MSII Neurologic Disorders Checklist PDF

Review CNS Anatomy & Physiology Review Neurologic Assessment - Mental status - General Appearance - Cognition - Affect, mood - Strength, coordination, muscle ability, ROM, & sensation - Cranial nerves - Motor system - Strength & tone co...

Review CNS Anatomy & Physiology Review Neurologic Assessment - Mental status - General Appearance - Cognition - Affect, mood - Strength, coordination, muscle ability, ROM, & sensation - Cranial nerves - Motor system - Strength & tone coordination - Sensory system - Touch, pain, temperature - Vibration & position sense - Reflexes Review pupil assessment and documentation Review stroke Review seizures - Causes of seizures - Systemic & metabolic - Acidosis - Electrolyte imbalance - Hypoglycemia - Hypoxia - Drug & alcohol withdrawal - Dehydration - Identify cause & ASAP and treat it - Epilepsy - Spontaneous - Recurring - Underlying issue! - Understand the trigger - Pt usually get an aura like a metallic taste in mouth, blurry vision - Clinical - Generalised - Both sides of the brain - No warning - Tonic-clonic (grand mal) - Tonic stiffening, fall - Clonic - jerking - Typical absence aka petit mal - Smaller motions, zoning out or no responses - Partial - Focal irritant  - Simple partial - Complex partial - Psychogenic - Complications - Physical - Status epilepticus - Emergency!! - IV ativan or valium STAT - Short-acting, but give long-acting also - Social - Stigma - Lifestyle changes - Coping mechanisms - Treatments - surgery/other - Resection of epileptic foci - Before surgery: - Confirm dx - Trial of drugs done - Type of seizure known - Benefits - Stop or reduce freq - Vagal nerve stimulation - Biofeedback - Meds - Valproic acid (depakote) 50-100 - Phenytoin (Dilantin) 10-20 - Phenobarbital 10-20 What is intracranial pressure (ICP) - Hydrostatic force measured in the brain CSF compartment - Total pressure exerted by the 3 components of the skull: the brain tissue, blood, & CSF - Primary injury - MVC, blunt trauma, local injury - Secondary injury - Resulting hypoxia, ischemia, edema, IICP - Hours to days after initial injury - Nursing management is important - Factors affecting ICP - Arterial & venous pressure - Intra-abdominal and intrathoracic pressure (position pt in ways to reduce→ elevate the head) - Posture - Temperature - Blood gases (increase in CO2 causes vasodilation) → try to decrease What components of the cranium contribute to ICP - Total pressure exerted by the 3 components of the skull: the brain tissue, blood, & CSF What is increased intracranial pressure (IICP) - An acute unconscious pt = increased ICP until proven otherwise - First sign of IICP is a change in mental status & loss of consciousness - Goals - Preseve cerebral O2 perfusion - ID neurologic changes - Prevent complications - Cerebral edema - Increased accumulation of fluid in extravascular space of brain tissue - An increase in tissue volume leads to IICP - Life-threatening - Types of edema - Vasogenic - Cytotoxic - Interstitial - Normal ICP: 5-15 mmHg What are the causes of IICP - Factors affecting ICP - Arterial & venous pressure - Intra-abdominal and intrathoracic pressure (position pt in ways to reduce→ elevate the head) - Posture - Temperature - Blood gases (increase in CO2 causes vasodilation) → try to decrease What are the signs and symptoms of assessments for IICP - Level of consciousness is the FIRST SIGN - Impaired cerebral blood flow → decreased O2 - Headache - Can quickly progress to coma and death - Compression of arteries, veins, & CN - Vomiting - Nonspecific and without food - No nausea - Change in VS - Increased pressure in the thalamus, hypothalamus, pons, & medulla - Cushing’s Triad - Altered temperature - Ocular - Compression of CN III (II, IV, VI) - Shifting brainstem - Herniation - Decrease in motor  - Contralateral hemiparesis or hemiplegia - Decorticate (flexor) in cerebral cortex - Decerebrate (extensor) midbrain & brainstem - Complications - Inadequate cerebral perfusion - Cerebral herniation - Herniation - when a mass in the cerebrum forces the brain to herniate downward through the brainstem - Tentorial (brain stem down) - Uncal (combo of tentorial & cingulate) - Cingulate (side to side) How can you prevent IICP - What is head trauma - Scalp lacerations - Monitor for blood loss and infection - Result in profuse bleeding due to the poor vasoconstriction of the blood vessels of the scalp - Skull fractures - Basilar skull fracture: base of skull - Battles sign, periorbital ecchymosis - Associated with a tear of the dura and leakage of CSF from nose or ears - Test with dextrostix to determine if glucose is present (if clear check glucose levels) - If blood is present, test for the halo (blood centralizes, fluid around it) or ring sign - linear/depressed - simple/comminuted - Closed or open - Monitor cranial infection (if exposed) or hematoma - Brain might be damaged - Pt can have localized pain at the site of the fracture & swelling can occur - Nurse should be alert for drainage from the ears or eyes (can be CSF) - Minor head trauma - Concussions - Postconcussion syndrome - Includes persistence of cognitive and physical manifestations for an unknown period of time - Occurs after head trauma that results in a change in the pt’s neurologic function but no identified brain damage and usually resolved within 72 hours - Major head trauma - Contusion  - When the brain is bruised and the pt has a period of unconsciousness associated with stupor and/or confusion - Lacerations - Skull fractures What risks are associated with head trauma - Motor vehicle or motorcycle crashes - Illicit drug & alcohol use - Sports injuries - Assault - Gunshot wounds - Falls What assessments and interventions for head trauma - Expected findings - Amnesia (loss of memory) before or after the injury - Loss of consciousness: length of time the pt is unconscious is significant - CSF leakage from the nose and ears can indicate a basilar skull fracture - Test for the halo signs - Manifestations of IICP - Severe HA, N/V - Deteriorating LOC, restlessness, irritability - Dilated or pinpoint nonreactive pupils - Cranial nerve dysfunction - Alteration in breathing pattern - Deterioration in motor function, abnormal posturing - Cushing's triad - Seizures - Respiratory: tachypnea, irregular breathing patterns, apnea - Treatments - Airway and O2 are NUMBER 1 PRIORITY - Immobilize c-spine - IV with caution - Don’t fluid overload, IICP - Temperature - NO SHIVER OR HYPERTHERMIA - Keep pt warm but prevent fever - Monitor - VS, LOC, GCS, pupils - Anticipate intubation How do you determine if otorrhea or rhinorrhea have CSF in them - Halo or ring sign What are the treatments for IICP - Drugs - Mannitol  - Osmotic diuretic → helps decrease the amount of fluid circulating and can help draw some of the edematous fluid and tissue into the vascular space to remove - Hypertonic saline - Helps draw fluid into the vascular space - Decadron - For tumors & abscess’ - Barbiturates - Dilantin - For prevention - Hyperventilation therapy - CO2 60) What is a craniotomy - Removal of nonviable brain tissue that allows for expansion and/or removal of epidural or subdural hematomas - Used to decrease ICP and to remove tumors - It involves drilling a burr hole or creating a bone flap to permit access to the affected area What risks are associated with a craniotomy - What assessments and interventions for a craniotomy - Nursing interventions - Medications (mannitol and dexamethasone) can be administered every 6 hr for 24 to 72 hr postoperatively. - Phenytoin or diazepam can be used to prevent seizure activity. - Monitor ICP. Follow written protocols to assess for changes in ICP. - For supratentorial surgery, maintain HOB at least 30° with body positioning to prevent increased ICP. - For infratentorial craniotomy, keep client flat and on either side for 24 to 48 hr to prevent pressure on neck incision site.  - Calm and reassure clients, clarifying misconceptions (brain surgery can be an extremely fearful procedure). - What is a Burr hole - Burr holes are circular openings through the skull - The burr hole is used to assess cerebral swelling, injury, size, and position of the ventricles What risks are associated with a Burr hole - What assessments and interventions for a Burr hole - What is a VP shunt - What risks are associated with a VP shunt - What assessments and interventions for a VP shunt - What is a brain tumor - Types - Gliomas (65% of most brain tumors) - Astrocytoma (from astrocytes) - Glioblastoma multiforme (most common) - Meningioma - 50% malignant - Classified from tissue they originate in - Do NOT respond to surgery What are the signs and symptoms of assessments for a brain tumor - Headaches NUMBER 1 - Seizures from IICP - N/V with or w/o food - Memory and mood issues - Changes in mood, & physical function - Aphasia (lack of speech) - Sensory & motor issues - Dysarthria - Dysphagia - Positive Romberg and Babinski sign - Vertigo - Hemiparesis - Cranial nerve dysfunction - Papilledema - Assessment - Ask about medical hx  - Hx of dementia? Loss of emotional control, confusion, disorientation, memory loss, impulsivity, and depression - Assess pt’s LOC, motor abilities, sensory perception, integrated function (bowel/bladder), balance & proprioception - Determine the presence of seizures, syncope, N/V, HA, and other pain - Nursing management - Baseline neuro status (#1 priority) - assess LOC frequently - Support pt and family - understand changes - Behavior/personality changes are drastic - Confusion (BIG safety risk) - Perceptual problems - Keep the same routine - Frequently orient - Minimal stimuli - Seizures - Meds - Safety - Safe position - ALWAYS note time and type of seizure - Language (dysphagia) - RN must establish a system to communicate - Nutrition - Monitor and assist with feeding - May need a G-tube - BIG aspiration risk - Care of pt with cranial surgery: - Care & compassion - Pre-op teaching - Post-op - Prevent increased ICP (LOC, pupils, pain (e.g. HA) - I/O - Serum osmolality (prevent fluid overload) - No lying on back and no flexion of the neck (can increase ICP) - Dressing - Monitor for pain & N/V (increased BP leads to IICP) - Lifestyle changes What are the treatments for brain tumor - Surgery - Complete removal or reduce the tumor/relieve sx (in conjunction with radiation or chemo) - Shunts (internal or external) - Craniotomy - Stereotactic surgery - Precise!!!  - Targets tumor (reduces) & biopsy - Computer guided - Radiation - Follow-up to surgery - Stereotactic radiosurgery (cobalt radiation) - Seeds (help kill tissue around the tumor) - Complications - IICP - Cerebral edema (from steroids) - Chemotherapy and targeted therapy - Nitrosoureas - Intrathecal (through the spine) - Oral - Temozolomide (Temodar) - US - MRI & CT with contrast used to identify the lesions’s location - Mapping - Radiation & stereotactic radiosurgery - Follow-up to surgery - Stereotactic radiosurgery - Seeds (help kill tissue around the tumor) - Complications - IICP - Cerebral edema (from steroids) - Chemotherapy & targeted therapy - Nitrosoureas - Intrathecal (through spine) - Oral (temozolomide) Why is a headache an important sign to evaluate with a patient with a brain tumor - Is it your typical HA? - OLDCART - Triggers - Coping mechanisms - Relaxation techniques - Diet - Exercise - Pt teaching - When to contact the provider if there is a hx of trauma/cancer/IICP What is Guillaume Barre syndrome (GBS) - Cell mediated immunologic reaction at peripheral nerves; myelin damage - Triggers: viral, trauma, surgery, HIB (1-3 weeks) - Bilateral - Equal descending loss of muscular function - Symptoms  - Acute, ascending, rapidly progressing, symmetrical weakness of limbs - Pain! - Worse at night - Weakness in lower extremities - Bilateral (hours - 14 days) - Paresthesia & paralysis - Hypotonia (loss of muscle tone) - Areflexia (no typical reflexes) - ANS dysfunction - Orthostatic, high BP, low HR, heart block, asystole - bowel/bladder dysfunction, facial flushing, diaphoresis - SIADH (trigger) + fluid overload - Facial weakness - Complications - Respiratory failure - Monitor RR, pulmonary function, & fever - Diagnositc - Hx, clinical, CSF, EMG, MRI What risks are associated with GBS - Ventilation-respiratory failure - Monitor RR, pulmonary function, & fever What assessments and interventions for GBS - Management - Supportive tx - Tx within 2 