Module 5.pdf

Module 5: Problems Related To Neurological Function Neurological Anatomy + Physiological Review Cells and Neurotransmitters Neurons Basic functional unit of the brain Cell Body Dendrite → Branch like structure → Receives messages from other dendrites Synaptic cleft → Electrical Impulses jump over the synaptic cleft Axon → Carry impulses away from the cell body Myelin Sheath ○ Produced by the Schwann Cells ○ Allows for more rapid transmission of messages Neurotransmitters Acetylcholine ↳ ○ Major neurotransmitter of the Parasympathetic Nervous System (PNS) ○ Controls “Rest + Digest” response Serotonin Dopamine Norepinephrine ↳ ○ Major neurotransmitter of the Sympathetic Nervous System (SNS) ○ SNS is aka Adrenergic ○ Controls “Fight or Flight” response Gamma-aminobutyric Acid (GABA) Enkephalin, endorphin Central Nervous System Brain Cerebrum → Hypothalamus + Pituitary Gland Brainstem → Autonomic System → Controls heart rate, breathing, and swallowing Cerebellum ○ Coordination of all movements ○ Gives awareness of body parts → *Sensory Input* Corpus Callosum ○ Located in the center of the brain in the longitudinal fissure ○ Collection of nerve fibers that transfers signals between the hemispheres of brain Gray Matter → Makes up the outer portion White Matter → Makes up the innermost portion Alzheimer's Disease ○ White matter shrinks ○ Gray matter takes up more space Frontal Lobe → Emotional Control + Personality Parietal Lobe - deals with the senses ○ Touch ○ Pain ○ Temperature ○ Language Processing Occipital Lobe → Vision Temporal Lobe →Gives meaning to things seen and heard Structures protecting the brain Skull → Protects the brain Meninges → Connective tissue that covers the brain and the spinal cord Cerebrospinal Fluid (CSF) ○ Clear, colorless fluid ○ Allows for nutrient delivery and waste elimination ○ Not normal to leak clear fluid out of nose or ears if don’t have a cold Blood Brain Barrier → Many drugs don't cross the blood brain barrier Peripheral Nervous System Cranial Nerves Oh L Sensory Nerve 1 → Olfactory part of peripheral ○ Function: Sense of Smell Oh nervous system ○ Tests: Smell substance with eyes closed Oh To Test each nostril separately trigeminal , TouchSensoryfromeasions Sensory Nerve 2 → Optic ○ Function: Vision ○ Test And Clench teeth cotton ball + Snellen Chart Ophthalmoscopic Exam Feel e facial , taste + Confrontation to check peripheral vision facial expression Sensory Nerve 8 → Acoustic Virgin smile puff cheeks taste , , ○ Function: Hearing and Balance ○ Tests: Girls - glassopharyngeal "Swallowing" Vagina Whisper Test sensation e vagus , in throat and Weber Test gag Ah reflex Rinne Test Motor Nerve 3 → Oculomotor ○ Function: Ocular (eye) Motor (movement) Heavens Most Eye Movements Pupil Constriction eyemovemena Upper Eyelid Rise ○ Tests: Look up, down, and inward Ask the patient to follow your finger as you move it towards their face Motor Nerve 4 → Trochlear ○ Function: Controls downward and inward eye movement ○ Tests: Look up, down, and inward CNIII , IV + VI are tested tested together Ask the patient to follow your finger as you move it towards their face Motor Nerve 6 → Abducens ○ Function: Controls parallel eye movement Abduction → Move laterally (away from the midline) ○ Tests: Look up, down, and inward Ask the patient to follow your finger as you move it towards their face Motor Nerve 11 → Spinal Accessory ○ Function Controls strength of neck and shoulder muscles ○ Tests: Ask the patient to rotate their head and shrug their shoulders Motor Nerve 12 → Hypoglossal ○ Function: Tongue Movement → Swallowing + Speech ○ Tests: Inspect Tongue Ask to stick tongue Spinal Nerves Autonomic Nervous System & Regulates involuntary physiologic processes including heart rate, blood pressure, respiration, digestion, and sexual arousal Sympathetic Nervous System: Fight or Flight Parasympathetic Nervous System: Rest and Digest Gerontologic Considerations Older adults are more vulnerable to general systemic illness Loss of cognitive function or dementia is not a normal change Find the root cause of confusion or cognitive changes ○ UTI ○ Medical Interactions ○ Medication Interactions Structural Changes Brain weight decreases Decreased myelin production Slowing of ANS & SNS Impaired temperature regulation Reduced pupillary response More sensitive to changes to lighting Sensory Changes Atrophy of taste buds Decreased Smell Balance & proprioception → Depth perception changes increases risk of falls Decreased in REM Sleep Cataracts Decreased tactile sensation Assessment of the Neurological System Assessment of Neurological Status Health History Common Complaints Pain Headache/Migraine Seizures Dizziness/Vertigo Visual Disturbances Weakness Abnormal Sensation Medical History Trauma or falls (car accidents + sports injuries) that involved the head or spinal cord Forgetfulness Family History: Genetic diseases Huntington’s Dystonia: Unwanted muscle contractions Epilepsy Social History Alcohol → CNS Depressant → Withdrawal causes seizures Medications + Illicit Drugs ○ CNS Depressants: Benzodiazepines + Opiates ○ CNS Stimulants Lifestyle Limitations Physical Assessment of Neurological Status Complaints **Pain** Radiating Nerve Pain Vertigo Neuropathy:Tingling Glascow Coma Scale Assessment of eye opening, motor response, and verbal response Get a neurological assessment baseline upon admission and recheck status Motor Response: ○ 6: Obedient scale : glascow coma the patient ○ 5: Purposeful · motor e score of : 1 4 - - can follow commands ?? done can not be ○ 4: Withdrawal · verbal escore of : I-5 + when intubated ○ 3: Flexion eye · ○ 2: Extension score of: 1.4 ○ 1: None Mild: 13-15 opening Moderate: 9 -12 1 = Worst Severe: 3-8 Coma: Less than 8 Cerebral Functions **Level of consciousness & mental status** Perception → Ability to recognize + determine objects and feeling Motor ability Language ability Cranial Nerves Motor Function Compare side by side to see if they are equal Muscle Size Muscle Tone