Med Surg A Exam 3

Divisions of Nervous System - CNS (brain, spinal cord) & PNS (cranial nerves, spinal nerves, ANS) ANS (parasympathetic, sympathetic) Cerebrum - area of the brain responsible for all voluntary activities of the body Frontal Lobe - reasoning, motor control emotion, Broca's area (language) Temporal Lobe - hearing, memory, emotion Parietal Lobe - language processing/orientation, sensory perception of stimuli Occipital Lobe - primary visual cortex Brainstem - the oldest part and central core of the brain, beginning where the spinal cord swells as it enters the skull; the brainstem is responsible for automatic survival functions Cerebellum - the "little brain" at the rear of the brainstem; functions include processing sensory input and coordinating movement output and balance Blood Flow in Brain - arterial circulation: primarily supplied by right/left internal carotids; also right/left vertebral circle of willis: communication, 85% of aneurysms occur here dural sinuses are venous channels through dura mater and brain Epidural Space - space between the dura mater and the wall of the vertebral canal Subdural Space - space between dura mater and arachnoid mater Subarachnoid Space - a space in the meninges beneath the arachnoid membrane and above the pia mater that contains the cerebrospinal fluid Neuro Assessment: History - regular healthcare, medical history of self + immediate family, allergies, medications, social history, current history of chief complaint Neuro Assessment: Physical - LOC: glasgow coma scale, orientation, conscious, confused, lethargic, stuporous, obtunded, comatose cognitive function: MMSE cranial nerve assessment cerebellar assessment: balance, coordination, gait, posture reflexes vitals Age-Related Neurological Changes - brain and spinal cord atrophy, nerve cells pass messages slower, waste products collect in brain, reduces or lost reflexes or sensation, slowing of though Pediatric Neurological Differences - birth: cranial bones not well-developed (risk for fracture); brain highly vascular (risk for hemorrhage) children: spinal cord more mobile (risk for c-spine injury) Pediatric Neuro Assessment - PMH: prematurity, precipitous birth, infection during pregnancy, falls, trauma prenatal risk factors inspection: LOC, vitals, head, face, neck, motor, cranial nerves, reflexes, sensory perception, increased ICP common S&S: N/V, HA, change in gait, loss of motor function, visual disturbance, change in LOC, confusion, increased irritability, altered muscle tone Common Pediatric Neurological Disorders - bacterial/viral meningitis, encephalitis, Reyes syndrome, hydrocephalus, shunt infection, head trauma thru falls/MVA/sports/bike/abuse/shaken baby/closed head injury, acute stroke Cerebral Angiography/MRA - provides visualization of cerebral arteries which is used to assess blood flow, identify aneurysms, define vascularity of tumors, inject medications that treat clots, administer chemo Pre: NPO 4-6 hrs, remail still, void right before, contrast dye precautions Intra: catheter into artery, dye injected, x-ray pictures taken Post: ensure clotting, ice on insertion site Complications: bleeding & hematoma risk at entry site - check it frequently, check distal extremities for circulation, apply pressure over artery if bleeding Cerebral CT - provides cross-sectional images of cranial cavity to identify tumors and infarctions, detect abnormalities, monitor response to treatment, guide needles for biopsy Pre: contrast precaution, pillow in small of back Intra: lie supine w head stabilized Post: monitor for allergic rxn, monitor until stable if sedation used Electroencephalography (EEG) - noninvasive procedure that assesses electrical activity of brain and is used to determine abnormalities in brain wave patterns which provides info about ability to function; used to identify and determine seizure activity, detect sleep disorder or behavioral change Pre: review meds, wash hair, stay awake prior, avoid stimulant/sedative meds for 12-24 hrs prior Intra: lasts 45-120 mins, small electrodes on scalp Glasgow Coma Scale - concentrates on neurological function and is useful to determine LOC and monitor response to treatment; can also determine change in LOC 8: coma 9-12: moderate injury 13: minor