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199 Cards in this Set

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it is a complex groups of events that occurs because of multipe neuro conditions. Occurs suddendly, progressess rapidly and requires surgical intervention
specific causes of ICP include
space occupying lesions that increase tissue volume, cerebrospinal problems, cerebral edema
when the pressure buildup is greater than the brains ability to compensate, pressure is exerted on surrounding structures where the pressure is lower. The movement of pressure is called the
supratentorial shift - it can result in herniation
the detection of ICP should be made when, and why
early so you can reverse the situation
what is the earliest sign of ICP
decrease in the LOC
the change in the LOC may include
Restlessness, lethargy, disorientation
collectioin of subjective data includes
presence of visual changes, diplopia or double vision, change in personality, and ability to think. the presence of nausea or HA is important
HA that occur w/ICP usually increase intestity w/
coughing, straining of stool, stooping. it is usually present in the early morning or awaken the pt at night
pupillar signs may change w/ ICP they include
changes on the same side as the lesion
first most subtle sign is the pupil reacts , but sluggishly
the ipsilateral pupil (when the nerve lesion is in one hemisphere)
remains dilated and is incapable of consricting. the pupil appears larger than that of the affected side and does not react to light.
a pupil that is fixed and dilated is also known as a
blown pupil and should be reported to the dr immediately
a widened pulse pressure, increased systolic b/p, and bradycardia are together called
cushings response
what are additional signs of decreased motor function
babinskis relfex - hyperreflexia, and rigidity
fexion of arms, wrists and fingers with adduction in upper extremities. extension, internal rotation, and plantr flexion in lower extremities
decorticate response
all four extremities in rigid extension, with hyperpronation of forearms and plantar extension of feet
decerebrate response
what are the dx tests for ICP
in postop or critically ill pts what is used to detect ICP
internal measuring devices are used to dx ICP
what is the first step in ICP
ensuring adequate oxygenation to support brain function
what are some nursing measures
1. elevat HOB 30 - 45 degrees
2 place the neck in a neutral position
3.position the pt to avoid flexion of the hips, waist, and neck as well as rotation of the head
4. pt should do isometric or resistance excercises
5. restric fluid intake
6. enemas and lax should be used
7. foley if pt not alert
8. suction if nec no longer than 10 sec
9. administer oxygen
10. use a hypothermia blanket to control body temp
the presence of a lesion anywhere within the sensory system pathway, from the receptor to the sensory cortex does what
, alters the transmission or perception of sensory information
the ability to know the position of the body and its parts without directly looking at the part is called
total or parial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage
what is objective data for distrubed sensory perception
noting the pts ability to perform purposeful movements or to recognize familiar objects
what is the most importan nursing intervention for pts with sensory dysfunction is
teaching the pt protective measures in relation to hte sensory deficity or alteration
the onset of seizures is before the age of
20 but can occur at any age
defined as a transitory disturbance in consciousness or in motor, sensory, autonomic function with or without a loss of consciousness.
seizures occur for a variety of reason they are
hpoglycemia, infection, electrolyte imbalance, alcohol, barbituate withdrawal, water intoxication
excessive neuronal discharges may result in a
tonic convulsion - they have the jerking movements
seizures are followed by a rest period of variable length called the
postictal period - pt feels groggy, act disoriented, c/o of HA and muscle aches are common.