O worst Muscle Strength - S , is the best muscle strength = Coordination Reflexes Deep Tendon Reflexes Superficial/Cutaneous Reflexes Gag reflex → Use a tongue depressor Uvula → Use a swab to see if uvula is equal and midline Corneal Reflex → Use a cotton swab + Touch the inner areas to see if they blink Pupillary Reflex → Use a pen light Babinski Reflex ↳ ○ Positive (Infants): Toe fanning ○ Negative (Adults): Toes contract and draw together Plantar Reflex Neurological Diagnostic Evaluations Computed Tomography (CT) > No - metal on patient Uses a narrow X-ray beam to scan the body part in successive layers, providing cross-sectional views Non-invasive and painless, high degree of sensitivity of detecting lesions Nursing Interventions May be performed with or without contrast Contrast: - assess BUN and creatining ○ Large IV (20 gauge or larger) at/above the AC ○ Monitor for allergies to shellfish,iodine,or contrast If test will causesedation , patient needs to be NPO before ○ Monitor renal function Patient must lie perfectly still can differentiate between, tissue, needles for biops be used to I can guide bone and tumor 2 Magnetic Resonance Imaging (MRI) > - NOISY Uses a magnetic field to obtain images of different areas of the body safer for Can identify a cerebral abnormality earlier and more clearly than other diagnostic tests pregnantthan women Particularly useful in diagnosis of multiple sclerosis CT Scan Time Frame: 1 -2 hours Checklist: Pacemaker, patches, piercings, welder (metal shards in eyeballs), cochlear implant, fit in MRI machine Nursing Interventions May be performed with or without contrast Removal of all metal objects Positron Emission Tomography (PET) A nuclear imaging technique that produces images of actual organ functioning Permits measurement of blood flow, tissue composition, and brain metabolism Useful for showing metabolic changes in the brain (Alzheimer’s Disease), locating lesions (brain tumor), identifying blood flow (strokes), and revealing biochemical abnormalities associated with mental illness Patient either inhales a radioactive gas or is injected with radioactive substance that emits positively charged particles Single Photon Emission Computed Tomography (SPECT) Not common but very helpful Perfusion study that uses 3D imaging to capture a moment of cerebral blood flow Useful in detection, localization, and sizing of a stroke before it is visible on CT scan Localization of seizure foci in epilepsy Detection of tumor progression Evaluation of perfusion before and after neurosurgical procedures Radionuclide is injected and detected by camera, transmitted to computer risk for Nursing Interventions bleeding !! Pregnancy and breastfeeding are contraindications Patient preparation and monitoring & Cerebral Angiography - dyeinjectedinooralize ! & Contrast agent injected into selected artery (femoral artery) and radiographic imaging used to detect abnormalities in cerebral circulation Detects perfusion Gold standard for diagnosis of vascular disease, aneurysms, and arteriovenous malformations Nursing Interventions Contrast precautions IV 20 gauge or larger Assess for kidney infection Patient should be well-hydrated and should void prior to the test Observe for signs and symptoms of altered cerebral blood flow Care of injection site Assess using Glasgow Coma Scale Monitor area distal to injection site (pedal pulse) → Assess for phlebitis Concerns: Bleeding, Infection Myelography X-ray providing outline of the spinal subarachnoid space following injection of contrast agent through a lumbar puncture Allows visualization of any distortion of the spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral disks, or other lesions Nursing Interventions Teach relaxation techniques/provide sedative or anxiolytic Post-Procedure ○ Patient should lie in bed with HOB elevated 30-45 degrees for 3 hours ○ Drink liberal amounts of fluid for rehydration and replacement of CSF ○ Keep lighting down ○ Monitor vital signs frequently ○ Observe for manifestations of meningitis: Headache, fever, stiff neck, photophobia, seizures ○ Monitor for cerebral and CSF Infection Non-Invasive Carotid Flow Studies Non-invasive test that uses ultrasound to evaluate carotid and deep orbital circulation ○ Increased blood velocity may indicate stenosis or partial obstruction Assess for plaque and 100% patency Electroencephalography (EEG) Represents a record of the electrical activity generated in the brain Electrodes applied to scalp or microelectrodes placed within brain tissue Want to trigger seizures Useful for diagnosis and evaluation of: ○ Seizure disorders, coma, organic brain syndrome ○ Possible abnormal brain activity due to abscesses, blood clots, and infection ○ Making determination of brain death Nursing Interventions Deprive patient of sleep night before EEG to increase chance of seizure activity Hold anti-seizure agents, tranquilizers, stimulants and depressants for 24-48 hours prior Electromyography (EMG) Insertion of needle electrodes into skeletal muscles to measure changes in the electrical potential of the muscles and the nerves leading to them Useful for determining the presence of neuromuscular disorders and myopathies Paralyzed patients will have no electrical impulses Nursing Interventions Patient warned to expect sensation similar to IM injection Muscles may ache for a short time after the procedure →more move, better off will be I DO NOT DO IF ICP IS & !!! + will lead to brain herniation ! done between S Lumbar Puncture and test Examination of CSF for fluid ,cancer > - L3-L4 ASEPTIC done to AKA Spinal Tap y , infections **Pt lays on side to spread out subarachnoid spaces, and CSF will drip out** TECHNIQUE !! or measure CSF relieve , Can last up to 15-20 minutes pressure or givemesa May need to poked up to 3-4 times have patient Obtain CSF for examination → CSF should be clear and colorless antibiotics) Measure and/or reduce CSF pressure emptybladder S Assess for infection or presence or absence of blood