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215 Cards in this Set
- Front
- Back
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What does the CNS consist of?
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brain and spinal cord
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What is the PNS?
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peripheral and cranial nerves
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Wht is the ANS?
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motor neurons that regulate activity of visceral organs, smooth muscle, cardiac muscle, muscle and glands
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What is the parasympathetic nervous system?
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rest and digest
baseline body functions |
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What is the sympathetic nervous system?
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fight or flight
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What will happen if there are lesions on the resp. center in the brain?
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respirations will be abnormal
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How much 02 does the brain use?
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20%
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How much glucose does the brain use a min>?
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60mg
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What is munroe-kellie hypothesis?
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the brain, cerebral blood volume and cerebrospinal fluid all usually remain stable. if there is a change in volume in any 3 components there ust be accompanied by a recipitcal change in one of the 3 components. if not the result is increased ICP
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What are used to decrease ICP?
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diuretics, burr holes
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Where is the respiratory center located in the brain?
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lower brain stem
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What major nutrients does the brain need?
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glucose and 02
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What is most of the volume of the brain?
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water
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Where is most of the volume in the brain?
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intracellular
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What is the blood-brain barrier?
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cells and membranes in the brain capillaries are very selective in the membrane permability and the molecular size of the substances coming into the cerebral circulation
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What are some things that are very permeable to the blood-brain barrier?
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water, 02, lipid-soluble compounds, C02, Na
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What controls blood volume?
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blood brain barrier and cerebral blood flow
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What is autoregulation?
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allows the brain to maintain a constant blood flow despite changes in systemic blood pressure by constriction or dilation of cerebral blood vessels in response to systemic BP, 02 and C02 unless it's <50 or >160
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What can happen when BP gets above 160?
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infarcts, stroke
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What happens when systemic BP increases?
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vessels constrict to protect from blood engorgement and the tissue from full impact of rise in pressure
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What happens when systemic BP decreases?
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cerebral blood vessels dilate to increase cerebral blood flow
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What happens when there is a high C02?
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cerebral vessels dilate
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What happens when there is a low C02?
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cerebral vessels constrict
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What do cerebral vessels do when there is a decrease 02?
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dilate to get more blood to the brain
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What is a HA?
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pain w/in the cranial vault
usually a symptom can be mild and transient or chronic and recurrent |
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What is a tension HA?
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bilateral pain
feels like a tight band around head gradual onset |
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What is a migraine?
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abnormal cerebral vascular flow
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What causes a migraine?
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spasms in blood vessels leading to the brain constrict the arteries which decreases blood flow and platelets start to clump which releases serotonin and further constricts vessels in response to other vessles in the brain trying to vasodilate which spreads to the head and neck arteries which caues a release of prostaglandins
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What are tension HAs precipitated by?
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stress, anxiety, sinus, congestion, eye strain, cervical vertebrae disorder, poor posture
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What is the aura stage of a HA?
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visual, sensory or speech type of manifestations, precipitated before a HA
can last from 5-60 minutes numbness or tingling confusion, drowsiness, lack of coordination, flashy lights |
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What is a classic migraine?
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1 in 5 will have an aura
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What is a common migraine?
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do not have an aura
associated with hereditary factors develope gradually and can last from hrs to days |
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What can cause a migraine?
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during or before period
fluid retention chills NV nasal congestion fatigue |
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What can trigger a HA?
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chocolate
sulfites changes in routine- sleep, weather, hormones missed meals excessive caffeine or withdrawal emotional stress noise large crowds bright lights strong perfumes or cologne |
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What happens during the HA phase?
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vasodilation
pain increase in intensity over several hours NV sensitivity to light and sound tender scalp can last from hours to days |
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What is the post HA phase?
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vessels and serotonin levels return to normal
scalp sensitive to touch and achy pain subsides exhausted |
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Who mostly gets cluster HA?
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middle age men 20-40 yrs
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What causes cluster HA?
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disturbance to serotonin, sympathetic defect, or disregulation to hypothalmus
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How long do cluster HA last?
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15-45 minutes
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When do cluster HAs occur?
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2-3 hrs after falling asleep
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Why are they called cluster HA?
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can happen from 1-8 per day for few weeks, months then on occurence for period of time
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What are some symptoms of a cluster HA?
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rhinorrhea
tearing flushing perspiration |
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What should you not do for a cluster HA?
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lay down
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What are some triggers for cluster HA?
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spring and fall months
heavy smoking and ETOH use |
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What are some nursing diagnosis for HA?
