3 levels Does not replace complete neurological assessment Numerical ratings Score from 3-15 < 7 = coma This is a common assessment tool <7 prognosis bad Motor Response 6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No response II. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and/or jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No sounds III. Eye Opening 4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye opening |
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Diagnostic Tests
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CT - cross section of the brain
With and without contrast, metal distorts pictures MRI – more detailed than CT MRA – looks at blood vessels Metal implants, pacers MRS – uses a scanner PET- glucose metabolism and cerebral flow and volume (could be tumor cancer) Radioactive material CT will be noncontrast if a bleed is a possibility MRI also require much more time to do than a CT PET may be used if there is a likelihood of a neoplasm or nondissecting aneurysm |
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Diagnostics
d50 narcan-opiods |
EEG – electrical activity
Electrodes placed over the scalp Cerebral Angiography - cerebral circulation Uses a contrast dye Carotid Duplex Study – carotid arteries Lab studies Looking for a metabolic cause |
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Lumbar Puncture
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Procedure
Consent Side effects HA CSF leak – blood patch Indicated when infection or meningitis is the suspected cause of decreased LOC, or ICP |
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Gerontological Considerations
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Structural
Decreased number of brain cells, cerebral blood flow and metabolism May show cerebral atrophy Sensory Sensory is usually decreased due to age Temperature regulation May not be able to regulate body temperature as well and often have lower than normal baseline body temp Taste and smell Mental status Mental status should be checked with a family member or friend if at all possible when abnormalities are noted |
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Progression of Deterioration Brain Function
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Due to trauma, infection, tumor or injury
Brain deterioration usually follow a predictable pattern Direct injury to the brainstem and reticular activation system (RAS) The more primitive functions are preserved Consciousness requires functioning of RAS and cerebral hemispheres |
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Consciousness
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Full consciousness involves arousal and full cognition
Arousal – depends on the RAS Cognition – involves all mental activities controlled by the cerebral hemispheres Consciousness depends on the normal physiologic function of and connections between the two |
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Arousal and Cognition
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Damage to RAS – unable to maintain arousal
Stroke, tumors, abscess, MS, head injury, ICP, hematomas, hemorrhage, drugs Damage to the cerebral – a more generalized effect; impairs cognition and arousal Lack of blood/glucose or nutrients to the area – ischemia, hypoglycemia, edema, tumors, infections, pressure place on the other hemisphere, drugs 5 levels of deterioration 1 – alert, oriented X3 2 – responds to verbal stimuli, decreased concentration, confusion, agitation, disoriented 3 – requires to continuous stimulation to rouse 4 – reflexive posturing 5 – no response to stimuli As brain impairment progresses… Need more stimuli to get a response Become agitated and confused, responses to verbal stimuli Posturing movements to painful stimuli Orientation is lost in the reverse order Eventually no response at all to stimuli AMS can happen over hours or days and weeks |
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Describe Patterns Respirations
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Controlled by neural centers in the pons and medulla – responding to PaO2 and PaCO2
When damage to the RAS and/or cerebral hemispheres – then brainstem regulate breathing responding to only PaCO2 |
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Lists the types REspiratory pattern
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1 - Regular pattern
2 - Yawning, sighing 3 - Cheyne-Stokes Building up of rapid inspirations and expirations followed by a pause 4 - Central neurogenic hyperventilation Rapid, regular, deep or Apneustic breathing Prolong inspiration with pauses at inspirations and expirations Cluster breathing or Ataxic respirations irregular pattern, deep respirations, gasping, apnea |
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Pupil Changes
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1 –brisk, equal, regular
2 – small, reactive 3 – pupils fixed, midposition Note: Generalized damage – pupils are effected equally If lesion on one side or 3rd cranial nerve (uncus) effected, then same side pupil affected |
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Pupil Changes
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1 –brisk, equal, regular
