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73 Cards in this Set
- Front
- Back
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Meningitis
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Infection/Inflammation of Brain & Spinal Cord
Purulent Exudate Increased Intracranial Pressure Possible Cranial Nerve Involvement |
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Causes of Meningitis
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Often a complication of another bacterial infection:
Meningococcus Pneumococcus Viral Haemophilus Influenzae b |
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Diagnostic Evaluation Techniques of Meningitis
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(1) Lumbar puncture to identify the causative organism in the cerebrospinal fluid.
(2) Blood cultures. (3) Physical examination. |
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Signs and Symptoms of Meningitis
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Fever
Photophobia Petechial Rash Nuchal Rigidity Positive Kernig’s and Brudzinski’s Signs Nausea and Vomiting Encephalopathy |
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Cranial nerves affected by Meningitis
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III, IV, VI: Causes ocular palsies, unequal & slightly reactive pupils
VII: Causes facial weakness VIII: Causes deafness & vertigo |
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Meningeal Signs: Positve Kernig’s Sign
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Elicitation: Flexing the patient’s hip 90 degrees then
extending the patient’s knee causes pain. |
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Meningeal Signs: Positive Brudzinski’s sign.
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The patient’s head is suppoted & raised in a supine position. Any flexion of the
patient’s lower extremities constitutes a positive sign. |
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Increased Intracranial Pressure
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Blood, brain & CF fluids extert greater than normal pressure (0-15mm Hg) within the cranial cavity. Common causes: brain trauma, intracranial hemorrahage & tumors.
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Signs & Symptoms of IICP
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Initial: restlessness, irratiblity, < LOC, N/V, headache, dilated pupil (on affeted side)
Late: Rising temperature, abnormal posturing, Cushings response |
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Clinical Manifestations Increased Intracranial Pressure
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(1) Change in level of consciousness.
(a) May occur over a period of minutes, hours, or days. (b) Characterized by a diminished response to environmental stimuli. (c) Responsiveness ranges from alert and oriented to no response to stimuli. (d) Confusion, restlessness, disorientation, and drowsiness may be signs of an impending change. (2) Headache--increases in severity with coughing, sneezing, or straining at stool. (3) Vomiting. (4) Papilledema/pupil changes. (a) Edema and pressure of both the optic nerve and the oculomotor nerve at the point at which they enter the globe is caused by venous congestion resulting from increased intracranial pressure. (b) Pupil on the affected side may be nonreactive. (c) Pupils may be unequal, dilated, pinpoint, or nonreactive. (d) Elevation of blood pressure with a widened pulse pressure. (e) Decreased pulse rate (may be increased initially). (f) Decreased respiratory rate (may be irregular). |
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Increased Intracranial Pressure and Cushing’s Triad
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Bradycardia (slowed HR), bradypnea (Slowed breathing), and aterial hypertension (Systolic increases while dystolic remains the same) = widening pulse pressure
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IICP Nursing Dx
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Disturbed thought process Self care
Pain Sensory perception disturbance Impaired physical mobiliy Risk for injury r/t to seizures |
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Headaches
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Headache is defined as pain in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck. Headache, like chest pain or dizziness, has many causes
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Tension headaches
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Most common type of headache caused by persistant contraction of scalp, facial, cervical, & upper thoracic muscles. Causing pain to the crown of the head to the base of the skull. Often described as pressure, steady, tightness, and aching.
