Neuro

Front 1

Head Injuries Using Glasgow coma scale

Back 1

Glasgow Coma Scale
•Measures:
•Eye opening response
•Verbal response
•Motor response
•Lower the score, worse the condition

Hint 1

Front 2

Assessment of head injuries

Back 2

4 part neuro ck

Head injury can cause--Trauma to brain tissue Intracranial hemorrhage Cerebral edema
•Increased intracranial pressure (IICP)

Hint 2

Front 3

neurological assessments*

Back 3

4 parts- LOC (verbal/tactile, orientation), pupillary response (penlight outside--->in), neuromuscular response (grips/pushes), VS

Hint 3

Front 4

Prioritizing care for new head injury

Back 4

Discharge Teaching for Mild Head Injury
•Observe q 2 hrs for 8 hrs after accident
•Return to ED:
•Increasing drowsiness, confusion, slurred speech
•Difficulty waking client
•Vomiting Blurred vision; one or both pupils dilated Prolonged headache Fluid from ears or nose Weakness in arm or leg
•Seizures

Front 5

Assessing and caring for leaking cerebral spinal fluid

Back 5

halo sign

To assess CSF/ S of infec--Clear drainage from ear and nose tested for glucose with reagent strip (positive indicates CSF)
•Sterile cotton in ear; 4x4 dressing under nose
•Change when wet to prevent bacteria through opening
•Client not to blow nose, cough, or stop sneeze
•Aseptic technique for wounds

(post craniotomy)Sterile dressing over drainage, change when damp
•CSF leak from nose: elevate HOB 20°, do not suction nose, no fingers in nose
•CSF leak from ear: client on side of leakage, do not clean ear, no fingers in ear
•Monitor for seizures

Hint 5

Front 6

Diagnostic exams

Back 6

Head Injuries: Diagnostic Tests
•Diagnostic Tests
•Blood glucose
•Arterial blood gases
•Toxicology screening
•Bun and Creatinine
•Liver function tests
•Complete blood count

Diagnostic Tests (determine cause of IICP)
•CT Scan
•Hemorrhage
•Edema
•Hematoma
•Tumor
•Cerebral angiography
•Invasive procedure with injection of dye to view blood flow through cerebral vessels
•Lumbar puncture
•CSF for meningitis

CVA: Diagnostic Tests
•CT scan
•Size and location of CVA
•MRI
•Area of brain infarction
•Cerebral arteriography
•Blood flow through vessel to evaluate patency
•Doppler ultrasound
•Blood flow through carotid arteries
•Positron emission tomography (PET)
•Amount of tissue damage
•Lumbar puncture
•Blood in CSF for hemorrhagic CVA

Front 7

Osmotic diuretics

Back 7

Mannitol-Closely monitor for dehydration, electrolyte losses (Na⁺ and K⁺)I & O

Front 8

nursing assessments and interventions

Back 8

x

Front 9

Nursing care of clients with head trauma, teaching

Back 9

Discharge Teaching for Mild Head Injury
•Observe q 2 hrs for 8 hrs after accident
•Return to ED:
•Increasing drowsiness, confusion, slurred speech
•Difficulty waking client
•Vomiting Blurred vision; one or both pupils dilated Prolonged headache Fluid from ears or nose Weakness in arm or leg ,Seizures

Front 10

Basic neuro checks: how to perform and correct techniques

Back 10

4 parts- LOC (verbal/tactile, orientation), pupillary response (penlight outside--->in), neuromuscular response (grips/pushes), VS

Hint 10

Front 11

Cushing’s Triad

Back 11

^ systolic, widening pulse pressure ie from one reading to another, goes from 98 difference to 90 difference,Bradycardia
,Decreased respirations
(often irregular and deep like Cheyne
Stokes)

Seen in late stage IICP

Hint 11

Front 12

Care of unconscious client- All care including lungs skin oral bathing nutrition tube feedings etc

Back 12

W/ ICP..Assess:Breathing patterns; Babinski reflex: stroke bottom of foot (abnormal if big toe flexes upward, toes fan out); Corneal reflex: wisp of cotton to corneal surface; Gag reflex: tongue blade to back of throat; Abnormal posturing: decorticate or decerebrate; Diagnostic test results

NPO

Front 13

Medications used for cerebral edema

Back 13

Edema not tx?---> iicp

Osmotic diuretics (Mannitol)
•Closely monitor for dehydration, electrolyte losses (Na⁺ and K⁺)I & O

Front 14

Care and assessment of diabetes insipidus

Back 14

x

Hint 14

Front 15

Prevention of complications that may cause IICP

Back 15

Causes of iicp--Head trauma- incl cerebral edema, brain surgery, meningitis, tumor, post craniotomy, brain abcess

Hint 15

Front 16

IICP: Assmt interventions s/s late/early

Back 16

Subjective:LOC, HA, N&V, Visual changes, Ringing in ears
Dizziness,Numbness or tingling, Medications, drug use, alcoho

Objective Assessment: VS;Memory loss, altered thought processes;Glasgow coma scale;Pupil response: PERRLA;Grips, feet: Squeeze, push, raise legs;Drainage: ears, nose (halo sign);Raccoon eyes, Battle’s sign

Norm- 5-15mmHg

^icp leads to swelling

HOB up 30°
•Keep head midline
•Oxygen as ordered
•PaO₂ level > 95%
•PaCO₂ at 35 - 45
•Avoid hip flexion and ABD distention
•Avoid Valsalva maneuver (e.g. coughing, straining during BM)
•Stool softeners as ordered

Avoid rectal temp
•Keep room quiet
•Speak softly and calmly
•Use sheet to turn pt gently
•Limit fluids
•Monitor for seizure activity
•Seizure precautions
•Keep oral airway and suction equipment at BS
•Pad side rails
•Keep bed in low position; Side rails up

Breathing
•Assess resp rate, depth, rhythm
•Assess client’s ability to clear secretions
•Suction airway less than 10 seconds
•Insert oral airway as needed (prevent tongue obstructing airway)
•Turn q 2 h
•NPO if unconscious
•Oral hygiene (remove secretions that could be aspirated

Nutrition
•Tube feedings or TPN (prevent malnutrition)
•Check placement
•Check gastric residual prior to tube feeding
•Excess gastric residual means feeding not absorbed.
•Monitor weight daily

Skin
•Turn q 2 h; lift not drag
•Special mattress
•Keep bed linens clean, dry, wrinkle free
•Bath daily; clean after BM or incontinence
•Hydrate
•Oral hygiene (turn to side, swab mouth, suction)
•Cornea moist with methyl cellulose solution (0.5% to 1%)
•Eye shield if corneal reflex absent

Mobility
•Maintain extremities in position of function
•Pillow in axilla area
•Hand splints
•Foam boots or high-top tennis shoes
•Remove support q 4 h for skin care
•ROM exercises (no Passive ROM if IICP)

Infection
•Assess for CSF leakage and signs of infection
•Clear drainage from ear and nose tested for glucose with reagent strip (positive indicates CSF)
•Sterile cotton in ear; 4x4 dressing under nose
•Change when wet to prevent bacteria through opening
•Client not to blow nose, cough, or stop sneeze
•Aseptic technique for wounds

Osmotic diuretics (Mannitol)- For cerebral edema.Closely monitor for dehydration, electrolyte losses (Na⁺ and K⁺)I & O; Loop diuretics; Anticonvulsants (Dilantin)- Seizures; Antipyretics--Fever; Histamine antagonists or proton pump inhibitors;
Zantac, Protonix--Prevent gastric irritation and ulcers;
Barbiturates-To place pt in coma, rest injured brain tissue, will be in ICU

•ICP monitoring device can be inserted into skull- Pressures monitored, Changes can be caught early, Client will be in ICU

Surgery to reduce IICP:
•Craniotomy - bone flap removed from skull to allow room for brain to expand; Burr holes drilled into skull to remove blood clot or evacuate hematoma.