injury Intracranial Pressure Monitoring - device inserted into cranial cavity to record pressure, connected to a monitor that shows pressure waveforms; useful for early identification and treatment of ICP in those who are comatose Pre: head shaved & cleansed Intra: local anesthetic if some LOC Post: inspect site q 24 hrs, balance/recalibrate equipment Complications: infection & bleeding Lumbar Puncture - procedure during which a small amount of CSF is withdrawn from spinal canal then analyzed; used to detect MS, syphilis, meningitis, infection, malignancy, reduce CSF pressure, instill contrast, administer meds/chemo Pre: educate about brain herniation, void prior, cannonball position Intra: manometer Post: monitor puncture site, client should remain lying for several hours Complication: CSF leak - HA, infection Safety: not used during increased ICP to prevent herniation MRI - provides cross-sectional images of cranial cavity; no radiation (safe during pregnancy); detects abnormalities, monitors response to treatment, guides needles for biopsy, determines tumor size and vessel location Pre: remove any patches with foil backing, NPO 4-8 hrs if sedated, pillow in small of back Intra: supine w head stable Post: monitor for allergic rxn if contrast was used, monitor until stable if sedation was used PET/SPECT Scans - nuclear medicine procedures that produce 3D images of head which can depict vessels or activity; captures metabolic processes which is used in determining tumor activity, can also determine presence of dementia Pre: uses radiation Intra: lie flat w head restrained Post: assess for allergic rxn Radiography (X-Ray) - uses electromagnetic radiation to capture images of internal structures of an individual; when the skull/spine is examined it can reveal fracture, curvature, bone erosion, dislocation, soft tissue calcification - all of which can affect CNS Epilepst - term used to define chronic recurring abnormal brain electrical activity resulting in 2+ seizures Generalized Seizure - involve both cerebral hemispheres, can begin with an aura tonic-clonic, tonic, clonic, myoclonic, atomic/akinetic Aura - precedes seizure, alteration in vision/smell/hearing/emotions Tonic-Clonic Seizure - begins for only a few seconds with a stiffening of muscles and loss of consciousness (tonic episode) followed by 1-2 minutes of rhythmic jerking of the extremities (clonic episode) breathing can stop during tonic and become irregular during clonic, cyanosis, biting of cheek/tongue, incontinence, confusion/sleepiness follows Tonic Seizure - only tonic phase experienced clients suddenly lose consciousness and experience sudden increased muscle tone, arrythmia, apnea, vomiting, incontinence, salivation generally last 30 seconds Clonic Seizure - only clonic phase is experiences lasts several minutes muscles contract & relax Myoclonic Seizure - consist of brief jerking or stiffening of extremities, which can be symmetrical or asymmetrical lasts for seconds Atonic/Akinetic Seizure - characterized by a few seconds in which muscle tone is lost followed by period of confusion loss of muscle tone frequently results in falls Partial or Focal/Local Seizures - involve only 1 cerebral hemisphere complex partial or simple partial Complex Partial Seizure - associated automatisms (behaviors that client is unaware of) can cause loss of consciousness of blackout for several minutes amnesia can occur immediately before and after Simple Partial Seizure - consciousness maintained throughout, consists of unusual sensations such as deja vu, change in heart rate or rhythm, flushing, unilateral abnormality extremity movement, pain, offensive smell Phases of Seizure Activity - prodromal aural ictal postictal Unclassified/Idiopathic Seizures - don't fit into other categories, account for half of all seizure activity Seizures: Risk Factors - genetics, acute febrile state, head trauma, cerebral edema, abrupt cessation of anti-epileptic drugs, infection, metabolic disorder, exposure to toxin, stroke, heart disease, tumor, hypoxia, acute substance withdrawal, fluid/electrolyte imbalance, increased activity or stress, hyperventilation, fatigue, alcohol, caffeine, flashing lights, drugs Lab/Diagnostic Tests: Seizures - alcohol and illicit substances, HIV, presence