in CSF lateral ○ May be blood tinged due all of the poking assess for · recumbent ○ CSF should not be cloudy or yellowish dizziness !! position !! Administration of antibiotics + Chemotherapy into the CSF Knees to Remove spinal fluid !! abdomen Nursing Interventions monitor neurological signs and chin to chest!! Rapid visual inspection of CSF (sample should be sent promptly to laboratory) CT scan must be done prior to procedure if intracranial mass is suspected Patient must be relaxed for successful lumbar puncture patient must remain drink Monitor for complications of lumbar puncture fluids May need to help patient on side FLAT AFTERI to replace Monitor for signs of meningitis ↳ to avoid leak of CSF Monitor for sepsis: Temperature + Heart Rate CSF headaches "Post-dural" : Lay flat for 24 hours · Drink a lot of fluids (including caffeinated fluids for headaches) May have spasms and backaches after Stroke Fifth leading cause of death in the US Considered a major cause of disability worldwide Is an interruption of perfusion to any part of the brain that results in infarction (cell death) Risk Factors. 2 Combination of genetic and environmental risk factors Smoking Obesity black risk for aspiration Pneumonia dysphagia : suction - have ready Diabetes Elevated cholesterol Hypertension Substance Abuse Disorders: Cocaine Heavy Alcohol Consumption Oral Contraceptives by women who are at risk for cardiovascular adverse effects Stroke Types Acute Ischemic Stroke (AIS) Tend to happen early in the morning Gradual progression Caused by occlusion (blockage) of a cerebral or carotid artery by a thrombotic clot or embolic clot Thrombotic Stroke Y ○ Clot is attached to the blood vessel wall ○ Gradual Onset ○ Contributing Factor → Hypertension + Atherosclerosis ○ Manifestations: Slight Headache Bebalance ? Speech Deficits E vision? usually caused by Visual Problems neyes , blurry atrial septal defect, clot is able to thru Feface drooping goL ventricle , Confusion hole between R + by passing lungasin ! ○ Deficits: and ? Improve over weeks to months A +arm numb/weak & Embolic Stroke Still possible to get permanent deficits & - slurred speech? normal? e time last ↳ ○ Dislodged clot moves around the body ○ Sudden Onset ○ Contributing Factors → Cardiac Disease ○ Manifestations: Immediate Maximum Deficits Paralysis Expressive Aphasia: Difficulty to understand or express speech Deficits → Rapid improvements once blockage is free Hemorrhagic Stroke Tend to occur during activity Abrupt progression Vessel integrity is ruptures (interrupted) and starts bleeding Intracranial Hemorrhage ○ Results from bleeding occurs in the brain tissue ○ Caused by severe or prolonged hypertension Leads to changes within the arterial wall that make it likely to rupture Cocaine use triggers sudden dramatic blood pressure increase ○ Damage to the brain occurs due to bleeding, edema, irritation, and displacement Subarachnoid Hemorrhage E ○ Much more common ↳ ○ Results from bleeding into the subarachnoid space Space between the pia mater and the arachnoid layers of the meninges covering the brain (protective later) ○ Causes: Aneurysm Abnormal localized out-pouching, sac, or dilation formed at a weak point in artery wall Arteriovenous Malformation (AVM) Angled collection of malformed, thin walled, dilated vessels that don’t have a capillary network Uncommon abnormality occurs during embryonic development Vasospasms can occur as a result of sudden inferiotic constriction of the cerebral artery often following a subarachnoid hemorrhage from an aneurysm or a bleed Constriction interrupts blood flow to distal areas to the brain Reduced perfusion from vasospasms can contribute to secondary cerebral ischemia Will cause cerebral dysfunction Stroke Prevention Aspirin use when appropriate Blood Pressure Control Cholesterol Management → Fruits, Vegetables, Low Saturated Fats Smoking Cessation Exercise Assessment Onset of symptoms is essential for making treatment options Know what the patient was doing when the symptoms began Know how the symptoms progress Did the symptoms worsen after the initial onset or did they start to improve? Medical history Head Trauma HEMORRHAGIC STROKE : ICP Diabetes !! broken blood vessel-bleeding and swelling headache = Hypertension · Heart Disease #1 cause · aneurysm = altered LOC · Anemia facial drooping · Obesity hemiparesis · Medications slurred speech · NIV vertigo · Prescribed , trouble swallowing · OTC unequal pupils · Seizures t risk within 21 hrs !! Illicit drugs · is a bladder/bowel this VASCULAR · flucuating BP · Seizure · Poor prognosis Herbal Drugs Herbal Supplements Caffeine Physical Assessment Complete neurological assessment upon admission to ED or unit Blood Pressure Assessments are done every 4 hours ADLs Psychosocial Assessment Education Employment Travel Leisure Activities Stress Levels Financial Status No health insurance Primary Family Provider Laboratory Assessment No specific labs for this but we can look at Hgb and hematocrit, A1C, and PT/INR Imaging Assessment Computed tomography perfusion (CTP) scan and/or computed tomography angiography (CTA) Assesses the extent of ischemia of brain tissue Cerebral aneurysms or AVM may also be identified Magnetic resonance angiography (MRA) and multimodal techniques such as perfusion weighted imaging Enhance the sensitivity of the MRI to detect early changes in the brain, including confirming blood flow. Ultrasonography (carotid duplex scanning) Planning Care Outcomes Improved cerebral perfusion to maintain adequate brain function Prevent further brain injury Supportive Care Prevention Prevent complications like falls Interventions Monitor or neurologic changes or complications, especially LOC changes Fibrinolytic Therapy ○ Clot busting drugs ○ Alteplase is the only drug approved at this time for the treatment of acute ischemic stroke. ○ **The most important consideration is the time between symptom onset and time seen at the stroke center. FDA approves administration of alteplase