Early IICP- #1 CHANGE LOC irritable,personality changes,restless;short term memory loss; time disorientation...then place and person; perrla, decreased visual acuity, blurred vision ,diplopia; weakness to one extremety/side progessing to hemiplegia opposite brain injury site, difficulty speaking, ^bp, slightly ^pulse, RR may ^, temp may ^/decrease, HA worse on rising in a.m. and position changes

LATE- decreasing LOC..progresses to coma/no response painful stimuli, sluggish response to light progressing to fixed (no response to light). Pupils may dilate on one side progressing to bilat dialation, cannot assess vision, *decorticate/decerecrate, cannot assess speech, Cusing triad, bradycardia, decreased RR, altered resp patterns ie cheyene stokes, ^temp, continual HA, projectile vomiting, loss of -- puppil corneal, gag , swallow reflexes---Brain Herniation:
•Pressure rises-->Brain shifts--->No place to go->Brain pushed through foramen magnum->Compresses brainstem-->Death
36

Hint 16

Front 17

Spinal Cord Injuries Psychosocial nursing interventions

Back 17

Focus:
•Prevent complications of immobility
•Promote self-care
•Teaching client and family

Situational Low Self-Esteem:
•Allow time to grieve or express denial, depression, and anger
•Provide accurate information
•Include family and others to treat pt as normally as possible
•Referral to support groups

Hint 17

Front 18

Spinal Cord Injuries Prevention of complications (all)

Back 18

Complications
•Pressure ulcers
•Pain, hypotonia, autonomic dysreflexia
•Spinal shock, orthostatic hypotension, bradycardia, deep vein thrombosis
•Limited chest expansion, pneumonia
•Urinary retention, urinary incontinence, neurogenic bladder
•Muscle spasms

Life-threatening complications with cervical injury:
•Autonomic dysreflexia
•Pneumonia
•Respiratory failure
•Pulmonary emboli
•Sepsis

Spinal Shock
•Loss of motor function, sensation, spinal reflexes, autonomic function
•Temporary loss of reflex activity below injury
•Other
•Bradycardia
•Hypotension
•Loss of sweating and temperature control below injury
•Bowel and bladder dysfunction
•Flaccid paralysis

Hint 18

Front 19

Spinal Cord Injuries Bowel retraining

Front 20

Spinal Cord Injuries Nursing diagnoses & prioritizing

Back 20

Immediate Care
•In ED:
•Neck and spine immobilized
•O₂
•IV and fluids
•Monitor respiratory, cardiac, urinary, GI complications
•High dose methylprednisolone (Solu-MEDROL), a corticosteroid started for edema and ischemia

Diagnostic Tests
•Cervical spine x-rays
•CT scan or MRI
•ABGs

SCI: Stabilization and Immobilization
•Cervical Injuries
•Cervical tongs (Gardner-Wells tongs)
•Tongs into skull and weights attached for traction
•Placed on kinetic bed (side-to-side slow rotation)

Halo vest
•Cervical or thoracic injury without cord damage
•Pins inserted into skull
•Provides mobility

Nursing care for Halo vest:
•Inspect pins for looseness
•Never lift pt by halo ring
•Assess pin sites for redness, edema, drainage
•Clean pin sites daily
•Inspect, wash, and dry skin under vest
•Turn client q 2 hrs
•Analgesic for headache

Prioritizing Nursing Care
•Respiratory function
•Prevent complications of immobility
•UTI
•Paralytic ileus
•Pressure ulcers

Subjective Assessment
•Breathing difficulty
•Loss of strength, movement, sensation below injury
•Numbness or tingling in extremities
•Fear, anger, depression

Objective Assessment
•VS
•Motor strength
•Sensation, note areas pt cannot feel touch
•Bladder for fullness
•Bowel sounds

Ineffective Breathing Pattern:
•Monitor pulse oximetry levels
•TCDB q 2 hrs
•Suction PRN
•O₂ as ordered
•Increase fluids 2,000 mL/day (to thin secretions)
•Monitor for altered respiratory function for injuries above C4:
•Difficulty swallowing or coughing, respiratory stridor, increased motor and sensory loss

Impaired Physical Mobility:
•Passive ROM exercises to all extremities twice daily
•Use splints, trochanter rolls, high-top tennis shoes to prevent wrist drop, footdrop, external rotation of hips
•Inspect skin for pressure ulcers
•Turn q 2 hrs
•Diet high in protein, carbohydrate, calories
•Assess lower extremities for thrombophlebitis
•Apply TEDs/SCDs; remove for 30-60 min. ea shift

Impaired Urinary Elimination and Constipation:
•Foley or intermittent catheterization during spinal shock
•Reinforce bladder training program after spinal shock
•Teach trigger voiding techniques:
•Stroking inner thigh
•Pulling pubic hair
•Tapping on suprapubic area or abd

Palpate bladder for fullness
•Place client on bedside commode if possible
•Monitor for cloudy, foul-smelling urine; increase fluid intake

Discharge Teaching:
•Medication
•ADLs, exercises
•Bowel and bladder program
•Urinary catheterization
•Skin care
•Prevention of potential complications:
•Constipation, urinary retention, pressure ulcers, contractures, DVT, autonomic dysreflexia, infections
•Resources: National Spinal Cord Injury Association and American Paralysis Association
•Begin bowel training program using stool softeners, rectal suppositories, digital stimulation
•Monitor for decreased or absent bowel sounds for possible paralytic ileus

Front 21

Spinal Cord Injuries Antiinflammatory meds-- purpose s/e NX

Back 21

Corticosteroids
•To decrease or control edema of the spinal cord
•Anticoagulants
•Thrombophlebitis prevention
•Vasopressors
•To increase BP
•Atropine
•For bradycardia

Antispasmodics
•Baclofen (Lioresal), Diazepam (Valium), Dantrolene (Dantrium)
•Given to decrease muscle spasms and pain
•Give with food
•Monitor for drowsiness, dizziness

Front 22

Autonomic dysreflexia-- prevention interventions meds teaching

Back 22

AD is an exaggerated sympathetic response with injury at or above T6 level.
•AD is caused from increase in BP
•Triggered by stimulus below level of injury:
•Restrictive clothing (belt, socks, shoes)
•Full bladder
•Fecal impaction
•Medical emergency
•If untreated may cause seizures, CVA, or death

S/S
•Increased BP
•Severe headache
•Flushing and sweating above level of injury
•Bradycardia
•Goosebumps
•Anxiety

Treatment
•Elevate HOB 45°
•Loosen tight clothing
•Monitor BP q 2-5 min.
•Antihypertensive meds as ordered
•If Foley, check for obstruction, irrigate catheter
•In-and-Out catheterization with lidocaine jelly into urethra
•If fecal impaction, insert anesthetic ointment, wait 10 minutes, remove impaction manually

Hint 22

Front 23

Herniated Intervertebral Disk-- Assessment of cervical and lumbar

Back 23

Spinal x-rays
•CT scan, MRI
•Myelography
•Rule out tumors, locate herniation
•Electromyography (EMG)
•Spinal nerves affected by pressure

Physical therapy
•Sleep on firm mattress
•Warm, moist compresses to neck for muscle spasms

