Create
Learn
Share

MedSurg II - Neuro

rename
olanjones's version from 2017-03-23 18:03

Assessment

Question Answer
Mental statusAlert/oriented, orderly thought processes, Appropriate mood/ affect
Cranial nervesSmell intact; Visual fields full; Intact extraocular movements; No nystagmus; PERRLA; Intact facial sensation to light touch & pinprick; Facial movements full; Intact gag/swallow reflexes, Symmetric smile, Midline protrusion of tongue; Full strength with head turning/shoulder shrugging
Motor systemNormal gait & station; Normal tandem walk; Negative Romberg test; Normal & symmetric muscle bulk, tone, & strength; Smooth performance of finger-nose, heel-shin movements
Sensory systemIntact sensation to light touch, position sense, pinprick, heat and cold
ReflexesBiceps, triceps, brachioradialis, patellar, & Achilles tendon reflexes 2/5 bilaterally, Downgoing toes w/ plantar stimulation
Subjective-Blackouts/loss of memory; Headaches, especially new onset; Orientation to person, place, & time
-Weakness, numbness, tingling in arms or legs; Loss of balance/coordination
Objective (physical)-Inspect: LOC, gag reflex/soft palate movement, Peripheral sensation; Smell; Eyes (movement/PERRLA/nystagmus); Gait
-Palpate: Strength in neck/shoulders/arms/legs full & symmetric
-Percuss: Reflexes
Objective (diagnostics)Lumbar puncture; CT or MRI of brain; EEG
memorize

GCS

Question Answer
Min & Max score3; 15 (<8 considered coma - intubate)
Eyes Open StimulusApproach to bedside; Verbal command; Pain
Eyes Open Response/ScoreSpontaneous response – 4
Opening of eyes to name or command – 3
Lack of opening of eyes to previous stimuli but opening to pain – 2
Lack of opening of eyes to any stimulus – 1
Verbal StimulusVerbal questioning with maximum arousal
Verbal Response/ScoreAppropriate orientation, conversant, Correct identification of self, place, yr, and mo – 5
Confusion, Conversant, but disorientation in one or more spheres – 4
Inappropriate or disorganized use of words (e.g., cursing), lack of sustained conversation – 3
Incomprehensible words, sounds (e.g., moaning) – 2
Lack of sound, even with painful stimuli – 1
Motor StimulusVerbal command; Pain (pressure on proximal nail bed)
Motor Response/ScoreObedience of command – 6
Localization of pain, lack of obedience but presence of attempts to remove offending stimulus – 5
Flexion withdrawal – 4
Abnormal flexion (decorticate) – 3
Abnormal extension (decerebrate) – 2
Lack of response –1
memorize

Diagnostics

Question Answer
LPCSF is aspirated by needle (from L3-4 or L4-5 interspace) - assess many CNS diseases
Cerebral angiographySerial x-ray of intracranial/extracranial blood vessels to detect vascular lesions/tumors of brain (contrast is used)
CT scanX-ray of multiple cross sections of body to detect problems such as hemorrhage, tumor, cyst, edema, infarction, brain atrophy, etc (contrast may be used)
MRIMagnetic energy imaging; Used to detect strokes, MS, tumors, trauma, herniation, & seizures (no invasive procedures required, contrast may be used); greater contrast of soft tissue structures than CT scan
Magnetic resonance angiography (MRA)Uses differential signal characteristics of flowing blood to evaluate extracranial/intracranial blood vessels; Provides both anatomic & hemodynamic info (can be used in conjunction w/ contrast)
Positron emission tomography (PET)Measures metabolic activity of brain to assess cell death/damage; Uses radioactive material that shows up as a bright spot on the image; Used for patients with stroke, Alzheimer’s disease, seizure disorders, Parkinson’s disease, & tumors
Single-photon emission computed tomography (SPECT)Similar to PET but uses more stable substances & different detectors. Radiolabeled compounds are injected & their photon emissions can be detected; Images made are accumulation of labeled compound. Used to visualize blood flow/O2/glucose metabolism in brain. Useful in diagnosing strokes, brain tumors, & seizure disorders
MyelogramX-ray of spinal cord &vertebral column after injection of contrast medium into subarachnoid space. Used to detect spinal lesions (e.g., herniated/ruptured disc, spinal tumor)
Electroencephalography (EEG)Electrical activity of brain is recorded by scalp electrodes to evaluate seizure disorders, cerebral disease, CNS effects of systemic diseases, brain death
Magnetoencephalography (MEG)Uses a biomagnetometer to detect magnetic fields generated by neural activity. It can accurately pinpoint the part of the brain involved in a stroke, seizure, or other disorder or injury. Measures extracranial magnetic fields and scalp electric field
Electromyography (EMG) & nerve conductionElectrical activity associated w/ nerve & skeletal muscle recorded by insertion of needle electrodes to detect muscle & peripheral nerve disease
Evoked potentialsElectrical activity associated w/ nerve conduction along sensory pathways recorded by electrodes placed on skin/scalp. Stimulus generates the impulse. Procedure is used to diagnose disease (e.g., MS), locate nerve damage, & monitor function intraoperatively
Carotid duplexCombined ultrasound & pulsed Doppler technology. Probe placed over carotid artery & slowly moved along the course of the common carotid artery. Frequency of reflected US signal corresponds to the blood velocity. ↑blood flow velocity can indicate stenosis of a vessel
Transcranial DopplerSame technology as carotid duplex, but evaluates blood flow velocities of the intracranial blood vessels. Probe placed on skin at various “windows” in the skull (areas in the skull that have only a thin bony covering) to register velocities of the blood vessels
memorize