within 3 hours of stroke onset. ○ Exceptions: Older than 80 years old Anticoagulation, no matter what their INR is Evidence of ischemic injury involving more than ⅓ of their brain tissue supplied by the middle cerebral artery Baseline NIHSS score of more than 25 History of both stroke and diabetes Evidence of active bleeding Endovascular Interventions After Alteplase Evidence-Based Nursing Interventions During and After IV Administration of Alteplase Admit the patient to a critical care or specialized stroke unit. Perform a double check of the drug dose. Use a programmable pump to deliver the initial dose of 0.9 mg/kg (maximum dose 90 mg) over 60 minutes, with 10% of the dose given as a bolus over 1 minute. Do not manually push this drug. Patient will be in the critical care unit Perform neurologic assessments, including vital signs, every 10 to 15 minutes during infusion and every 30 minutes after that for at least 6 hours; monitor hourly for 24 hours after treatment. Be consistent regarding the device used to obtain blood pressures because blood pressures can vary when switching from a manual to a noninvasive automatic to an intra-arterial device. If systolic blood pressure is 185 mm Hg or greater or diastolic is 110 mm Hg or greater during or after alteplase, give antihypertensive drugs, such as labetalol, as prescribed (IV is recommended for faster response). To prevent bleeding, do not place invasive tubes, such as nasogastric (NG) tubes or indwelling urinary catheters, until the patient is stable (usually for 24 hours). Discontinue the infusion if the patient reports severe headache or has severe hypertension, bleeding, nausea, and/or vomiting; notify the primary health care provider immediately. Obtain a follow-up CTA or CTP scan after fibrinolytic therapy and before starting antiplatelet or anticoagulant drugs. Endovascular Interventions Intra-arterial thrombolysis using drug therapy ○ Have fibrinolytic therapy or endovascular therapy ○ Puts fibrinolytic agents right onto the thrombus ○ Can be within 6 hours of stroke onset ○ Helpful for patients who have an occlusion in the middle of the cerebral artery for those who arrive to the ED after the 3 hour window Mechanical embolectomy Carotid stent placement After Stent Placement Teach the patient and family to report the following immediately: Severe headache Changes in LOC or cognition (e.g., drowsiness, new-onset confusion) Muscle Weakness or motor dysfunction Severe neck pain Swelling at neck incision site Hoarseness or dysphagia (due to nerve damage) Increased intracranial pressure (ICP) Normal ICP: 10-15 mm/Hg - potentially life threatening Most At Risk → Edema during first 72 hours after stroke onset Some patients may have worsening of their neurologic status starting within 24 to 48 hours after their endovascular procedure from increased ICP FIRST SIGN = LOC CHANGE Early Manifestations First Sign: Change in LOC → Do a baseline neurological assessment Headaches, dizziness, poor sense of awareness, confusion, blurred vision Disorientation, restlessness, increased respiratory effort, purposeless movements, mental confusion → Brain cells responsible for cognition extremely sensitive to decreased oxygenation Weakness in one extremity or one side of the body → Compresses pyramidal tracts, which control motor function. Pupillary changes and impaired extraocular movements → Displaces brain against the oculomotor and optic nerves, which arise from the midbrain and brainstem Late Manifestations LOC continues to deteriorate until the patient is comatose Respiratory rate decreases or becomes erratic, blood pressure and temperature increase. The pulse pressure widens and the pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne–Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla Hemiplegia (half of the body won’t move) or decorticate or decerebrate posturing may develop as pressure on the brainstem increases; bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, which is an ominous sign of impending death. -or craniotomy Surgical Interventions Ventriculostomy Finebone needle is inserted into a lateral ventricle, in the nondominant hemisphere The catheter will be connected by a fluid filled system to a transducer that will record ICP Will let the CSF drain a little bit and hopefully decrease the pressure Can also be used to drain the blood from the ventricle Subarachnoid Screw Bolt or screw that’s hollow and inserted through the wall of the skull and through the dura mater into the cranial subarachnoid space Advantage of not requiring a ventricular puncture Is attached to a pressure transducer Advantage of avoiding the complications from a brain shift because it’s a smaller size Nursing Management Patients are located on the critical care unit Elevate HOB to improve perfusion pressure. Provide oxygen therapy to prevent hypoxia for patients with oxygen saturation less than 95% or per agency or primary health care provider protocol or prescription. Maintain the head in a midline, neutral position to promote venous drainage from brain. Avoid sudden and acute hip or neck flexion during positioning. Extreme hip flexion may increase intrathoracic pressure, leading to decreased cerebral venous outflow and elevated ICP. Extreme neck flexion also interferes with venous drainage from the brain and intracranial dynamics. Avoid cluster care Hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia Provide airway management to prevent unnecessary suctioning and coughing Maintain a quiet environment for the patient experiencing a headache Keep the room lights low to accommodate any photophobia the patient may have. Monitor BP, heart rhythm, oxygen saturation, blood glucose, and body temperature to prevent secondary brain injury + promote positive outcomes after stroke. Brain Tumors Arise anywhere within brain structures + named according to cell/tissue where originate Primary Brain Tumors Originate within the CNS and rarely metastasize (spread) outside this area Secondary