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anxiety r/t to lack of knowledge of HA and how to treat
hopelessness r/t acute pain, alteration in lifestyle, infective treatment acute pain |
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What are the goals for a HA?
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reduce or control pain
decrease anxiety verbalize the confidence in their treatment |
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What are some interventions for a HA?
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assess pain
keep pain log- what are precipitating pain, intensity, quanity, time of day/night, anything to do to make it better alternative therapies- massage, mediation, yoga, relaxation technique stress reduction- maintain regular sleep patterns avoid factors that can trigger HA wake up at the same time every morning exercise 15-20 min/3x week |
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What are some medications to reduce frequency/severity of migraine?
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sansert
inderal isoptin |
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How does sansert work?
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vasoconstricts
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How does inderal work?
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prevents dilation and prevents serotonin uptake
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How so isoptin work?
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controls cerebral spasm
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What are topamax and depakote?
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anticonvulsants used to treat HA
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What are the drugs used once a HA is in progress?
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ergotomine
imitrex zomig |
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What are erogotomine used for?
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cluster HA and 70% of migraines
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How does imitrex work?
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binds with serotonin receptors
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How is imitrex given?
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PO
subQ intranasal |
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What is zomig?
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selective serotonin antagonist
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What is maxalt?
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helps HA w/in 30 min
5-10mg X 3 |
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What is Axert?
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works w/in 30 min
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What drugs are given for severe pain from HA?
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demerol, dilaudid,
antiemetics- zofran, phenergan |
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What is migranal used for?
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NV, dizziness associated with cluster HA
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How much 02 would be given for a cluster HA?
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100%
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What type of HA would predinosne be used for?
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cluster
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How could lithium treat a HA?
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increases dopamin and NE
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How and when would lithium be taken for a HA?
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PO BID
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What indicates seizure d/o?
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multiple unprovoked seizures
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What can provoke a seizure?
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fever
PIH abrupt withdrawal hypoglycemia hoypoxia electrolyte imbalance (Na) tumors on brain meningeal irritation increased ICP edema or hemorrhage in the brain |
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What is a partial seizure?
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involve one portion of a brain
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What is a generalized seizure?
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involves whole brain
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What is a simple partial seizure?
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has no effect on consciousness
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What is a complex partial seizure?
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consciousness is impaired
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What is an aura like with a seizure?
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unusual smell, deja vu, uneasiness, intense emotion, flashing lights
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What is a jacksonian?
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simple partial seizure
recurrent muscle contraction one portion of body contracted |
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What portion of the brain is affected with a jacksonian?
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motor cortex
sensory cortex |
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What is a complex partial seizure?
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temporal region usually have an aura
repetitive nonpurposful activity amnesia after seizure |
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What are automatisms?
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lip smacking
picking aimless walking |
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What is a generalized seizure?
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involves both hemispheres and deeper brain structures
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What is a petit mal seizure?
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usually occur in children
blank stare unresponsive for 5-10 secs may have several hundred per day |
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What is grand mal seizure (tonic clonic)?
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have an aura
have sudden LOC and fall to the ground |
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What is the tonic phase?
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loss of postural control, fall down LOC
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What is a complex partial seizure?
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consciousness is impaired
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What is an aura like with a seizure?
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unusual smell, deja vu, uneasiness, intense emotion, flashing lights
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What is a jacksonian?
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simple partial seizure
recurrent muscle contraction one portion of body contracted |
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What portion of the brain is affected with a jacksonian?
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motor cortex
sensory cortex |
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What is a complex partial seizure?
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temporal region usually have an aura
repetitive nonpurposful activity amnesia after seizure |
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What are automatisms?
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lip smacking
picking aimless walking |
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What is a generalized seizure?
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involves both hemispheres and deeper brain structures
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What is a petit mal seizure?
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usually occur in children
blank stare unresponsive for 5-10 secs may have several hundred per day |
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What is grand mal seizure (tonic clonic)?
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have an aura
have sudden LOC and fall to the ground |
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What is the tonic phase?
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loss of postural control, fall down LOC
muscles become rigid, jaw is clenched, breathing ceases, urinary incontinence, pupils fixed and dilated lasts 15secs-1min |
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What is an epileptical cry?
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air is being forced out when they fall
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What is the clonic phase?
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jerking movements, contractions and relaxation in all extremities, hyperventilation, eyes roll back, frothing at mouth
1-1.5 minutes |
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What is the post itcal phase?