pt usually sleeps after the seizure and will experience amnesia
recurrent, generalized seizure activity occurs at such freqency that full consciousness is not regained between seizures it is called
status epilepticus
what is important to consider in the presence of a seizure
an aura occurs in 50% of pts
with tonic clonic seizures
sensation as of light or warmth that may precede an attack of migraine or an epileptic seizure
an epileptic aura may be
psychic, or sensory w/ olfactory, visual, auditory, or taste hallucinations
objective data for seizures is the
number of seizures, character, duration, nature of pts movements, and sounds, level of alertness
what is the most common dx for seizures
until seizures are controlled the pt should not
drive a car, swim, operate machinery
pt receiveing phenytoin (dilantin) should do what
make sure they have good hygiene for the mouth and teeth (side effects are red and enlarged gums)
primary goals of the nurse and family caring for a pt haveing a seizure are
protection from aspiration and injury and observation and recording of the seizure activity
what are other nursing priorities
the pt should not be left alone
- support and protect the head
what is the most common seizure
generalized tonic clonic (grand mal)
what are the characteristics of a tonic clonic
- loss of consciousness and falling to the floor or ground
-stiffing of the body (tonic phase) this happens for 10 - 20 seconds and then subsequent jerking of the extremities (clonic phase) for another 20 - 40 seconds
what are the clinical signs of tonic clonic seizures
cry, loss of consciousness, fall, tonic clonic movements, incontinence, cyanosis, excessive salivation, tongue or cheek biting
aura for tonic clonic is
flashing lights, smells, spots before eyes, vertigo
postictal period for tonic clonic
yes, need for 1 - 2 hours of sleep, HA and muscle soreness are common
absence (petit mal) incidence
usually occur in childhood and adolescence

decrease as child gets older

rarely continues beyond adolescence
characteristics of petit mal
sudden impairment in or loss of consciousness or loss of consciousness with little or no tonic clonic movement

occurs w/o warning

tendency to occur a few hours after person arises or when person is quiet
what are the clinical signs of an absence seizure
sudden vacant facial expressions w / eyes focused straight ahead that lasts only a few seconds

- all motor activity increases except a sligh twitching about eyelids

- possible muscle tone loss

- brief loss of consciousness
aura with absence seizure
postictal period with absence seizure
psychomotor ( automatisms)
occur at any age
characterstics of psychomotor ( automatisms)
sudden change in awareness associated with comples disortion of feeling and thinking and partially coordinated motor activity

longer than absence seizures
clinical sx of psychmotor (automatisms)
- partially conscious

- often appears intoxicated
-may do antisocial things, such as exposing self or carrying on violent acts
autonomic c/o - shivering, lip smacking, repetitve movement,
-urinary incontence
is there an aura iwth autoatisms
complex hallucinations or illusions
postictal period with automatisms
yes, confusion, amnesia, need for sleep
jacksonian focal (local or partial)occurs almost entirely with pts with
structural brain disease
characteristics of jacksonian focal
depends on site of focus

may or may not be progressive
clinical signs of jacksonian focal
commonly begin in hand, foot and face

may end in tonic clonic seizure
is there an aura in jacksonian
numbness, tingling, crawling feeling
is there a postictal period
may antedate tonic clonic by months or years
characteristics of myoclonic
may be very mild or may have rapid forecrul movements
clinical signs of myoclonic seizures
sudden, excess jerk of hte body or extremities the jerk may be forceful enough to hurl the person to the floor or ground. they may be brief or occur in clusters

no loss of consciousness
is there aura or postictal period
not common
characteristics of akinetic
peculiar generalized tonelessness
clinical signs of akinetic
person fals in flaccid state

unconsciouss for minute or two
is there an aura or postictal period with akinetic seizures
rarely aura
no postictal period
this is a chronic, pregressive degenerative neuro disease that affects many people
with MS the T cells
attack the body
myelin damage occurs do to
viral infection early in life that becomes apparent as an immune process later in life
people living in temperate climates have an
increased risk for MS
the onset of signs and symptoms of MS occurs between what ages
women are affected more than men
the highest number of people w/MS live in
the great lakes area
pacific northwest
north atlantic states
what are some signs and symmptoms of MS
urinary problems, fatigue , swallowing difficulties, sexual problems,
what is some subjective data of MS
eye problems such as diplopia, scotomata (spots before the eyes), blindness
what are other subjective data of MS
weakness, or numbness of part of hte body, fatigue, emotional instability, vertigo, loss of joint sensation, ataxia and tremor
pain is
not a common sx of MS
objective data may include what for MS
nystagmus (involuntary or rhythmatic movemments of the eye), muscle weakness and spass, spastic, ataxic. dysarthria, dysphagia, euphoria, emotional lability or mild depression. urinary incontincen and intention tremors of he upper extremities
dx tests
CSF shos elevated gamma globulin and prliferation of T cells in the initial phase


