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52 Cards in this Set
- Front
- Back
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neurological assessment health history |
pain seizures dizziness visual disturbances weakness |
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assessment |
mental status cranial nerve function cerebellar function reflexes motor and sensory function level of consciousness |
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Gerontological considerations |
distinguish normal aging from abnormal changes determine baseline mental status for comparison
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What do we need to know about a neurological assessment of the elderly |
mental functions are slower. takes longer to complete tasks and problem solve temperature regulation declines with aging gait slows and becomes wide based with aging. risk for falls the ability to feel and identify objects declines with aging. decline in tactile sensation, may bump into objects and injure herself visual acuity and peripheral vision decrease, and develops sensitivity to glare and a decrease in the ability to adjust from light to darkness hearing loss develops so accommodations must be made to ensure that the patient hears communications taste buds and olfactory cells decrease the patient will have a change in taste and smell as a result |
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What additional areas should the nurse assess the patient and what findings reflect normal aging |
muscle strenght and coordination decline equally and symmetrically hearing acuity decreases because auditory nerves degenerate balance declines and deep tendon reflexes decline or may disappear amount and quality of sleep change pain perception decreases with aging mental processing decreases |
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what neurologic assessment findings do not change with aging |
language does not change as a person ages the ability to judge does not change because of aging |
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causes of altered level of consciousness |
head injury stroke drug overdose drug/alcohol use |
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How would you further assess c hang in level of consciousness |
glasgow coma scale |
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Glasgow cma scale |
assesses patient's response to stimulation scale 3-15 based on 3 evaluation areas eye opening response (1-4) best verbal response (1-5) best motor response (1-6) |
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decorticate posturing |
plantar flexed internally rotated thigh flexed/adducted arms flexed fingers |
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decerebrate posturing |
plantar flexed flexed fingers pronated/extended/adducted arms |
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what are the priorities the nurse should be concerned with a person that has an altered level of consciousness |
maintain airway maintain circulatory status (adequate perfusion) protection (safe environment, fluids and nutrition, skin and join integrity, thermoregulation) |
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what would be additional needs for a person with altered LOC |
urinary output and bowel funciton oral and hygiene care sensory stimulation family involvement |
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Increased cranial pressure (ICP) compensatory mechanisms pathophysiology |
rise in the pressure inside the skull that can result form or cause brain injury auto regulation (change vessel with sys BP changes) decreases cerebral perfusion, stimulates edema, shifts brain tissue=herniation and death |
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Causes of ICP |
brain tumor encephalitits head injury hydrocephalus (increased fluid around the brain) meningitis subdural hematoma status epilepticus stroke |
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what are the earliest signs or symptoms of increased intracranial pressure |
change in LOC slowing speech, delay in responses increasing drowsiness |
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What are the later signs or symptoms of ICP |
changes in vital signs - cushing's triad (irregular respirations, bradycardia, hypertension (widening pulse pressure)) projectile vomiting paralysis or weakness changes in respiratory pattern |
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see concept map on neuro assessment part 1 |
slide 32 |
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what are the goals in treating ICP |
goals (relieve ICP, decrease cerebral edema, decrease cerebral spinal fluid volume or cerebral blood flow without compromising perfusion) |
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what are the methods to manage ICP |
administering Mannitol corticosteroids to reduce edema restricting fluids draining CSF controlling fever maintaining system BP and oxygen decrease cellular metabolic demand positioning of patient |
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Other ICP interventions |
fever increases metabolic demand that increases edema (antipyretics, cooling blanket, environmental alterations) decreasing metabolic demands (sedation - high doses barbiturates - nembutol, pharmacological induced paralysis in conjunction with sedation and analgesics) |
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To relieve ICP surgically what type of surgery would they need |
intracranial surgery craniotomy (opening into skull) reasons (to decrease ICP, remove tumor, evacuate a clot or control bleeding) |
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Post op concerns of Intracranial surgery |
decrease pain prevent seizures maintain cerebral perfusion |
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Plan of care during and after a seizure |
observation and documentation of patient signs and symptoms before, during, and after seizure nursing actions during seizure for patient safety and protection after seizure care, prevent complications |