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totally unconscious
breath quietly gradually regain conscious disoriented, tired, muscles are achy HA sleep a lot amnesia may have injury from seizures- burn, head injury, car accident |
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What is status epilepticus?
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seizure after seizure
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What can occur with status epilepticus?
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hypoxia
acidosis hypoglycemia exhaustion increased risk for aspiration |
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What would be given for status epilepticus?
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ativan
valium phenobarb dilantin |
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What are some nursing diagnosis for seizures?
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ineffective breathing patterns
risk for injury ineffective coping ineffective therapeutic regimen |
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What are some safety measures that can be done during a seizure?
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protect from injury
protect head no restraints nothing in mouth |
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What should be observed and documented about a seizure?
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time it started
length of time behavior prior to seizure behavior during post itcal phase any interventions that you did to protect them from injury eptileptic cry |
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What are some side effects of anticonvulsants?
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visual changes
slurring of speech confusion calcium deficiency nystagmus |
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What is nystagmus?
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involuntary control of pupils
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When would dilantin usually be given?
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at night
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What is the therapeutic range for dilantin?
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10-20
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What are some side effects of dilantin?
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drowsy
ginaval hyperplaysia rash on trunk |
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Why are neurontin and keppra being used more often?
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control seizures without having to impair normal CNS functioning
large therapeutic range |
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What is vagus nerve stimulation?
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impulses sent to the vagus nerve
may still have to have anticonvulsants |
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What are some side effects of vagus nerve stimulation?
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hoarseness
throat irritation |
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What causes Parkinson's d/s?
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neurons in the brain that produce dopamine become impaired
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What are the four cardinal assessment findings with parkinson's ds?
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tremor
rigidity slow movement (akensia, bradykensia) postural instability |
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What are some drugs that can cause parkinson's?
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aldamet
lithium haldol thorazine |
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What are some assessment findings with parkinson's ds?
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rigidity
stopped posture slow, shuffling gait tremors mask like face difficulty chewing and swallowing uncontrolled drooling excessive perspiration on the face and neck soft, low pitched voice orthostatic hypotension heat intolerance confusion disorientation sleep disturbances changes in skin texture emotionally labile |
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What are some nursing diagnosis for parkinson's ds?
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impaired mobility
risk for falls risk for self care deficet risk for impaired verbal communication chronic confusion imbalanced nutrition: less than body requirements |
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What are some interventions for parkinson's ds?
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nontraditional exercise
ambulation assistance fall precautions administer medications |
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What are three ways that parkinson's ds medications work?
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increase dopamine levels in the brain
increase the effect of other neurotransmitters control non-motor signs and symptoms |
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What is symmetrel?
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antiviral used for young pts
reduce early or mild tremors |
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Why isn't symmetrel used for older adults?
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may cause confusion
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What does carbadopa do?
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reduces the side effects of levodopa and makes it work better but inhibiting the conversion of levodopa into dopamine until it reaches the brain
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What does levodopa do?
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increases the amount of dopamin that improves movement and balance
breaks down quickly in the stomach |
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What is sinemet?
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carbadopa and levodopa mixed
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What does comtan do?
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prevents the breakdown of any peripheral levodopa
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When is deprenyl used?
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early stages of parkinson's ds
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What is mirapex?
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mimics the action of dopamine
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What are some nursing interventions for parkinson's ds?
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small, frequent meals
thicket for liquids assess for constipation speech assistance |
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What is hypophonia?
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low pitched voice
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What should be added to the diet of a person with parkinson's?
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vitamin K
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When should protein be eaten if on levodopa?
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last meal of day
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What kind of recovery occurs with transient concussion?
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full recovery
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What kind of recovery occurs with a contusion, laceration or compression of the spinal cord?
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partial
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What kind of recovery occurs with a complete transection?
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no recovery, paralysis
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Where does paralysis usually occur with a cervical injury?
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arms and legs
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Where does paralysis usually occur with a thoracic injury?
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legs and chest
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Where does paralysis usually occur with a lumbar or sacral injury?
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hips and legs
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Where are the most common places for a spinal cord injury?
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C5, C6, C7, T12, L1
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If there is a lesion or problem from C4 and up what will happen?
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resp arrest
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What will injury from C7 and up lead to?
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quadaplysia
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What indicates a good prognosis of recovery with a spinal cord injury?
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immediate loss of all sensation and complete loss of all movement below injury that lasts more than 24 hours
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What is parethesia?
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numbness and tingling
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What does spinal cord assessment data depend on?
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type and level of injury
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What are some assessment findings of a spinal cord injury?