Subjective Assessment
•Pain radiating from hip to foot or neck to hand
•Muscle weakness or spasms
•Numbness and tingling
•Neck stiffness
•Hx of falls, sudden straining of back, heavy lifting, osteoarthritis, myelogram

Objective Assessment
•Observe posture
•Assess ROM of affected extremity and level of weakness
•Assess location and type of pain
•Test patellar, Achilles, triceps reflexes

Acute Pain
•Bed rest as ordered, log roll when changing positions
•Firm mattress
•Elevate client’s head, small pillow under knees, under neck
•Muscle relaxant, analgesic meds on regular basis
•Apply moist heat as ordered
•Do not refer to client as addict
•Referral to pain management clinic

Discharge teaching:
•Medications
•Relaxation techniques
•Referral to pain management center and/or PT
•Proper body positioning and body mechanics
•Sleep on firm mattress; small pillow under neck, sleep on side with knees flexed
•Sit in straight back chairs
•Avoid activities that flex spine (bending or lifting), do not twist back
•Wear flat heeled shoes

Front 24

Herniated Intervertebral Disk Care of client undergone laminectomy or/and diskectomy

Back 24

x

Front 25

Herniated Intervertebral Disk --TENS

Back 25

NSAIDs
•Aspirin, ibuprofen, naproxen
•Opioids – short term
•Muscle relaxants
•TENS (transcutaneous electrical stimulation)
•Corticosteroids
•Prednisone

Front 26

Herniated Intervertebral Disk-- Myelogram

Back 26

Nursing Care for Myelography:
•Assess iodine or shellfish allergy
•NPO prior to test (per orders)
•Teach
•Placed on table that tilts for dye to circulate spinal column
•Dye injected through lumbar puncture
•May feel warmth or burning sensation; tell MD if feeling pain
•Immediately report fever, stiff neck, or seizures

post procedure nursing care:
•VS and neuro checks q 1 to 4 hrs
•Monitor puncture site for CSF leakage or bleeding q 4 hrs
•Increase fluids 2,400 to 3,000 mL in 24 hrs
•Client should void within 8 hrs after procedure
•Analgesics and antiemetics PRN
•If oil-based dye, pt flat for 6 to 8 hrs
•If water-based dye, elevate head at least 30 degrees for 12 hrs (or as ordered)

Front 27

Herniated Intervertebral Disk -MRI

Back 27

x

Front 28

Stroke (Brain Attack/CVA)--What is it?? R/f Thrombolytic and hemorrhagic stroke- differences in care**

Back 28

Decreased blood supply to local area of brain & Leads to neurological deficits.Third leading cause of death in US, Highest incidence > 65 yrs of age,Increased risk: male, family hx of CVA, African AmericanRisk factors:
•HTN
•Diabetes
•Obesity
•Atrial fibrillation
•Atherosclerosis
•Smoking
•High cholesterol
•Cocaine, heroin
•Oral contraceptives

CVA is sudden loss of neurologic function
•Reduction of blood flow to cerebral tissue
•Causes decreased O₂ to area of brain
•Brain cells initially ischemic but quickly die (cerebral infarction)
•Lack of O₂ to brain (anoxia) more than 10 minutes, irreversible brain damage
•Altered blood supply, loss of neurologic function

Thromblytic/ischemic-- caused by artherosclerosis of large cerebral arteries, onset during or after sleep

Hemorrhagic caused by htn occuring suddenly often during some activity. Break in blood vessel aka aneurism

Front 29

Stroke (Brain Attack/CVA),tx, meds, Thrombolytic therapy

Back 29

CLIENTS WITH SUSPECTED STROKE MUST RECEIVE IMMEDIATE TREATMENT (WITHIN 3 HRS) TO PRESERVE AS MUCH BRAIN FUNCTION AS POSSIBLE.

Subjective Assessment:
•HTN
•Anticoagulants
•Contraception, HRT
•Previous TIA, CVA
•Diabetes
•Dysrhythmias
•Cardiac disease

Vision, memory, confusion
•Sudden, severe HA
•Difficulty with speech or understanding
•Dizziness, loss of balance
•Numbness, tingling, weakness of face, arm, leg

Objective Assessment:
•VS
•Signs of IICP
•Orientation, memory loss
•Speech
•Facial sensation
•Grips, pushes
•Ability to swallow
•Loss of bowel/bladder control or distention
•Identify complications

Antiplatelet to prevent CVA/clot formation--Antiplatelet Medications
•Prevent CVA
•Prevent clot formation
•Aspirin
•Other antiplatelets
•Dipyridamole (Persantine)
•Ticlopidine (Ticlid)
•Clopidogrel (Plavix)

Thrombolytic Medications
•Given for thrombotic or embolic Stroke (Ischemic Stroke)
•Dissolves clots/”clot busters”
•Recombinant tissue plasminogen alteplase (Activase rt-PA)
•Given within 3 hrs of symptoms to be effective
•NOT given if bleeding in brain

Anticoagulant Medications
•Thrombotic strokes
•Prevent new clots from forming
•Heparin
•Warfarin (coumadin)
•Lovenox
•Started 24 hrs after thrombolytic therapy
•NOT given if bleeding in brain

Carotid endarterectomy
•Prevent stroke
•Removes atherosclerotic plaque
•Occluded area is clamped off, incision made in artery
•Plaque removed
•Artery sutured or graft inserted

Transluminal angioplasty
•Nonsurgical procedure
•Compresses plaque against arterial wall
•Stent placed to keep artery open

Nursing care once client stable:
•Physical mobility
•Communication
•Sensory-perceptual deficits
•Bowel and urine elimination
•Swallowing

Activities to prevent stroke:
•Stop smoking and drug use
•Cholesterol screening for hyperlipidemia
•Weight control
•Reduce risk of HTN and diabetes
•Public awareness of signs of stroke

Public Awareness – Signs of Stroke
•CALL 911:
•Sudden weakness or numbness on one side of body
•Sudden difficulty speaking or walking, dizziness, confusion
•Sudden change in vision in one or both eyes
•Sudden severe headache without cause

Hint 29

Front 30

Stroke (Brain Attack/CVA)Emotional imbalances with stroke

Back 30

Cognitive and behavior changes:
•Memory loss
•Short attention span
•Poor judgment
•Poor problem-solving ability
•Emotional lability (extreme emotion and mood swings)
•Depression

Hint 30

Front 31

Stroke (Brain Attack/CVA) Communication**/eye sight/sensory problems

Back 31

Speech Deficits
•Expressive aphasia
•Inability to speak or write
•Can understand words
•Receptive aphasia
•Inability to understand words
•Can speak, words don’t make sense

•Global aphasia
•Combination of expressive and receptive aphasia

•Dysarthria
•Difficulty speaking

Impaired Verbal Communication
•Speak to client as an adult
•Allow time for client to respond
•Face client, speak slowly
•Be honest when you cannot understand
•Use simple questions, that require a nod or yes or no answers
•Provide pad/pencil if client can write

Visual deficits
•Diplopia
or
•Homonymous hemianopia
•Loss of vision in half of eye
•Sees only one-half of normal vision
•Must turn head to see environment

Sensory-perceptual deficits:
•Agnosia
•Inability to recognize a familiar object
•E.g., can’t recognize toothbrush
•Apraxia
•Inability to carry out familiar routine
•E.g., can’t comb hair
•Neglect syndrome
•Client ignores affected side of body
•Bumps into walls, walks on one side