Brain Tumors Result from metastasis from other areas of the body Brain Tumor Classification Benign Noncancerous Malignant Surgery, radiation, chemotherapy Metastatic Require aggressive interventions Surgery, radiation, chemotherapy Brain Tumor Types Gliomas & Intracerebral brain neoplasm Spread in the cerebrum by infiltrating the surrounding brutal connective tissue Will have surgery or radiation A total surgical resection is hard to do because have fingerlike tentacles and spread out Glioblastoma multiforme (GBM) → Most common + aggressive malignant brain tumor Meningiomas These tumors grow on the meninges (membrane covering of the brain) Will spread to the brain and spinal cord Don’t have a good prognosis and usually can’t be completely resected Manifestations depends on the location of the tumor in the brain ○ They compress brain rather than invade brain tissue Can run in families Grade I meningiomas → Most common type and can be cured by surgery Acoustic Neuromas Occurs in the auditory meatus Slow growing and is diagnosed once it grows into a large size Manifestations ○ Loss of hearing ○ Tinnitus ○ Vertigo ○ Staggering gait ○ Painful sensation Occurs once tumor gets bigger because its compressing on cranial nerve Acoustic neuroma (Vestibular Schwannoma)→ Benign tumor of eighth cranial nerve Pituitary Adenomas 12-19% of all tumors Grow Slowly Most are benign, but some might be malignant Exert pressure on the optic nerves, optic tracts, third ventricle, or hypothalamus Nonfunctioning tumors do not produce hormones. Functioning tumors can produce one or more hormones, normally by anterior pituitary. Angiomas 4 Are masses composed largely of abnormal blood vessels ○ Increases risk of hemorrhagic stroke ○ Hemorrhagic strokes in people under 40 years would would suggest an angioma Are found either in the brain or on its surface Occur most often in the cerebellum Manifestations ○ Some may never go through any manifestations ○ Seizures ○ Headaches Diagnosis ○ Bruit can be heard in the skull Cerebral Metastases Primary sites of cancer that commonly metastasize to the brain include the lung, breast, and gastrointestinal tract as well as melanoma Primary lung cancer accounts for 50% of all brain metastases Clinical Manifestations Symptoms are based on brain invasion, compression of structures, or ICP Headaches without a fever in the morning are suggestive of a tumor !!! Headaches + fever suggests an infectious process like meningitis or encephalitis Seizures occur in 60% of patients Nausea and vomiting Fatigue Cognitive impairment Visual disturbances New onset of seizures Weakness Sensory loss Aphasia - loss of ability to express speech Visual dysfunction Cerebral Edema 3 Results from changes in capillary endothelial tissue permeability that allows plasma to seep into the extracellular spaces Leads to increased ICP and, depending on tumor location, brain herniation syndromes A variety of neurologic deficits result from edema, infiltration, and distortion The tumor may enter the walls of the vessel, causing it to rupture and hemorrhage into the tumor bed or other brain tissue Many patients who have brain tumors have headaches and seizures from interference with the brain’s normal electrical activity, and compression of surrounding brain tissue. Pituitary Dysfunction May occur as the tumor compresses the pituitary gland Causes syndrome of inappropriate antidiuretic hormone (SIADH) or diabetes insipidus. ○ Result in severe fluid and electrolyte imbalances and can be life threatening. Assessment MRI is the gold standard for detecting brain tumors Computed tomography (CT) Enhanced by a contrast agent Can give specific information concerning the number, size, and density of the lesions and the extent of secondary cerebral edema Also provides information about the ventricular system (the communicating network of cavities filled with CSF and located within the brain parenchyma). Positron emission tomography (PET) Measures the brain’s activity rather than simply its structure Useful in differentiating tumors from scar tissue or radiation necrosis. Cerebral angiography Provides visualization of cerebral blood vessels and can localize most cerebral tumors. Cytologic Studies of the CSF ↳ Performed to detect malignant cells because CNS tumors can shed cells into the CSF. Medical Management of Primary Tumors Chemotherapy IV Oral 2 ↳ ○ Temozolomide Part of the systemic therapy Can pass through the blood brain barrier Intrathecally ○ Introduced into or occurring in the space under the arachnoid membrane of the ↳ brain or spinal cord ○ Direct drug delivery to the tumor ○ Disc shaped wafer that can be placed right into the cavity ○ Occurs through surgery Pharmacology Analgesics → Codeine or Acetaminophen → Given for headaches Dexamethasone → Given to control edema Seizure Medications Proton Pump Inhibitors → Given to decrease gastric acid and prevent stress ulcer Antiemetics → Reduce nausea and vomiting ○ Given 30 minutes before chemotherapy is administered Surgical Management ○ Remove the tumor without increasing the deficit ○ Ability to get tumor depends on size, location, and access the tumor Radiation ○ Gamma Knife is a form of stereotactic radiosurgery, where precise beams of radiation produce a targeted approach of concentrated radiation for the brain, head, and neck, whereas CyberKnife is used to treat cancer anywhere on body. -S Medical Management of Metastatic Tumors Treatment Is palliative and involves eliminating or reducing serious symptoms. Therapeutic Approach Radiation therapy Surgery → Single Intracranial Metastasis Chemotherapy GammaKnife Radiosurgery ○ Considered if three or fewer lesions are present ○ Survival rates vary, depending on type and extent of tumor at time of diagnosis ○ The overall prognosis is poor in most cases Nursing Management Monitor for signs and symptoms of ICP Neurological checks Vital signs Help with self care Interventions for safety Monitor for seizures Address emotional issues regarding