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By: Diana Blum Msn NURS 2150 Metropolitan Community College.

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1 By: Diana Blum Msn NURS 2150 Metropolitan Community College

2 Selective Anatomy 12 cranial nerves 31 spinal nerves Neuron transmits impulses to facilitate movement or sensation Meninges serve as protection of the brain and spinal cord Bronca’s area in frontal lobe forms speech Hypothalamus regulates water, appetite, temp CSF: surrounds and cushions brain and cord

3 Physical assessment Orientation LOC Memory ◦ LTM (DOB) ◦ STM (mode of transportation to hospital) ◦ Immediate memory (repeat 3 words after 5 minutes) Attention ◦ Serial 7 test Language/copying ◦ Follows simple commands Cognition ◦ Current events

4 functional Assessment Appearance Speech Motor function Family history Ethnicity Diet ADLs Right handed or left handed ◦ Brain injury is more pronounced in dominant hemisphere

5 Sensory assessment Pain and temp ◦ Cotton ball vs paper clip ◦ Cold vs warm Touch ◦ Pt closes eyes and you touch hand etc and then have them touch where you touched ABNORMAL FINDINGS  Propioception-position sense below injury  Contralateral- loss of sensation in opposite side of body affected

6 Motor assessment Hand grasps Foot strength Arm drift Coordination Gait Balance Reflexes ABNORMAL FINDINGS tremors, weakness, paralysis, jerking muscles

7 Rapid assessment Glascow coma scale: eye opening, motor response, and verbal response ◦ painful stimuli  Supraorbital pressure  Sternal rub  Mandibular pressure  Trapezius squeeze ◦ LOC  Decortication-hands/arms turned in  Decerebration- hands/ arms turned out ◦ Pupil assess  Response to light

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9 The GCS is scored between 3 and 15, 3 being the worst score, and 15 the best. It is composed of three parts: Best Eye Response, Best Verbal Response, Best Motor Response When doing a neuro assessment it is important to watch for trends indicating a decreasing LOC. Keep in mind that when patients have ingested alcohol, mind altering drugs, have hypoglycemia or shock with a systolic BP <80, the GCS may be invalid. 9 to 12 is a moderate injury 8 or less is a severe brain injury. 7 or less = Coma

10 A client has a 5 on the Glasgow Coma Scale. When assessing this client, the nurse would expect what level of consciousness? Sleepy or drowsy Stuporous Fully alert and oriented Comatose

11 This is testable material.. So read CHAPTER 20 That was review from nurs 2520 and A&P

12 Seizures/Epilepsy Seizure: abnormal sudden, excessive, uncontrollable electrical d/c of neurons w/in the brain that may result in altered LOC, motor/sensory ability, and/or behavior. No known cause but may be from tumors

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15 Types of Seizures Tonic-Clonic: lasts 2-5 minutes Rigidity/stiffening arms/legs and Loss of Consciousness cyanosis excess drooling Tonic: loss of consciousness, muscle contraction and relaxation Clonic: rhythmic jerking, may bite tongue, incontinence Post seizure lethargy Absence: more common in kids, runs in families, blank staring, loss of consciousness (resembles daydreaming) Myoclonic: brief jerking or stiffening, symmetric or assymetric movement Atonic (akinetic): sudden loss of muscle tone, lasts for few seconds confusion after seizure. Partial: begin in one part of cerebral hemisphere, most often in adults and are less responsive to medical treatment Complex Partial: blacks out for 1-3 minutes and automatisms present (lip smacking, picking), amnesia after seizure,temporal lobe most affected Simple partial: remains conscious, senses unusual sensation, smell, or pain before (déjà vu). Unilateral movement during seizure, and may have tachycardia, flushing, or psychic symptoms Idopathic: account for ½ of seizures, no known cause

16 Causes Metabolic disorders ETOH withdrawl Electrolyte disturbances Heart disease Altered gene function Defective genes for channels that regulate ions in/out of cell Myoclonus clients are missing cystain B protein Etc. Triggers Physical activity Stress Fatigue Alcohol or caffeine Certain foods

