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Neuro Lecture: Anatomy and Physiology
Neuro Lecture: Anatomy and Physiology
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-Peptides
-Gases [Nitrous]
-Neuroglial cells – four types, provide protection, structure, and nutrition for neurons;
part blood brain barrier; assists in regulating composition of CSF
-CNS – brain and spinal cord
-Cerebral circulation – Circle of Willis
-PNS [peripheral nervous system] – spinal nerves, cranial nerves, and autonomic nervous
system
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Anatomy and Physiology
-ANS – exerts control over “involuntary” functions
*Sympathetic – vasodilation in skeletal muscle and vasoconstriction in skin and viscera;
increased heart rate and force of contraction; bronchiolar dilation; liver conversion of
glycogen into glucose; increased sweat gland activity; decreased peristalsis and
gastrointestinal secretions; papillary dilation; thick saliva; hair strands on end; most
sympathetic neurons release norepinephrine (from adrenal medulla)
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Assessment
Health Hx: amyotrophic lateral sderosis (ALS), multiple sclerosis (MS), Parkinson’s
disease, tumors (glioma, astrocytoma), guillain-barre syndrome, cerebral aneurysm,
arteriovenous malformation (AVM), stroke (CVA), migraines, Alzheimer’s disease,
myasthenia gravis, congenital defects, metabolic disorder, childhood seizures, diabetes
mellitus, pernicious anemia, cancer, infections, thyroid disease, HTN, delivery or child
birth event, substance abuse
Neuro Assessment
Surgical Hx: craniotomy, laminectomy, carotid, endarterectomy, transsphenoidal
hypophysectomy, cordotomy, aneurysmectomy or repair
Injuries/Accidents: closed head injuries (CHI), chronic subdural hematoma, spinal cord
injury, peripheral nerve damage
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Social: ETOH use – Korsakoff’s psychosis, Wernicke’s encephalopathy, polyneruopathy,
tremors, tobacco use, drug use – seizures (withdrawal from ETOH, give Ativan) cocaine
and meth
Communication:
-Should be spontaneous, coherent, effortless flow, normal inflections, volume, pitch,
articulation, rate and rhythm
-Language comprehension should be intact
-Ability to read and write should match level of education
Aphasia [communication]
Sensory or receptive: inability to understand and interpret oral or written communication
Expressive or Broca’s: inability to speak or write, can comprehend speech and written
communication (frontal lobe, left side)
Mixed: involves both sensory and motor aspects of speech, rarely is aphasia only motor
or sensory
Neuro Assessment
Level of Consciousness (LOC)
Eye Opening: open, spontaneous open, open to name, open to tactile stimuli (touch),
open to painful stimuli (sternal rub)
[state of arousal, reticular activity system; change in LOC signifies trouble]
Verbal Responses
-Oriented 5 points
-Confused conversation, but able to answer questions 4 points
-Inappropriate words 3 points
-Incomprehensible speech 2 points
-No response 1 point
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Motor Responses
-Obeys commands for movement 6 points
-Purposeful movement to painful stimulus 5 points
- Withdraws in response to pain 4 points
-Flexion in response to pain (decorticate posturing) 3 points (cortex = flexion)
-Extension response in response to pain (decerbrate posturing) 2 points [damage to
cerebellum]
-No response 1 point
Neuro Assessment
Orientation
Person – identifies self
Place – states town or state, building
Time – time of day, season, year, month, date
Situation – states current circumstances or current event
Infants and young children – recognize parents
Sensory
Exteroceptive Sensation: light touch, superficial pain, temperature
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Peroprioceptive Sensation: motion, position, vibration (how to sit in chair correctly, not
on head)
Cortical Sensation: stereognosis, two point discrimination, extinction (ability to identify
object)
Respiratory Patterns
Rate, Depth, and Rhythms
-Bradypnea (depress CNS)
-Apnea (brain death)
-Cheyne – Stokes (brain stem problems, rapid apnea, rapid – but has a rhythm)
-Biot’s or Ataxic – random pattern
-Apneustic (timing of inspiration, except not normal)
-Neurogenic hyperventilation (panting)
-Agonal (guppy fish breathing, only mouth breathing)
Eyes
-Oculomtor, CN III, pupils, EOM/Trochlear, CN IV, EOM/Abducens, CN VI,
EOM/Acoustic, CN VIII, nystagmus
-Position of pupils at rest (conjugate [seated together], disconjuaged [don’t line up])
-Eye movements: nystagmus (constant involuntary movement of eyeball), oculocephalic
(Doll’s eyes)
Equality of pupils – size and shape
-Anisocoria (one pupil bigger than other)