MR later for presence of multiple lesions
what are some nursing interventions for MS
nutrition - high in fiber
skin care - turn frequently to avoid skin tears
activity - excercise but not to the point of exhaustion
control of environment - hot baths should be avoided, traveling in hot weather should be avoided, air conditioned surrounding in the summer,
pts with MS should be in a
peaceful and relaxed enviornment.
this is a syndrome that consist of a slowing down in the initiation and execution of meovement, increased muscle tone, tremor, impaired postural relfexes
parkinsons disease
what is the cause of parkinsons
loss of the dopamine producing cells
parkinsons effects
1.5 % of the population more than 65 years of age
major s/s of parkinsons are
tremors, muscle rigidity, slowed movements, impaired balance and coordination
this is a neurotransmitter that is essential for normal functioning of the extrapyramidal motor system, including control of posture, support, and voluntary movement
what is the ultimate confirmation of parkinsons
positive response to a low dose trial of an antiparkinsonsian medication such as carbidopa -levodopa (sinemet)
tremors are usually the
first sign and they are minimal, pt is the only one who notices it.

it is described as pill rolling
the second sign - cogwheel rigidity caused by sustained muscle contraction, and has complaints of muscle soreness
bradykinsea - loss of autonomic movement
lack of spontaneous activity
subjective data for parkinsons includes
fatigue, incoordination, judgment defects, emotional instablity, heat intolerance
objective data include
pill rolling, bradykinesia, muslce rigidity, masklike appearance, monotonous speech, drooling, swallowing may be abnormal constipation, scaly red rash near the ears , eyebrows and in the scalp . moist oily skin
what is the dx of parkinsons
no firm test
when at least two of the three characteristics are noted - tremor, rgidity, bradykinesia
what are some nursing interventions for parkinsons
- special attention to posture - lying on a firm bed w/o a pillow, holding hands folded back when walking may help keep the spine erect
diet - foods should be bite size, six small meals a day,
it is a chronic progressive degenerative disorder that affects the cells of hte brain and causes impaired intellectual functioning it is a common cause of dementia
the changes in the brain of pts with AD include
plaques in the cortex and neurofibrillary tangles
the nuero changes occur mainly in the
cerebral cortex and causes a decrease in brain size
AD is divided into
4 stages
in the early stage a person with AD has relatively
mild memory lapses, and may have difficulty using the correct word

attention span is decreased, may be disinterest in surroundings. depression may occur at this time
second stage of AD
more memory loss, esp. w/ short term memory, disoriented to time, loss of personal belongings is common, confabulating (makig up) stories for lost items

inability to recognize familiar items
third stage
person is totally disorientaed, to person, place, time, and motor problems such as apraxia, visual agnosia, and dysgraphia (difficulty communication via writing

wandering is common

total incontience
what is usually the first sympto
memory loss
nursing interventions are aimed at
adquate nutrition
- finger foods, eating while walking, foods high in calories

fluids 2000 ml a day
an autoimmune disease of the neuromuscular junction characterized bhye the fluctuating weakness of certain skeletal muscle groups. it is unpredictable neuromuscular disease with lower motoneuron characteristics
myasthenia gravis (MG)
what age does it occur
any age, most common between 10 - 65
peak onset is women in there 20 - 30
mg is caused by an
autoimmune process
the fatigue and muscular sx of MG are caused by an antibody mediate attak against the bodys
acetylcholine receptors at the nueromuscular junction
wha are the CM of MG
ptosis (eye lid droopin)
diplopia (double vision)