17 Epilepsy Def: chronic disorder characterized by recurrent unprovoked seizure activity. May be caused from abnormality in electrical neuronal activity, abnormal transmitters, or both. Approximately 2 million people in the USA with epilepsy

18 can be defined as abnormal, uncontrolled electrical activity in brain cells. Nerve cells transmit signals to and from the brain in two ways by (1) altering the concentrations of salts (sodium, potassium, calcium) within the cell (2) releasing chemicals called neurotransmitters (gamma aminobutyric acid). The change in salt concentration conducts the impulse from one end of the nerve cell to the other.

19 Types of Epilepsy Primary or idopathic Not associated with identifiable brain lesion Secondary Most common cause is brain lesion, tumor or trauma Status epilepticus Prolonged seizures that last greater than 5 minutes or repeated seizures over the course of thirty minutes. Causes: Med withdrawl Infection Acute alcohol withdrawl Head trauma Cerebral edema Metabolic disturbances

20 CONVULSIVE STATUS EPIEPTICUS IS A NEUROLOGICAL EMERGENCY AND MUST BE TREATED PROMPTLY AND AGGRESSIVELY. Call 911or staff emergency Get airway established if needed by RT, Anesthesia O2 as needed Establish large bore IV access Start NS Get ABGs Transfer to ICU

21 Education of seizure/epilepsy patient Teach importance of taking meds as prescribed Promote balanced diet, rest, and stress reduction techniques Instruct pt. to keep a seizure diary to identify causative factors

22 Phases of seizures Preicteral phase: aura present.. The first phase involves alterations in smell, taste, visual perception, hearing, and emotional state. This is known as an aura, which is actually a small partial seizure that is often followed by a larger event. Ictus: The seizure.. There are two major types of seizure: partial and generalized. What happens to the person during the seizure depends on where in the brain the disruption of neural activity occurs. Postictal state: The period in which the brain recovers from the insult it has experienced. Drowsiness and confusion are commonly experienced during this phase. the period in which the brain recovers from the insult it has experienced

23 TREATMENT Nonsurgical Antiepileptic drugs Seizure precautions During: Protect the client from injury Do not force anything into mouth Turn client to side Loosen restrictive clothes Do not restrain After Take vitals Perform neuro checks Keep on side Allow rest document Teach family Info about disease Info about medication Support groups available Teach about alcohol avoidance To investigate state laws pertaining to driving and working with machinery Care of seizure client

24 Surgical treatment Vagal nerve stimulation For simple or complex partial seizures Stimulating device is surgically placed in the left chest wall with a lead wire on the vagus nerve Activates with hand held magnet Corpuscalostomy Used for tonic-clonic seizures For those not candidates for other surgical procedures Sections of the anterior and 2/3 of the corpus collosum are created to prevent neural discharges

25 Nursing diagnosis Risk for falls Ineffective coping Risk for ineffective breathing

26 HUNTINGTON’S DISEASE Formerly huntington’s chorea Hereditary Transmitted as an autosomal dominant trait at time of conception people in usa have 2 main symptoms are progressive mental status changes and choreiform movements (rapid, jerky) in the limbs trunk and face

27 No known cause No known treatment Only prevention is to not have children Antipsychotics and monoamine depleting agents used to manage movement TX: PT, OT, speech therapy, meal planning by dietician, HHC, social work to line up community resources

28 Osteoporosis

29 Metabolic condition Bone demineralizes Easy to fracture Wrist, hip, and vertebrae are most affected

30 Osteopenia: low bone mass Osteoclasic: bone resorption Decreased bone mineral density 40-45% loss in women throughout lifespan Trebecular (Spongy bone) is lost first Then Cortical (compact bone) lost 2 nd Pathophysiology is unknown

31 classes Generalized:involves many structures Primary: more common Post menopausal women Men in 60s-70s seconday Regional: limb involved r/t fx, injury, paralysis, joint inflammation Immobilization greater than 8-12 weeks Weightless environment (astronauts)