Disturbed Sensory Perception
•Environment free of clutter
•Bed in lowest position, side rails up
•Place items on unaffected side
•Approach client on unaffected side
•Speak before touching
•Unilateral neglect, encourage client too handle affected extremities

Hint 31

Front 32

Stroke (Brain Attack/CVA) Contralateral effects

Back 32

Strokes usually occur in one hemisphere
•Sensory and motor nerves cross at neck
•Deficit develop on opposite side of damage
•CVA on left side of brain affects right side of body
•CVA on right side of brain affects left side of body
•Called contralateral deficit

Motor deficits: (weakness, paralysis, or spasticity)
•Hemiparesis
•Weakness of left or right half of body
•Hemiplegia
•Paralysis of left or right half of body
•Facial Droop

Motor deficits:
•Hemiparesis
•Hemiplegia
•Initially arm and leg flaccid
•Spastic within 6 to 8 weeks
•Shoulder adducts
•Flexion of fingers, wrist, elbow, knee
•Hip, external rotation
•Immobility complications:
•Clots, aspiration, pneumonia, contractures, decubitus ulcers

Front 33

Heparin/Coumadin/labs

Back 33

note--Anticoagulant Medications
•Thrombotic strokes
•Prevent new clots from forming
•Heparin
•Warfarin (coumadin)
•Lovenox
•Started 24 hrs after thrombolytic therapy
•NOT given if bleeding in brain

Hint 33

Front 34

Oral care/skin care

Back 34

Immobility complications:
•Clots, aspiration, pneumonia, contractures, decubitus ulcers

CVA-Impaired Urinary Elimination and Constipation
•Offer bedpan or urinal or assist to bedside commode q 2 to 4 hrs
•Assess for bladder distention if voiding small frequent amounts
•Promote daily intake 2,000 mL, limit intake at night
•Keep skin dry
•Physical activity as tolerated
•Stool softeners as ordered

Front 35

catheter insertion and care

Back 35

CVA GU problems-Incontinence, frequency, urinary retention

Front 36

respiratory care

Back 36

Cva Respiratory problems
•Airway obstruction
•Decreased ability to cough
•Pneumonia-Risk for Ineffective Airway Clearance
•Monitor respiratory status
•Monitor airway patency
•Suction airway as needed
•Client side-lying position to prevent aspiration
•O₂ as ordered

Front 37

prevention of immobility complications

Back 37

CVA probs
•Contractures
•Muscle atrophy, footdrop
•Shoulder adduction--Impaired Physical Mobility
•Turn q 2 hrs
•Body aligned and extremities proper position with pillows
•Monitor calves q shift for thrombophlebitis
•Hand splints to prevent contractures
•Active ROM unaffected extremities
•Passive ROM affected extremities q 4 hrs
•PT for correct transfer and ambulation methods

CVA-Self-care deficits
•Encourage client to use unaffected side
•Teach to put clothing on affected side first, (increases awareness of affected extremity)
•Collaborate with OT on how to use assistive devices

Immobility complications:
•Clots, aspiration, pneumonia, contractures, decubitus ulcers, constipation

Front 38

feedings with dysphagia/tube feedings

Back 38

GI problems
•Dysphagia (can result in choking, aspiration)
•Constipation (from immobility)

CVA--Impaired Swallowing
•Upright position for meals and 30 min afterward
•Oral care before meals
•Thickened liquids and pureed or soft food
•Encourage small bites of food, place food on unaffected side of mouth
•After eating nurse to check mouth for “pocketing” of food
•Limit distractions during mealtime
•Suction equipment available during mealtime

Front 39

Monitoring urinary output

Back 39

x

Front 40

Transfer techniques

Back 40

x

Front 41

Lung/heart assessment and complications

Back 41

x

Hint 41

Front 42

Giving Lasix

Back 42

x

Hint 42

Front 43

DNR clients following stroke/nursing responsibilities

Back 43

x

Front 44

Care of pressure ulcers

Back 44

x

Hint 44

Front 45

Neuro Disorders- Meningococcal meningitis/viral

Back 45

Bacterial Meningitis
•Inflammation of meninges
•Bacteria enter brain by bloodstream respiratory tract, skull wound
•Or secondary to another infection (otitis media, respiratory infection, pneumonia)
•Viral Meningitis
•Less severe

Inflammatory response begins
•Spreads to ventricles, CSF
•Cerebral edema starts
•IICP starts
•Viral has quicker recovery

HA, high fever
•N/V, photophobia
•Nuchal rigidity (stiff neck)
•Positive Brudzinski’s sign, positive Kernig’s sign
•Restlessness, irritability
•Confusion
•Signs of IICP
•Petechial rash if meningococcal meningitis

Meningitis Complications:
•Seizures
•Hydrocephalus
•Cerebral infarction, coma, death
•Visual impairment, deafness, cranial nerve palsies, paralysis

Meningococcemia
•Form of bacterial meningitis
•Spread by airborne droplets
•Highly contagious
•High fever, petechial rash
•Can cause death within 10-12 hrs

Bacterial Meningitis
•MEDICAL EMERGENCY
•Rapid diagnosis
•Antipyretics
•Analgesics
•Do not give antibiotics with viral

Bacterial Infections
•Penicillin, cephalosporins
•Must force antibiotic across blood brain barrier with very large doses
•Exposure to meningococcal meningitis, must take prophylactic antibiotics (Cipro)
•Viral meningitis
•Anti-viral meds

Hint 45

Front 46

Neuro Disorders- Lumbar puncture

Back 46

Preprocedure:
•Consent form
•Lumbar tray
•Client empty bowel and bladder
•Lateral recumbent position on side of bed
•Assist client to take slow, deep breaths and maintain position

Post Procedure:
•VS and neuro checks
•Puncture site for CSF leakage or hematoma formation
•Encourage fluids, 3,000 mL in 24 hrs if not contraindicated
•Pain meds as ordered
•Flat in bed 4 to 24 hrs as ordered
•Pain meds for headache or backache

Hint 46

Front 47

Neuro Disorders- Migraines

Back 47

common, unknown cause- r/f woman, fam hx,

Triggers- stress/crisis/foods ie alcohol, chocolate, caffeine, nuts,monthly cycle

hrs--days duration

If w/ aura-- usually <1h

Nx: identify cause-- brain scan MRI xray of skull cervical spine EEG lumbar puncturefor csf, if systemic probs suspected- serum metabolic screen/ hypersensitivity testing

Subjective Assessment:
•Type, frequency, location, radiation, precipitating factors, time of day, relieving factors
•N/V
•Exposure to chemicals
•Family hx
•Meds and alcohol use

Objective Assessment
•Facial flushing, tearing of eyes
•Pallor, diaphoresis, one-sided weakness
•N/V
•Tightness in neck and shoulder muscles

meds -Amitryptoline
•Inderol
•Verapamil
•Ergotamine
•Imitrex
•Narcotic analgesics

Acute Pain
•Client rate pain
•Minimize light, noise, activity
•Relaxation techniques
•Apply cold or warm cloth to head and neck as ordered
•Back massage

Clients with long-term or migraine headaches
•Referral for stress reduction techniques or biofeedback classes
•Medication use, dosage, SE
•Eliminate:
•Caffeine
•Cured meats
•MSG
•Tyramine containing foods (chocolate, red wine, aged cheese)
•Avoid smoking

Front 48

Neuro Disorders-Bell’s Palsy

Back 48

Bell’s palsy – facial paralysis
•Associated with herpes simplex virus
•Inflammation and pressure on facial nerve
•One-sided facial weakness and paralysis
•Distorts affected side of face