-Ipsilateral dilatation (one pupil bigger and pupil sluggish)
-Pin point (drugs)
-Irregular (cataract sx, lens sx, trauma)
Presence of direct light and accommodation reflexes
-Sluggish (drugs, ICP)
-None (blind, glass eye)
-Hippus: constricts to light then appears to rhythmically vacillate in size, midbrain lesion
-Marcus Gunn: inappropriate consensual reaction, trauma to optic nerve
-Non accommodating: blindness, chemical, trauma, death
Assessment
Motor Function
-Face – symmetry, equality of movement (smile), CN VII (facial) strokes
-Gag and cough reflexes – present, ability to swallow, ability of infant to suck and
swallow, CN IX, glossopharyngeal
-Movement of Extremities – controlled, to command, no tremors, jerking or twitching
-Strength and muscle tone – increased tone (spasticity), decreased tone (flaccid),
hemiplegia – loss of function
-Babinski reflex – normally negative in adults and children over 1 year of age
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Kernig’s sign – flexion of thigh and knee to right angles and when extended leads to
painful spasm of hamstring Knee already flexed
Motor Function
-Seizure activity
Posturing
-Decerebrate: extensor posturing, extension and adduction of arms, hyperextension of
legs; cerebellum – think like celebrating *worse
-Decorticate: flexion posturing, flexion, internal rotation of arms, and extension of legs;
cortical – cortex - core
-Opisthotonos: position with rigid arching of the back, associated with strychnine
poisoning, tetanus, meningitis, epilepsy, rabies; arching can interfere with respiratory
muscles
-Flaccid posturing: absence of motor activity in any extremity **Worst one to have!
From acute spinal cord injury, brain death
Neuro Assessment
Vital Signs (Late sign)
Blood pressure and pulse changes: Cushing response or reflex – decreased pulse rate
(bounding, slow) with increasing systolic blood pressure, widening pulse pressure (norm
difference is 40 to 50)
Respiratory rate and pattern (there will be a change, brain stem impairment)
Temperature: assess in context to overall condition, damage to hypothalamus can lead to
neurogenic fever; be sure to rule out infection causing the fever first (hypothalamus)
Pain
Headache: increased ICP, brain does not have sensory nerves, pain is d/t compression of
arterial walls, veins, and CNs, constant with increasing intensity, aggravated by
movement
Projectile Vomiting: may occur with nausea, without nausea, unexpected, r/t pressure
changes in the cranium
Infants: size of fontanel, should match growth and development level, soft with slight
pulsations, no bulging or bounding pulsations, approximated cranial suture lines {good
final question}
Cranial Nerves
CN I [Olfaction] – 1st you smell it (have pt smell something)
CN II [Optic] – next you see it (Snellen eye chart, newsprint, Rosenbaum’s chart);
measure distance, near, and peripheral
CN III [Oculomotor] – then you adjust you pupils *typically assessed (to focus on it)
want round pupils, responses to light [drug influence – atropine, will dilate pupils]
CN III [Oculomotor], CN IV [Trochlear], and CN VI [Abducens] – next you look around
(work in conjunction with each other, up, down, side to side
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CN V [Trigeminal] – then you blink (3 branched nerve, motor/sensory/corneal reflex);
protect eyes with lube and tape shut; couldn’t not have corneal reflex – drug influenced;
trigeminal neuroalgia-very painful, hurts to eat, drink, increased suicide rates from pain
CN VII [Facial] – then you smile (if cooperate, want to see symmetry – stroke, tumor,
can drool and aspirate or even pocket food and protect airway
CN VIII [Acoustic; Cochlear-Vestibular] – then you listen and balance (hearing, vertigo,
nystagmus, strabismus); can do Rhine test-measures conduction; Weber test-measures if
conduction or nerve issue; Caloric test-vestibular neuro response with water in ear, want
to see nystagmus and pt vomit
CN IX [Glossopharyngeal] CN X [Vagus] – next you cough, gag, and talk (*manage
airway and aspiration, ask pt to cough, tongue depressor – have them say awwwww and
look at symmetry of uvula
CN XI [Spinal Accessory] – then you shrug your shoulders (against RN’s hands to check
strength, symmetry and if equal tone)
CN XII [Hypoglossal] – last you stick out you tongue (check midline)
Cerebellar Function
Coordination – keeps a moving part from overshooting intended target; skilled
movements in a sequence; predict distance and speed of approaching object; voluntary
control of movement; ipslateral control of side of body
Gait and equilibrium – observe walking and balance; heel to toe walking, Romberg test
[where you have pt stand with feet together and close eyes, are they swaying?]