weeks - Ventilation-respiratory failure is a common complication - Plasmapherisis (plasma exchange) - IV high dose immunoglobulin - Sandoglobulin - Hydrate!! - Normal BUN/Cr - Diet - Monitor weight, albumin, calorie counts - Dysphagia is a risk - Upright posture - Tube feedings - TPN - Nursing interventions - Ventilation - ABGs, vital capacity, bronical hygiene, chest PT - Intubation, sputum cultures - Aspiration - Assess gag reflex & drooling - Pain  - Communication - RN verbalize eveyrthing - Diet - Assess secretions, drooling - Bowel regimen - Tube feeds, TPN, F/E imbalances - Make sure they can clear their own airway - Physical - PT, ROM, eye care (aritifical tears) - might not be able to blink on their own - Urinary retention - Foley with large amounts of fluid What is Multiple Sclerosis (MS) - Autoimmune disease with autoreactive t-cells - T cells migrate to CNS, disrupt BBB, & demyelinate nerve fibers - Antigen-antibody reaction activates demyelination - Lose myelin, excess astrocytes - Plaque and scar tissue forms in CNS - Myelin CAN regenerate (remission) - Nerve impulses slow, blocked, or absent - Progressive disease!! - Viral or genetic - Symptoms - Motor: - Weakness/paralysis limbs, trunk, head - Diplopia - Speech changes - Muscle spasticity (increased risk for falls) - Sensory - Paresthesias (numbness), blurred vision, tinnitus, decreased hearing, neuropathic & radicular pain - Cerebellar - Ataxia, dysarthria, dysphagia, cognitive dysfunction, memory impairment - Fatigue, depression, self-esteem issues - Diagnostics - Hx & PE - CSF, MRI, CT - Surgical interventions - Meds - Immunomodulators (B-interferon) - Cholinergic (UA retention) - Corticosteroids - Anticholinergics (UA frequency/urgency)  - Muscle relaxants - Antiviral/antiparkinson, CSN stimulants - Nursing mngt - Maximize ADLs - Maintain independence! - Manage fatigue - Social well-being - Slow exacerbations - URIs, UTIs, stress, temp (sx of infection) - Spacing out activities - Reduce risk of infection - AIRWAY!!! At risk for aspiration What is Amytrophic Lateral Sclerosis (ACLS) or Lou Gerrig’s Disease - Progressive neurological disorder (loss of motor neurons) - Motor neurons in the brain and SC gradually degenerate - Dead neurons can’t produce or transport nerve impulses - Muscles cannot be activated - Pt remains cognitive during deterioration - Death occurs secondary to URI due to compromised respiratory system function - Clinical manifestations - Limb weakness - Dysarthria (difficulty moving joints) - Dysphagia - Muscle wasting and fasciculations (small muscle twitching) - Pain - Sleep disorders - Spasticity - Depression/emotional lability What risks are associated with ACLS - Risk of aspiration - Risk for falls What assessments and interventions for ACLS - Nursing considerations - Facilitate communication - Reduce risk of aspiration - Early ID or respiratory insufficiency - Treat pain due to muscle weakness - Decrease risk of injury and risk for falls What is Bacterial Meningitis - Acute inflammation of meningeal tissues surrounding the brain and SC - Usually secondary to viral respiratory infection - H. influenza, strep - Medical emergency - Can be treated with abx, but if untreated → 100% mortality rate - Symptoms  - Inflammatory process (IICP) - Fever - HA - N/V - Nuchal (neck) rigidity - Photophobia - Decreased LOC = IICP - Can lead to coma & seizures - Skin rash & petechiae - Non blanchable What risks are associated with Bacterial Meningitis - Due to IICP & cranial nerve dysfunction - Diplopia, blindness - Impaired ocular motor, ptosis, unequal pupils - Tinnitus, vertigo, hearing loss - Hemiparesis, dysphagia - Most resolves with tx - Deafness may be permanent - DIC and circulatory collapse if untx - DX: CSF, respiratory and blood cultures What assessments and interventions for Bacterial Meningitis - Treatments - Medical emergency - Rapid diagnosis and tx are key to recovery - Usually advanced when entering healthcare - Abx: ampicillin, penicillin, vancomycin, cephalosporins - Corticosteroids, defamethasone - Reduce stimuli - Treat fever - Prevent seizures & shivering - IVF - Adequate rest & nutrition