32 Health prevention Teach about exercise Teach about diet rich in calcium Teach about bone health Teach about safety

33 Assessment Risk for falls Head to toe assessment Inspect and palpate vertebrae Assess pain Assess for fallophobia No definitive lab tests Bone scan to check density

34 Nursing diagnosis Risk for falls Impaired physical mobility Acute or chronic pain

35 Interventions Client education is #1 Hormone replacements Calcium supplements Multivitamins Diet Fall prevention Exercise Pain management Braces

36 Osteomalacia Softening of the bone tissue Inadequate mineralization of osteoid (mature compact and spongy bone) Vitamin D deficiency is a key player Similar characteristics with osteoporosis Rare in USA Prevent with vitamin D, sun exposure, and diet

37 s/s: early stages : nonspecific Muscle weakness Bone pain Hypophosphatemia Hypocalcemia Generalized bone tenderness

38 Paget’s Disease

39 Metabolic disorder of bone remodeling Bone deposits that are weak, enlarged, and disorganized Phases: Active  increased osteoclasts cause massive bone destruction Osteoclasts are multinuclear Mixed Inactive  2 nd phase New bone becomes sclerotic and very hard Osteoclasts return to normal amount 2 nd most common bone disease Most common sites are vertebrae, femur, skull, sternum, and pelvis Unknown cause

40 Assessment 80% asymptomatic Assess past history of fractures, skin color and temp, gout, hyperparathyroidism, lethargy, hyperuricemia Pain that is aching, deep, poor description Pain worsens with weight bearing and pressure Pain most noticeable at nite or at rest Arthritis at infected joints Assess posture, gait, and balance Assess vision, speech, and swallowing, hydrocephalus, Neoplasm is the dreaded complication

41 Diagnostics Serum alk phosphate Those treated for paget’s need ALP drawn 3-4 times/year Urine hydroxyproline Shows bone collagen turnover and degree of severity Calcium levels are normal or elevated Increase noted in uric acid May initially be thought to be gout X-rays, CT, MRI, bone biopsy

42 Treatment Drugs for pain relief Drugs to decrease bone resorption Calcitonin (thyroid hormone) Mithramycin (antineoplastic) Biphosphanates Heat therapy Gentle massage Exercise PT Diet Osteotomy or joint replacement

43 osteomylelitis

44 Inflammatory process Increase in vascularity and edema Vessel becomes thrombosed once inflamed Ischemia is next Then necrosis Sequestrium forms and retards bone healing

45 Categories Exogenous: infection enters from outside Endogenous: infection enters from inside Contiguous: results from skin infection The most common offending organism is pseudomonas aeruginosa Staph, salmonella are aslo culprits

46 s/s and assessment Pain Fever Erythema Heat Swelling Assess circulation Assess for septic shock

47 Treatment Contact precautions IV antibx therapy PICC line Use sterile techniques Pain meds Hyperbaric oxygen therapy Bone grafts Muscle flaps Amputations

48 Bone tumors

49 Chondrogenic Osteochondroma: most common, benign, tumor…onsets in childhood, grows until skeletal maturity..has a bony stalk like appearance..may become malignant Chondroma: lesion of mature hyaline cartilage of the hand and feet. Ribs, sternum, spine, and long bones can also be affected…can get at any age or gender

50 Osteogenic Osteoid osteoma: pinkish granular appearance..any bone affected..femur and tibia most affected Osteoblastoma: affects vertebrae and long bones..large in size and lies in spongy bone..reddish granular appearance Giant cell tumor: origin unknown..aggressive and extensive..affects women 20s-30s

51 Assessment/ tx Assess pain Palpate involved area CT scan and MRI done for diagnosis Interventions Meds and surgery combination Pain meds Meds taken with meals or milk