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Reflex Activity
Deep tendon reflexes
0: absent reflex [from too much Mag]
1+: trace or seen only with reinforcement
2+: normal [normal]
3+: brisk [normal]
4+: nonsustained clonus (eg repetitive vibratory movements)
5+: sustained clonus [seizure]
…putting pressure on tendon and hammer stretches it
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-Achilles Tendon S1
Laboratory/Diagnostic Studies
For Each Listed Study:
1. Define and describe
2. Explain why it would be done (indications)
3. Describe normal and abnormal results [generally speaking]
4. Identify client teaching and preparation
5. List follow up care including prevention and detection of potential complications
Laboratory/Diagnostic Studies
-Blood cultures necessary
-CSF analysis
-Skull and spine x-ray tests
-Cerebral angiography
-Myelogram
CT scan: possible use of contrast medium, assess for allergic response, fluids [use of
medium contraindicated with hemorrhagic bleed]
-Positron emission tomography (PET)
-Single photon emission CT (SPECT)
-EMG/nerve conduction
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-Evoked potential
-MRI/MRA
-Transcranial Doppler
-Cerebral blood flow
-Carotid duplex studies
Lumbar Puncture
-Insertion of spinal needle into the subarachnoid space (between the third and fourth
lumbar vertebrae)
-Contraindicated in clients with increased intracranial pressure
-Position
-Spinal headache possible from spinal tap
Electroencephalography (EEG)
-Graphically records the electrical activity of the cerebral hemispheres
-Sleep deprivation requirement
-Anticonvulsants possibly withheld
Neurologic (Part I B)
Headaches
Migraine headache
-Episodic familial d/o manifested by unilateral, frontotemporal, throbbing pain in the
head, often worse behind one eye or ear
-Often accompanied by a sensitive scalp, anorexia, photophobia, nausea
-Aura: sensation that signals the onset of a headache or seizure
Drug therapy
-Abortive therapy: alleviating pain during the early aura phase includes prescribing
ergotamine derivatives, NSAIDS, triptans, isometheptene combinations
-Acetaminophen and NsSAIDs are usually effective for mild migraine headaches
Preventive Therapy
-NSAIDS prescription
-Beta adrenergic blocker
-Ca+ channel blocker
Cluster Headaches
-Histamine cephalagia, uncommon type of headache
-Cause unknown; attributed to vasoreactivity and oxyhemoglobin desaturation
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-Unilateral, radiating to forehead, temple, or cheek
-Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis
Therapy
-Same types of drugs used for migraines
-Client to wear sunglasses and avoid sunlight
-Oxygen via mask
-Avoidance of precipitating factors, such as anger, excitement
-Surgical management
Tension Headache
-Neck and shoulder muscle tenderness and bilateral pain at the base of skull and in
forehead
-Head pain without associated symptoms
-Treatment: non-opioid analgesics, muscle relaxants, occasional opioids
-Ibuprofen plus caffeine
-Prophylactic treatment similar to that used in treating migraine headaches
Types of Seizures
Generalized seizures [impairs consciousness]
Absence (petit mal) – lapses of awareness, staring, no warning, no after effect [age 4 to
12, just not there during seizure]
Atonic (akinstic, drop attack) – abrupt loss of muscle tone [and loss of consciousness,
injury to self, and has resistance to AED [anti epilepsy drug]
Myoclonic – rapid, brief contractions of muscles
Tonic clonic (grand mal) – stiffening of limbs (tonic) [may turn cyanotic], jerking limbs
(clonic)
*Concerned with injury and airway, describe seizure, find triggers and prevent seizures,
and health maintenance
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Types of Epilepsy
Primary or idiopathic epilepsy: not associated with any identifiable brain lesion
Secondary epilepsy: results from an underlying brain lesion, most commonly a tumor or
trauma [give Dilantin]
Collaborative Management
-Complete description of the type of seizure activity that occurs and events surrounding
the seizure determines that best treatment plan
-Determine whether an aura was present before the seizure in the preictal phase; what
was pt doing/what was going on before seizure
-Diagnostic testing is performed [may involve inducing seizure]
-Manage airway
-Describe seizure to HCP
Drug Therapy
-Evaluate most current blood level of medication, if appropriate
-Dilantin – therapeutic drug level is 10 to 20 mcg/mL; know side effects
-Be aware of drug-drug and drug-food interactions
-Maintain therapeutic blood levels for maximal effectiveness
-Do NOT administer warfarin with Phenytoin (Dilantin with coumadin, they effect each
other; Dilantin causes gingival hyperplasia, lowered BP, and sedative effects)
-Document and report side and adverse effects
Seizure Precautions
-Oxygen and suctioning equipment should be readily available
-Saline lock may be necessary [for Ativan or valium]
-Side rails should be UP at all times
-Padded side rail use is controversial [contraindicated with children]
-Place bed in lowest position
-Never insert padded tongue blades into the client’s mouth during a seizure
