IX. NEURO A. Neurological Assessment · Neuro. 4. Reflex assessment a. Babinski Reflex: Normal in a...

IX. NEURO

A. Neurological Assessment:

1. Glasgow Coma Scale: a. Define: A scale that measures the degree or level of ______________________.

b. Used to assess the level of consciousness in a client who already has

_______________ consciousness or has the potential of altered consciousness.

c. Three responses of the Glasgow Coma Scale: 1) ________ Opening 2) Motor Response 3) __________ Response

Rule: We like a high number ranging from 13 to 15 for the Glasgow Coma scale.

*LOC is always #1 with neurological assessment

2. Pupillary changes (normal pupil size is 2-6 mm) PERRLA

3. Hand grips/lifts legs/pushing strength of _______________ (strength, equality) Also assessing if they can follow a command.

Glasgow Coma Scale Eye Opening:

Spontaneous - 4 To verbal command - 3 To pain - 2 No response – 1 Motor Response: To verbal command - 6 To localized pain - 5 Flexed/withdraws - 4 Flexes abnormally - 3 Extends abnormally - 2 No response – 1 Verbal Response: Oriented/talks - 5 Disoriented/talks – 4 Inappropriate words – 3 Incomprehensible sounds – 2 No response - 1

Critical Thinking Exercise:

Assessment data

1. Opens eyes when talked to but goes back to sleep between questions.

2. Answers with mumbles and moan and gives no reliable data.

3. Slaps your hand away with pressure on nail beds. Score: ________________

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4. Reflex assessment

a. Babinski Reflex:

Normal in a child up to ______ year.

Abnormal in the __________.

The adult or child greater than one year should have a ____________ reflex or curling of the toes when the bottom of the foot is stroked.

What does it mean if the adult has a present Babinski reflex or fanning of the toes when you stroke the bottom of the foot?

A severe problem in the ________________ nervous system. (Tumor or lesion on the brain or spinal cord, Multiple sclerosis, Lou Gehrig’s disease)

b. Reflexes: (0) = absent, (1+) = present, diminished, (2+) = normal, (3+) = increased but not necessarily pathological, (4+) = hyperactive

A normal reflex response would be documented as___________.

B. General Diagnostic Tests:

1. CT:

a. With/without contrast (dye)

Will you need the client to sign a consent form prior to the test when using dye? ____________________

b. Takes pictures in _____________

c. Keep __________________ still

d. No ____________________

Grading Responses:

0 = No response

1+ = Sluggish or diminished

2+ = Active or expected response

3+ = More brisk than expected. Slightly hyperactive

4+ = Brisk, hyperactive, with intermittent or transient clonus Ankle clonus- a series of abnormal reflex movements of the foot, induced by sudden dorsiflexion.

Babinski Reflex

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2. MRI (Magnetic Resonance Imaging):

a. Which is better, CT or MRI? ___________

b. Is dye used? _____________

Is radiation used? _____________

A _____________is used

c. Will be placed in a tube where client will have to lie flat.

d. Remove ______________________

e. No credit cards

f. No ______________

g. Do fillings in teeth matter? _____________

h. Do tattoos matter? _____________

i. Will hear a thumping sound

j. What type of client can’t tolerate this procedure? _____________________

k. Can talk and hear others while in the _______________

3. Cerebral Angiography

Will a consent form be needed? __________ Why?_________________________ X-ray of cerebral circulation Go through the _____________________ artery.

a. Pre:

1) Well hydrated/void/peripheral pulses/groin prepped

Anytime an iodine based dye is used, the client will need to be well hydrated to promote excretion of the dye.

Watch: BUN and Creatinine Output Hold metformin (Glucophage)

2) Explain they will have a warmth in face and a metallic taste; 3) Allergies? _________ __________

An iodine based dye is used.


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b. Post:

1) Bed rest for 4-6 _______________

2) Watch for bleeding at the femoral artery site (BLEEDING/HEMORRHAGE)

3) Embolus

An embolus can go lots of different places:

Arm, Heart, Lung, Kidney

Since we are performing a test on the brain….if the embolus goes to the brain… the client will have a change in _____________, one-sided weakness, and ______________________, motor/sensory deficits.

4. EEG (Electroencephalography):

a. Records electrical activity of the brain

b. Helps diagnose ________________ disorders and evaluate the types of seizures occurring

c. Evaluates loss of consciousness and dementia

d. Screening procedure for __________________

e. Indicator of __________________________death

f. Used to diagnose sleep disorders like narcolepsy, cerebral infarct, brain tumors or abscesses.

g. Pre procedure:

Hold sedatives. Why? _________________________

No caffeine

Not ___________________________________(drops blood sugar)

h. Beginning of the procedure:

Will get a baseline first with client lying quietly (normal EEG)

May be asked to hyperventilate to assess brain circulation; assess photo stimulation for seizures, or sedate for sleep study.

If you have someone who is completely unconscious, a pain response or noxious stimuli may be introduced to stimulate a brain wave. This can be anything from a strong smell like ammonia to a bright light.