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Lolook in book for anti seizure medication |
neuroassessment slide 43 |
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nursing intervention focus |
preventing injury identifying precipitating factors educaiton compliance with medications (mouth care-gingival hyperplasia with dilantin) monitoring med levels (therapeutic and toxic) coping/quality of life (QOL) issues -stigma, alienation, depression, effects on employment, driving, activities, support groups |
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general stroke symptoms |
numbness confusion changes in mental status speech/visual disturbances balance/coordination difficulties headache often sudden and severe |
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Cerebral vascular disease (CVA) |
sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain |
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early treatment of CA |
fewer symptoms and loss of function |
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causes of CVA |
arteriosclerosis hypertension changes arteriovenous malformation (AVM) (abnormal connection between arteries and veins) vasospasms (a blood vessels spasm leads to vasoconstriction) inflammation embolism |
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brain injury to right side |
paralysis/loss of strength left side of body left visual field deficit spatial perceptual deficits increased distractibility impulsive behavior and poor judgment lack of awareness of deficits |
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Left sided injury brain injury |
losses on the right side of the body right visual field deficit aphasia (expressive, receptive or global) altered intellectual ability slow cautious behavior (look at table 62-3 pg 1899) |
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aphasia receptive |
person can hear the voice or read print but not understand the meaning |
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aphasia expressive |
person knows what they want to say but has difficulty communicating it to others |
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global aphasia |
impairment to both receptive and expressive parts |
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Non hemorrhagic ischemic (CVA types |
thrombus cerebral embolism |
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5 types of thrombus cerebral embolism |
artery small penetrating artery thrombus cardiogenic embolus crytogenic other |
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hemorrhagic CVA types |
rupture of cerebral blood vessel (aneurysm, AVM, drugs, uncontrolled HTN) |
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ischemic stroke |
disruption of the blood supply due to an obstruction, usually a thrombus or embolism that causes infarction of brain tissue |
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symptoms of ischemic stroke |
depends upon the location and size of the affected area numbness or weakness of face, arm, or leg, especially one sided confusion or change in mental status trouble speaking or understanding speech difficulty in walking, dizziness, or loss of balance or coordination sudden, severe headache perpetual disturbances |
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Thrombolytic therapy |
only or ischemic type strokes T-PA (recombinant plasminogin activator) 3 hour window contraindications (look at chart 67-2 page 1977) |
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hemorrhagic strokes bleeding into |
the brain tissues ventricles subarachnoid space usually more severe dysfunction than ischemic pathology depends on cause |
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causes of hemorrhagic strokes |
hypertension and cerebral atherosclerosis (causes blood vessels to rupture) brain tumor medications (oral anticoagulants, amphetamines, illicit drugs - crack, cocaine) cerebral aneurysm |
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clinical manifestations of hemorrhagic storke |
similar to ischemic stroke severe headache early and sudden changes in LOC vomiting |
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Medical management of hemorrhagic storke |
prevention (control of hypertension) care is primarily supportive e bed rest with sedation oxygen treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding |
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hemorrhagic stroke risk factors |
vessel wall abnormalities defects in hemostasis hypertension |
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ischemic stroke risk factors |
hypertension smoking lipid disorders diabetes |
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non modifiable risk factors for stroke |
age (over 55) male gender african american race |
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modifiable risk factors for stroke |
hypertension (the primary risk factor) cardiovascular disease elevated cholesterol obesity diabetes oral contraceptive use smoking and drug and alcohol abuse |
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teaching ofr the patient recovering from a stroke |
prevention of subsequent strokes, health promotion and follow up care medication teaching safety measures adaptive strategies and use of assistive devices for ADLS nutrition - diet, swallowing techniques, tube feeding administration elimination - bowel and bladder programs, catheter use exercise and activities recreation and diversion socialization, support groups and community resources |
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Transient ischemic attack medical management |
anticoagulatns platelet inhibiting medicaitons prevention (treat risk factors) |
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surgical management TIA |
carotid edarterectomy (removal of plaque or thrombus) angioplasty (balloon inserted to compress plaque against vessel wall) |
