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

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1 IX. NEURO A. logical 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. 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 *LOC is always #1 with neurological assessment 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: 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. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 127

2 4. Reflex assessment a. Babinski Reflex: Normal in a child up to year. Abnormal in the. Babinski Reflex 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 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. 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 128 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

3 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. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 129

4 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. 130 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

5 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? Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 131

6 C. General Care for Any Client with Increased Intracranial Pressure: 1. Signs and Symptoms of ICP: a. Early Signs: Normal Lab Value: ICP: 0-15 mm Hg 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. 132 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

7 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. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 133

8 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). 134 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

9 D. logical 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. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 135

10 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. 136 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

11 c. Complications of Seizures: 1) Status epilepticus: a continuous seizure without returning to consciousness seizures. 2) Trauma: Protect the client d. Treatment: 1) logical 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 Rule: The NCLEX lady only uses the generic name of a drug in an NCLEX question. 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: Do not put anything in the mouth of a seizing client. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 137

12 E. logical 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 All of these are signs that the ICP is going! b. Hematomas: A small hematoma that develops rapidly may be fatal, while a massive hematoma that develops slowly may allow the client to. 138 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

13 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 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 changes= maxed out Acute or Chronic: immediate craniotomy and remove :control Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 139

14 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? Critical Thinking Exercise: Which shoes would you buy for a Parkinson s client? 1. Hot pink furry slippers 2. New Balance tennis shoes Critical Thinking Exercise: 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 Critical Thinking Exercise: 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 140 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

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