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paresthesias
paralysis loss of bowel or bladder control hypotension bradycardia asystole acute pain respiratory problems |
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What is spinal shock?
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temporary reflex suppression below level of injury, immediately or 1 hr after injury
hypotension bradycardia warm dry extremities vasodilation loss of sympathetic activity flaccid paralysis absence of sensation transient urinary and fecal retention bowel distention, paralytic ileus no perspiration or paralyzed portion of body |
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What would a pt be more prone to if they have a cervical or thracic injury and can't cough?
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pneumonia
may need suctioning or ventilation |
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How would you know spinal shock is getting better?
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reflex start to come back, muscle spasms
reflex emptying of bowel and bladder |
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When does rehab start for spinal shock?
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once it has resolved and BP and HR can be maintained
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What is autonomic dysreflexia?
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lesion above T6 and after spinal shock resolves
response exaggerated autonomic stimuli (constipation, full bladder) |
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What will happen if autonomic dysreflexia is left untreated?
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stroke, seizure, heart attack
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What are some symptoms of autonomic dysrefelxia?
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severe pounding HA
paroxysmal HTN profuse diaphoresis above lesion, pale, cold, dry skin below lesion anxiety nausea nasal congestion bradycardia |
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What should be done for autonomic dysreflexia?
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sitting position
take off TEDs or SCDs page Dr. STAT loosen clothing look for cause (kinked cath, abdominal distention, check room temp) |
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What would be given for autonomic dysreflexia?
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nitrates IV
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What are some nursing diagnosis for spinal cord injuries?
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risk for ineffective breathing pattern
airway clearance decrease CO physical immobility altered sensory perception impaired skin integrity altered elminiation consitpation acute and chronic pain self care deficet |
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What are some nursing interventions for spinal cord injuries?
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maintain airway
immobilize, proper body alignment supplemental 02 monitor VS ROM turn q2h catheter/bladder retraining NG tube prevent DVT- TEDs, SCDs |
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What kind of diet would a pt with a spinal cord injury be on?
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high cal, protein and fiber diet once bowel sounds return
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What would steroids be used for with a spinal cord injury?
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decrease inflammation
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What would freddex be used for with a spinal cord injury?
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decrease edema and increase recovery
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When would sygen be given and for how long?
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w/in 72 hours for 32 days
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What would dopamine be used for with a spinal cord injury?
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BP
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What would dobutamine or atropine be used for with a spinal cord injury?
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HR
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What would bicophin or valium be used for with a spinal cord injury?
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muscle spasms
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What are some interventions for a spinal cord injury?
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maintain high P02
halo traction to stabilize neck closely monitor vitals TEDs and SCDs |
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What would be seen with a basilar skull fracture?
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CSF leakage from nose or ear
bilateral bruising around eyes unilateral bruising from eye down to neck- battle's sign |
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How can you check to see if drainage is CSF?
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dextrose stick + for glucose = CSF
if bloody watch for halo sign- yellowish around blood after it drops |
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What happens with a concussion?
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brief LOC
amnesia HA |
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What is coup-contre coup phenomenon?
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where there is bruising in the front and the back b/c of the impact
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What is a normal ICP?
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5-10
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What should the HOB be when measuring ICP?
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30
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What is an epidural hemorrhage?
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arterial
dura and inner surface of skull |
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What is a subdural hemorrhage?
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venous
dural and arachnoid space |
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What is intracerebral hemorrhage?
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in brain
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What could cause an intracerebral hemorrhage?
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depressed fracture
gun shot long standing HTN |
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What is decorticate posturing?
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flexion of arms, wrists and fingers
adduction of upper extremities extension and plantar flexion |
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What could cause decorticate posturing?
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lesions of the cortico spinal tracks
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What is decerebrate posturing?
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all extremities with rigid extension
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What could cause decerebrate posturing?
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lesions of midbrain, pons, dincephalon
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What is cerebral perfusion pressure?
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amt of pressure it takes to provide the brain with blood
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What is a nmoral CPP?
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70-95
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How can you determine CPP?
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MAP-ICP
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What is ALS?
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progressive degeneration and loss of upper/lower motor neurons
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What do pts usually die from with ALS?
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aspiration pneumonia
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What are the early assessment findings with ALS?
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fatigue while talking
dysphagia weakness in hands and arms twitching of the face (fasciculations) slurred speech |
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What are the late assessment findings with ALS?
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muscle weakness and atrophy
flaccid resp. muscles pneumonia/ death |
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What are some nursing diagnosis for ALS?