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5. Lumbar Puncture:

a. Puncture site: lumbar subarachnoid space

b. Purpose:

1) To obtain _____________fluid to analyze for __________, infection, and tumor cells.

2) To measure pressure readings with a manometer

3) To administer drugs intrathecally (brain, spinal cord)

c. How is the client positioned, and why? __________________________________

___________________________________________________

d. Inspect the surrounding skin at the puncture site for any infection.

e. CSF should be clear and colorless (looks like water)

f. Post-procedure:

Lie flat or prone for 2-3 hrs. Increase ____________to replace lost spinal fluid. What is the most common complication? _________________ The pain of this headache______________________ when the client sits up

and ________________ when they lie down. How is this headache treated? Bed rest, fluids, pain med, and a

________________ patch

g. Life threatening complications:

Brain herniation: With known increased ICP, a lumbar puncture is

contraindicated.

Meningitis

Can bacteria get into the puncture site? ________

Can bacteria get into the spinal fluid? _________

What would that cause? ____________________


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C. General Care for Any Client with Increased Intracranial Pressure:

1. Signs and Symptoms of ↑ ICP:

a. Early Signs:

1) Earliest sign? ________________

2) Speech? ____________________ 3) Delay in response to _________________ suggestion. Slow to respond to

commands

4) Increasing drowsiness

5) Restless with no apparent reason

6) Confusion

b. Late Signs:

1) Marked change in LOC progressing to stupor, then____________.

2) Vital sign changes:

Called Cushing’s Triad and requires ____________________intervention to prevent brain ischemia. Cushing’s Triad:

Systolic hypertension with a ____________________ pulse pressure. Slow, full, and bounding pulse

____________________ respirations. Look for a change in pattern, like

Cheyne Stokes or ataxic respirations. 3) Posturing: A response to ______________ or noxious stimuli. Posturing

indicates that the motor response centers of the brain are compromised.

Decorticate posturing: Arms flexed ______________ and bent in toward the body and the legs are extended.

Decerebrate posturing: all __________ extremities in rigid extension; WORST.

Client will be rigid and tight and burning ___________________________.

Normal Lab Value: ICP: 0-15 mm Hg


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c. Miscellaneous Signs: 1) Headache 2) Changes in _______________ and pupil response. (fixed and dilated) 3) Projectile ___________________ can occur because the vomiting center in

the brain is being stimulated.

2. Complications of Increased ICP:

a. Brain Herniation: This herniation obstructs the blood ___________to the brain leading to anoxia and then brain_____________.

b. DI and SIADH: Can be either so you must assess for both.

3. Tx of ↑ ICP:

a. Maintain ________________________.

Decreased O2 levels and high CO2 cause cerebral vasodilation which increases ICP.

b. Maintain adequate cerebral perfusion.

Don’t want _______________________ or bradycardia because that

would________________ brain perfusion.

Isotonic saline and inotropic agents: dobutamine (Dobutrex) and norepinephrine (Levophed)

c. Keep temperature below ______________________________

1) An increased temp will increase cerebral metabolism which increases ICP.

2) The hypothalamus may not be working properly, and a cooling blanket may be needed.

3) Hypothermia is used as a treatment to decrease cerebral _______________ by decreasing the metabolic demands of the brain.

d. Elevate the _________________________.

e. Keep ____________in midline so jugular veins can drain.


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f. Watch the________________monitor with turning, etc.

g. Avoid __________________/, bowel/ bladder distention, hip flexions, Valsalva, and isometrics. No sneezing and no nose ________________

h. Limit ____________________ and coughing

i. _______________ nursing interventions

Anytime you do something to your client, ICP increases.

j. Monitor the Glasgow coma scale Rule: If the Glasgow coma score is below 8, think intubate.

k. Monitor vital signs for Cushing’s Triad.

l. Barbiturate induced coma-________________ cerebral metabolism: phenobarbital (Luminal®).

m. Osmotic diuretics: mannitol (Osmitrol®) → pulls ____________ from brain cells and filters it out through the kidneys. This ______________ the ICP.

n. Steroids: dexasone (Decadron®) – decreases cerebral _____________.

o. ICP monitoring devices:

Ventricular catheter monitor or subarachnoid screw

Greatest risk? _____________________

No loose connections

Keep dressings __________. (Bacteria can travel through something that is wet much easier than something that is dry).


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D. Neurological Alterations:

1. Meningitis: a. Definition: Meningitis is ___________________ of the spinal cord or brain.

b. Causes: Can be either viral or ___________________. Bacterial is transmitted

through the respiratory system.

c. Signs and Symptoms:

1) Chills and Fever

2) Severe ___________________.

3) Nausea and Vomiting

4) Nuchal rigidity (stiff neck)

5) Photophobia

d. Treatment: 1) Steroids

2) Antibiotics if _________________

3) Analgesics

4) Droplet ______________________ for bacterial meningitis.

Bacterial meningitis is a very contagious, medical emergency. It has a

high mortality and________________________ is recommended for college aged students.

5) Viral meningitis is transmitted by feces and requires________________ precautions. Commonly seen in infants and children.


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2. Seizures: a. Define:

Should be thought of as a ______________of an underlying disorder

rather than a disease.