such a difficult diagnosis Monitor for aspiration or breathing if tumor is near the brainstem ○ Have HOB elevated ○ Turn the patient on their side RNEXPLAINED BRAIN LOBES AND THEIR FUNCTIONS FRONTAL AKA EXECUTIVE FUNCTION Problem solving PARIETAL Concentration & reasoning THINK "Piranha" → the piranha Planning & organizing is biting the parietal lobe which Personality, behavior & mood; regulates emotion is extremely sensitive! Sensations... "piranha" 2. MOTOR AREA Perception → body awareness TWO IMPORTANT PARTS AKA primary motor Attention cortex - controls Calculations 1. BROCA'S AREA voluntary movement Controls expressive speech MAIN FUNCTION: IF DAMAGED, THINK: 1. Sensory Area - processing sensory information! "broken" - can understand Temperature but speech is disjointed Pressure, touch Smell, pain, taste ca NIcKE bro WER OCCIPITAL THINK: OPTIC Visual system TEMPORAL THINK: "TEMPO" Visual information Process visuals + perception of shapes Hearing & attention and sizes Storing verbal and visual memories Short and long term memory BRAIN STEM Helps with some balance THINK: Your ear has hearing and balance Consciousness, breathing, heart CEREBELLUM rate AKA: MINI BRAIN characteristics Understanding language Balance, coordination, rhythm Proprioception Posture, movement IMPORTANT PART 1. WERNICKE'S AREA Receptive speech Controls language comprehension IF DAMAGED, THINK: "Wernicke is crappy" - unable to understand AND respond to what people are saying 55 Increased ICP Intracranial Pressure Pathophysiology Causes Increased pressure within the head compresses Aneurysm stroke: burst blood vessels that ﬁll up the brain with blood. blood vessels leading to cerebral hypoxia & can - Head Trauma or Meningitis: Increased swelling & put pressure on the brain stem - killing the patient. inﬂammation. Tumor: Increased brain tissue Signs & Symptoms Late DEADLY Signs: Lungs: Irregular Respirations Early Sign: NCLEX TIP “Cheyne Stokes Respirations” Moderate Signs: Neck: Altered LOC: Irritability, Nuchal rigidity (stiﬀ neck) Restless Headache - Constant “Can not FLEX chin toward chest” Sudden Vomiting “Emesis” Brain Stem Aﬀected: Decreased Mental Status Eyes Without Nausea = Sleepiness Report to HCP! !!! Pupils “Fixed & Dilated” 8 mm Unequal Flat aﬀect and 8 mm (Normal 2 - 6 mm) drowsiness Doll's eyes: this means Brainstem is intact! If the eyes stay ﬁxed & dilated when the head is turned, it means BRAINSTEM is Critical LATE signs Memory Trick: aﬀected. Foot Cushing triad NCLEX TIP CUSHing triad think Babinski reﬂex (Toes fan out when stimulated = BAD) CRUSHing triad means brain stem herniation! Normal in an infant Wide pulse pressure HIGH BP “Hypertension” below 1 year old, NOT NORMAL in adult! Crushed HR & RR with Seizures & Coma Low HR “Bradycardia” Wide blood pressure Abnormal posturing: Low RR “Decreased Decorticate: arms ﬂex toward core Respirations” SYS 150 DIA 78 Decerebrate: arms ﬂexed out to sides = Far WORSE! PULSC 70 NORMAL HIGH LOW NCLEX Questions Diagnostics ↳ Question: Which client is priority? Imaging - CT scan 1st test - quick easy picture of the brain Answer: - showing the root cause Closed head injury waiting for brain imaging NOT an MRI - they are too long & slow who reports a headache NO lumbar puncture (spinal tap) & emesis of 200 mL ICP monitoring (for long-term patients) without nausea Normal ICP: 5 - 15 mmHg Priority assessment ﬁndings for a HIGH RISK of infection! client recovering from a head trauma? Select all that apply 1. Eyes that move in the opposite NCLEX Questions direction when patient is turned. 2. Extremities that contracted to Client found on the Answer: the core of the body. ﬂoor, appearing Immediate C- Spine 3. Fixed pupils that remain 8mm ↓RR lethargic, bleeding at immobilization & when assessed with a pen light. 4. Level of consciousness that has the back of head, heart CT scan to rule out not diminished since admission. widened ↓BP rate of 45 BPM & a intracranial bleed 5. Grips 5/5 bilateral 6. Toes that fan out when the sole of the foot is stroked. prBus &BP blood pressure of BP 220/88. First action? Increased ICP Intracranial Pressure II Nursing Interventions I Immobilize Head “C-Spine” CI C02 LOW P Positioning S Suctioning HOB - Semi-Fowler’s Head in neutral position Lower CO2 means Lower ICP. 10 Seconds or Less 30 - 35 Degrees or higher Log Roll “As one unit” Carbon dioxide vasodilates the brain resulting in more NO ﬂexion & bending 100% O₂ swelling from more blood extremities before/after suction ﬂow. NO coughing, sneezing, Hyperventilation decreases CO2 by blowing it out blowing nose NO valsalva maneuvers O₂ or holding breath KAPLAN Question HESI Question Client on ventilator... Instruct patient to HESI Question increased PaCO2. The nurse exhale when turning Interventions for increased ICP? Interventions.. increased ICP & receives an order to increase or moving in bed. Select all that apply ineﬀective breathing pattern? the respiratory rate on the Select all that apply Position - Semi-Fowler’s ventilator. This change Suction no longer than 10 seconds Place neck in neutral position should have what change on Teach avoid valsalva maneuver 100% O₂ before and after suctioning the patient’s ICP? Position avoid ﬂexion of hips, Perform neuro checks using GCS Answer: NCLEX Question waist, and neck Decrease the ICP …. Immediate intervention Suction only as necessary but no decrease in carbon when client with ICP longer than 10 seconds dioxide. states… “I will turn cough, & deep breathe” GCS Score: ↓ score is bad !! NCLEX Questions HESI Questions GCS Score Patient replies…. correct name & location, but 15 = Highest Score incorrect year & date. 8 = intubate Snor How should the nurse 3 = lowest score document the patient’s responses? REPORT Decreasing Alert and oriented GCS score! 