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risk for ineffective breathing patterns
self care deficit risk for injury risk for disuse syndrome |
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What may be given for ALS?
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riluzole/rilutek 50mg BID
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What does GBS usualy follow?
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viral illness
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What is GBS?
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targets myelin sheath of peripheral nerves which disrupts nervous impulses to periphery
progressive ascending flaccid paralysis |
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What are the assessment findings with ALS?
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progressive muscle weakness
paresthesia of fingers and toes difficulty chewing, swallowing, talking sensory distortion diminished or absent tendon reflexes tachycardia ortho hypotension bladder disturbances CSF has elevated protein |
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What are some nursing diagnosis for ALS?
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anxiety and powerlessness
ineffective airway clearance, breathing pattern, swallowing |
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Wht are some interventions for ALS?
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watch airway
breathlessness while talking, shallow or irregular breathing change in resp. pattern increased pulse intubate if resp. problems monitor for dysrhythmias observe for urinary retention positioning to avoid nerve palsy hypotension skin integrity |
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What are the assessment findings for trigeminal neuralgia?
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one side of mouth rises toward ear, eye or nostril on one side of face
stabbing pain mostly women |
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What are some nursing diagnosis for trigeminal neuralgia?
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acute pain
risk for altered nutrition impaired oral mucous membranes |
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How can you treat trigeminal neuralgia?
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keep room at moderate temp
careful with thermometer probe and sudden movement in bed medicate before ADLs increase protein/calories with easy to chew foods |
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What medications would be used for trigeminal neuralgia?
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tegretol
dilantin neurtontin baclofen |
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What surgery can be performed for trigemnial neuralgia?
|
rhizotomy- removal of nerve root
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What's bell's palsy?
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swollen or inflamed cranial nerve 7 (facial nerve)
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What are the assessment findings of bell's palsy?
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unilateral facial paralysis
facial pain behind ear, along jaw line, unilateral paralysis increased tearing paralysis of upper eyelid 1/2 of tongue |
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What are some interventions for bell's palsy?
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eye care(tape eyelid down, eye drops)
massage, warm moist heat for pain soft diet mouth care (soft tooth brush) |
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What are some ND for bell's palsy?
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acute pain
risk for injury disturbed body image |
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What does the glasgow coma scale measure?
|
eye opening (1-4)
best verbal response (1-5) best motor response (1-6) |
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What indicates a coma on the glasgow coma scale?
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8 and lower
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What would pinpoint to fully dilated pupils indicate?
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increased ICP
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What is the first sign of increasing ICP?
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decrease in LOC
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What is cushing's triad?
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respiratory slow to apneic
widening pulse pressure- elevated systolic BP and diastolic stays the same bradycardia |
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What is a mild to moderate ICP?
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10-20
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What is a severe ICP?
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over 20
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What is diabetes insipidus?
|
decreased ADH increases fluid to be excreted through renal system which leads to copious amounts of diluted urine
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What is SIADH?
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increased ADH which decreases fluid to be excreted through the renal system which decreases serum sodium (dilutional hyponatremia)
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What are some ND for traumatic brain injuries?
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ineffective tissue perfusion
hypothermia acute pain |
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What are some interventions with traumatic brain injuires?
|
airway, breathing
cushings is a late sign assess LOC bilateral motor responses severe HA, NV, seizures HOB 30 degrees PC02 b/t 35-45 PO2 b/t 80-100 glucose b/t 80-110 |
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How does dexamethazone work?
|
improves nueronal functioning by improving cerebral spinal flow
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What would mannitol and lasix be used for?
|
traumatic brain injury
increased ICP |
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Why is it hard to get rid of increased ICP?
|
ICP causes decreased cerebral perfusion which causes tissues to become hypoxic which decreases the serum pH and increased C02 which causes cerebral dilation which increased ICP even more
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What is meningitis?
|
inflammation of meninges and spinal cord
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What are some risk factors for meningitis?
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upper resp. infection
head trauma severe otitis media sinusitis head/back surgery systemic sepsis |
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What are some s/s of meningitis?
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fever
chills HA photophobia diplopia back pain abdominal pain nuchal rigidity kernigs brudzinskis |
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What is kernig's sign?
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patient cannot extend the leg at the knee when the thigh is flexed
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What is brudzinski's sign?
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involuntary lifting of the legs in meningeal irritation when lifting a patient's head
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What would be seen in a spinal tap with meningitis?
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cloudy
turbid WBC protein glucose polymorpho nuclear cells |