of toxins; EEG, MRI, Ct, CAT, PET, CSF analysis, skull x-ray Seizures: Care - During: protect privacy, protect from injury, provide position for patent airway, suction, turn, loosen cloths, don't restrain or open jaw, document onset and duration Postictal phase: side-lying, vitals, neuro check, assess for injury, rest, reorient, determine trigger Nursing Diagnoses: Seizures - risk for ineffective breathing pattern, risk for injury, ineffective coping Education: Seizures - med adherence, med alert bracelet, driving restrictions Status Epilepticus: Seizure Complications - repeated seizure activity within a 30- min time frame or a single prolonged seizure lasting 5 mins; complications associated w/ it are decreased oxygen, inability of brain to return to normal functioning, and continued assault on tissue; usual causes are substance withdrawal, sudden AED withdrawal, head injury, cerebral edema, infection, metabolic disturbance Stroke - CVA/brain attack; involves disruption in cerebral blood flow secondary to ischemia, hemorrhage, brain attack, or embolism; most commonly involves middle cerebral artery Hemorrhagic Stroke - occur secondary to ruptured artery/aneurysm, poor prognosis due to amount of ischemia and ICP Ischemic Stroke - a type of stroke that occurs when the flow of blood to the brain is blocked; can be reversed with fibrinolytic therapy using tPA if given within 3-4.5 hrs of manifestations Thrombotic Stroke - ischemic stroke that occurs secondary to development of clot on an atherosclerotic plaque in a cerebral artery that gradually shuts off artery; manifestations evolve over hours - days Embolic Stroke - ischemic stroke caused by embolus traveling from another part of body to cerebral artery Lacunar Stroke - a stroke resulting from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue Brainstem Stroke - affects bilateral functions and has high mortality rate Cerebellar Stroke - stroke that strikes the cerebellum area of the brain, which controls balance and coordination and some forms of learning and memory; S&S: dizziness, n/v, gait and balance issues, loss of bowel and bladder control Stroke Prevention - control HTN and DM, quit smoking, maintain healthy weight, exercise, BEFAST: balance, eyesight, face, arm, speech, time Risk Factors: Stroke - cerebral aneurysm, AV malformation, DM, obesity, HTN, hyperlipidemia, atherosclerosis, hypercoagulability, afib, OCs, smoking, cocaine use Findings: Stroke - Transient manifestations: visual disturbance, dizziness, slurred speech, weak extremities - can indicate TIA which is a warning of an impending stroke Vary based on area of brain that is deprived of oxygenated blood Left hemisphere: expressive and receptive aphasia, agnosia, alexia, agraphia, right extremity hemiplegia or hemiparesis, slow/cautious behavior, depression, anger, frustration, visual change Right hemisphere: altered perception of deficits, unilateral neglect syndrome, loss of depth perception, poor impulse control/judgement, left hemiplegia or hemiparesis, visual change Diagnostic Tools: Stroke - CT (r/o hemorrhagic stroke), MRI (confirms stroke after 24 hrs), MRA, lumbar puncture with blood in CSF, Glasgow coma scale Nursing Care: Stroke - o Vitals q 1-2 hrs o Monitor temperature o Make sure oxygenation 92% o Cardiac monitor, cardiac assessment, auscultate apical heart rate to detect murmurs, EKG o Assess change in LOC o Monitor for hyperglycemia - associated with poor neurological outcome o Elevate HOB at 30 degrees to reduce ICP and promote venous drainage o Seizure precautions o Assist with client's communication o Assist with safe feeding o Prevent complications of immobility - atelectasis, pneumonia, pressure injury, DVT o Teach client to protect and care for affected extremity if there is one-sided neglect o ROM exercises q 2 hrs o Elevate affected extremities to promote venous return and reduce swelling o Reduce fall risk o Instruct client to use scanning technique in case of homonymous hemianopsia o Assistance with ADLs as needed o Frequent rest periods o Shoulder subluxation can occur if affected arm isn't supported o Support client during periods of emotional lability/depression o Priority: maintain airway o Biggest risk during acute phase: aspiration pneumonia