2 – small, reactive 3 – pupils fixed, midposition Note: Generalized damage – pupils are effected equally If lesion on one side or 3rd cranial nerve (uncus) effected, then same side pupil affected |
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Oculomotor Changes
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1 – eyes move as head turns, caloric testing causes nystagmus
2- roving eye movements-sick Doll’s eyes – gaze fixed straight ahead Caloric testing - eye deviation away from cold caloric test and eye toward if warm caloric test. warm-toward cold-away vestibulo-ocular reflex 3 – caloric testing produces nystagmus 4 – no spontaneous movement, no nystagmus |
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Motor Responses
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1 - Purposeful movement, responds to commands
2 - Purposeful movement to pain Agitation, confusion, lethargy, disorientation 3 - Decorticate posturing 4 - Decerebrate posturing 5 – Extension of upper extremities with flexion of lower extremities, no response/flaccid |
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Decorticate
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arching back
rigidity abnormal flexing |
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Deceribrate
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pulling away extension posturing
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Acute and Chronic Outcomes
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With progression of deteriorating brain function
You may seen the full range of changes, or can jump for one change to all the way to brain death (depends on the insult) After the event, the patient may fully recover Or be left with a deficient, residual damage with one or more of the states Or be left in persistent vegetative state, locked in syndrome, brain death |
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Describe Persistent Vegetative State
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Irreversible coma
Unaware of self and environment Loss of all cognitive function Caused by severe brain injury or global ischemic event Diagnosed - if state last for at least 1 month Has sleep-wake cycles Still has basic reflexes Chew, swallow, blink, eyes wander, yes/no responses |
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Describe Blocked in syndrome
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Blocked pathways from the brain so no voluntary muscle movement
Full cognitive awareness & cranial nerves intact Can blink and move eyes The RAS remains intact The patient is “locked-in” and can not move |
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Describe Brain Death
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Cessation and irreversibility of all brain functions including brainstem
Different criteria of brain death exists Confirm diagnosis with: No motor or reflexes Apnea Fixed pupils Fails caloric testing Flat EEG |
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ICP
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If not corrected can lead to herniation, occlusion of blood flow = brain death
Brain death occurs when cerebral function is destroyed Pulse, BP, ventilator support Never recover to better state Organ procurement |
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Changes in Vital Signs Unique to IICP
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Ischemia in the brainstem triggers the CNS ischemic response
Neuronal ischemia in the vasomotor center cause a marked elevation in the MAP, with a significant increase in the systolic reading giving a widening pulse pressure This increased MAP causes a reflexive slowing of the HR This trio is known as Cushing triad |
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Cerebral Blood Flow
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IICP may signal a decrease in blood flow ischemia
Early stage ischemia, the vasomotor centers increases SBP in attempt to increase blood flow See slow bounding pulse with respiratory irregularities |
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Decompensation
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Efforts no longer effective
AMS Pupillary dysfunction Drooping of eyelid Blurred vision Hemiparesis/hemiplegia Posturing movement Projectile vomiting Widen pulse pressure Bradycardia and respiratory changes Temperature regulation fails |
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cerebral
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Occurs when there is an increase in volume of brain tissue
Leads to IICP Two types Vasogenic – increase in capillary permeability Tumors, infections, ischemia, injuries Cytotoxic – actual increase in intracellular fluid (failure of the sodium/potassium pump) Cells swell then IICP Ischemia, hypoxia, acidosis, trauma The amount of edema is directly proportionate to the amount of tissue damage |
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Hydrocephalus
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The CSF is being overproduced, abnormal circulation or reabsorption
Causes dilation of the ventricles Noncommunicating – CSF drainage is obstructed Tumors, hemorrhage, inflammation Communicating – CSF is not reabsorb and causes a build up Subarachnoid hemorrhage, scarring If not corrected – leads to IICP |
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Brain Herniation