1 to person and place ‘ a Orientat SCORE: 11 + 1 Treatment: Pharmacology HCP Phenytoin Phenytoin: prevent seizures Steroids: Dexamethasone Phenobarbital Phenobarbital: a barbiturate to decrease brain activity Mannitol: osmotic diuretic #1 drug to know Side eﬀect: edema & s/s of heart failure NCLEX TIP MANNITOL Notes Stroke ‘’CVA’’ Pathophysiology Types of Strokes Cerebral Vascular Accident (CVA) happens when the brain lacks oxygen resulting in long-term permanent TIA - Transient Ischemic Attack - tiny lack of oxygen damage. Typically resulting from a blood clot, narrowed Transient: short time frame blood vessels (arteriosclerosis) or a ruptured blood vessel Ischemic: Low oxygen (aneurysm). Attack: Happens suddenly...TIAs come & go often resolving Causes CVA - Cerebral vascular accident - no oxygen causing long-term damage! #1 Hypertension (Over 140 sys) MOST TESTED Ischemic CVA - Clot = Low O2 (called embolic or thrombotic stroke) Most important to PREVENT a stroke: Hemorrhagic CVA - Bleed = HIGH ICP (from an Take Antihypertensive Meds regularly aneurysm) HESI Question Highest risk for stroke 142/94 mmHg. KAPLAN Question Hypertension = highest risk factor for Tricky NCLEX Question CVA For clients recovering from Stroke with HIGH BP: Smoking: Scars the blood vessels making them weak Hyperlipidemia (HIGH cholesterol) create narrowed blood Over 200 systolic Intervention: vessels Keep Systolic BP above Uncontrolled Diabetes: THICK sugar in the blood puts 170 mmHg for the ﬁrst loads of pressure on the vessels 24 - 48 hours Signs & Symptoms Hemiparesis - Unilateral weakness F A S T Facial & Smile Droop Arm Drift Speech Impairment Time to CALL 911! One-sided weakness “1 sided weakness” CT scan Immediately NCLEX TIP New, Sudden “Arm Drift” NCLEX TIP NCLEX Question Hemorrhagic Stroke Most concerning patient statement with diplopia “Ruptured cerebral aneurysm” and new weakness, & onset Severe headache vomiting without nausea: “I have the worst headache of my life” Stroke ‘’CVA’’ II L R Left Brain Right Brain Language & Logic Reckless & Really Creative Diagnostics NCLEX Question CT scan immediately!!! Teaching for families of patients with right-sided Treatment: Pharmacology brain injuries? Answer: lack of impulse control and behavioral changes. Strokes cause by Clot - Give clot busters Thrombolytics - within ATI Question 4.5 hours of onset of Manifestations of symptoms right -sided hemispheric stroke... tPA Visual & spatial “-as” Alteplase, deﬁcits Streptokinase Left homonymous hemianopsia One-sided neglect tPA Alteplase Streptokinase 2 Tricky NCLEX Questions: Strokes - Hemorrhagic Question 1: Question 2: (no clot busters) Interventions for initial plan Priority nursing action for a Implement seizure precautions of care for a patient with patient with left-sided suspected embolic stroke? - strict bed rest weakness, lack of verbal Select All that Apply response, and drooping face? No Blood Thinners ASPIRIN NO Aspirin & Clopidogrel Obtain a STAT CT Maintain patent airway NO Heparin & Enoxaparin of the head Stats CT scan NO Warfarin Perform neuro NO Thrombolytics Neuro assessment assessment Limit any activity that may Give tPA Prepare to initiate increase ICP: alteplase within Administer PRN stool softeners daily 4.5 hours of to prevent straining & bearing down symptoms onset during bowel movements Stroke ‘’CVA’’ III Patient Education H HEMIANOPSIA Half Vision Loss C COMMUNICATION KEY TERMS Risk of Self Neglect Broca Aphasia - “Expressive” Eat “Dress the weaker side ﬁrst” Meat “Apply clothing on aﬀected side ﬁrst” Easily frustrated (attempting to speak) Safety Speech limited to short phrases “Scan surroundings” “Turn head to aﬀected side” Wernicke Aphasia - “Receptive” KEY TERMS ???... Misunderstanding to verbal cues Unable to comprehend speech Right Side - Reckless Lack of impulse control Behavioral changes Educate family that behavioral changes are expected ATI Nursing Interventions Priority ﬁnding patient recovering from stroke... F FEEDING Dysphagia with a regular diet ordered NPO until swallow screen is performed Eating KAPLAN 1. “Flex neck” while swallowing Priority intervention for a patient with 2. AVOID sedation meds before meals right-sided hemiplegia, and inability to eat without assistance... 3. HOB Up - High Fowler's “Upright” Answer: pureed diet for client with 4. Dysphagia (diﬀ. swallowing) dysphagia Puree diet - NOT regular diet Add thickening agent to ﬂuids Prevention of sensory overload in client AVOID with stroke? Seizure precautions Answer: Obtain vitals and assists with Frequent neuro assessments morning care in one visit Cluster Care (prevents sensory overload) Transferring A W B I Use a transfer belt Safe transfer from Bed to Chair (ALWAYS transfer toward the STRONGER SIDE) AVOID completing tasks for the client Big No Nos! (to promote independence) 1. Patiently allow time to understand each instruction DO NOT - complete tasks for the client! Allow them to learn DO NOT - speak loud, speak normally - allow time for client to 2. Simple gestures (point) & Show Pictures! RESPOND Example: shower, toilet, toothbrush DO NOT - give complex instructions or questions - simple yes 3. Ask Yes or No questions or no questions Normal voice - Not Loud... Seizures Pathophysiology Causes Sudden, uncontrolled electrical discharges Anything that can cause brain swelling or hypoxia in the brain. Epilepsy is lifelong episodes Infection: meningitis of seizures. Trauma: TBI, Concussion Memory Trick Brain mass: BRAIN tumors ePILEpsi - like a PILE of seizures that Increased ICP Fever in infants = “febrile seizure” come & go over a lifetime Withdrawal from drugs & alcohol Types of Seizures Generalized Partial “Focal” Tonic - Tight & Tense - Tonic Simple: Fully conscious Clonic - convulsions, Complex: impared or Loss of contraction - clonic clicking Consciousness Tonic Clonic - tight & convulsions Lip smacking Atonic Biting Myoclonic Picking Absent - “spaced out” HESI Question Kaplan Question Phases of tonic clonic seizure? Care for a child with a history Loss of consciousness of absence seizures… Pt. Falls to ground Body stiﬀens for 10-20 seconds Monitor for brief interruptions Extremities jerk for 30-40 seconds in consciousness Pt. feels