Seizures are not considered ___________________if they discontinue when the disease has gone away

b. Classifications:

1) Partial Seizure:

A partial seizure is limited to a specific _______________ area of the brain.

An aura may be the only manifestation

Called _______________ seizures.

Symptoms can range from simple to complex. Simple means _______________ loss of consciousness; will see numbness, tingling, prickling or ____________.

Complex means that they have impaired consciousness and may be confused and unable to respond.

2) Generalized Seizure:

Involves the ______________ brain.

Called non-focal seizures.

Loss of consciousness is the ________________ manifestation.

International Classifications of Seizure Disorders:

Tonic – Clonic – formerly known as grand mal

Myoclonic – sudden, brief contractions of a muscle or group of muscles

Absence – formally called petit mal and characterized by a brief loss of consciousness.


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c. Complications of Seizures: 1) Status epilepticus: a continuous seizure without returning to consciousness

__________________ seizures.

2) Trauma: Protect the client

d. Treatment: 1) Neurological examination including lab and X-ray

2) Anticonvulsants:

Can be ___________ or short term therapy.

Rapid acting: lorazepam (Ativan®) and diazepam (Valium®) Long Acting: phenytoin (Dilantin®) or phenobarbital

Have ____________ side effects.

Monitor drug levels for toxicity through lab values.

Abrupt _____________________ can cause a seizure.

3) Don’t forget the basics of _______________ and safety during a seizure.

Rule: The NCLEX® lady only uses the generic name of a drug in an NCLEX® question.

Rule: Do not put anything in the mouth of a seizing client.


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E. Neurological Injuries:

1. Skull Injury May/may not damage ___________.

Open fracture→ dura ______________

Closed fracture→ dura _________ torn

With basal skull fractures, you see bleeding where? __________________

Battle’s sign: bruising over ________________.

Raccoon eyes (peri-orbital bruising)

Cerebrospinal rhinorrhea- leaking spinal fluid from your ____________________

How do we tell CSF from other drainage? Positive for _______________ and the

halo test.

Non-depressed skull fractures usually do not require surgery; depressed fractures do require surgery.

2. Brain Injury:

a. Concussion: Temporary loss of neurologic function with _________________ recovery

Will have a short (maybe seconds) period of unconsciousness or may just get

dizzy/see spots

Teach caregiver to bring client back to ED if the following occurs:

Difficulty awakening/speaking, confusion, severe headache, vomiting, pulse changes, unequal pupils, one-sided weakness

b. Hematomas:

A small hematoma that develops rapidly may be fatal, while a massive hematoma that develops slowly may allow the client to _________________________.

All of these are signs that the ICP is going ______________!


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1) Epidural Hematoma:

Pathophysiology:

This is rupture of the middle meningeal artery (fast bleeder under high pressure).

Injury→ Loss of consciousness→ Recovery period→ Can’t compensate any longer→ Neuro changes.

Tx:

Burr Holes and remove the clot; control the _____________.

Ask questions to ID the type of injury and the treatment needed:

Did they pass out and stay out?

Did they pass out and wake up and pass out again?

Did they just see stars?

Epidural hematoma is an ___________________

2) Subdural Hematoma:

Pathophysiology:

Usually a ___________________ bleed

Can be acute (fast), subacute (medium), or chronic (slow)

Tx:

Chronic: imitates other conditions;

Bleeding & compensating

Neuro changes= maxed out Acute or Chronic: immediate craniotomy and remove ________:control___________


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3. Spinal Cord Injury:

Autonomic dysreflexia:

a. Pathophysiology:

With __________ spinal cord injury (above T6), the major complication to look for is autonomic disreflexia or hyperreflexia.

b. S/S:

It is a syndrome characterized by: severe _____________ and headache, bradycardia, nasal stuffiness, flushing, sweating, blurred vision and anxiety.

Sudden onset. It is a neurological emergency if not treated promptly. A _______________ stroke could occur.

c. Causes:

What can cause it? Distended ________________, constipation, painful stimuli.

d. Treatment:

First, sit the client up to lower _________________ ________________.

Treat the cause: Put in catheter, ________________ impaction, look for skin pressure, painful stimuli, or a cold draft breeze in the room.

Teach prevention measures. Why?


Which shoes would you buy for a Parkinson’s client?

1. Hot pink furry slippers

2. New Balance tennis shoes


Which home health client would you go see first?

1. The Alzheimer’s client who fell yesterday and confusion has increased a little

2. The Type 2 diabetic client who has been out of medicine for three days


Your client has been diagnosed with an ischemic stroke. Signs and symptoms: right side paralysis, trouble swallowing and difficulty speaking. What is the priority intervention for this client?

1. Prevent aspiration 2. Assist with range of motion

exercises 3. Promote self-care 4. Provide a communication

board


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IX. NEURO A. Neurological Assessment · Neuro. 4. Reflex assessment a. Babinski Reflex: Normal in a...

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Transcript of IX. NEURO A. Neurological Assessment · Neuro. 4. Reflex assessment a. Babinski Reflex: Normal in a...