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The brain herniates down on the brainstem, then through the foramen magnum
This is brain death – it puts pressure on the vital centers of the medulla |
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ICP
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If not corrected can lead to herniation, occlusion of blood flow = brain death
Brain death occurs when cerebral function is destroyed Pulse, BP, ventilator support Never recover to better state Organ procurement |
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Changes in Vital Signs Unique to IICP
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Ischemia in the brainstem triggers the CNS ischemic response
Neuronal ischemia in the vasomotor center cause a marked elevation in the MAP, with a significant increase in the systolic reading giving a widening pulse pressure This increased MAP causes a reflexive slowing of the HR This trio is known as Cushing triad |
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Nursing Measure to Improve IICP
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Neuro assessments
HOB 30 degrees Head alignment No noxious stimuli No increase in intrathoracic pressures (Valsalva) Control of temperature Careful fluid intake Protect eyes |
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IICP
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Diagnoses
CT, MRI Supportive labs and x-rays Treatment Diuretics osmotic (Mannitol) and loop Sedation, Paralysis, Antipyretics, PPI, Vasopressive agents, neuroprotectants (treat or alter pathologic pathway Mechanical ventilation CO2 is a potent vasodilator =IICP Surgery |
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ICP Monitoring
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Used to measure pressures
ICP CPP = MAP- ICP 70-95mmHg DBP X2 + SBP/3 = MAP Also monitors can drain and measure oxygen saturation & temperature of the brain |
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Monitoring ICP
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Position of monitor
Lateral ventricle, subarachnoid or epidural space Purpose Early identification, initiate tx, evaluate effectiveness of tx, quantify degree of abnormality Can drain CSF Devices Intraventricular catheter, subarachnoid screw, epidural probe |
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Traumatic Brain Injury
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Traumatic Brain Injury is the most frequent and serious neuro disorder
Also called craniocerebral trauma Incidence – 1.4 million/year, 230,000 survive, 50,000 die Types – Focal (confined to one area) or diffuse Scalp Skull Brain Secondary cause – trauma, edema, blood, IICP |
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Craniocerebral Trauma
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Contact – head hit by moving object
Related to the mechanism of injury Acceleration Deceleration Acceleration-deceleration injury (Coup-contra coup phenomenon) Rotational Primary vs Secondary effects Edema, hematoma, IICP |
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(Coup-contra coup phenomenon)
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?
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Traumatic Brain Injury
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Diffuse injury to brain
Leads to decreased oxygenation Systemic Effects of ABI Sympathetic effects Increase glucocorticoids & mineralocorticoids Increase catecholamine Altered release of ADH Pulmonary dysfunction Stress response Increase platelets, fibrinogen, thromboplastin Immunosuppression Increase gastric acids and decrease motility |
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What is a contusion?
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Bruising on the brain with possible venous bleeding
Decrease in pH, build of lactic acid leading to decrease oxygen use which will interfere with cellular function Swelling – 12-24 post injury Signs and symptoms depend on size of injury Loss of consciousness |
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where Location of hematomas/hemorrhage
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Epidural – between the scalp and the dura mater
Subdural – between the dura mater and the arachnoid mater Acute – onset of symptoms usually develop in minutes but within 48 hours Chronic – symptoms are seen over weeks to months Intracerebral – deep within the brain |
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Levels of head Injury
Epidural subdural intracerebral hemorrhage |
Arterial source, brief period of unconsciousness, followed by lucid period, then rapid neuro decline; HA, vomiting, seizures, dilated pupil on effected side, death
Usually a venous source, same symptoms as above, but onset is slower May have single or multiple lesions, generally same types of symptoms, can be based on the area of the brain affected |
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Treatment for Focal Injuries
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Contusion
Reduce IICP, maintain adequate oxygenation, ICP monitoring Hematoma/Hemorrhage Reduce IICP, maintain adequate oxygenation, ICP monitoring Surgery – flap or Burr holes Get rid of the clot/blood, stop the bleeding Surgery not an option for intracerebral bleeds |