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Seizure Management
-If simple partial seizure, observe the client and document the seizure
-Turn the client on the side during a generalized tonic-clonic seizure; if possible, turn the
client’s head to prevent aspiration
-Cyanosis is usually self limiting
-Do not restrain
Assessment/Clinical Manifestations
-Headache, nausea, vomiting, and fever
-Photophobia and indications of increased ICP
-Nuchal rigidity: positive Kernig’s and Brudzinski’s signs (only present in 9% of clients)
-Seizure, decreased mental status, focal neurologic deficits
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-Computed tomography scan
-Blood cultures
-Counterimmunoelectrophoresis
-Complete blood count
-X – ray study to determine presence of infection
Drug Toxicity
-Long term drug therapy regimens often cause delirium, cognitive impairment, decreased
effectiveness of the drug, or hallucinations
-Reduce medication dose
-Change medications or frequency of administration
-Take “drug holiday”, especially in the use of levodopa therapy
Alzheimer’s Disease
-Chronic, progressive, degenerative disease that accounts for 60% of dementias occurring
in people older than 65 years of age
-Loss of memory, judgment, and visuospatial perception, and changes in personality
-Increasing cognitive impairment, severe physical deterioration, death from
complications of immobility
Structural Changes
-Alzheimer’s disease creates changes that include:
-Neurofibrillary tangles
-Senile or neuritic plaques
-Granulovascular degeneration
-Increased amounts of an abnormal protein, beta amyloid
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-Significantly increased vascular degeneration a contributor to mortality in this d/o
-Abnormalities of ACH, norepinephrine, dopamine, and serotonin
Manifestations
-Changes in cognition
-Alterations in communication and language abilities
-Changes in behavior, personality, and judgment
-Changes in self care skills
-Psychosocial assessment, especially client’s reaction to changes in routine
Interventions
-Provide consistency, orientation, and validation therapy
-Promote independence in activities of daily living
-Promote bowel and bladder continence
-Assist with facial recognition as the disease progresses to prosopagnosia, an inability to
recognize one self and other familiar faces
-Promote communication with clear, short sentences
Drug Therapy
-Cholinesterase inhibitors
-Memantine
-Donepezil
-Anti-depressants
-Psychotropic drugs
-Complementary and alternative therapies
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-Ensuring safety by removing all potentially dangerous objects, particularly in case
seizures occur
-Minimizing agitation by talking calmly and softly; displaying positive affect; making
calm movements; offering diversion
Huntington Disease
-Hereditary d/o transmitted as an Autosomal dominant trait at the time of conception
-Gradual clinical onset of progressive mental status changes, leading to dementia and
choreiform movements in the limbs, trunk, and facial muscles
-Three stages each lasting about 5 years over an average 15 years of the disease
Multiple Sclerosis
-Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the
CNS
-Characterized by period of remission and exacerbation
-Inflammatory response resulting in random or patchy areas of plaque in the white matter
of the CNS
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Common Physical Assessment
Findings include:
-Flexor spasms at night
-Intention tremor
-Dysmetria
-Blurred vision, dipolpia, decreased visual acuity, nystagmus
-Hypalgesia, numbness, tingling or burning
-Bowel and bladder dysfunction
Drug Therapy
-Biological response modifiers
-Immunosuppresives
-Steroids
-Anti-spasmodics drugs
-Adjunctive
Management
-Promoting mobility and self care
-Managing cognitive problems
-Adapting to changes in sexual functioning
-Managing bladder and bowel problems
-Treating visual disturbances
-Complementary and alternative therapies
Interventions
-Riluzole, only drug approved by FDA to extend survival time
-Exercise and mobility program (at risk for pneumonia, urosepsis, depression,
constipation)
-Management of swallowing difficulties
-Respiratory support
Guillain-Barre Syndrome
-An acute auto immune d/o characterized by varying degrees of motor weakness and
paralysis
-The client’s life and ultimate potential for rehabilitation dependent upon appropriate
interventions and effectiveness of nursing care
-Chronic inflammatory demyelinating polyneuropathy
Clinical Manifestations
-Muscle weakness and pain have abrupt onset; cause remains obscure
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-Cerebral function or papillary signs are not affected
-The most common clinical pattern is that the immune system starts to destroy the myelin
sheath surrounding the axons
-Weakness and Paresthesia being in the lower extremities and progress upward toward
the trunk, arms, and cranial nerves in ascending GBS
Drug therapy
-Plasmapheresis or IV immunoglobin
-Plasma exchange
-IV immunoglobin
Plasmapheresis
-Plasmapheresis removes the circulating antibiotics assumed to cause the disease