52 Malignant bone tumors Primary: originate in bone / 2 nd ary: mets to bone Primary Osteosarcoma: most common Large lesion, pain and swelling of short duration, warm site, central portion is sclerotic, usually mets to lung in 2 yrs then death Ewing’s sarcoma: most malignant Pain and swelling, fever, anemia, leukocytosis, pelvis and lower extremities most affected, any age..but kids and young adults age 20s more Pelvic yields poor prognosis Chondrosarcoma: dull pain, swelling for long period.. pelvis and femur fore affected Destroys bone and often calcifies Affect middle age to elders and more in men Fibrosarcoma: from fibrous tissue; most common in long bones of legs and mets to lungs Histiocytoma is most malignant type Local tenderness, with or w/o mass palpated

53 Bone Mets Primary tumors are in prostate, breast, kidney, thyroid, and lung Fractures are major problem with management Femur and acetabulum Primarily affects those under 40

54 Assess/ diagnostics Assess pain, swelling, palpate for masses Monitor vs Assess ADLs Assess support structures Assess coping skills Check ALP levels for elevation CT scan Stage tumor

55 Nursing diagnosis/tx Pain Anticipatory grieving Disturbed body image Fear Anxiety Tx Pain management, chemo, radiation, surgery, dressing changes, be active listener, establish goals, safety precautions, HHC

56 Carpal Tunnel

57 Education Use ergonomic work stations Teach client to take regular breaks s/s Parathesia in hands Weak pinch, clumsiness, weakness Hand activity worsens symtoms Swelling may occur Tx: nsaids, surgery

58 Dupuytren’s contractures Slow progressive contracture Common problem Affects 4 th or 5 th digit of the hand Trigger finger release surgery performed to fix

59 Disorders of the foot Hammertoe: fix with surgery Tarsal tunnel syndrome: ankle version of carpal tunnel Plantar fasciitis: inflammation of the plantar fascia located in the arch of the foot s/s: pain in arch, pain worsens w/ wt bearing Tx: ice, rest, stretches, strapping, nsaids, surgery Hallux valgus: aka bunion

60 Associated with 8 th cranial nerve or cellebellum Menieres disease is an example of a disorder of vertigo. most common Ultimately just means dizzy Vertigo

61 The brain Headaches pg 506 ◦ 3 MAIN types  Migraine-genetic predisposition  s/s: sensitive scalp, anorexia, photophobia, N/V  Spasming of arteries at the base of the brain causing arterial constriction, decrease cerebral blood flow, platelets clump, and serotonin released. Other ateries release prostoglandins that cause swelling and inflammation  With aura- sensation that signals onset  Most are without aura  Atypical- less common  Tx: tylenol, migraine medicine, beta blocker, yoga, meditation, relaxation, etc.

62 Cluster headache one sided headache usually felt deep around eye. They come and go Onset is associated with relaxation, napping or REM sleep s/s: ipsilateral (one side) tearing of the eye, rhinorrhea(runny nose), ptosis(droopy), eyelid edema, facial sweating, miosis (abn. Constriction of eye). There may be bradycardia, pallor, increased temp. Tx: same as migraine, wear sunglasses, O2 for 15 minutes, surgery

63 Tension headache Muscle and shoulder tenderness, base of skull and forehead pain. Similar s/s to migraines Classic s/s:N/V, photophobia, phonophobia, aggravates with activity Tx: NSAIDS,muscle relaxers

64 Parkinson’s

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66 Alzheimer’s Disease

67 Stages Early mild Middle moderate Late severe

68 s/s Aggressive Rapid mood swings Increased confusion at nite (sundowner’s) Decrease interest in personal appearance Inappropriate clothing selection Loss of bowel/bladder Decreased appetite

69 diagnosis CBC BMP Folate level checked Thyroid and liver function test Test for syphilis Drug tox screening (OTC) Alcohol screening CT MRI PET EEG

70 Nursing diagnosis Chronic confusion Risk for injury Disturbed sleep pattern

71 Tx Meds Prevent overstimulation Be consistent Reorient Promote independence Bowel/bladder training Promote facial recognition Speech therapy Safety precautions Minimize agitations