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Migraine headaches
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Cuased by cerebral vasoconstriction followed by dialation. Consctriction is thought to be due to a response of the trigeminal nerve which stimulates substance P causing the release of amines resulting in pain. Described as throbbibg, boring, viselike and pounding
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Encephalitis Pathophysiology
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Inflammation of brain tissue
nerve damage, edema, necrosis & risk of intracranial hemorrhage. Caused by a virus (Herpes I), parasite, toxic substance, bacteria, vaccine, or fungi. |
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Encephalitis therapeutic Interventions
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Analgesics
Anticonvulsants Antipyretics Corticosteroids Antivirals Sedatives Neurological Assessment Symptomatic Care |
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Encephalitis Signs & Symptoms
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Headache & Fever (Common presenting synptoms)
N/V, confusion, Nuchal Rigidity, decreased LOC, seizures, photophobia ataxia (abnormal sleep), & tremors. |
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Encephalitis complications
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Cognitive Disabilities
Personality Changes Ongoing Seizures Motor Deficits Blindness |
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Diagnosotic tests for Encephalitis
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CT
MRI EEG LP with CSF Analysis |
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Nursing Diagnoses: CNS Infections
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Pain
Hyperthermia Disturbed Thought Processes Self Care Deficit Sensory Perceptual disturbance Impaired Physical Mobility Risk for Injury: Seizures |
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Nursing Care for Headaches
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WHAT’S UP?
Patient Education Keep Diary Record Triggers, Timing, Symptoms Teach Relaxation and Stress Reduction Teach re: Medications |
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Seizures
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Sudden, abnormal, and excessive electrical discharges from the brain that can change motor or autonomic function, consciousness, or sensation.
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Types of seizures
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-Partial
Begin on One Side of Cerbral Cortex -Generalized Both Hemispheres Involved |
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Etiology of seizures
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Idiopathic
No Cause Identified Acquired Underlying Neurological Disorder Brain Injury |
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Etiology of seizures
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Idiopathic
No Cause Identified Acquired Underlying Neurological Disorder Brain Injury |
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Signs & Symptoms of seizures
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Aura
Visual Distortion Odor Sound |
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Signs & Symptoms of Partial Seizures
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Dreamlike state involving repetitve behaviors called automatisms.
- No loss of consciousness = Simple partial - Loss of consciousness = Complex partial Usually < 1 Minute Paresthesias Visual Disturbances |
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Signs & Symptoms of Complex Partial seizures
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Lose Consciousness, 2 – 15 minutes
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Signs & Symptoms of
Absence (Petit Mal) Tonic Clonic |
Staring
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Signs & Symptoms of
Tonic Clonic |
May Have Aura
Usually Lose Consciousness Rigidity Followed by Muscle Contraction and Relaxation Incontinence Postictal Period |
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Diagnosis of seizures
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EEG
Look for Underlying Cause |
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Therapeutic Interventions of seizures
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Correct Cause
Anticonvulsant Medication Surgical Resection |
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Emergency Care: Seizure
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Pad Side Rails
Prevent Injury Monitor Airway Do Not Restrain Turn on Side to Prevent Aspiration Suction PRN Observe and Document |
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Status Epilepticus
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30 Minutes of Seizure Activity
Therapeutic Interventions Ensure Airway and Oxygenation Administer IV Diazepam |
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Status Epilepticus
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30 Minutes of Seizure Activity
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Therapeutic Interventions for Status Epilepticus
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Ensure Airway and Oxygenation
Administer IV Diazepam |
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Nursing Diagnoses epilepsy
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Risk for Injury
Risk for Ineffective Management of Therapeutic Regimen |
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Traumatic Brain Injury
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Trauma
Hemorrhage Contusion Laceration Can Cause Cerebral Edema Hyperemia Hydrocephalus Brain Herniation Death |
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Traumatic Brain Injury Etiology
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MVA Most Common
Falls Assaults Sports-Related Injuries |
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Traumatic Brain Injury Mechanisms of Injury
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Acceleration
Deceleration Acceleration-Deceleration Rotational |
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Types of Traumatic Brain Injury
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Concussion
Contusion Hematoma Subdural Epidural |
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Traumatic Brain Injury diagnosis
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CT
MRI Neuropsychological Testing |
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Therapeutic Interventions Traumatic Brain Injury
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Surgical Removal of Hematoma
