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46 Cards in this Set
- Front
- Back
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ICP complications
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brain stem herniation
diabetes insipidus syndrome of inappropriate antidiuretic hormone (SIADH). |
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ventricular catheter monitoring
complications |
infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood, and problems with the monitoring system
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ICP
Nursing Interventions |
Maintaining a Patent Airway
Achieving an Adequate Breathing Pattern Optimizing Cerebral Tissue Perfusion Monitoring Intracranial Pressure Monitoring for Secondary Complications Maintaining Negative Fluid Balance Preventing Infection Monitoring and Managing Potential Complications Detecting Early Indications of Increasing Intracranial Pressure Detecting Later Indications of Increasing ICP |
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Simple partial seizures
def |
with elementary symptoms, generally without impairment of consciousness
With motor symptoms With special sensory or somatosensory symptoms With autonomic symptoms Compound forms |
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Complex partial seizures
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with complex symptoms generally with impairment of consciousness
With impairment of consciousness only With cognitive symptoms With affective symptoms With psychosensory symptoms With psychomotor symptoms (automatisms) Compound forms |
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Generalized Seizures
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convulsive or nonconvulsive, bilaterally symmetric, without local onset
Tonic-clonic seizures Tonic seizures Clonic seizures Absence (petit mal) seizures Atonic seizures Myoclonic seizures (bilaterally massive epileptic) Unclassified seizures |
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Causes of acquired seizures include:
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Cerebrovascular disease
Hypoxemia of any cause, including vascular insufficiency Fever (childhood) Head injury Hypertension Central nervous system infections Metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticides) Brain tumor Drug and alcohol withdrawal Allergies |
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A major responsibility of the nurse during a seizure is to .
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observe and record the sequence of signs
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Assessing Traumatic Brain Injury
Be on the alert for the following signs and symptoms: |
Altered level of consciousness
Confusion Pupillary abnormalities (changes in shape, size, and response to light) Altered or absent gag reflex Absent corneal reflex Sudden onset of neurologic deficits Changes in vital signs (altered respiratory pattern, widened pulse pressure, bradycardia, tachycardia, hypothermia or hyperthermia) Vision and hearing impairment Sensory dysfunction Headache Seizures |
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Concussion
If the brain tissue in the frontal lobe is affected |
the patient may exhibit bizarre irrational behavior
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Concussion
involvement of the temporal lobe |
can produce temporary amnesia or disorientation.
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Concussion
Familly teaching: following signs and symptoms and to notify the physician or clinic (or bring the patient to the emergency department) if they occur: |
Difficulty in awakening
Difficulty in speaking Confusion Severe headache Vomiting Weakness of one side of the body |
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Most serious Brain injuries
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Hematomas (collections of blood) that develop within the cranial vault
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Nursing Interventions
brain Injury |
Monitoring for Declining Neurologic Function
Level of Consciousness Vital Signs Motor Function Maintaining the Airway Monitoring Fluid and Electrolyte Balance Promoting Adequate Nutrition Preventing Injury Maintaining Body Temperature Maintaining Skin Integrity Improve cognitive function Preventing Sleep Pattern Disturbance Support Family Coping |
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Adequate CPP
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is greater than 70 mm Hg
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Controlling Intracranial Pressure in Patients With Severe Brain Injury
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Elevate the head of the bed as prescribed.
Maintain the patient's head and neck in neutral alignment (no twisting or flexing the neck). Initiate measures to prevent the Valsalva maneuver (eg, stool softeners). Maintain normal body temperature. Administer O2 to maintain PaO2 >90 mm Hg. Maintain fluid balance with normal saline solution. Avoid noxious stimuli (eg, excessive suctioning, painful procedures). Administer sedation to reduce agitation. Maintain cerebral perfusion pressure >70 mm Hg. |
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The vertebrae most frequently involved in SCI
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the 5th, 6th, and 7th cervical (neck) vertebrae (C5–C7), the 12th thoracic vertebra (T12), and the 1st lumbar vertebra (L1). These vertebrae are most susceptible because there is a greater range of mobility in the vertebral column in these areas
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CENTRAL CORD SYNDROME
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Characteristics: Motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.
Cause: Injury or edema of the central cord, usually of the cervical area. May be caused by hyperextension injuries. |
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ANTERIOR CORD SYNDROME
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Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact.