15 % of pts remains in eye muslces

vocal cords become weak and voice sounds nasal
as MG progressess what can happen
lower limbs can be affected - leads to difficulty walking, sitting, raising arms over head;;
what is the simplest test for MG
havethe pt look upwards for 2 - 3 minutes. if the problem is MG there will be an increased droop of the eyelids, so the person can barely keep the eyes open
what problem usually occurs in people w/MG
respiratory probles
aspiration is common w/ MG pt should be taught to do _____ for airway protective technques
chin tucks, double swallow
what is the prognosis for MG

periods of exacerbation and remission

some severe cases lead to res death
pts with thymoma from MG may experience improvement when _________ is performed
stroke is also known as a
brain attack
it is an abnormal condition of the blood vessels of the brain, characterized by hemorrhage into the brain or hte formation of an embolus or thrombus that occludes an artery ,resulting in ischemia of hte brain tissue normally perfused byh the damaged vessels
it is the most common disease of the nervous system
who does stroke effect
people of all ages
but higher incidence in ages 75 - 85
strokes may lead to long term disability such as
hemiparesis, inability to walk, complete or partial dependence in ADLS, aphasia
strokes can be classified as either
ischemic or hemorrhagic
ischemic strokes are
thrombolytic or embolitic
they are cause of 85 % of strokes
hemorrhagic strokes account for
15% of all strokes as a result from bleedig into the brain tissue
contributing factors to strokes
atherosclerosis, heart diseae, kidney disease, peripheral vascular disease, DM, family history,, obesity, sedentary lifestyle, stress, smoking, cocaine use, sedentary lifestyle, oral contraceptives
a stroke can affect many parts of the body functions including
motor activity, elimination, intellectual function, spatial perceptual alterations, personality, affect, sensation, communication
vessels most commonly affected is the
middle cerebral artery
what is the most common cause of stroke
the most common cause of cerebral thrombosis is
symptoms of thrombotic stroke occur during
sleep or soon after rising
second most common cause of stroke is the
emboli stroke
the emboli most commonly originate from a thrombus in the
endocardial (inside) layer of the heart
less common causes of emboli are
air, fat from long bone fx, amniotic fluid after childbirth, tumors
hemorrhagic stroke
bleet into the brain itself or bleeding into the subarachnoid space. 3rd most common cause of stroke.
right sided brain damage
- paralyzed on the left side
-left side neglect
-spatial perception defecits
-tends to deny or minimize problems
-rapid performance
-short attention span
-impaired judgement
-safety px
-impaired time concepts
left sided brain damage
- paralyzed right side
- impaired speech/language aphasia
- impaired right/left discrimination
- slow performance, language
- aware of defictis; depression, anxiety
- impaired comprehension, r/t language , math
what might be restricted for the first few days after a stroke in an effort to prevent edema of the brain
goals in the initial phase are directed toward preventing
neuro deictis
neuro assessment on a pt w/ stroke is done
at reg. intervals but at least once each shift to detect changes in status and an complications such as worsening stroke
many speech problems associated w/ stroke are
dysarthria and aphasia
pts with stroke should approached how
in an unhurried manner
often the pt does much better w/communication if they
are not feeling pressure to speak
one specific nerve problem, degeneration of or pressure on the fifth cranial nerve, etiology is unkown
trigeminal neuralgia
trigeminal neuralgia is also called
tic douloureux
commonly affects
people in middle or late adulthood, slightly more common in women
characterized by
excruciating knifelike or lightnininlike shock in the lips, upper or lower gus, cheek , forehea, or side of the nose
the attacks last how long
usually brief 2 - 3 minutes are generally unilateral.

