Neurolgy, Med Surg

Front 1

What does the Reticular Activating System do?

Back 1

It creates a state of arousal, or a state of being by connecting us to our cortex. It directs the content of our consciousness: thought, behavior, language, expression; and is off when we are sleeping.

Front 2

What 2 general problems can interfere with the RAS?

Back 2

Structural Problems - Edema, etc. - Usually show asymmetric symptoms
Metabolism Problems - Ketoacidosis, hypoglycemai, hyponaturemia, etc. - Usually show symmetric symptoms

Front 3

What is the difference between delirium and dementia?

Back 3

Delirium is reversible disorientation and dementia is a permanent, progressive disorder that can manifest as the pt being unable to lay down new memories.

Front 4

What is a persistent vegetative state?

Back 4

The pt can open his/her eyes, but there is no cognitive function from the cortex. The brain stem is usually still functioning for things such as breathing.

Front 5

What is Locked-In Syndrome?

Back 5

This is where a pt is present cognitively, but not physically. Locked in their own body.

Front 6

What are the responses with brain death?

Back 6

The pt is unresponsive to painful stimuli, has no activity from the brain stem or cortex, and there is no respiratory effort.

Front 7

What are four general areas to when doing a mental status exam?

Back 7

1. Orientation
2. Recognizing their name
3. LOC may fluctuate
4. Note delirium or dementia

Front 8

When doing a mental status assessment, what things tend to deteriorate in order?

Back 8

Problems with orientation tend to go first: They lose info about the day, month, year, last holiday, etc first.
They then loose orientation regarding location.
The last part is that they lose the ability to recognizer their name, which indicates severe impairment.

Front 9

When doing a motor exam, what general areas do you assess?

Back 9

~Muscle strength - symmetry
~Muscle coordination - able to follow commands
~Stimulus needed to get response

Front 10

When looking for a response to stimulus, what makes a difference concerning LOC regarding pain?

Back 10

With a sternal rub, how do they react?
~Do they localize pain by pushing your hand away? This is better.
~Do they just withdraw from the pain, this is an impaired reaction.

Front 11

Regarding stimulation, how should a pt respond to light touch?

Back 11

They should be able to feel the touch of a Kleenex or cotton ball.

Front 12

When performing a cranial nerve exam, what general things do you check?

Back 12

~Corneal reflexes
~Gag reflex
~Cough reflex
~Doll's Eyes
~Calorics

Front 13

When testing corneal reflexes, what does this tell you?

Back 13

~This is the last reflex to go - touch the cornea with a tissue and it should cause a blink and pulling away of the pt. This is good with psych patients because it is an automatic response.

Front 14

What is the Doll's Eyes test looking for?

Back 14

This is when you move the pt's head and their eyes move with their head. They should fix on one point and stay when their head is turned.

Front 15

What are calorics used for in neuro assessment?

Back 15

It is a test to check for brain stem function. Cold water is instilled into the ear canal and if there is brain stem function, the pt's eyes should shift toward that side.

Front 16

Give a brief description of the Glascow Coma Scale.

Back 16

It is used to measure LOC and has a total of 15 points. It assesses the responses of the pt through the pt opening their eyes in response to different levels of stimuli, as well as verbal response and motor response.

Front 17

What things are measured in the Mini-Mental Exam?

Back 17

Orientation, registration (repeat 3 words), attention (follow directions, name an object, read and follow directions), recall (recall three common words), language (ability to say words)

Front 18

Regarding altered LOC, what things do we need to watch for regarding breathing?

Back 18

Hypoventilation, fever, using the IS, development of atelectasis

Front 19

Regarding altered LOC, what things do we need to watch for regarding altered thoughts?

Back 19

Keep things in the pt's visual field, speak slowly and use simple phrases, decrease noise and stimulation (it can increase the pt's problems)

Front 20

Regarding altered LOC, what things do we need to watch for regarding skin care?

Back 20

Turn the pt q2hr at the lease, position so there is the least pressure on bony prominences, protect the elbows and heels

Front 21

Regarding altered LOC, what things do we need to watch for regarding general injuries?