72 gXI

73 Monitor electrolytes especially sodium levels and protein levels Chart 8-2 talks about labs to monitor– albumin transferrin---prealbumin total lymphocytes. Diets chart 8-4 Nutrition

74 glaucoma 2 types Primary open angle: most common Angle closure: less common..emergency

75 s/s Open angle: small cresent shaped defect Angle closure: visual fields quickly decrease, severe pain around eye, headache, n/v, halos, blurred vision

76 Macular degeneration Central vision declines Mild blurring or distortion More rapid to produce in smokers

77 Spinal Cord Injury (SCI) Chapter 24

78 Causes of SCI Primary Hyperflexion (moved forward excessively) Hyperextension (MVA) Axial loading (blow at top of head causes shattering) Excessive rotation (turning beyond normal range) Penetrating (knife, bullet) Secondary Neurogenic shock Vascular insult Hemorrhage Ischemia Electrolyte imbalance

79 Types Complete: spinal cord severed and no nerve impulses below level of injury Cervical/Thoracic Incomplete: allow some function and movement below level of injury Includes: Central cord syndrome Anterior cord syndrome Brown-Séquard syndrome

80 Complete Tetraplegia (quadriplegia): paralysis from neck down Loss of bowel and bladder control Loss of motor function Loss of reflex activity Loss of sensation Coping issues *Christopher Reeve is example of this injury*

81 Incomplete Central Cord Syndrome Hyperextension damage to center of spinal cord Greater loss of function in upper extremities Anterior Cord Syndrome Cause: Direct injury to anterior spinal cord or disrupted anterior spinal artery Paralysis, loss of pain and temperature sensation Light touch, vibration, proprioception preserved Prognosis for recovery is variable

82 Incomplete Posterior cord lesion Damage to posterior white and gray matter Motor function intact, but loss of vibratory sense, crude touch, and position sensation Brown Sequard syndrome Result of penetrating injury that causes hemisection of spinal cord. Motor function, proprioception, vibration, and deep touch are lost on the same side as injury (ipsilateral) On the other side (contralateral) the sensation of pain, temperature and light touch are affected

83 Assessment 1 st -respiratory status 2 nd - intra-abdominal hemorrhage (hypotension, tachycardia, weak and thready pulse) 3 rd assess motor function C4-5 apply downward pressure while the client shrugs C5-6 apply resistance while client pulls up arms C7 apply resistance while pt straightens flexed arms C8 check hand grasp L2-4 apply resistance while the client lifts legs from bed L5 apply resistance while client dorsiflexes feet S1 apply resistance while client plantar flexes feet

84 Complications Cerebral ischemia DVT/PE Pneumonia/Atelectasis Vomiting and Aspiration GI stress ulcers Constipation UTI Pressure Ulcers

85 Autonomic Dysreflexia Severe HTN, bradycardia, sever headache, nasal stuffiness, and flushing Caused by noxious stimuli like distended bladder or constipation Immediate interventions Place in sitting position Call doctor Loosen tight clothes Check foley tubing if present Check for impaction Check room temp Monitor BP q10-15 minutes Give nitrates or hydralazine per md order

86 Treatment Immobilize fx- C-collar Proper body alignment Traction is possible Monitor VS q4 hr and prn Neuro checks q4 hr and prn Monitor for neurogenic shock (hypotension and bradycardia) Prepare for possible surgery Teach skin care, ADLs, wound prevention techniques, bowel and bladder training, medications, and sexuality

87 NRSG DX for SCI Ineffective tissue perfusion r/t interruption of arterial flow Ineffective airway clearance r/t SCI Ineffective breathing pattern r/t SCI Impaired gas exchange r/t SCI

88 Traumatic Brain Injury (TBI)

89 Head Injury Classification: Severe Head Injury----GCS score of 8 or less Moderate Head Injury----GCS score of 9 to 12 Mild Head Injury----GCS score of 13 to 15 (Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