unpredictable recurrence, usually several times a dayor weeks or months apart.
the area along the course of the nerve is known as a _________ and the slightest stimulation of these areas may initiate pain
trigger points
what stimoulates the nerves
chewing, toothbrushing, hot or cold blast of air, washing face, yawning, talking
what might be injected into the peripheral branches of the nerves to promote relief for weeks to months
absolute alcohol
permanent relief of pain is obtained only by
surgery that involves inserting a fine needle through the cheek and injecting an alcohol solution or surgically resectioning the sensory root of the trigeminal nerve
surgery is
not always successful, and within 24 hours many pts develop herpes simplex of the lips, (cold sores) lesions heal in one week
comfort measure for pt w/trigeminal neuralgia
1 keep room free of drafts
2 avoid walking briskly to pts bedside
3. dont jar bed
4 . avoid touching the pt face
5. do not urge pts to wash or shave the affected area or to comb the hair
6. avoid hot/cold liquids
7. puree food
prognosis for trigeminal neuralgia
can be continous and interfere with lifestyle
a widespread inflammation and demyelination of the peripheral nervous system
guillain barre syndrome (polyneuritis)
guillain barre syndrome is also called
acute nflammatory polyradiculopathy or postinfectious polyneuritis
the GBS antibodies attack the
schwann cells, causing the sheath to break down (deymelination and the insulated portion to become inflammed)
s/s are
muscle weakness, tingling, and numbness, which begin in the legs or feet and owrk their way upward
who is affected from GBS
men and women are affected the same
paralysis usually starts in the lower extremties
once GBS is suspected the pt should be
hospitalized immediately because deteriration can happen rapidly
close monitoring of what is important
respiratory function
prognosis for GBS
85% will regain complete function
20% will have a weakness for 1 year
5% will have severe permanent disability
spinal cord injury and accidents are a common cause of
injury and death
approx ___ % of injuries occur to hte nervous sx involve the spinal cord
most people involved in spinal cord injuries are between the ages of
causes are
auto accident, sports related, diving, surgin
a total transection is also called a
complete cord injury
a partial transection or incomplete injury involves a
partial transection or injury of hte cord
quads (tetraplegic) are those who sstain injuries to one of hte
cervical segments of the spinal cord
paraplegic pt are those whose lesions are confined to the
thoracic and lumbar region, sacral
in most spinal cord injuries there is a period of
flaccid paralysis and a complee loss of reflexes below the trauma.
areflexia is
spinal shock and is temporary
one complication of spinal cord injury is autonomic dysreflexia or also known as
what is hyperreflexia
a neuro condition characterized by increased refex actions
it is most common in pts with
cervical injuries
autonomic dysreflexia occurs as aresult of
abnormal cardio response to stimulation of the sympathetic division of hte autonomic nervous sx, the bladder, lgintestine, visceral organs
signs of hyperreflexia are
bradycardia, hypertension, diaphoresis, gooseflesh(flushing above the level of hte lesion), dilated pupils, blurred vision, restlessness, nausea,severe HA, nasal stiffness
most common cause of dysreflexia is
distended bladder, fecal impaction. it is a med emergency requires immediate tx to prevent a stoke
this is a visual exam to inspect, treat, diagnose disorders of the urinary bladder and proximal structures
what position will the pt be placed in for this procedure
the pt will experience pressure. continous what will be necessary to facilitate visualization
fluid irrigation
care after the procedure includes ______ to dilute the urine
the first voiding after the procedure shoud be monitored for
dysuria, time , amount , color
the nurse should expect the first voiding to occasionally be
blood tinged due to the trauma of the procedure
in chronic glomerulonephritis what will happen to the kidneys
they will atrophy
signs and symptoms of Glomerulonephritis are
malaise, morning HA, dyspnea, visual and digestive disturbances, edema, fatgue
pt c/o
fatigue and inability to perform ADLs
what is the normal range of creatinine clearance
107 - 139 ml in men
and women it is 87- 109
person with glomerularnephritis might have a range of
5 - 10 ml they would be very low
with chronic Gnephro med managment may include
use of renal dialysis and possible kidney transplantation
what is TURP used for
removal of the tissue is done through the
what is expected after prostetic surgery
vital signs and urine will be monitored for
2 hours for the first 24 hour
with continuous bladder irrigation the urine will be
light red pink
intermittent irrigation the urine will be a
bright cherry red
continous irrigation is achieved by using a
three way catheter (one lumen for for irrigation fluid, one for urine drainage,one for retention balloon) or by using two catheters (foley and superpubic)
to determine urine output the nurse will
subtract the mount of irrigation fluid used from the foley catheter output to calculate urine output this is reported as actua urine output
prolonged what is to be avoided
catheter is removed when the urine becomes