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Neurological Problems and Management

Neurological Problems and Management

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Published by josephabram051590

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Published by: josephabram051590 on May 08, 2012
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Assessing Vital Neurological Signs
frequently and looking for deviation trends (stability, deterioration, or improvement)
Perform an initial baseline assessment and frequent subsequentassessments:
Every 5 - 15 minutes for unstable patients
Every 2 - 4 hours after patient is well stabilizedOnset of cerebral herniation and new intracranialhemorrhage are the major life threatening problemsassociated with acute deterioration
Include the following in the neurological assessment:
Level of consciousness
Orientation to time, place, and person isassessed in patients who can respond verbally
Glasgow Coma Score is used in patients who arecomatose
Assess by asking simple questions, e.g., "showme 2 fingers", in patients who can respondverbally
Glasgow Coma Score is used in patients who arecomatose
Brain stem function
Pupil assessment for any change in size or reaction; e.g.
1 pupil becomes dilated and progressively nonreactive to light as aresult of transtentorial herniation or afocal lesion
an oval or ovoid pupil is usually an earlysign of transtentorial herniation.The automated pupillometer is more accurateand reliable than the manual examination inmeasuring pupil size and reactivity
Other assessment; e.g.
Absent corneal and gag reflexes usually indicatea poor prognosis
Absent corneal reflex should be treated withspecial protective eye care and lubrication
Grimacing in response to the insertion of acotton-tipped applicator, in one nostril and thenthe other, can indicate a facial nerve deficit
Absent gag reflex may indicate a high risk for aspiration pneumonia
Eyes can be checked for doll's eye reflex
Motor function
Asymmetrical spontaneous movement andlateralization (e.g. hemiparesis and hemiplegia)suggest a focal mass lesion on the side of the brain opposite the side of motor weakness
Decortication and decerebration are seenin comatose patients following TBI
Bilateral or unilateral flaccidity may beseen in spinal injuries
Other assessments
Abrasions or contusions on the face and scalp
Ecchymosis on the mastoid bone (Battle's sign)
Periorbital ecchymosis (raccoon's eyes)
Conjunctival hemorrhage
Clear or bloody drainage from ear, nose, or  postnasal area
 Nuchal rigidity of the nec
Elevated ICP and shape of P1, P2, and P3components
1.Appearance colorless, clear 
Pressure 50-180 mm H
O3.Proteina.Lumbar 15-50 mg/dlb.Cisternal 15-25 mg/dlc.Ventricular 6-15 mg/dl4.Cell Counta.RBCs negativeb.WBCs 0-55.Glucose 50-80 mg/dl6.Gram stain negative for organisms7.Culture and sensitivity: no growth
Cerebrospinal fluid analysis
a.obtained via lumbar, cisternal or ventricular punctureb.indications: inflammation, infectionc.standard precautions are requiredd.maintain strict asepsisCerebrospinal Fluid (CSF)
: A watery cushion that protects the brain and spinal cord from physical impact and bathesthe brain in electrolytes and proteins.
: The fluid is formed by the choroid plexuses of the lateral and third ventricles. That of thelateral ventricles passes through the foramen of Monro to the third ventricle, and through theaqueduct of Sylvius to the fourth ventricle. There it may escape through the central foramen of Magendie or the lateral foramina of Luschke into the cisterna magna and to the cranial and spinalsubarachnoid spaces. It is reabsorbed through the arachnoid villi into the blood in the cranial venoussinuses, and through the perineural lymph spaces of both the brain and the cord.
: The fluid is normally watery, clear, colorless, and almost entirely free of cells. Theinitial pressure of spinal fluid in a side-lying adult is about 100 to 180 mm of water. On average, thetotal protein is about 15 to 50 mg/dl, and the concentration of glucose is about two-thirds theconcentration of glucose in the patient's serum. Its pH, which is rarely measured clinically, is slightlymore acidic than the pH of blood. Its concentration and alkaline reserve are similar to those of blood.It does not clot on standing. Turbidity suggests an excessively high number of cells in the fluid,typically white blood cells in infection or red blood cells in hemorrhage.CSF may appear red following a recent subarachnoid hemorrhage or when the lumbar puncture thatobtained the CSF caused traumatic injury to the dura that surround the fluid. Centrifugation of thefluid can distinguish between these two sources of blood in the spinal fluid: the supernatant is usuallystained yellow (xanthochromic) only when there has been a recent subarachnoid hemorrhage.Many conditions may cause increases in total protein: infections, such as acute or chronic meningitis;multiple sclerosis (when oligoclonal protein bands are present); Guillain-Barré syndrome; and chronicmedical conditions like cirrhosis and hypothyroidism (when diffuse hypergammaglobulinemia ispresent). The concentration of glucose in the CSF rises in uncontrolled diabetes mellitus and dropsprecipitously in meningitis, sarcoidosis, and some other illnesses. Malignant cells in the CSF,demonstrated after centrifugation or filtering, are hallmarks of carcinomatous meningitis.
: The CSF is normally sterile. Meningococci, streptococci,
Haemophilus influenzae,Listeria monocytogenes
, and gram-negative bacilli are recovered from the CSF only in cases of meningitis. Syphilitic meningitis is usually diagnosed with serological tests for the disease, such asthe venereal disease research laboratory (VDRL) test, the rapid plasma reagin (RPR) test, or thefluorescent treponemal antibody test. Cryptococcal infection of the CSF may be demonstrated byIndia ink preparations, or by latex agglutination tests. Tuberculous meningitis may sometimes bediagnosed with Ziehl-Neelsen stains, but more often this is done with cultures. These last threeinfections (syphilis, cryptococcosis, and tuberculosis) are much more common in patients who haveacquired immunodeficiency syndrome (AIDS) than in the general population.

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