-Plasma is selectively separated from whole blood; the blood cells are returned to the
client without the plasma
-Plasma usually replaces itself, or the client is transfused with albumin
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-Ensure safety in ambulation, position changes
-Encourage independence
-ROM exercises every 2 to 4 hours
-Diet plan to guard against malnutrition
-Prevention of pressure ulcers
-Prevention of pulmonary embolic and DVT
Myasthenia Gravis
-Chronic disease characterized by weakness primarily in muscles innervated by cranial
nerves, as well as in skeletal and respiratory muscles
-Thymoma: encapsulated thymus gland tumor
-Progressive paresis of affected muscle groups that is partially resolved by resting
-Most common symptoms: involvement of eye muscles, such as ocular palsies, ptosis,
diplopia, weak or incomplete eye closure
Tensilon Testing
-Within 30 to 60 sec after injection of Tensilon, most myasthenic clients show marked
improvement in muscle tone that lasts 4 to 5 minutes
-Prostigmin is also used
-Cholinergic crisis is d/t over medication
-Myasthenic crisis is d/t under medication
-Atropine sulfate is the antidote for Tensilon complications
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-Enhance neuromuscular impulse transmission by preventing decrease of Ach by the
enzyme ChE
-Administer with food
-Observe drug interactions
Emergency Crisis
-Myasthenic crisis: an exacerbation of the myasthenic symptoms caused by under
medication anticholinersterase
-Cholinergic crisis: an acute exacerbation of muscle weakness caused by over medication
with cholinergic (anticholinersterase) drugs
Management
-Immunosuppression
-Plasmapheresis
-Respiratory support
-Promoting self care guidelines
-Assisting with communication
-Nutritional support
-Eye protection
-Surgical management usually involving thymectomy
Health Teaching
-Factors in exacerbation include infection, stress, surgery, hard physical exercise,
sedative, enemas, and strong cathartics
-Avoid over heating, crowds, over eating, erratic changes in sleeping habits, or emotional
extremes
-Teach warning signs
-Teach importance of compliance
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Peripheral Nerve Trauma
-Vehicular or sports injury or wounds to the peripheral nerves
-Degeneration and retraction of the nerve distal to the injury within 24 hours
-Peri operative and post operative care
-Rehabilitation through physiotherapy
Trigeminal Neuralgia
Affects trigeminal or 5th cranial nerve – painful chronic condition affecting one or more
branches of the 3 branches of the trigeminal nerve, possibly d/t trauma, infection,
degeneration of teeth; other causes include pressure on the trigeminal nerve from a tumor,
blood vessel, aneurysm, or multiple sclerosis
Symptoms – clusters of severe, lightening-blot stabs of unilateral facial pain (lips, gums,
nose, cheeks); pain may be triggered by brushing teeth, washing face, chewing food, food
or fluids of extreme temperatures, clients may be emaciated, depressed, or suffer suicidal
ideations
Stroke/CVA/Brain Attack
Brain Attack
-A disruption in the normal blood supply to the brain may lead to death after a few
minutes
-The brain is unable to store oxygen or glucose and must receive a constant flow of blood
to function
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-Extent of disability is not known until swelling abates
-Return of function – cranial nerve 9 and 10 to assess airway and gag reflex
Types of Strokes
-Ischemic strokes [blockage or chunk of stuff]
-Thrombotic strokes [plaque from diabetes, smoking, carotid stenosis]
-Embolic strokes [a-fib, rheumatic heart dz]
-Transient ischemic attack [TIA] and reversible ischemic neurologic deficit [similar to
chest for of the heart, can turn permanent]
-Hemorrhagic stroke resulting from ruptured aneurysm [head trauma], arteriovenous
malformation – tangled mess of veins and arteries, a bulge forms and an aneurysm is
made
Neurologic Assessment
-Cognitive changes include aphasia [can’t talk], alexia [can’t read], agraphia [can’t write]
-Motor changes include hemiplegia [one sided paralysis], hemiparesis [one sided
weakness], hypotonia [low tone], flaccid paralysis, hypertonia [spacitiy]
Drug Therapy
- Thrombolytic therapy (systemic or localized) [to treat embolus, thrombus and
contraindicated with hemorrhagic]
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-Anti-coagulants, fibrinolytics [ex TPA; onset <3 hrs – will give systemically –OR- >3
hours, will thread cath to the site and give drug there]
-Lorazepam and other anti – epileptic drugs [Ativan or Dilantin to prevent seizure]
-Ca+ channel blockers [prevent dysfunction of vessels –vasospams-]
-Antihypertensives [reduce pressure]
-Stool softeners [prevent, reduce strain and bearing down]
-Analgesic for pain [reduce pain to help cough and deep breath, but don’t want to mask
pain to see what is going on]
-Anti anxiety drugs [stress depletes energy that could be going to healing the body]
Surgical Management
-Carotid angioplasty (most common) – help prevent people from getting ischemia events