Diagnostics (Nursing Role)

Question Answer
CSF Analysis/LP-Ensure pt does not have signs of ↑ICP because of risk of downward herniation from CSF removal; Pt assumes/maintains lateral recumbent position
-Use strict aseptic technique; Ensure labeling of CSF specimens in proper sequence
-Encourage fluids; Monitor neurologic signs & VS; Administer analgesia prn
Cerebral angiography-Preprocedure: Assess pt for stroke risk before procedure (thrombi may be dislodged during procedure); Withhold preceding meal. Explain they will feel a hot flush of head/neck when contrast medium is injected; Administer premedication; Explain need to be absolutely still during procedure
-Postprocedure: Monitor neurologic signs & VS q 15-30 min for first 2 hr, q hour for next 6 hr, then q 2 hr for 24 hr; Maintain bed rest until pt is alert & VS are stable; Report any neurologic status changes
CT scanAssess for contraindications to contrast media (allergy to shellfish/iodine/dye); Explain appearance of scanner; Instruct pt to remain still during procedure
MRI or MRA-Screen pt for metal parts and pacemaker in body; Instruct pt on need to lie very still for up to 1 hr
-Sedation may be necessary if pt is claustrophobic
PET scan or SPECT scanExplain procedure to pt; Explain that two IV lines will be inserted; Instruct pt not to take sedatives or tranquilizers; Have pt empty bladder before procedure; Pt may be asked to perform different activities during test
Myelogram-Preprocedure: Administer sedative as ordered; Instruct pt to empty bladder; Inform pt that test is performed on tilting table that is moved during test
-Postprocedure: Pt should lie flat for a few hours; Encourage fluids; Monitor neurologic signs & VS; HA, N&V may occur after procedure
EEGInform patient that procedure is noninvasive and without danger of electric shock. Determine whether any medications (e.g., tranquilizers, antiseizure drugs) should be withheld. Resume medications and instruct patient to wash electrode paste out of hair after test
MEGpassive sensor, does not make physical contact with patient. Explain procedure to patient
EMG & nerve conductionInform patient that pain and discomfort are associated with insertion of needles
Evoked potentialsExplain procedure to patient
Carotid duplexExplain procedure to pt. Duplex scanning is a noninvasive study that evaluates the degree of stenosis of the carotid and vertebral arteries
Transcranial DopplerExplain procedure to patient. Noninvasive technique that is useful in assessing vasospasm associated with subarachnoid hemorrhage, altered intracranial blood flow dynamics associated with occlusive vascular disease, presence of emboli, and cerebral autoregulation
memorize

ICP

Question Answer
ICPhydrostatic force measured in brain CSF compartment (Factors that influence: arterial pressure; venous pressure; intraabdominal & intrathoracic pressure; posture; temperature; blood gases, particularly CO2 levels)
Volume components of skullintra & extracellular fluids of brain tissue (78%), blood (12%), CSF (10%)
Monro-Kellie doctrinethe three components must remain at a relatively constant volume within the closed skull structure. Normal ICP ranges = 5-15 mmHg; sustained pressure >20 mmHG must be treated
Calc for CPPCPP = MAP-ICP [MAP= (SBP + 2xDPB)/3]
Normal MAP for adequate perfusion70 – 150 mmHg
Normal CPP for adequate perfusion60 – 100 mmHg (<50 mmHg associated w/ ischemia/neuronal death; <30 incompatible with life)
Stages of Compliance1. Brain is in total compensation w/ autoregulation intact, ↑in volume does not ↑ICP risk (subtle change LOC/VS)
2. Compliance beginning to ↓, an ↑in volume puts pt at risk for ICP (N&V, ↓LOC, posturing)
3. Significant ↓compliance, small ↑in volume causes great risk for ICP (Cushing’s triad)
4. ICP ↑ lethal levels w/ little ↑in volume (herniation)
Effects of ↑PaCO2relaxes smooth muscle, dilates cerebral vessels, ↓cerebrovascular resistance, & ↑CBF
Effects of ↓PaCO2constricts cerebral vessels, ↑ cerebrovascular resistance, & ↓CBF
Cerebral oxygen tension <50 mm Hg results incerebrovascular dilation ↓cerebrovascular resistance, ↑CBF, & ↑oxygen tension (if O2 tension is not ↑, lactic acid will build up from anaerobic metabolism)
↓PaO2 + acidosis causevasodilation which may result in the loss of autoregulation & compensatory mechanisms – metabolic tissue demands cannot be met
Primary injuryoccurs at initial time of injury (e.g., impact of car accident, blunt-force trauma)
Secondary injury resulting hypoxia, ischemia, hypotension, edema, or increased ICP that follows the primary injury (can occur hours to days after initial injury & is primary concern when managing brain inj)
memorize