Control IICP ICP Monitoring Osmotic Diuretic Mechanical Hyperventilation Therapeutic Coma |
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Complications of TBI
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Brain Herniation
Diabetes Insipidus Acute Hydrocephalus Labile Vital Signs Posttraumatic Syndrome Cognitive and Personality Changes |
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Traumatic Brain Injury Nursing Diagnoses
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Ineffective Cerebral Tissue Perfusion
Ineffective Airway Clearance Ineffective Breathing Pattern Disturbed Thought Processes Self-Care Deficit Pain Sensory-Perceptual Disturbance Impaired Physical Mobility Risk for Injury |
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Brain Tumor Pathophysiology
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Neoplastic Growth of the Brain or Meninges
Primary or Metastatic Compress or Infiltrate Brain Tissue Cause IICP |
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Signs & Symptoms Brain Tumor
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Seizures
Motor and Sensory Deficits Headaches Visual Disturbances Hormone Disturbances |
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Diagnosis Brain Tumor
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MRI
CT Angiogram, MRA Hormone Levels |
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Therapeutic Interventions Brain Tumor
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Surgical Removal
Radiation Therapy Chemotherapy Symptom control Anticonvulsants Dexamethasone |
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Complications of brain tumor
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Seizures
Headaches Memory Impairment Cognitive Changes Ataxia Hemiparesis Aphasia Lethargy Coma Death |
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Nursing Diagnoses brain tumor
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Disturbed Thought Processes
Self-Care Deficit Pain Sensory-Perceptual Disturbance Impaired Physical Mobility Risk for Injury |
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Closed Head injury/non penetrating injury
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rapid back and forth movement of th ebrain causing bruising and tearing of brain tissue and vessles
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Acceleration injury
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A moving object hitting a stationary head
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Deceleration injury
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When the head is in motion and strikes a stationary surface.
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Rotational injury
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Potential to cause shearing damage to brain as well as laceration and contusions. Cuased by a direct blow to the head that results in the twisting of the brainstem.
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Concussion
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Mild brain injury when loss of consciousness less than 5 min. May exoerience N/V, headache, dizziness
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Contussion
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Bruising of the brain tissue possibly accompanied by hemorrage
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Subdural hematoma
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(Acute or Chronic)
-Acute Appearance of symptoms within 24/hrs of injury. Venous bledding within dura and arachnoid membranes -Chronic Forgetful, letahegic, irratable, and headache |
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Epidural hematoma
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Collection of blood between dura mater and skull. Arterial in nature asscociated with skull fracture. Loss of consciusness, dialted pupil, paralyed extraocular movement
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Primary brain tumor
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Arise from cells within the CNS
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Intra-axial brain tumors
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Arise fromglial cells within the cerebrum
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Extra-axial tumors
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Arise from the skull, meninges, pituitary gland, or cranial nerves.
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Secondary brain tumor
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Metastatic from a primary malignancy
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Herniated disks
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Occurs when the disk between two vertabea moves out of its normal alignment cuasing the disk to compress nerve roots.
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Signs and symptoms of herniated disk
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pain,,muscle spasms, weakness, and atrophy
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Theraputic interventions for herniated disk
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Physical therapy, TENS, traction, medication, surgery
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Possible nursing diagnoses for herniated disk
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Pain r/t surgical procedure, Risk for impaired elimination r/t effects of surgery
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Spinal Stenosis
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The spinal canal compresses the spinal cord. (Arthritis major cause)
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Spinal Shock
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Complication following injury. Areas below the injury no longer communicate w/ CNS causing a disruption in sympathetic nervous function. Vasodialtion, hypotension, bradycardia, hypothermia.
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Complications of Meningitis
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Seizures
Cranial Nerve Damage Occasional Permanent Neurological Deficits |
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Therapeutic Interventions for Meningitis
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Antibiotics
Antipyretics Cooling Blanket PRN Dark, Quiet Environment Analgesics Codeine Products Corticosteroids Antiemetics Isolation if Contagious |
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Possible Nursing Dx for Meningitis
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Hyperthermia r/t to Meningitis
Risk for injury r/t to positive CFS culture Acute pain r/t to nuchal rigidity |