Back 21

Pt is not cognitively aware, so protect them from heat, cold, and falling. Restraints can further agitate the pt, use bed rails and bed/chair alarms. Infections arise frequently, perform peri care BID and watch for s/s of infection.

Front 22

When looking at intracranial volume and IICP, what premise must be followed to keep pressure from rising?

Back 22

There are three components in the intracranial compartment: brain tissue, blood, and CSF. If the volume of one goes up, the others must go down to prevent increased intracranial pressure.

Front 23

What is the patho regarding perfusion and problems with CO2 elevation in the brain?

Back 23

Arterial perfusion decreases as ICP increases due to compression of the arteries.
As CO2 rises, it results in dilation of cerebral arteries, thus causing increased ICP. In a critical situation, a pt may be hyperventilated to buy some time until the cause is fixed.

Front 24

What are the three types of herniations in the brain?

Back 24

Falx cerebri, uncal, transforaminal

Front 25

What are 2 early clinical manifestations of IICP?

Back 25

Decreasing LOC is the best indicator,
and headache.

Front 26

What are 8 late clinical manifestations of IICP?

Back 26

~Decline in LOC
~Elevated SBP
~Decreased DBP (widened gap)
~HR <60 from vagal stimulation
~Slow, shallow breathing, apnea, or irregular breathing pattern from pressure on the brain stem
~Decorticate or decerebrate posturing
~Dilation of both, or one, eye; starts as a sluggish response and then progresses
~Fever from pressure on the temperature control center of the brain stem; can go very high and pt may need a cooling blanket
~

Front 27

What does decorticate/decerebrate posturing look like? What part of the brain is being affected to produce these postures?

Back 27

Front 28

What are activities that increase ICP?

Back 28

~Increased intra-abdominal or intra-thoracic pressure from coughing, Valsalva maneuver, vomiting, acute hip flexion
~Neck flexion (blood can't drain)
~Pain
~Elevated CO2 and hypoxia (dilates cerebral arteries

Front 29

What are activities that decrease ICP?

Back 29

~Decreased intra-abdominal or intra-thoracic pressure (inspiration)
~Decrease CO2 (hyperventilation)
~CNS depressants (barbituate coma - the brain requires less O2, which can be life-saving

Front 30

What are treatments for increased ICP?

Back 30

~Osmotic diuretics (decreases volume rapidly)
~Corticosteroids (decreases inflammation and edema)
~Anticonvulsants (decrease seizures)
~Antibiotics (decrease infection risk)
~Keep neck in alignment (increase venous drainage)
~Keep HOB up (promotes venous drainage)
~Keep pt slightly dehydrated (know minimum requirements!)
~Decrease coughing, vomiting, straining, shivering, and agitation (these increase ICP)

Front 31

Know the major veins and arteries of the head and neck

Back 31

Front 32

Know the basic arteries of cerebral circulation.

Back 32

Front 33

What are the two types of strokes and what are they caused by or what are the characteristics?

Back 33

~Ischemic stroke (83%) - Caused by atherosclerosis, thrombosis, embolism (25% of ischemic strokes) from the heart, esp with a-fib
~Hemorrhagic (7%) - 1-2 mL from a ruptured vessel can cause symptoms, 50 mL can be lethal. This disrupts the blood-brain barrier and causes IICP.

Front 34

What is the pathology of a stroke?

Back 34

~Ischemia results in death of neurons
~Blood-brain barrier is disrupted and the brain gets the toxic effects from free radicals from tissue ischemia.
~Edema creates pressure on brain tissue
~Vasodilation of the blood vessels causes IICP
~Acidosis results

Front 35

What are the four phases of stroke development?

Back 35

1. Transient Ischemic Attack (TIA) - Resolves in 24 hrs w/o neuro deficit
2. Reversible Ischemic Neurologic (RIND) - "Small stroke" resolves in 48 hrs to 3 weeks w/o neuro deficit
3. Stroke in evolution (progressive stroke) - Continues to get worse over 72 hrs and causes permanent damage
4. Completed Stroke - Neuro deficits within an hour and up to 72 hours

Front 36

What are some symptoms that can be associated with TIAs and what are they related to?