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Describe Intracranial Surgery
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Better results today r/t
Improved imaging Surgical equipment Pre-op care Usually an emergent situation Post-op care Basically the same for any postop patient except Complications – think in terms of IICP Nursing care |
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Describe Diffuse Cerebral Injury
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Concussion
Shaking of the brain tissue Brief loss of consciousness followed by amnesia, HA, drowsiness, blurred vision, seizure, respiratory arrest, bradycardia, coma Postconcussion syndrome Diffuse Axonal Injury Acceleration-deceleration cause, mild to severe, coma, permanent damage in cognitive, sensorimotor, verbal, written communication, reason, emotion |
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Treatment for Diffuse INjury
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Treat IICP
The usual A, B, C, pain control measures Oxygenation, decrease CO2, diuretics, temperature control, drain CSF, neuroprotectants, PPI |
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Nursing Care for all Traumatic Brian Injuries
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Patent airway
Aspiration Suctioning Respiratory support On ventilator Cardiovascular support Positioning Balance with widening pulse pressure and bradycardia |
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Brain Tumors
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Tumors within the cranium
Classification are by cell type and whether primary or secondary Symptoms vary by type (how fast it grows) and location Compression of brain tissue, tumor infiltration, direct invasion, altered blood flow, brain edema Diagnosis by CT or MRI with contrast, Arteriography, EEG Treatment – Chemoterapy Surgery, Radiation, Laser (Gamma Knife) |
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Brain Abscess
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An infection with a collection of purulent material with the brain
Acute infection symptoms, seizures, altered LOC and signs of increased ICP Diagnosis by LP, culture of CSF, MRI or CT Treatment is aimed at treating the cause. ABT therapy may be done via Ommaya reservoir |
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OMMAYA RESERVIOR
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Central Nervous System Infections
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An infection of the CNS may be from bacteria, viruses, fungi, protozoans or rickettsia
May also be affected by toxins from bacterial infections Major types are meningitis, encephalitis and brain abscesses |
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Meningitis
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Infection of the pia mater, arachnoid and subarachnoid spaces.
May be acute or chronic May be bacterial, viral, fungal or parasitic May be direct (trauma) or indirect from systemic infection Bacterial is most deadly Viral from herpetic, Epstein-Barr or CMV |
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Encephalitis
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Acute infection of the parenchyma of the brain or spinal cord
Almost always viral though may be bacterial, fungal Arboviruses increasing Less common is lead poisoning, post-vaccination syndrome and HIV Course is directly related to the amount of brain tissue involved |
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Headache
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Most common of all physical complaints
Actually a symptom Many causes Can benign or pathological, intracranial or extracranial, other diseases, stress, musculoskeletal, or a combination |
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describe Migraine
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Caused by a trigging event
Food, smell, hormonal, alcohol, stimuli (flashing lights, lack of sleep Autosomal dominant trait Aura Starts with vasoconstriction of the brain vessels follow by vasodilation Extreme pain, N/V, blurred vision, altered speech, sensitivity to light After the HA, the scalp is tender and feels a deep aching |
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Cluster Headache
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Cause not really understood
Severe pain, unilateral, burning around the eye Called cluster because comes as clusters, several a day/more weeks to months then remission for months/years Can have certain triggers like migraines Usually happens after person falls to sleep, last several hours Other symptoms Rhinorrhea, lacrimation, flushing, sweating |
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Management of headaches
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Migraines
Beta blockers, tricyclic, ergotamine, SSRI, calcium channel blockers Imitrex (Sumatriptan) – oral, nasal spray, subq Zomig (Zolmitriptan) – oraly, nasal spray Narcotics/antiemetics Take early Caffeine for early migraine treatment Prevention is KEY Cluster Ergotamine before hs, calcium channel blockers, lithium, baclofen Inhaling oxygen |
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Cushings Triad
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x
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