Symptoms
•Ptosis of eyelid
•Tearing
•Mouth drooping
•Drooling
•Inability to smile
•Difficulty chewing
•Pain behind ear

Medications:
•Steroids
•Antiviral meds
•Teach:
•Apply warm moist heat, gel packs
•Increases circulation and relieves pain
•Facial sling during meals
•Prevent muscle stretching
•Soft diet, six small meals a day
•No chewing required

Teach:
•Warm moist heat, gel packs
•Facial sling during meals
•Soft diet, six small meals a day
•For risk of corneal drying from loss of blinking:
•Artificial tears four times a day
•Eye patch at night
•Report eye pain, redness, swelling, or discharge
•Dark glasses or goggles outside or in dusty conditions

Hint 48

Front 49

Neuro Disorders- Parkinson’s Disease

Back 49

Most common neurologic disorder in the U.S.
•1.5 million in US
•Most common over age 40
•Chronic, progressive disease
•Degeneration of motor function
•Cause: unknown

Deficiency of dopamine
•Dopamine
•Chemical produced in midbrain
•Neurotransmitter for voluntary motor function
•Dopamine deficiency
•Neurons atrophy, dopamine receptors decrease
•Imbalance between dopamine and acetylcholine

Onset gradual
•Disease progresses slowly
•Three cardinal signs:
Tremors
•“Pill-rolling” tremor
•Tremors disappear during sleep and movement
•Rigidity
•Cogwheel rigidity – jerky movement of extremity
•Bradykinesia
•Slow movements (stooped posture and shuffling gait)
•Slurred speech
•Expressionless face

Goal:
•Retain highest level of function for as long as possible

No specific tests to diagnose PD
•Diagnosed by history and presence of two of three cardinal symptoms
•PET scan – decreased levodopa (precursor of dopamine)

Four drug classes:
•Dopaminergics
•Dopamine agonists
•Anticholinergics
•Monoamine oxidase inhibitors (MAOIs)
•Must receive meds at scheduled times to reduce “off-times”.

Dopaminergics
•Levodopa
•Carbidopa
•Amantadine
•Nursing implications:
•Check for drug interactions
•Do not give if closed angle glaucoma
•Assess for “on-off” effect
•Hold levodopa 8 hrs before give amantadine

Dopamine Agonists
•Decrease tremor, rigidity, bradykinesia
•Nursing implications: same as dopaminergics
•Anticholinergics
•Given if no longer taking levodopa
•Ease drooling, tremors, rigidity
•Side effects: dry mouth, blurred vision, urinary retention
•Nursing implications:
•Do not stop med suddenly
•Drink adequate fluid to prevent dehydration

Surgery
•Pallidotomy
•Destroy basal ganglia in cerebral cortex to control rigidity and tremors
•Performed under local anesthesia
•Stereotaxic thalamotomy
•Destroys part of thalamus to decrease tremors
•Younger person with extreme unilateral tremor
•Performed under local anesthesia

Electrical Stimulation
•Surgically implanted neurostimulator device
•Wires placed in thalamus
•Connected to generator placed under skin
•Electrical impulses block signals that cause tremors

Subjective data assessment:
•Difficulty making decisions
•Mood swings
•Drooling; difficulty swallowing; wt loss
•Arm or leg stiffness; frequent falls
•Inability to write; loss of dexterity
•Urinary incontinence; constipation
•Past hx of head trauma, exposure to metals or carbon monoxide

Objective data assessment:
•Height, wt
•Observe for:
•Expressionless face
•Slurred speech
•Stooped posture; shuffling gait
•Small jerky movements
•Tremors that disappear with movement, or “pill-rolling”
•Palpate skin for excessive sweating, oiliness

Impaired physical mobility
•ROM exercises twice daily
•Assist with ambulation at least 4 times a day
•Assistive devices; canes, splints, braces
•PT consult

Impaired verbal communication
•Teach client to face listener and speak in short sentences
•Provide write-on, wipe-off slate; flash cards with common phrases
•Speech therapist referral
•Anticipate client’s needs

Imbalanced nutrition; less than body requirements
•Upright position for meals
•Massage throat as client swallows to help swallowing
•Keep suction equipment at bedside
•Cut food in small pieces
•Reduce distractions during mealtime
•Obtain easy to grasp utensils
•Increase daily fluid intake and fiber
•Serve semisolid or thickened liquid foods to prevent aspiration

Discharge teaching:
•Provide info about disease
•Coping strategies:
•Tremors
•Dysphagia
•Speech problems
•Medications
•Gait training, ROM exercises, proper posture
•Appointments with speech therapy, PT, OT

Hint 49

Front 50

Neuro Disorders-Multiple Sclerosis

Back 50

Caucasian females
•Ages: 20–40
•Family history
•Cold, damp, northern U.S.

Cause:
•Unknown cause
•May be triggered by viral infection

Onset
•Stress
•Fatigue
•Pregnancy
•Acute respiratory infection

Autoimmune response triggered by virus
•Destroys myelin sheath of spinal cord, brain, optic nerve
•Nerve impulse conduction slows
•Like frayed electrical cord
•Nerve cells eventually permanently damaged
•Symptoms become permanent

Periods of exacerbation and remission
•May appear suddenly, last for days to months
•Fatigue
•Diplopia
•Weakness
•Tingling and numbness in extremities
•Worsen after hot shower or exercise
•Triggers for exacerbations
•Heat
•Sun
•Infections
•Stress

Disease progresses:
•UTIs
•Pressure ulcers
•Joint contractures
•Falls
•Pneumonia
•Depression

Goal:
•Keep client functioning for as long as possible
•Client becomes more disabled
•Speech therapist
•Physical therapist
•Occupational therapist

Diagnosis
•Client’s hx
•Physical exam
•Symptoms
•Diagnostic tests to follow disease
•CSF
•T cells, protein, IgG for immune activity
•MRI/CT Scan
•Plaque in white matter

Medications
•Decrease inflammation
•Steroids
•Slow MS progression - immunomodulators
•Beta-interferon: Avonex, Betaseron, Copaxone, Novantrone
•Pain
•baclofen (Lioresal)
•dantrolene (Dantrium)
•Fatigue
•amantadine (Symmetrel)
•pemoline (Cylert)
•Urinary retention/frequency
•bethanechol (Urecholine)
•propantheline (Pro-Banthine)

Physical therapy
•Ways to maintain balance
•Walker or cane for ataxia
•Manage spasticity
•Stretching exercises
•Gait training
•Braces or splints

Plasmapheresis
•Plasma exchange
•Removes plasma from whole blood
•Remove T lymphocytes that cause inflammation

Well-balanced diet
•Provides energy
•Strengthens immune system
•Low-calorie diet, high in calcium and vitamin D
•Weight gain from inactivity
•Weight bearing activities
•Prevent bone loss
•Dysphagia
•Thickened liquids, small bites of food
•Avoid crackers, dry toast, chips

Assess:
•Fatigue
•Diplopia or blurred vision
•Mood swings
•Muscle weakness or ataxia; numbness, tingling
•Urinary frequency, retention
•Difficulty chewing, swallowing
•Hx of viral infections, living in northern U.S.
•Stress, pregnancy
•Use of steroids, immunosuppressive drugs

Fatigue
•Observe how fatigue affects ADLs
•Assist with planning care
•Plan for rest periods
•Perform tasks in morning
•Fatigue usually worsens in afternoon
•Client to avoid extreme temperatures (e.g. hot showers)

Self-Care Deficits
•Encourage to perform as much self-care as possible
•Adequate time to perform tasks
•Adaptive devices
•Arm or wrist braces
•Long-handled combs
•Modified clothing