Back 36

~The sx are related to what artery the clot is in
~A carotid artery clot can cause blindness in one eye, blurred vision, hemiparesis (weakness on one side of the body), sensory deficit to the face or extremities
~A vertebral artery clot can cause ataxia (uncoordinated movements), clumsiness, dysarthria (motor speech difficulties), dysphagia, sensory and motor deficits, blindness in both eyes, decreased LOC, dizziness or vertigo, tinnitus.

Front 37

What are the motor and language deficits that can result from a stroke?

Back 37

~Motor deficits - Decreased movement and strength on one side of the body, incontinence of urine.
~Language deficits - Aphasia, expressive aphasia, receptive aphasia, alexia, and agraphia

Front 38

What is aphasia, expressive aphasia, and receptive aphasia? What area of the brain is affected to cause these symptoms?

Back 38

~Aphasia - Total impairment of language ability (technically)
~Expressive aphasia - Motor area (Broca), can't speak, but can understand
~Receptive aphasia - Sensory area (Wernicke), speak nonesnse and can't understand

Front 39

What is alexia and agraphia?

Back 39

~Alexia - Can't understand writing
~Agraphia - Can't write

Front 40

Know the areas of the brain that can be affected by stroke and manifest in symptoms.

Back 40

Front 41

What are the sensory-perception deficits that can result from a stroke?

Back 41

~Sensory loss - Risk for injury due to not being able to feel cold or hot
~Visual deficits - Depends on the type of optic nerve involvement
~Lack of ability to judge spatial relationships; denial of physical effects which leads to risk for injury
~Pt can't identify familiar objects, including ones needed for self care

Front 42

What are the cognitive-emotional deficits that can result from a stroke?

Back 42

~Can develop exaggerated, flat, or inappropriate emotions
~Can cry a lot, feel depressed, etc
~Their memory and judgment skills are impaired
~They can't think abstractly or reason

Front 43

What are some treatments for stroke? This includes medications and surgical intervention.

Back 43

Medications
~Anitplatelet - Primary prevention of recurrence; ASA, Plavix (clopidogrel)
~Neuroprotectants - Protect the brain from secondary injury; calcium channel blocker, oxygen free radical scaventer, GABA agonists
~Anticoagulants - Decreasing extension of clots; warfarin (keep INR >2.0
~Thrombolytics - Tissue plasminogen activator (t-PA) lyses clots, but must be given within 3 hours of stroke!
Surgery
~Carotid endarterectomy to reestablish blood flow and reduce further unjury

Front 44

When caring for a post stroke pt, what things do you do to monitor neuro signs and vitals?

Back 44

~Monitor the stroke evolution and notify the MD if it progresses - May have to wake the pt at night to assess
~Rule out IICP
~Monitor LOC, orientation, bilateral muscle strength
~Test cranial nerve function and swallow and gag reflexes
~Assess their ability to follow commands, speak, and understand
~Reduce the risk of IICP through minimizing coughing, straining, head and neck flexion

Front 45

What interventions can we do to care for a post stroke pt?

Back 45

~Keep HOB ≥30° to protect their airway
~Provide oxygen as ordered and as needed
~Provide assistive devices as needed to maintain positions of normal function in affected limbs: Braces, splints, etc to prevent foot drop
~Keep pt's heels off of the mattress
~Decrease areas of pressure, like the area of the coccyx from developing a pressure ulcer

Front 46

What are more interventions when caring for a post stroke patient?

Back 46

~They need PT for ROM and to keep/develop muscle strength
~Ensure safe transfer to a chair and during ambulation
~Use both sides of the body during activities; use weight-bearing on the affected side for sitting and standing to get them used to being aware of the affected side, create movement toward the affected side
~Normalize body posture
~Participate in ADLs until they can perform self care; Grooming, feeding, hygiene, dressing, toileting
~Use assistive devices; Velcro, non-slip bowls and glasses, sock puller, etc
~Practice recognition and naming of familiar objects

Front 47

When a pt's vision is impaired, what NIs can we do to help them to adapt and keep them safe?

Back 47

~Have them look toward the affected side to avoid hitting objects/injury
~Approach them from the unaffected side
~Position them so their visual field includes the door to enter their room
~Have them scan side-to-side to see their surroundings
~Place food and objects in their visual field
~Later, place things to stimulate the affected sice
~Have the pt touch and look at the affected side

Front 48

What is the definition of epilepsy and what does it disrupt? What can seizure activity affect?