-Endarterectomy (less safe) – cut open vessel and scrape out junk from vessel
-Extracranial – intracranial bypass – by-pass of vessels in veins in the brain
Diagnostic Procedures
-CT scan [may not show anything in the first scan, may have to wait 24 hours,
hemorrhagic will NOT get contrast-
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-SPECT [single photon emission]
-MRI/MRA [MRA is more specify to arteries]
-Trans cranial Doppler [portable device helps evaluate blood flow, like ultrasound for the
brain, looks like altered blood flow, stenosis]
-Angiography [sign consent, femoral/carotid artery, assess allergy to dye, hemor – watch
closely, assess for s/sx of clot being released and do neuro checks hourly (watch for MI
or such)]
-CBC, blood glucose, sedimentation rate, PT, PTT, lipid (cholesterol) profile, blood
cultures
-EKG [a fib or atrial flutter]
-Pulse Ox [ensure pt is oxygenated, watch respiratory drive]
-Cardiac monitoring
-Echocardiogram and/or transesophageal echo [see if there is valve leaflet issues or
veggies getting dislodged]
Unilateral Neglect
-This syndrome is most commonly seen with right cerebral stroke
Teach client to:
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-Observe safety measures
-Touch and use both sides of the body
-Use scanning techniques of turning the head from side to side to expand the
visual field
Impaired Swallowing
Interventions include:
-Assessment of client’s ability to swallow [CN 9 and 10]
-Client positioning to facilitate the process of swallowing before feeding
-Appropriate diet for the client, including semi soft foods and fluids (thicken)
-Aspiration precautions
Brain Injuries
Blunt trauma – caused by acceleration, deceleration, and rotational forces (MVA, falls,
sports, physical assault) [brain hitting the inside of the cranium]
Penetrating Injuries – damage to brain and support tissues from piercing forces that
transverse skull, projectiles [entered the brain tissue, bullets aka projectiles]
Shock wave injuries – like shaken baby issue
Brain Injuries
-Process which begins at time of initial insult and may last days to weeks
-Neuronal damage consists of neuro-excitation which activates neurotransmitters
resulting in depolarization of neurons, aberrant cell signaling (seizures), as well as long
term to permanent dysfunction [like a self toxic cycle, keep it calm and not stimulated]
-Neuro-filament destruction leads to edema [inflammatory response] and retraction of the
axon, eventually permanent destruction of neuron results
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Depressed fracture – bone is pressed inward into the brain tissue to at least the thickness
of the skull [clean, debrided and put on antibiotics]
Comminuted fracture – involves fragmentation of the bone, with depression of bone into
brain tissue
Open fracture – scalp is lacerated, creating a direct opening to brain tissue
Diffuse axonal injury – can be mild to severe; diffuse areas of white mater have been
sheared; evolves over time and may not be apparent on initial CT scan
Contusion (coup [initial injury like MVA-when brain hits first time] and countercoup
[bounces back and hits other part of brain] injury) – brain bruising associated with
lacerations/tearing and capillary hemorrhages – can occur with subdural or extraduaral
collections of blood [evacuate out hematoma]
Rotational – force impacting head with transfer of energy in a non-linear fashion; boxing
injury causing shearing and tearing of axons [boxing injuries]
Brain Injuries
-Classified according to Glasgow coma scale
Severe GCS < or = 8
Moderate GCS 9-12
Mild GCS 13-15
Brain Injury/Complications
Immediate – cerebral bleeding, hematomas, IICP, infection, inflammation, seizures
Secondary – 90% of individuals who die after head trauma die from SBI that may occur
within minutes of the initial injury [preventing secondary issues and monitoring for
additional problems from initial injury]
Residual – ex changes in personality or behavior, cranial nerve damage; dependent on
area and extent of injury [discharge teaching to family, they will be different – impulsive]
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-An increase in IICP occurs any time there is an increase in the size of intracranial
contents; results in progressive neurologic deterioration; specific deficiencies r/t area of
brain tissue compression
-The cranial vault is rigid with minimal area for expansion of intracranial components
[anytime there is an increase in pressure, volume in the cranial vault, there is a change in
neuro]
*Tentorium [posterior, under tentorium, have to cut neck muscles, lay flat]; don’t lay
them on the site of the craniotomy, keep them off of incision]
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-DI or SIADH [pituitary damage, ADH at risk for dehydration, give desmopressin]
[SIADH – too much fluids, diuretics]
Epidural Hematoma
-Neurologic emergencies with potentially catastrophic ICP elevation
-Arterial bleeding into space between the dura and inner table of skull
-Temporal bone fractures, middle meningeal artery
-Momentary unconsciousness follows lucid interval within minutes of injury