Discharge teaching:
•Support group
•Diary of symptoms
•Medications
•Adequate fluid intake
•Regular bowel and bladder elimination
•Well-balanced meals
•Prevention of pressure ulcers, respiratory, urinary infections
•Ways to cope with pain, dysphagia, spasticity, vision changes

Hint 50

Front 51

Neuro Disorders-Myastenia

gravis

Back 51

Chronic, autoimmune disease
•Women, 20-30 yrs of age
•Periods of exacerbations and remission
•Stress, pregnancy, secondary infections may cause acute onset

Unknown cause
•Thymus gland produces antibodies
•Blocks or reduce acetylcholine at neuromuscular junction
•Nerve impulses not sent to face, lips, tongue, neck, throat
•Weakness of facial, speech, and chewing muscles

Eyelid ptosis
•Diplopia
•Slurred speech
•Nasal voice
•Difficulty chewing and swallowing
•Fatigue
•Onset gradual
•Symptoms vary each day

Two possible life-threatening emergencies:
•Myasthenic crisis
•Missed doses of medications or infection
•Increased muscle weakness, inability to speak or swallow, respiratory distress
•Cholinergic crisis
•Over medication with cholinergic meds
•Severe muscle weakness, N/V, abd cramps, increased salivation, sweating, bradycardia

Diagnosis
•Injection of edrophonium chloride (Tensilon)
•For diagnosis
•Short acting anticholinesterase
•Clients show improved muscle strength, lasts only 5 min.
•Electromyography (EMG)
•Show muscle fatigue
•CT scan
•Chest scan for thymus gland tumor

Anticholinesterase Medications
•Pyridostigmine (Mestinon, Regonol)
•Treatment of choice
•Dosage adjusted until symptoms decrease
•Client records s/s for dosage adjustment

Anticholinesterase Medications:
•Nursing implications:
•Anticholinesterase meds improve muscle contraction
•Contraindicated with GI or urinary obstruction, asthma, hyperthyroidism
•Identify client’s swallowing ability
•Give med on regular schedule at exact time.
•Monitor for myasthenic crisis or cholinergic crisis

Anticholinesterase medications administered on strict time schedule:
•Taken late may cause myasthenic crisis
•Taken early may cause cholinergic crisis

Assessment:
•Muscle weakness; speech, chewing, swallowing, vision changes
•Care
•Decrease or prevent respiratory and swallowing problems
•Reduce fatigue
•Nursing diagnosis: see MS or PD

Discharge teaching:
•Family knows CPR
•Medication
•Actions
•Side effects
•Take on exact schedule
•Wear MedicAlert bracelet
•Pregnancy discussed with physician

Hint 51

Front 52

Neuro Disorders-Guillain Barre’ Syndrome

Back 52

Acute, progressive inflammation of peripheral nervous system (PNS)
•Cause unknown
•Most often follows recent respiratory or GI infection, viral vaccination, or surgery
•60% of cases infection with Campylobacter jejuni

Immune response destroys myelin sheath covering peripheral nerves
•Impulses poorly conducted to sensory and motor nerves
•Rapid, muscle weakness, loss of reflexes, paralysis

Symptoms start in lower extremities and move upward
•First symptoms bilateral weakness, numbness, tingling in legs
•Within 24 to 72 hrs, weakness in arms and respiratory muscles
•Progresses to paralysis
•Causes chewing, swallowing, speech problems
•Person remains mentally alert
•Serious complication: respiratory failure (tracheostomy and mechanical ventilation)

Diagnosis
•Symptoms, recent viral infection
•Lumbar puncture
•Elevated CSF protein levels
•Electromyography (EMG)
•Slowing of nerve conduction

Most clients recover
•Recovery time depends on myelin sheath self repair (average 6 months)
•Nerves recover, symptoms improve in reverse order

Plasmapheresis
•Remove antibodies that caused GBS
•IV immune globulin
•Antibiotics
•Infections
•Anticoagulants
•Prevent DVT, PE
•Morphine
•Muscle pain

Managed in ICU
•Interventions
•Prevent immobility problems
•Promote hydration, nutrition
•Respiratory function
•Psychosocial support
•Fear permanent paralysis

Hint 52

Front 53

Neuro Disorders-Huntington’s Disease

Back 53

Inherited neurologic disease
•Men and women, 30 to 50 yrs old
•No cure
•Lack of GABA neurotransmitter
•Causes acetylcholine to drop, dopamine to rise
•Excess dopamine causes uncontrolled movement
•Develops slowly

Intellectual function
•Memory and intellectual decline to dementia
•Movement
•Chorea – constant, jerky, uncontrolled movements of the body
•Facial tics affect speech, chewing, swallowing; leads to choking, malnutrition
•Loss of bowel and bladder control
•Death from aspiration pneumonia

No specific test
•Diagnosis based on symptoms, family hx
•PET scan
•Changes in brain

Meds given to control symptoms
•Chorea movements: Haldol or valium
•Antidepressants
•antipsychotics

Hint 53

Front 54

Posturing

Back 54

x

Front 55

decerbrate vs decorticate

Back 55

either of these seen late stages iicp

Hint 55

Front 56

Tonic-clonic seizures

Back 56

Tonic-Clonic Seizure (Grand Mal):
•Most common
•Develop suddenly
•Risk for injury
•Lasts 1 to 2 minutes

Aura Phase
•Bright light, odd taste, or unusual sound
•Loud cry, air forced out of lungs
•Falls to ground, loses consciousness
•Tonic phase
•Tonic contractions – muscles rigid, jaws clenched, briefly stops breathing, cyanosis
•Clonic phase
•Clonic contractions – jerky movements, tongue and check biting, frothing from mouth
•Urinary and bowel incontinence
•Postictal phase
•Unconscious for up to 30 min
•Headache , muscle aches, fatigue
•Sleep for several hrs afterward

Status Epilepticus--Continuous tonic-clonic seizure
•Lasts 5 minutes or more
•Causes respiratory distress
•Life-threatening medical emergency
•Causes:
•Stops taking medications, head injury, or hypoxia

Status Epilepticus Treatment:
•Must be treated immediately
•Priority – establish airway
•Medications:
•IV Valium (diazepam) or Ativan (lorazepam) to stop seizure activity
•Phenytoin and phenobarbital to control seizure activity

http://www.youtube.com/watch?v=4CNmWpowFTM

Electroencephalography (EEG)
•Record brain electrical activity
•Location of seizure activity
•Skull X-ray
•Skull fractures
•CT scan or MRI
•Tumor, CVA, or hemorrhage

Hint 56

Front 57

Post-ictal phase of seizures

Back 57

Unconscious for up to 30 min
•Headache , muscle aches, fatigue
•Sleep for several hrs afterward

Hint 57

Front 58

CVA-- L vs R

Back 58

Hint 58

Front 59

Neuro anatomy

Back 59

Hint 59

Front 60

Cranial nerves

Back 60

Hint 60

Front 61

Efferent vs afferent neurons in regards to CNS

Back 61

Senory (afferent) neurons – carry impulses from skin and muscles to CNS
•Motor (efferent) neurons – Carry impulses from CNS to muscles and glands

Hint 61

Front 62

R & L hemispheres-- Where do sensory/motor impulses come from? What do both the R and L hemisphere control?