Back 48

~A rapid, repetitive electrical discharge from brain cells in the cortex
~Disruption of neural cell membranes
~Seizure activity can be any alteration in sensation, behavior, movement, perception, and consciousness

Front 49

What are the two stages of seizure activity?

Back 49

~Ictal state - Time during the seizure
~Postictal state - Recovery time after a seizure: Pt may be confused, lehtargic and require many hours of sleep, can't follow instructions, can't speak clearly

Front 50

Name the three types of seizures;

Back 50

1. Partial
2. Generalized
3. Status Epilepticus

Front 51

Explain the possible components of a partial seizure.

Back 51

~Muscle twitching - conscious - no postictal state
~Visual - conscious - no postictal state
~Speech arrest - conscious - no postictal state
~Autonomic behavior (lip smacking, chewing motion) - consciousness impaired - postictal state

Front 52

Explain the possible components of a generalized seizure.

Back 52

~Absence - consciousness impaired - no postictal state
~Tonic-clonic - tonic=muscle rigidity, loss of consciousness, unable to breathe, incontinent bowel and bladder - clonic=muscle jerking - postictal state

Front 53

Explain what happens with status epilepticus.

Back 53

~Continuous seizures without full recovery
~Oxygen consumption increases
~Can result in brain death from hypoxia

Front 54

What 7 things need to be assessed and documented regarding epilepsy?

Back 54

1. Do they get an aura (feeling, sensation, smell, etc) prior to a seizure?
2. Are there precipitating factors that bring on a seizure (lack of sleep, alcohol, caffeine, time of day, emotional stress, hyperventilating)?
3. Describe exactly what happened
4. How long was the seizure?
5. How long was the postictal state?
6. Was there any incontinence?
7. Note if there was more than one seizure and the time in between them.

Front 55

What treatments are there for a person who has epilepsy?

Back 55

~During a seizure, protect them from injury; they may not be able to drive or hold certain jobs, don't force something in their mouth, administer O2, if they are in a bed, put the side rails up and pad them
~Medications that can be give are: Anticonvulsants (dilantin, barbitol, etc) and benzodiazepine IV to stop status epilepticus
~Adequate rest and sleep
~Manage life stress
~No alcohol or caffiene

Front 56

What 4 types of tumors are there regarding the nervous system and explain them?

Back 56

1. Gliomas - Not encapsulated, grow rapidly, and are resistant to chemo
2. Meningiomas - Benign, slow growing, from meninges
3. Neuroma - Grow from Schwann cells on the 8th cranial nerve, benign
4. Angioma - Grow from vascular structures

Front 57

What are some examples of Gliomas?

Back 57

~Astrocytoma
~Glioblastoma
~Oligodendroglioma
~Ependymoma
~Meduloblastoma

Front 58

What are the clinical manifestations for tumors in the brain?

Back 58

~Headache
~N/V
~IICP
~Blurred vision
~Double vision
~Blind spot
~Seizures
~Weakness/hemiparesis
~Aphasia (expressive-frontal lobe-Broca's motor area; receptive-temporal lobe-Werinike's sensory area)
~Decreased LOC
~Personality changes 9may be one of the first sx)
~Inappropriate affect
~Sensory or perceptual defects

Front 59

Know where the CSF is produced and how it flows through the CNS.

Back 59

Front 60

What are 3 general classifications that describe causes of hydrocephalus?

Back 60

1. Non-communicating hydrocephalus - CSF can't flow our of the ventricular system, but continues to be produced
2. Communicating hydrocephalus - An obstruction prevents reabsorption of CSF via the arachnoid space
3. Infection can obstruct drainage/reabsorption

Front 61

How do they treat hydrocephalus?

Back 61

A shunt is placed in a ventricle that is then tunneled under the skin and empties into the abdominal cavity.

Front 62

What is the general progression of a degenerative disease regarding the nervous system? What are the treatments?

Back 62

~Progressive dysfunction
~Progressive loss of independence
Treatments:
~Symptom management
~Support their independence

Front 63

What are 5 neurologically degenerative diseases?