Subdural Hematoma
-Venous bleeding into the space beneath dura and above arachnoid
-Most commonly from a tearing of the bridging veins within the cerebral hemispheres or
from a laceration of brain tissue
-Bleeding occurs more slowly than with a epidural hematoma
Assessment
-Airway and breathing pattern assessment
-Vital signs assessments: Cushing reflex [late sign, slow-bound-full pulse], severe
hypertension, widened pulse pressure, and bradycardia
-Neurologic assessment *****
-Eye assessment [is there pressure on the ocular motor nerve]
-Motor assessment [following commands] of posturing
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-Secure airway, maintain patency
-Chest physiotherapy, turning as tolerated
Positioning
-AVOID pt positions which contribute to increased ICP:
-Neck in flexion, extension or misalignment
-Knee/hip flexion
-HOB flat when ICP elevated [depends on situation]
-Completely flat not usually
-Trendelenberg [don’t ever do this position]
-Pressure of endotracheal/tracheostomy ties on neck veins
-Note: If spine clearance has not been determined, consult with MD for pt positioning
Drug Therapy
-Glucocorticoids [not really used anymore]
-Mannitol [increase LOC, osmotic diuretic so monitor Na+ (osmolarity)], furosemide
[take off fluid]
-Opioids [calm pt], naloxone [narcan to reverse depression or opioid OD]
-Neuromuscular blocking agents [watch joints and movement, mechanical vent, monitor
amount of paralysis, neurostimulator]
-Anti-epileptic drugs [high % of people with Dilantin {be aware of levels and s/e}
-Acetaminophen and aspirin
-Barbiturate coma [induced coma using a barb with neuromuscular blocker]
Surgical Management
-ICP monitoring devices:
-Intraventricular catheter (IVC) [to drain CSF]
-Subarachnoid screw or bolt [does not drain off CSF]
-Epidural catheter
-Subdural catheter
Surgical Management
-Craniotomy, evacuation VP shunt, loebectomy, gamma knife, bone flap
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-Craniotomy may be performed in extreme instances of elevated ICP; bone flap [can be
put in abdomen [mini laparotomy], histology – freeze it, storage fee
Brain Tumors
Brain tumors can arise anywhere within the brain structures:
-Primary tumors originate within CNS and there will be a neuro change
-Secondary tumors result from metastasis in other parts of the body
*We will see them post op and have a specific post op assessment
Tumors can lead to cerebral edema, brain tissue inflammation, increased ICP, focal
neurologic deficits, obstruction of cerebrospinal fluid flow [hydrocephalus], pituitary
dysfunction [common thing]
Classification of Tumors
-Malignant or benign
-Tumor’s location places it in a class of supratentorial or infratentorial
-Tumor’s anatomic origins place it in a class of cellular, histologic, or anatomic
Types of Tumors
-Gliomas: malignant
-Meningoimas, which arise from the coverings of the brain
-Pituitary tumors
-Acoustic neuromas, which arise from the sheath of Schwann cells
-Metastatic or secondary tumors
Non-surgical Management
-Radiation therapy
-Chemotherapy
-Analgesics
-Dexamethasone [type of steroid, used for CNS issues and decrease infla
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-Phenytoin
-Ranitidine hydrochloride
-Radiosurgery
-Zantac
Surgical Management
-Craniotomy more often used
Post operative care – positioning, monitoring the dressing, monitoring laboratory values,
ventilating the client
Drug therapy – AED, proton pump inhibitors, histamine blockers, corticosteroids,
analgesics, acetaminophen, prophylactic antibiotics
Back Pain
-Low back
-Herniated nucleus pulposus
Physical assessment: continuous acute pain, altered gait, vertebral alignment, Paresthesia
-Diagnostic assessment using MRI, CT, and electromyography
Surgical Management
-Diskectomy
-Laminectomy
-Spinal fusion (arthrodesis)
-Minimally invasive lumbar procedures, such as pre cutaneous lumbar diskectomy,
microdiskectomy, laser-assisted laparoscopic lumbar diskectomy
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Post operative Care
-Prevention and assessment of complications
-Neurologic assessment; vital signs
-Client’s ability to void
-Pain control
-Wound care (prevent infection, monitor for CSF drainage, manage drains)
-Client positioning and mobility (log-rolling, brace, avoid twisting)
Stable – fractures are unlikely to cause further damage and may be treated non-surgically
Unstable – spine may need to be surgically realigned and fixed in position to prevent
further movement of the vertebrae and further injury to the spinal cord
*assume unstable until proven otherwise
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Initial assessment
-Assessment of the respiratory pattern and ensuring an adequate airway [airway patent]
-Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding
around fracture sites
-Assessment of LOC using Glasgow coma scale
The American Spinal Injury Association recommends use of the following scale of
findings for the assessment of motor strength in SCI:
0 = no contraction or movement
1 = minimal movement
2 = active movement, but no against gravity
3 = active movement against gravity