tired and sleepy Triggers S S S S S Stress Sleep deprived Strobe lights Stimulants Sugar - fatigue ﬂashing lights & Sodium LOW Sugar: NCLEX TIP below 70 (Hypoglycemia) Sugar Memory Trick: think hypogly Na+ brain will die HESI Sodium: below 135 (Hyponatremia) Warm, Stages or moist of Phases heat to CN VII Seizure Prodromal phase Warning signs before a seizure leading to Aura Phase Aura phase NCLEXKAPLAN TIP Visual, auditory clue that happens prior to a major seizure Ictal phase = Seizure Phase THINK ignition phase - the period of the active seizure. Postictal Phaseaction: Priority Hangover Assessphase the after the seizure - think POST-ignition phase Confused, disoriented, patient’s pain major headache, & typically feels tired or sleepy Seizures II Kaplan NCLEX Questions: Aura: Unusual sensations prior to the seizure ? Kaplan Scenario: Client with seizure disorder tells the This is documented as: History of epilepsy who nurse “I smell oranges and there aren’t Postictal phase reports having an aura any on my tray” What is the best response? Prodromal Aura Ictal Postictal “Have you experienced this sensation before?” Status Epilepticus Diagnostics MEDICAL emergency!! NCLEX TIP MRI or CT - to look for abnormalities. Key points EEG - electroencephalogram NCLEX TIP 5 min. or longer for 1 seizure, or Assesses electrical activity in the brain by 30 min. Repeated seizure activity placing sticky electrodes on the scalp #1 Priority = STOP the Seizure Wash Hair (before/ after) to make sure it sticks (after airway and breathing are secure) NO Caﬀeine (tea, coﬀee, soda) or stimulants: IV or Rectal benzodiazepine 12 - 24 hours before Lorazepam (brand: Ativan) NO Seizure meds Diazepam (brand: Valium) NO Sleep - Sleep deprivation is BEST YES Eat before test - no need for NPO 1ST Memory trick EEG think of EGG head - electrical activity of the EGGhead ECG - C think C - Cardiac rhythms Interventions during SZ #1 - Airway Turn client to side NCLEX TIP Prepare for suctioning NEVER insert anything in the mouth! NEVER restrain or “Hold down arms” Call for help & Stay with Client #1 Drug = STOP the Seizure Lorazepam (brand: Ativan) #1 Diazepam (brand: Valium) Rectal or IV Loosen restrictive clothing (Neck & chest) Safety Pharmacology Protect - Clear area for any objects Pad Side Rails Anticonvulsants AFTER seizure activity - Phenytoin: Toxic Over 20 hold med Record Time - Levetiracetam: Driving permissions Assess LOC, Neuro, Vitals from HCP Prepare for suctioning Palliative Care & Neutropenic Precautions Med Surg: Oncology (Cancer) Palliative Care & Hospice - Terminal Cancer Clients who will pass away from untreatable cancer will typically go home on hospice care for comfort. Palliative care is delivered by a team of medical professionals & goals of care must be set up. Decision making KAPLAN Family should participate in Client who has terminal cancer… tells the decision making nurse “I wish I could stop these treatments, I am ready to die.” Which of the following Patient’s ultimate choice statements should the nurse make? Intense psychosocial support “Discontinuing the treatments is your choice if you choose to do so” Therapeutic communication: factual, open, and honest H OICE LT I M ATE C U Neutropenic Precautions Neutropenia is the very low white blood cell (WBC) count - normally 5,000 - 10,000. This happens when clients with cancer undergo chemotherapy & radiation which kill the cancer cells, but also kill the bone marrow where WBCs are produced. Clients have HUGE risk for infection! Bone Marrow Interventions SAUNDERS HESI Client receiving chemotherapy... the white blood A patient about to undergo chemotherapy.... 2 BIG TEST TIPS cell count is extremely low and places the client Which expectations will the nurse have when on neutropenic precautions. Which interventions providing care to this patient? are components of these types of precautions? 1. NO Fresh Flowers, Select all that apply. Fresh ﬂowers should be discouraged from or Fresh Fruits Removing fresh-cut ﬂowers from the the room of a patient with neutropenia clients’ room 2. AVOID crowds Instructing family members on the proper & sick people! technique for handwashing KAPLAN Instructing family members to wear a mask 3. FEVER is a priority to enter the client’s room Q1: The nurse is planning care for a client with OVER 100.3 F (38 C)!!! neutropenia due to chemotherapy. Which intervention should be included? NCLEX TIP Monitor the client’s temperature every 4 hours Neutropenic precautions Q2: Client who is receiving chemo... Which of the following ﬁndings should the nurse identify as priority? Report of sore throat Brain Tumors Pathophysiology Course Pathophysiology A brain tumor is a mass or growth of abnormal cells in the brain. Benign: Noncancerous Malignant: Cancerous Causes & Manifestations Primary malignant brain tumors: Very invasive & diﬃcult to remove Causes (etiology) Prenatal exposure to carcinogens & embryonic development Adults: Don't know predisposing factors Manifestations (signs & symptoms) 1. Seizures 2. Signs of increased ICP Headache Vomiting Mental status changes “Change in mental status” 3. Death before general Signs & Symptoms (manifestations) Notes Osmotic Diuretic Mannitol Drug name: ATI Mannitol MANNITOL Give Mannitol for increased ICP Assess LOC every hour Indication: Decreases cerebral edema resulting in increased ICP: head injury, brain swelling, etc. HESI Decreases intraocular pressure - glaucoma emergencies Mannitol: Used to decrease ICP IV admin - cannot be given PO ESSURE Side eﬀect - Edema PR Begins 30 - 60 minutes Memory Trick: after administration. - Mannitol - Man ICP hurts or Man Eyes hurt ATI MANNITOL Mannitol Monitor for s/s heart failure: Bibasilar crackles, pulmonary edema MOA: Side Eﬀect: Drains ﬂuid out of brain cells & into vascular space = HIGH RISK for ﬂuid volume overload (too much ﬂuid in the body) Heart Failure Heavy Fluid Heart failure HF = Heavy Fluid all over the body Notes

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