Neurology Medical-Surgical (PDF)

Neurology Decorticate positioning Arms bent, legs straight, stiff Key Words Damage to cortex Aphasia- inability to speak Dysp...

Neurology Decorticate positioning Arms bent, legs straight, stiff Key Words Damage to cortex Aphasia- inability to speak Dysphasia- difficulty speaking Decerebrate positioning Arms and legs straight Dysarthira- slurred speech Severe damage to cerebellum or brain stem Apraxia- inability to perform movements or tasks Seizures Tonic- stiff then loss of consciousness Clonic- body spasms Myoclonic - quick muscle jerk Atonic - sudden lack of muscle strength Postictal phase - occurs after a seizure and ends when pt is back to baseline Status epilepticus Seizure lasting more than 5 min or having multiple seizures without regaining full consciousness Convulsive vs nonconvulsive Convulsive - most dangerous; tonic-clonic seizures Seizure Nursing Interventions (NI): help pt lay down, place on side (to maintain airway), loosen tight clothes, give O2, record seizure duration Strokes Risk factors: hypertension, atherosclerosis, history of strokes, diabetes, smoking S/sx: motor loss (hemiparesis or hemiplegia), communication loss (dysphasia, dysarthria, apraxia, aphasia), vision changes, decreased mental acuity Start rehabilitation as soon as patient is stable NI: control BP, neuro assessment, position pt to decrease edema, bed rest, stool softeners Ischemic Stroke; TIA Hemorrhagic Stroke Blockage of blood flow to brain due to clot Brain bleed due to ruptured blood vessels NI: give TPA within 3-4 hours of symptoms Anticoagulation therapy is contraindicated Aneurysm Bulge in a blood vessel that can lead to rupture → hemorrhagic stroke S/sx: vision changes, headache, nuchal rigidity, dizziness NI: promote calm environment, bed rest Parkinson’s Disease Central nervous system disorder that affects motor ability due to low dopamine levels S/sx: tremors, pill rolling movement, rigidity, stooped posture, bradykinesia, difficulties with gait NI: promote pt safety, schedule activities later in the day (conserves pt energy to perform self-care activities), calm environment, soft diet, physical therapy  Neurology Increased ICP Cushing's Triad Pressure builds in the skull; blocking brain circulation Sign = Cushing's Triad, change in LOC or pupil size, headache, Bradycardia blurry vision, vomiting Hypertension NI: elevate HOB 30 degrees, keep body midline, promote calm environment, give stool softeners, tell pt to avoid Wide pulse Valsalva maneuver pressure Meningitis Inflammation of the membranes surrounding the brain and spinal cord Caused by viral, bacterial, or fungal infections Early warning signs: photophobia, drowsiness, confusion S/sx: nuchal rigidity (stiff neck), Brudzinski’s (when pt neck is flexed → flexion of knees & hips) and Kernig’s sign (pt unable to straighten leg when hip is flexed), fever, headache, muscle pain Diagnostic test: Cerebrospinal fluid test If positive, CSF will have high protein and low glucose NI: give abx, Droplet/contact precautions, neuro assessment, vital signs, keep environment dark and calm, seizure precautions Guillain Barre Immune system attacks it’s own nerves, causing ascending paralysis S/sx: paresthesia (numbness and tingling), difficulty breathing, pain, vision changes NI: Assess respiratory status, mechanical ventilation may be needed Multiple Sclerosis Chronic disease that affects the brain and spinal cord; more common in women Immune system attacks myelin sheath → breakdown of communication between neurons Bladder and bowel dysfunction occurs in most cases S/sx: numbness, vision problems, slurred speech, fatigue NI: promote tolerable exercises, implement rest breaks, create voiding schedule, high fiber diet and fluid intake Myasthenia Gravis Muscle weakness and fatigue of voluntary muscles; d/t issues concerning ACh Improves with rest and worsens with physical activity S/sx: diplopia (double vision), ptosis (eyelid drooping), weakness, breathing issues NI: assess respiratory status, have trach kit at bedside, administer cholinergic meds, cluster care (to conserve pt energy), encourage deep breathing and coughing Myasthenia Crisis Medical emergency due to worsening muscle weakness, causing respiratory failure Caused by undermedication, stress, or infection S/sx: worsening MG symptoms Diagnostic: positive Tensilon test Cholinergic Crisis Occurs when there is excessive acetylcholine (ACh) in the neuromuscular junction Typically caused by too much anticholinesterase medication (given in myasthenia gravis) S/sx: cramps, diaphoresis, diarrhea NI: give antidote = atropine sulfate  Neurology Amyotrophic Lateral Sclerosis (ALS) Progressive muscular disease caused by the degeneration of nerve cells Affects voluntary muscle movements, such as walking, breathing, and talking NI: assess respiratory status, encourage PT/OT/SP Autonomic Dysreflexia Medical emergency seen in spinal cord injuries - T6 or higher S/sx: severe hypertension, bradycardia, sweating, anxiety, headache Nursing: elevate HOB to 90 degrees, remove tight clothing, administer antihypertensive medications Basilar Skull Fracture Fracture of one of the bones at the base of the skull S/sx: Bruise behind ear (battle sign), periorbital hematoma (raccoon eyes), halo sign, hearing loss NI: assess ABC, neuro exam, GCS, CT scan Wernicke’s Encephalopathy Neuro disorder characterized by low thiamine (Vitamin B1) D/t alcohol abuse, eating disorders, or chemo C S/sx: confusion, ataxia, abnormal eye movements Spinal Cord Injuries If injury is between: T1 - L4 - Paraplegia T C1 - C8 = Quadriplegia C2 - C3 = Typically fatal C4 and above = require ventilator NI: assess respiratory status, neuro checks, immobilize pt on backboard, keep body midline L S