90 Superficial Injuries Common Abrasions “Goose Eggs” Lacerations Scalp is very vascular Xray if suspect skull fracture

91 Skull Fractures Categorized according to type and severity Frequently seen in conjunction with brain injuries Linear skull fractures Comminuted skull fractures Basal skull fractures Possible associated cranial nerve deficits

92 Open Skull Fractures Linear- simple clean break Depressed - bone pressed in towards tissue Open -lacerated scalp that creates opening to brain tissue Comminuted - bone fragments and depresses into brain tissue Basilar- unique fx at base of skull with CSF leaking though the ear or nose Racoon eyes/Battles sign

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95 Closed Skull Fractures Closed- blunt trauma Mild concussion-brief LOC Diffuse axonal injury- usually from MVA May go into coma Contusion-bruising of brain Site of impact (coupe) Opposite side of impact (contrecoupe)

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97 Intracranial Hematomas Epidural- bleed b/w skull and dura Laceration of artery or vien Subdural-bleed below dura and arachoid layers Acute, subacute, chronic Intracerebral-accumulation of blood in brain tissue Blunt trauma Penetrating wounds Acceleration/deceleration injuries

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99 Increased Intracranial Pressure (ICP) Pg 568

100 Increase is caused by an increase in the volume of any of the intracranial components Drivers of increased ICP Hypoxia – triggers the vasodilatory cascade Ischemia in acute brain injury

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102 Increased ICP Normal ICP 10-15mmHg Normal increases occur with coughing, sneezing, defecation Leading cause of death for head trauma As ICP increases cerebral perfusion decreases causing tissue hypoxia, decrease serum pH, and increase in CO2

103 ICP continued 3 types of edema Vasogenic: increase in brain tissue volume Cytotoxic: result of hypoxia Interstitial: occurs with brain swelling

104 Assessment

105 Hydrocephalus abnormal increase in CSF volume Causes: impaired reabsorption from subarachnoid hemorrhage or menengitis

106 Brain Herniation Increased ICP will shift and move brain tissue downward Central Herniation Downward shift to brainstem S/S Cheyne stokes, pinpoint pupils, hemodynamic instability The most life threatening is Uncal because it causes pressure on the 3 rd cranial nerve S/S Dilated, nonreactive pupils, ptosis, rapidly decreased LOC

107 Herniation syndromes. Herniation syndromes.

108 Movement/musculoskeletal

109 Rheumatoid Arthritis

110 Most common connective tissue disorders Most destructive to joints RA factors looked for in lab Assess sedrate Assess immunoglobins MRIs performed EMGs are performed to measure function

111 Assessment/ S/S continued Joint stiffness Swelling Pain Fatigue Weight loss Reddened joints Deformity of joints Baker’s cysts may occur and cause pain Dry eyes, dry mouth, dry vagina Assess ADLs, coping, pain

112 interventions Nsaids Immunosuppressive drug Rest Proper positioning Pain management Ice Heart parafin wax Plasmapheresis Fish oil tablets

113 Gout Type of arthritis Urate crystals deposit in joints Primary gout is most common Inflammation is key sign 2 nd ary is when too much uric acid in blood Can affect kidneys Meds to treat Pain management

114 Fibromyalgia Chronic pain syndrome Pain is burning or gnawing Headache and jaw pain are also common Chest pain is common Pain control is the key Muscle relaxers, nsaids, antidepressants

115 Muscular distrophies 9 types Progression is slow or fast Most common is severe X linked recessive Diagnosis is difficult Comfort is key Treat symptoms

116 AMPUTATION REVIEW

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118 amputations Removal of part of the body Types Surgical-example digit Traumatic- example digit Levels Lower extremity: digits, bka, aka, midfoot Upper extremity: hands, fingers, arms Complications Hemorrhage Infection Phantom limb pain: perceive pain in the amputated limb Immobility Neuroma: sensitive tumor consisting of nerve cells found at several nerve endings Contractures

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120 Review Meds on Review cranial nerves TIPS!!


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