4 = active movement against resistance
5 = active movement against full resistance
C1 to C3 Injuries
-Limited head and neck movement; quadriplegia
-At risk for autonomic dysreflexia
-Electric W/C with “sip and puff” controller
-Ventilator dependent – cant’ control diaphragm; at risk for pneumonia, decubes
-Requires assistance with all ADLs
Cervical Injuries
C4 injuries – similar results as C1-C3 injuries except full movement of head and neck
with some shoulder movement *breathe no more*
C5 injuries – similar to C1-C4, however may be able to breath without mechanical
ventilation
C6 injuries – similar results as C1-C5, buy may have weak passive hand grip *ability to
use hands*
C7-C8 Injuries
-Movement of head, neck, shoulders, partial finger movement, elbow and wrist extension
and flexion
-Risk for autonomic dysreflexia
-Electric or manual w/c
-Transfer independently
-Drive car with adapted controls
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-Self feeding, self management of bowel and bladder
-Requires partial assistance with ADLs and home maintenance
T1-T4 Paraplegia
-Full use of head, neck, shoulders, arms, wrists, and fingers
-At risk for autonomic dysreflexia
-Electric or manual w/c
-Independent transfers
-Drive a care with hand controls
-Self feeding, independent with personal care
-Partial assistance needed for home maintenance
T5-T9 Paraplegia
-Function similar to T1-T4 injuries
-T5 and above associated with GI complications (hypomotility, paralytic ileus, ulcers)
-T6 and above associated with autonomic dysreflexia – life threatening ; don’t poop
bricks [constipated and have a T6 spine injury]
T10-L1 Paraplegia
-Partial paralysis of lower body and legs
-Manual wheel chair, independent transfer, may be able to transfer from sitting to
standing
-Drive hand control adapted care
-Self care independent in absence of other factors (additional injuries, severe spasticity-
can impair imobility)
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-Bradycardia [or tachy]
-Paralytic ileus
-Hypotension [fluid volume may be fine, but leaks out of vessels and fluid goes
everywhere]
*Can last for months, pt will start to have reflexes return like DTRs
T6 and above after spinal shock, at risk for autonomic dysrelexia
Cardiovascular Assessment
-Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous
system
-Bradycardia, hypotension, and hypothermia result from a loss of sympathetic input and
may lead to cardiac dysrhythmias
-Systolic BP lower than 90 mmHg (may have MAP < 70 mmHg) requires treatment
because lack of perfusion to the spinal cord worsens the condition
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-Reproductive [menstruation, pregnancy or delivery, sexual intercourse, ejaculation,
vaginal infection, epididymitis]
-Miscellaneous [pulmonary infarct or embol, DVT, heterotrophic ossification, fracture,
drug reaction]
Autonomic dysreflexia
Treatment = remove stimulus
-High Fowlers position
-Loosen any constrictive clothing or devices
-Assess bladder and bowel for distention
-Un-kink/un-clog indwelling urinary cath
-Perform fecal dis-impaction
-Administer anti-HTN agent
-Cardiac arrest
SCI Assessment
-Respiratory and have airway
-Gastrointestinal and genitourinary
-Musculoskeletal
-Psychosocial
-Laboratory
-Radio graphic and other diagnostic procedures
Halo Fixation
Pin site assessment – erythema, edema, pain, purulent drainage
Assess skin under vest daily – erythema, abrasion, irritation; may be necessary to use a
flashlight to visualize the skin under the vest
Notify MD immediately: if pt reports of feeling head is not secure, any head movement,
purulent drainage, erythema, or pain at pin site, fever, change in neuro assessment
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Have RN/MD provide C-spine control/alignment at all times during code
Slide CPR board under pt or use CPR mode on bed (if available)
Disconnect vest from halo ring using halo wrench and remove vest
Drug Therapy
-Methylprednisolone (controversial)
-Dextran – plasma expander, promotes perfusion
-Atropine sulfate – for symptomatic bradycardia
-Dopamine hydrochloride, Neo-synephrine – for HoTN
-Naloxone and TRH – improves spinal cord blood flow
-Dantrolene – muscle relaxant
-Baclofen – antispasmodic
-Etridronate disodium – regulates bone metabolism; treatment for over growth
-4-AP K+ channel blocker – experimental – may improve nerve conduction
Surgical Management
-Emergency surgery necessary for spinal cord decompression
-Decompressive therapy
-Spinal fusion
-Harrington rods to stabilize thoracic spinal injuries
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Impairded Urinary Elimination: Constipation
-bladder retraining
-Spastic bladder: manipulating external area
-flaccid bladder: valsalva maneuver
-Encouraging consumption of 2000 to 2500 mL of fluid daily to prevent UTI
Interventions:
-invite clients to ask questions about significant life changes; reply openly and honestly
-encourage clients to discuss their perceptions of their situation and copign strategies that
can be used
-begin a client education program to clarify misconceptions
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