Back 62

Each hemisphere receives sensory and motor impulses from opposite side of body
•One hemisphere more dominant
•Left hemisphere; speech, problem solving, reasoning, calculations- reading writing speaking
•Right hemisphere; visual-spatial information (R side controls L side motor coordination)

Hint 62

Front 63

The brain-- diencephalon

Back 63

Diencephalon includes:
•Thalamus
•Relays sensory information

•Hypothalamus
•Regulates temperature, fluid balance, thirst, appetite, emotions, sleep/wake cycle

Front 64

3 componenets of brain stem and what they control

Back 64

Brainstem
•Midbrain
•Center for auditory and visual reflexes

•Pons
•Controls respiration***

•Medulla oblongata**
•Controls HR, BP, Respirations, coughing, swallowing, vomiting

Front 65

Cerebellum

Back 65

Connected to brainstem
•Two hemispheres
•Coordinates involuntary muscle activity, fine motor movements, balance, posture. If damaged..balance issues- fall risk

Hint 65

Front 66

CSF

Back 66

Four ventricles in brain make CSF
•CSF in subarachnoid space of brain and spinal cord
•Clear, colorless liquid with high glucose content (50 to 70 mg/dL); no RBCs, a few WBCs, very little protein*** If RBCS=problem!!!
•Protects brain and spinal cord from trauma

Hint 66

Front 67

Spinal chord- gray vs white matter

Back 67

Inside of spinal cord is H shaped, consists of gray matter surrounded by white matter
•Gray matter
•3 specialized areas called horns
•Ventral horn (motor neurons)
•Dorsal horn (sensory neurons)
•Lateral horn (sympathetic neurons)
•White matter
•Spinal tracts that carry messages to and from the brain

Front 68

Somatic vs autonomic system of PNS

Back 68

Somatic nervous system – connects skin and muscles to CNS
•Autonomic nervous system – controls involuntary activity of visceral organs and some glands

Front 69

Cranial nerves-- 12 pairs

Back 69

Hint 69

Front 70

fx autonomic system (ANS)*

Back 70

Maintains homeostasis
•Regulates respiration, HR, digestion, urinary excretion, body temperature, sexual function

•Two divisions-
•Sympathetic Nervous System (SNS)
•Parasympathetic Nervous System (PNS)

Front 71

ANS-- Sympathetic nervous system (SNS)

Back 71

Prepares body to handle stress
•“fight-or-flight”
•E.g. – pupils dilated, increased HR, decrease saliva, relaxed brochi, decreased peristalsis, glucose release, relaxed bladder wall.

Hint 71

Front 72

ANS- Parasympathetic Nervous System (PNS)

Back 72

•Operates during nonstressful situations
•Conserves energy
•E.g. – pupils constricted, slowed HR, ^ saliva, constricts brochi, ^ peristalsis, no action on liver, bladder wall constricted

Front 73

4 types of skull fractures*

Back 73

Linear
•Simple clean break in skull

•Comminuted
•Skull in fragmented pieces

•Depressed
•Skull bone fragments pushed into brain

•Basilar (real bad one)
•At base of skull, may extend to temporal bone

Front 74

Open vs closed head injury

Back 74

Open Head Injury
•Opening through scalp, skull, dura to expose brain from blunt trauma (e.g. bullet)
•Risk for meningitis/infection
•Closed Head Injury
•Acceleration-deceleration injury (coup-contrecoup phenomenon)
•Concussion
•Contusion

Front 75

Linear fracture head

Back 75

simple clean break

Front 76

Comminuted head fracture

Back 76

shatters into peices

Hint 76

Front 77

Depressed head fracture

Back 77

skull bone fragments pushed into brain

Front 78

Basilar head fracture

Back 78

Basilar skull fracture may extend to nasal sinus or middle ear
•Rhinorrhea
•Otorrhea
•Battle’s sign
•Raccoon eyes

•Risk for infection if CSF leakage

Hint 78

Front 79

Coup-Contrecoup

Back 79

•Brain bounces forward (acceleration) and rapidly rebounds (deceleration) and hits the back of the skull
•Bruising of the brain tissue at two points

Hint 79

Front 80

concussion vs contusion

Back 80

Concussion--Brain injury caused by violent shaking of brain
•Immediate loss of consciousness for less than 5 minutes
•Headache, burred or double vision

Post Concussion Syndrome
•May be experienced for weeks to months after concussion:
•Headache Poor concentration
•Dizziness Personality changes
•Fatigue

Contusion is Bruising of brain tissue when brain strikes inner skull
•S/S vary with size and location of brain injury
•Initial loss of consciousness
•LOC remains altered
•Full consciousness regained slowly; residual effects my persist

Front 81

Brain tumor- s/s , diag, tx, nx

Back 81

General S/S:
•Headache (prominent early symptom)
•Seizures
•Vomiting
•Changes in memory, communication, concentration
•Motor weakness, visual-spatial disorders, sensory deficits

CT scan
•Location and size of tumor
•Electroencephalography (EEG)
•Record brain electrical activity
•Seizures present
•Cerebral angiography
•Measure blood flow of cerebral blood vessels
•Stereotactic needle biopsy

Chemotherapy
•Osmotic diuretic (Mannitol); to open blood-brain barrier, enable chemo meds to reach tumor
•Radiation
•External radiation, daily 5 times per week for 6 weeks
•Stereotaxic radiation “gamma knife” – large single dose at specific site of tumor
•Surgery
•Burr Hole
•Craniotomy

Brain Tumor: Nursing Care
•Disturbed Body image
•Assess for s/s of negative body image
•Withdrawal from family and friends
•Refusal to look in mirror
•Denial
•Arrange for surgical cap, scarf, turban, wig
•Reinforce hair will grow back

Front 82

Craniotomy

Back 82

Preop Care:
•Understanding, level of anxiety
•Prepare for appearance after surgery
•Large dressing covering head
•Swollen, bruised eyelids
•Endotracheal tube

Postop Care:
•Risk for altered LOC, IICP, and seizures
•Assess for IICP
•Airway
•O₂ sat level
•Position on nonoperative side
•Cool cloth over eyes; quiet room
•Acetaminophen with codeine for pain

Prevent infection
•Aseptic technique for dressing changes
•ABX as ordered
•Assess for s/s of meningitis
•Dressing removed 3 days postop, clean incision half-strength hydrogen peroxide

Assess for CSF leak from ears, nose, or wound
•If CSF leak:
•Sterile dressing over drainage, change when damp
•CSF leak from nose: elevate HOB 20°, do not suction nose, no fingers in nose
•CSF leak from ear: client on side of leakage, do not clean ear, no fingers in ear
•Monitor for seizures

Discharge Teaching:
•Anticonvulsant medications
•Wound care
•Do not shampoo head
•No curling irons, hair dryers on hot setting

Client to Report:
•Swelling at incision site
•Bloody, yellow, clear drainage
•Nose, ears, incision
•Increasing drowsiness
•Behavioral changes
•Stiff neck, severe HA, vision changes
•Seizures

•Wear protective hat for sun block
•Protect head until wound healed

Hint 82

Front 83

TIA

Back 83

Brief episode of reversible neurologic deficits
•Lasts few minutes to < 24 hrs
•Temporary reduced blood flow to area of brain
•Caused by atherosclerosis or embolus
•Often warning of future CVA

Signs of TIA:
•Dizziness
•Loss of vision in one eye
•One-sided numbness or weakness of fingers, arms, or legs,
•Aphasia (can’t talk)

Front 84

Nx CT scan head

Back 84

Nursing care for CT scan
•Consent form
•NPO 8 hrs
•Meds 2 hrs prior to test
•Identify allergy to iodine dye
•Remove hairpins, clips, earrings
•Teach:
•Exam lasts 30 to 90 minutes
•Test painless, machine makes clicking noise
•Contrast dye injected may feel warm sensation