Back 63

~Multiple Sclerosis
~Parkinson's
~Myasthenia Gravis
~Amytrophic Lateral Sclerosis
~Guillain-Barre' Syndrome

Front 64

What causes the problems associated with MS and why?

Back 64

There is demyelination and scaring of the myelin sheath on the nerves.
The myelin sheath is needed for fast nerve conduction through the axons.

Front 65

How is MS classified regarding the outcome of the disease? What usually causes it? Who usually gets it?

Back 65

~It is a debilitating disease rather than a fatal one
~A viral infection triggers a cell mediated autoimmune response that attacks the myelin sheath
~It usually occurs in young adults

Front 66

What are some general signs and symptoms of MS? How does it progress? What usually kills the pt?

Back 66

~There are variable s/s
~Early stages show visual problems and fatigue
~The pt experiences relapses and it is a transitory disease
~Pts usually die from complications from immobility, the inability to breathe effectively, etc

Front 67

What are the clinical manifestations of MS?

Back 67

~Numbness and tingling of the face or extremities
~Decreased proprioception
~Weakness, heaviness of the lower extremities
~Double vision
~Retention or urge incontinence
~Uncoordinated movements, ataxic gait
~Slurred speech
~Difficulty swallowing
~Emotional lability
~Short attention span, poor judgment, can't problem solve, decreased short-term memory

Front 68

What is the treatment for MS?

Back 68

~Focused on decreasing inflammation during acute attacks and decrease relapses
~Medications: Acute exacerbation-large doses of steroids; Long-term-decrease autoimmune response, spasticity, tremors, depression, fatigue, constipation
~Help the pt retain as much self care as possible
~Teach them safety from injury due to sensory losses
~Watch for s/s of a UTI, they typically get severe and pt requires a Foley

Front 69

What is the general cause of problems in Parkinson's disease? At what point do sx occur?

Back 69

~It is due to degeneration of Dopamine-secreting neurons in the basal ganglia, then later the receptors decrease
~The opposing effects of Acetylcholine make initiating voluntary movements more difficult
~The opposing effects of DOPA make it so inhibiting movement degenerates, too
~Sx occur when 70% of the neurons are destroyed

Front 70

What clinical manifestations, regarding motor control, are present in Parkinson's disease?

Back 70

~Posture - Unstable, forward tilt on toes, small shuffling steps, stooped-over, will propel forward until they fall
~Intentional movements that are not present during sleep are tremor and "pill rolling"
~Muscle tone that is not present during sleep includes rigidity, difficult to move, and freezing
~Fluidity problems include abnormal gait, akinesia, bradykinesia, arms don't swing, can't maintain balance

Front 71

What is akinesia, bradykinesia, and freezing?

Back 71

~Akinesia - The inability, or slowness in initiating a movement
~Bradykinesia - Slowness in execution of a movement
~Freezing - Inability to move muscles in any desired direction

Front 72

What are other clinical manifestations regarding Parkinson's?

Back 72

~Weakness, fatigue
~Loss of facial expression
~Difficulty in chewing and swallowing (NIs to prevent aspiration pneumonia)
~Voice changes
~Problem solving difficulty, which leads to memory loss
~Visual-spatial deficits
~Cognitive deficits develop later

Front 73

Specifically, what manifestations does Parkinson's have on facial features, speech, and vision?

Back 73

~Face - Mask-like appearance, eyes stare straight ahead
~Speech - Low volume, slurred, muffled, monotone, difficulty finding words
~Vision - Blurred, impaired upward gaze, decreased blinking

Front 74

Specifically, what manifestations does Parkinson's have on fine motor skills, autonomic disturbances, and cognitive (behavior) actions?

Back 74

~Fine motor - Small handwriting, decreased manual dexterity, clumsiness, decreased ability to perform ADLs
~Autonomic disturbances - Constipation, decreased gastric emptying, urinary frequency or hesitancy, retention (worse if a man also has BPH), dizziness or fainting, dysphagia, drooling, oily skin (even after just washing)

Front 75

What techniques are used to treat Parkinson's?

