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Neuro Test
Palestine Neuro Test - Ch. 47, 48, & 50
| Question | Answer |
|---|---|
| Neurological assessments = LOC, VS, Pupil response to light, extremity strength and movement, sensation | |
| Hx of Pt = S/S, medication use, surgical hx, family hx, life style, What's up? | S/S of IICP = Restlessness, irritability, hyperventilation, pupil changes, Cushing's response and decreased LOC b/c cerebral cortex func. is impaired. |
| Neurological Subjective status = Mental status, intellectual function, thought content, perception, language ability, memory, and pain | Causes of IICP = Brain tumor, brain trauma, or intracranial hemorrhage |
| Neurological physical assessment = LOC, mental state examination, pupillary response, muscle function, cranial nerve func. | Ways to monitor ICP = External Ventricular Drain, Subarachnoid Bolt, Intraparenchymal Monitor |
| Cranial nerves = (1)Olfactory-smell, (2)optic-sight, oculomotor-movement of eyeball and constriction of pupil, (4)trochlear-movement of eyeball, (5)trigeminal-sensation in face, scalp, and teeth, & contraction of chewing muscles, | (6)abducens-movement of eyeball, (7) facial-sense of taste, contraction of facial muscles, and secretion of saliva, (8)vestibulocochlear-sense of hearing, and sense of equilibrium, (9)glossopharyngeal-sense of taste, saliva, cardiac, resp., & BP reflexes. |
| (10)vagus-cardiac, resp., and BP reflexes, sensory & motor to lanrynx, decreases HR, contraction of alimentary tube,(11)accessory-contraction of neck and shoulder muscles, motor to lanryx/speaking (12)hypoglossal-movement of tongue | |
| Glasgow coma scale = used to assess LOC/ assesses 3 parameters of consciousness: eye opening, verbal response, and motor response/ ranges from 3-15; <7=comatose; 15= A&O x4; 13-14 =milds head injury; 9-12=moderate; 8 or below=severe pg.1047 Med Surg | Glascow Coma Scale (3-15) – opening eyes (1-4), best verbal response (1-5), best motor response (1-6), < 8 indicative of coma |
| 5 P's for physical neurovascular assessment = Pain, Pulse, Pallor, Paresthesia, Paralysis | Cushing Triad – ICP > 20 cause widening pulse pressure (seen w/ herniation), bradycardia, irregular respirations (cheyne stokes where rapid & then absent breathing), cannot control temp (cannot get it down, neuro not bacterial problem) |
| Abnormal Posturing - Flexor posturing= Decorticate - flexion of the arms at the elbow and bringing the hands up toward the chest with the legs extednded. Cerebral Cortex Disfunction / GCS of 3 | Bacteria causing meningitis = Meningococcus & Pneumococcus |
| Abnormal posturing - Extensor posturing = Decerebrate - both of upper and lower extremities are extended and the arms are internally rotated. Damage to brain stem/ GCS of 2 | Virus causing meningitis = Haemophilus Influenzae |
| Abnormal posturing - Flaccid= | Expreseeive Aphasia = unable to speak bc of a stroke |
| Pupil Assessment = PERRLA = Pupils, Equal, Round, Reactive to Light, Accomadation | Anisocoria = pupils are unequal in size |
| Normal range for ICP = 0-15mm Hg | Nustagmus = involuntary movement of the eyes (Common causes are Dilantin toxicity and injury to the brainstem) |
| FACTORS THAT INFLUENCE ICP: | a)Arterial Pressures – btw 50-150, make sure blood flow to brain sufficient |
| b)Intra-Abdominal Pressure – pushes pressure into lung -> increased intrathroacic pressure -> increased brain pressure. Nursing – monitor BS, NGT, make sure not constipated, monitor BM, keep abdomen deflated | c)Venous Pressure – w/out enough fluid then hard to maintain ICP. Nursing – monitor I&O, daily weights |
| d)Intrathoracic Pressures – lungs, < 8 glasgow then on ventilator. Prevent – pain, coughing, sneezing, straining, Valsalva, suctioning | e)Posture – flat, 30o & head straight & midline |
| f)Temperature – inc temp, if feel cold -> shiver -> inc ICP. Nursing – Tylenol, cooling blanket | g) CO2 Levels – ventilator pt need to monitor ABGs, high CO2 dilate blood vessels -> blood congestion -> inc stuff -> inc ICP; normal – 35-45 |
| h) O2 Levels – O2 sat 100% good & want this | |
| S/S of IICP: | a)Changes in LOC – sensitive indicator |
| b)VS Cushing Triad Changes – ICP > 20 cause widening pulse pressure (i.e. SBP 220, DBP 45-50, seen w/ herniation), bradycardia, irregular respirations (cheyne stokes where rapid & then absent breathing), cannot control temp ( neuro not bacterial problem) | c)Pupil Dilation Ipsilateral to Lesion – see one pupil larger than other; side have bleed on that’s pressing down on nerve will dilate & other side doesn’t, opposite side of motor function. Herniation – bilateral dilation. Sluggish Dilation – inc ICP |
| d)Contralateral Hemiparesis or Hemiplegia | e)Posturing to Noxious Stimuli – decorticate (flexed), decerebrate (serious damage; extension, rotated out, concerned abt motor fibers of brain stem) |
| f)HA – worst HA had in life | g)Vomiting – not associated w/ nausea; can have in some cases but it’s usually neurological |
| h)Hyperventilation | i)Rising temp. |
| Monitoring ICP:External Ventricle Drain- Placing a catheter in the ventricles of the brain (cerebral parenchyma or in the subdural or subarachnoid space) | |
| Collaborative care for IICP Pt:a)ICP <15mmHg, CPP >70-100mmHg (< 50 having injuries to brain tissue, < 30 brain dead) | b)Nursing – elevate HOB & lock out controls, may need mechanical ventilation, frequent VS & neuro checks (1.5 NS or NS, not dextrose) |
| c)Maintenance Of – PaO2 (@ 100%), CO2 (@ 35-45), fluid balance & osmolality (give drugs to dec fluid; diuretics, Lasix), BP (MAP not < 50 or >150) | d)Nutritional Support – start w/in 3 days of admit to ICU, full support by 7th day; do better when fed early, needs abt 100-150x normal person |
| e)Drug Therapy 1) Barbiturates (Pentobaritals, Thiopental) – for coma b/c affects every organs, brain activity diminish to nothing, EGG almost non-existence; use only when cannot get ICP down in any other methods | 2)Osmotic Diuretics (Mannitol) – DOC for diuretics, esp when have ventriculostomy, dec ICP by osmotic diuretics (pull fluid from extracellular space to vascular bed & inc UO) |
| 3)Loop Diuretics Lasix) – cardiac med, will use sometimes; monitor electrolytes (esp K) | 4)Antiseizures (Dilantin) – if have seizure then this wouldn’t be DOC b/c need to get blood level; Valium, Ativan for acute seizures; good for long term seizure activity or Depokote |
| 5)Cortiscsteriods (Decadron) – help w/ inflammation/swelling; hyperglycemia so do blood check6)Prevention of Ulcers (Protonics, Tagamet) – need esp when on ventilators |
Created by:
miller120304
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