Front 85

CVA surgery- NX carotid endarterectomy

Back 85

Prevent stroke
•Removes atherosclerotic plaque
•Occluded area is clamped off, incision made in artery
•Plaque removed
•Artery sutured or graft inserted

Nursing Care Post Carotid Endarterectomy
•Supine position or unoperated side with head midline
•HOB @ 30°
•Wound drains
•Bleeding at incision site; drainage under neck and shoulders
•Difficulty swallowing, tracheal deviation
•Facial drooping, hoarseness, dysphagia, speech difficulty, shoulder sag
•CVA: confusion, dizziness, slurred speech, hemiparesis
•Monitor HTN or hypotension hourly

Front 86

Cerebral Aneurysm: Symptoms
Expanding/ruptured, complications, diag, meds, surgery, care

Back 86

•Expanding aneurysm:
•Headache
•N/V
•Pain in neck and back
•Ruptured aneurysm:
•Sudden, explosive HA
•Stiff neck (nuchal rigidity)
•Change in consciousness
•Photophobia
•N/V
•Cranial nerve deficits

complications--Ruptured aneurysm - major complications:
•Rebleed
•Can bleed, stop and rebleed
•Can occur first 48 hrs and later 7 to 10 days
•Vasospasm
•One or more cerebral arteries narrow, leading to ischemia and infarction

CT scan
•Location and size of aneurysm
•Cerebral angiography
•View cerebral arteries, aneurysm, vasospasm
•Lumbar puncture
•Identify blood in CSF confirm bleeding in brain (cerebral hemorrhage)

Cerebral Aneurysm: Medications
•Calcium channel blockers
•Decrease vasospasm
•Anticonvulsants
•Prevent seizures
•Stool softeners
•Prevent straining, prevent IICP
•Acetaminophen or codeine
•Pain control

Surgery
•Treatment of choice as soon as client stable
•Prevent additional bleeding
•Skull opened and clip placed at neck of aneurysm

Care if surgery prohibited
•Neurologic checks
•VS hourly
•Aneurysm precautions
•To prevent IICP and risk of rebleeding:
•Client in private, quiet, darkened room
•Limit visitors to two family members
•Elevate HOB 15° to 30°
•Complete bed rest
•Avoid coughing, sneezing, straining, blowing nose

Front 87

Seizures- Causes, patho, types, meds, nx, surgery, prioritization

Back 87

Seizure - abnormal electrical activity in brain
•Convulsion – involuntary muscle contraction and relaxation seen with seizures
•Epilepsy – chronic pattern of seizures

Causes for seizures:
•Most unknown
•In adults: brain infection, CVA, brain tumor
•Conditions can cause seizure activity:
•Hypoglycemia
•High fever (febrile seizures)
•Hypoxia

Seizure activity greatly increases metabolism
•Increased consumption of O₂ and glucose
•Seizures classified by:
•Partial (one area of brain)
•General (both hemispheres of brain/loss of consciousness)

Absence seizure (Petit mal)
•Mostly children
•All motor activity stopped
•Lasts only 5 to 10 seconds
•Many times a day

Tonic-Clonic Seizure (Grand Mal):
•Most common
•Develop suddenly
•Risk for injury
•Lasts 1 to 2 minutes

Anticonvulsant medication
•Control seizures, not cure
•Therapeutic and toxic levels
•Need routine serum drug levels

Klonopin (clonazepam)
•Tegretol (carbamazepine)
•Neurontin (gabapentin)
•Dilantin (phenytoin)
•Depakene (valproic acid)

Nursing Implications:
•Give same time each day with meals
•Monitor for side effects (drowsiness, sedation, ataxia, diplopia, rash)
•Monitor Dilantin (phenytoin) for gingival hyperplasia
•Monitor serum drug levels
•Monitor CBC, platelet count, liver tests

Surgery
•Medications not effective to control seizures
•Client awake
•Surgeon maps area of abnormal electrical activity and removes it
•Effective for partial seizures of temporal lobe

Goal:
•Prevent recurrent seizures
•Prioritizing nursing care:
•Provide care during and immediately after seizure
•Maintain airway
•Prevent injury
•Decrease anxiety

Hint 87

Front 88

Seizures: Electroencephalography (EEG) nursing care:

Back 88

•Explain procedure
•Test lasts 1 to 2 hrs
•Test is painless
•Test done while on stretcher or reclining chair
•Electrodes to scalp with thick paste
•Withhold tranquilizer meds and caffeine for 24 to 48 hrs prior to procedure
•Shampoo hair night before

Front 89

Seizures- , assmt ,Nx, prioritization, teaching

Back 89

Goal:
•Prevent recurrent seizures
•Prioritizing nursing care:
•Provide care during and immediately after seizure
•Maintain airway
•Prevent injury
•Decrease anxiety

Subjective assessment
•Seizure activity
•Hx of head injuries, brain tumor, CVA, infections
•Anticonvulsant medications

Objective assessment
•Observe before, during, after seizure
•Precipitating factors
•Length of seizure
•Tonic to Clonic movements
•LOC, Respirations, cyanosis
•Amnesia after seizure

Risk for ineffective airway clearance
•Loosen clothing around neck
•Turn client on side
•Give supplemental O₂
•Provide suction at bedside
DO NOT FORCE ANYTHING INTO CLIENT’S MOUTH, COULD OBSTRUCT AIRWAY.

Risk for injury
•Bed low, padded side rails
•If needed, guide to floor for safety
•Place pillow under head
•Never restraint client during seizure
•Clear area of objects

Anxiety
•Identify concerns, misconceptions
•Community support groups
•State agencies for laws on driving

Discharge Teaching:
•Knowledge of medications, compliance
•Care needed before, during, after seizure
•PATENT AIRWAY/SAFETY
•Home safety
•No smoking in bed
•Showers, grab bars (prevent drowning)
•Keep bedroom doors unlocked, for emergency
•Wear ID bracelet
•Record seizure activity, meds taken
•Avoid triggers: fasting, stress, flashing lights

Hint 89

Front 90

Encephallitis

Back 90

Inflammation of white and gray matter
•Affects brain and spinal cord
•Usually caused by virus
•Virus spread by ticks, mosquitoes
•Herpes simplex
•Ranges from mild infection to serious disease (fatal)

S/S similar to meningitis:
•High fever
•Headache
•Stiff neck
•Seizures
•Confusion

Front 91

Brain Abscess

Back 91

•Purulent matter in brain
•From sinuses or middle ear infection
•Head injury or surgery
•Causes local infection, WBC’s destroy organism, pus forms
•Capsule forms around pus
•Leads to IICP

Front 92

Intracranial Infections: Diagnostic Tests, meds, nx

Back 92

•Lumbar puncture
•Culture, sensitivity
•Blood, urine, throat, nose culture
•CT, MRI, skull x-rays

Bacterial Infections
•Penicillin, cephalosporins
•Must force antibiotic across blood brain barrier with very large doses
•Exposure to meningococcal meningitis, must take prophylactic antibiotics (Cipro)
•Viral meningitis
•Anti-viral meds

Risk for ineffective cerebral tissue perfusion
•Monitor IICP
•Hyperthermia
•Temp q 4 hrs
•Antipyretics, remove bed linens, tepid sponge baths, cooling blanket if ordered
•Monitor for s/s of dehydration

Acute pain
•Quiet, dark room
•Gentle ROM, movements
•Keep client comfortable
•Put cloth over eyes: photophobia
•Acetaminophen or codeine