Back 75

~Sx control only (works for a limited time), there is no cure and it is progressive
~Medications
~Surgery to try to relieve tremors
~Attempt to provide safety concerning falls, home adaptation, and aspiration pneumonia

Front 76

What medications are used for the treatment of Parkinson's and what problem do they treat?

Back 76

~Levodopa - Increases CNS dopamine
~Anticholinergics - Decrease Ach to decrease rigidity; makes Ach and dopa in a better balance (Artane, Cogentin)
~Symmetrel - Blocks the reuptake/storage of dopamine
~Dopamine agonist - Stimulates dopa receptors (Parlodel)
~MAO inhibitor - Delays the disease process in some pts (Eldepryl)

Front 77

What are important aspects to know regarding Levodopa?

Back 77

~It should be taken on an empty stomach
~It is an "on/off" medication, in that if it is taken with food, it can be working and then all of the sudden turn off and the pt can't move; its effects are all or nothing
~Avoid protein intake with it
~Avoid vitamin B6 (pyridoxine) as it increases the conversion of Levodopa in the liver and there is less active drug in the blood

Front 78

What happens, on the cellular level, when a person has Myasthenia Gravis?

Back 78

~The Ach receptors are destroyed by an autoimmune response, which results in decreased muscle contraction

Front 79

What is the difference between agonists and antagonists?

Back 79

~Agonists increase the level of receptor action, antagonists lower it

Front 80

How does normal impulse transmission happen at the synaptic cleft?

Back 80

Front 81

What are the s/s of Myasthenia Gravis?

Back 81

~Double vision
~Eye lid ptosis
~Dysphagia, aspiration
~Dysarthria
~Generalized weakness - leaves the person at a higher risk for trauma and infection

Front 82

What happens to the muscarinic and nicotinic receptors and how does this manifest into sx with Myasthenia Gravis?

Back 82

~Muscarinic receptors are the first to be affected; this manifests in a loss of inhibition in glands, which results in copious amounts of secretions
~Nicotinic receptors are affected next and this results in a weakness in skeletal muscles due to decreased stimulation

Front 83

What are the treatments for Myasthenia Gravis?

Back 83

~No known cure
~Medications include:
Cholinesterase inhibitor drugs like Phridostigmine that decreases degradation of Ach for better nerve conduction
Immunosuppression through corticosteroids, Imuran, and Cyclosporine

Front 84

What is Amyotrophic Lateral Sclerosis?

Back 84

~It is a progressive degeneration and demyelination of lower motor neurons that progresses to the upper motor neurons in the brainstem
~It is very aggressive and can cause death within 18 months by weakening the respiratory muscles (notes say 2-5 years)
~Pt's sensory input and mental status are intact

Front 85

What are the clinical manifestations of Amyotrophic Lateral Sclerosis?

Back 85

~Muscle weakness and atrophy
~Decrease in fine motor skills
~Decreased tendon reflexes
~Muscle cramping
~Fatigue
~Slurring of speech-Dysarthria (impairment of the muscles for speech) and dysphagia (impairment of the muscles for swallowing)

Front 86

What is Guillain-Barre' Syndrome?

Back 86

~Temporary symmetric muscle weakness and paralysis that results from immune destruction of the myelin sheath, however it will eventually regenerate and the pt can recover

Front 87

What type of G-B Syndrome is most common?

Back 87

~Ascending G-B is the most common. It starts at the feet and moves up toward the brain stem, then reverses and goes back down to the feet and is gone

Front 88

How long does it take to recover from G-B Syndrome, and why?

Back 88

~Recovery can take 6 months to 1 year because it can take 1 month to 6 weeks to run its course, which causes profound muscle wasting and could require mechanical ventilation

Front 89

What other problems happen with G-B Syndrome?

Back 89

Autonomic dysfunction
~Unstable BP
~Tachy- or bradycardia
~Flushing and sweating
~Paralytic ileus that may cause nutrition to be given parenterally

Front 90

What NIs need to be considered when caring for a pt with G-B Syndrome?

Back 90

~Remember the pt is alert, aware, and cognitively intact
~Try to establish a method of communication prior to pt loosing the ability to speak, like eye blinking
~Watch for a decrease in ventilation
~Watch for s/s of impaired nutrition