Cerebral Edema

Question Answer
Cerebral edema↑accumulation of fluid in the extravascular spaces of brain tissue
CausesMass lesions, Head inj/Brain surgery, Cerebral infection, Vascualr insult, Toxic/Metabolic encephalopathic conditions
Factors that ↑formation/spreadhypercapnia, cerebral acidosis, impaired autoregulation, & systemic HTN
Types-Vasogenic: most common; occurs mainly in white matter & is char by leakage of macromolecules from the capillaries into surrounding extracellular space (osmotic gradient that favors flow of fluid from the intravascular to the extravascular space)
-Cytotoxic: results from disruption of integrity of the cell membranes
-Interstitial: usually a result of hydrocephalus (buildup of fluid in brain); Manifested by ventricular enlargement
Causes of Vasogenicvariety of insults (brain tumors, abscesses, ingested toxins) may cause ↑in the permeability of BBB & produce an ↑ in extracellular fluid volume
Causes of CytotoxicDestructive lesions or trauma to brain tissue resulting in cerebral hypoxia/anoxia & SIADH secretion
Causes of IntersitialCan be due to excess CSF production, obstruction of flow, or inability to reabsorb CSF
falx cerebrithin dural fold between the cortex, separating the two cerebral hemispheres
tentorium cerebelli rigid dural fold that separates the cerebral hemispheres from the cerebellum, forms a tentlike cover over the cerebellum
Tentorial herniation (central herniation)occurs when mass lesion in cerebrum forces the brain to herniate ↓through the opening created by the brainstem
Uncal herniationoccurs when there is lateral & downward herniation
Cingulate herniation occurs when there is lateral displacement of brain tissue beneath the falx cerebri
memorize

↑ICP

Question Answer
Manis of ↑ICPChanges in LOC & VS, Ocular signs (ispsilateral pupil changes, blurred vision, eye movement changes), ↓Motor function, HA, Vomiting (usu w/out nausea)
DiagnosisH&P; VS/Neuro assessment/ICP measures; Imaging/EEG/ECG/Evoked potential; Labs: CBC, coag, ABGs, lytes, tox screen, CSF analysis
Who should be monitoredpts with GCS 8 or ↓ & abn CT/MRI
Ventriculostomy(gold standard for monitoring ICP)Specialized catheter is inserted into lateral ventricle & coupled to an external transducer; Measures pressure w/in ventricles, facilitates removal/ sampling of CSF & allows for intraventricular drug admin
Fiberoptic cathetersensor transducer located w/in the catheter tip which is placed w/in ventricle or the brain tissue & provides a direct measurement of brain pressure
Subarachnoid bolt/screwPlaced just through the skull between the arachnoid membrane & cerebral cortex; does not allow for CSF drainage but ideal for mild/moderate head injury (can be converted to ventriculostomy)
LICOX cathMeasures brain O2 (PbtO2 = nl: 20-40 mmHG) & temp (cooler may be better 96.8) -placed in healthy white brain matter
Jugular venous bulb cathMeasures JV O2 (SjvO2 = nl: 55-75%)
Factors ↑ Infection riskICP monitoring >5 days, use of a ventriculostomy, CSF leak & a concurrent systemic infection
Causes of inaccurate ICP readingsCSF leaks around monitoring device; obstruction of intraventricular catheter/bolt (from tissue/blood clot); difference btwn height of bolt & transducer; kinks in the tubing; incorrect height of the drainage system relative to pt’s reference point; bubbles/air in the tubing
NIResp function, F&E balance, Monitor ICP, Positioning (avoid Valsalva/↑ICP)
Collabortaive tx↑HOB 30 degress (head in neutral position); Intubate/Mech vent; ICP/Cerebral O2 monitoring; Maintain systolic arterial BP btwn 100-160 mmHg/CPP >60 mmHg; ↓cerebral metabolism (barbiturates); Drug tx (osmotic diuretic, hypertonic saline, corticosteroid, histamine blockers)
memorize

Recent badges