Cause: The syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracture-dislocation of vertebra. It also may occur as a result of injury to the anterior spinal artery, which supplies the anterior two thirds of the spinal cord |
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BROWN-SÉQUARD SYNDROME (LATERAL CORD SYNDROME)
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Characteristics: Ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature.
Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture-dislocation of a unilateral articular process, or possibly an acute ruptured disk. |
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Injury at C1
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Little or no sensation or control of head and neck; no diaphragm control; requires continuous ventilation
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Injury at C2 to C3
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Head and neck sensation; some neck control; independent of mechanical ventilation for short periods
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Injury at C4
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Good head and neck sensation and motor control; some shoulder elevation; diaphragm movement
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Injury at C5
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Full head and neck control; shoulder strength; elbow flexion
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Injury at C6
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Fully innervated shoulder; wrist extension or dorsiflexion
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Injury at C7 to C8
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Full elbow extension; wrist plantar flexion; some finger control
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Injury at T1 to T5
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Full hand and finger control; use of intercostal and thoracic muscles
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Injury at T6 to T10
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Abdominal muscle control, partial to good balance with trunk muscles
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Injury at T11 to L5
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Hip flexors, hip abductors (L1–L3); knee extension (L2–4); knee flexion and ankle dorsiflexion (L4–5
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Injury at S1 to S5
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Full leg, foot, and ankle control; innervation of perineal muscles for bowel, bladder, and sexual function (S2–4)
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Brain Abscess
Clinical Manifestations |
Headache, usually worse in the morning, is the most prevailing symptom. Fever, vomiting and focal neurologic deficits occur as well
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MS
Clinical Manifestations |
fatigue
depression weakness numbness difficulty in coordination loss of balance pain Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision diplopia (double vision) patchy blindness (scotoma) total blindness |
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Nursing Interventions
MS |
Promoting Physical Mobility
Exercises Minimizing Spasticity and Contractures Activity and Rest Minimizing Effects of Immobility Preventing Injury Enhancing Bladder and Bowel Control Enhancing Communication and Managing Swallowing Difficulties Improving Sensory and Cognitive Function Strengthening Coping Mechanisms Improving Home Management Promoting Sexual Functioning |
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Myasthenia gravis
Clincal manifestations |
Diplopia (double vision) and ptosis (drooping of the eyelids)
weakness of the muscles of the face and throat generalized weakness dysphonia |
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Myasthenic Crisis
s/s |
Respiratory distress
dysphagia (difficulty swallowing) dysarthria (difficulty speaking), eyelid ptosis diplopia prominent muscle weakness |
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Guillain-Barré
clinical manifestations |
muscle weakness
reflexes of the lower extremities Hyporeflexia and weakness may progress to tetraplegia paresthesias of the hands and feet |
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A motor cortex tumor
Clincal Manifestations |
produces seizure-like movements localized on one side of the body, called Jacksonian seizures
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An occipital lobe tumor
Clinical Manifestations |
produces visual manifestations: contralateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumor) and visual hallucinations.
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A cerebellar tumor
Clinical Manifestations |
causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction.
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A frontal lobe tumor
clical manifestations |
frequently produces personality disorders, changes in emotional state and behavior, and an apathetic mental attitude. The patient often becomes extremely untidy and careless and may use obscene language.
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A cerebellopontine angle tumor
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Tinnitus and vertigo appear first, soon followed by progressive nerve deafness (eighth cranial nerve dysfunction).
Numbness and tingling of the face and tongue occur (due to involvement of the fifth cranial nerve). Later, weakness or paralysis of the face develops (seventh cranial nerve involvement). Finally, because the enlarging tumor presses on the cerebellum, abnormalities in motor function may be present. |
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Parkinson's Ds
Clinical manifestations |
tremor
rigidity bradykinesia (abnormally slow movements) postural instability |
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Parkinson's Ds
Nursing Interventions |
Improving Mobility
Enhancing Self-Care Activities Improving Bowel Elimination Improving Nutrition Enhancing Swallowing Encouraging the Use of AssiImproving Communication stive Devices Supporting Coping Abilities |
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Huntington's ds
Clinical Manifestations Early |
chorea
intellectual decline emotional disturbance Facial movements produce tics and grimaces slurred expolisive speech dosorganized gait personality changes |
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Huntingtons's Ds
Clinical Manifestation's Late |
constant writhing
uncontrollable movement unitelligible speech impossible to ambulate Dementia |
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ALS
clinical Manifestations |
fatigue
progressive muscle weakness, cramps fasciculations (twitching) incoordination |
