1. Medical Surgical Nursing Lecture 13 Neurology

2. The nervous system consists of: Brain Spinal Cord Peripheral Nerves

3. Divided system – Central Nervous System (CNS) Brain & Spinal Cord – Peripheral Nervous System (PNS) Nerves (peripheral & Cranial)

4. Nervous System Controls and coordinates all parts of the body By transmission of electrical impulses

5. Purpose of the Nervous System Control Coordinate Communication Stimulation of Movement

6. Purpsose of the Nervous System Maintains Homeostasis – Along with the what system? Endocrine

7. Neuron Basic functional unit

8. Synaptic Junction Neuron connect to each other end to end – Synaptic junction – Synapse

9. Central Nervous System Brain Spinal Cord Control center for entire system

10. Protection Brain: – Encased by the Skull Spinal Cord – Encased in vertebral column

11. The Meninges Function – Support – Protect – Nourish Dura mater Arachnoid – Cerebral Spinal Fluid Pia Mater

12. Brain – 3 main areas Cerebrum – Coordination of stimuli Cerebellum – Control muscle movement Brainstem – Vital Reflexes

13. Brainstem Connects brain with spinal cord – Vital reflexes – Relay for sight and hearing

14. Cerebellum “Lesser brain” Controls skeletal muscles  coordinated

15. Spinal Cord – CNS Continuous with brain stem Extend to L-1orL-2 Lumbar Punctures  – L3-4

16. Peripheral Nervous System Contains – Cranial nerves – Spinal nerves Location Function – Sensory impulses from PNS  CNS – Motor response from CNS  PNS Key word: – Nerves

17. PNS  Somatic & Autonomic NS Somatic Nervous System – Conscious activities Autonomic Nervous System – Connects CNS to visceral organs – Unconscious activities – Divided Sympathetic nervous system – Fight or flight Parasympathetic nervous system – Rest & digest

18. History Family member present Vaccination Major injuries Childhood illnesses Family Present illness

19. Complaints specific to neurology Pain – Location – Quality – Severity – Duration – Precipitating factors – Assoc. symptoms – Exasperation / diminished pain – Onset

20. Pain assessment: The 5 th vital sign

21. Headaches Multiple causes Not a good indicator of neuro trouble

22. Vertigo Sensation of moving around in space or objects moving around them

23. Paresthesia Definition – Unusual sensation Examples – Numbness – Tingling – Burning Assessment – ? Weak – ? Intermittent or constant

24. Vision Dysfunction Diplopia – Double vision Clarity Nystagmus – Eye twitching

25. Disturbances in… Thinking Memory Personality

26. Nausea and vomiting Projectile

27. Assessing Cerebral Function - PE Mental status Intellectual function Thought content Emotional status Perception Motor ability Language ability

28. Level of Consciousness Alert – Open eyes spontaneously Lethargic – Opens eyes to verbal stimuli – Slow to respond, but appropriate Stupor – Responds to physical stimuli with moans and groans

29. Semi Comatose – Responds to painful stimuli Coma – Unresponsive except to severe pain – Absent Protective reflexes

30. Types of Stimuli  response Voice Touch Shaking Voice + Shaking Noxious/painful stimuli

31. Nature of response Eye opens Remove stimuli Abnormal posturing No response

32. Glasgow Coma Scale Eye Opening – Spontaneous – 4 – To speech – 3 – To pain – 2 – Nil – 1

33. Glasgow Coma Scale Best Motor Response – Obeys -6 – Localizes – 5 – Withdraws – 4 – Abnormal flexion – 3 – Extension response – 2 – Nil - 1

34. Glasgow Coma Scale Verbal response – Oriented – 5 – Confused conversation – 4 – Inappropriate words – 3 – Incomprehensible sounds – 2 – Nil - 1

35. Glasgow Coma Scale A strong predictor of outcome  13: mild brain injury  9-12: Moderate brain injury  < 8: Severe brain injury (coma)

36. Sample Question The nurse is caring for an adult client who was admitted unconscious. The initial assessment utilized the Glasgow Coma Scale. The nurse knows that the Glasgow Coma Scale is a systemic neurological assessment tool that evaluates all of the following EXCEPT A.Eye opening B.Motor response C.Pupillary reaction D.Verbal performance

37. What is the lowest score you can get on the GCS? A.0 B.1 C.3 D.5 E.None of the above

38. What is the highest score you can get on a GCS? A.0 B.3 C.13 D.15 E.None of the above

39. Orientation x 3 – Person – Place – Time

40. General Appearance How do they look? – Grooming – Dress – Aids – Eye deviation – Skin

41. Vital Signs Temperature – With head trauma  increased

42. Vital Signs Pulse – Increased ICP  Bradycardia

43. Vital Signs Respirations – Ataxic Damage to medulla – Cheyne-stokes Lesion deep in cerebral cortex – Hyperventilation Metabolic problems

44. Vital Signs Blood Pressure – Orthostatic hypotension > 20mmHg  cerebral ischemia

45. Vital Signs Pulse Pressure formula: – Systolic – diastolic 120 ------=? 80

46. Vital Signs Pulse Pressure – Systolic – diastolic 120 ------=40 80 – Normal Pulse pressure = 40 – Widening pulse pressure = Increased ICP

47. Neuro Checks LOC Pupils – PERRLA Pupils Equal Round Reactive to Light Accommodation

48. Neuro Check Pupils – Anisocoria Inequality in the size of the pupils – Nystagmus – Progressive dilation  Increase ICP – Fixed & dilated Poor prognosis

49. Computer Tomography Scan - CT X-rays Distinguishes tissue density – Tumors

50. Computer Tomography Scan - CT Nursing Considerations – Explain procedure 30-60 minutes Lying still – If contrast medium is used  for iodine & shellfish allergies NPO Push fluids after procedure watch for S&S of  ICP

51. Magnetic Resonance Imaging: MRI Description Magnetic field + radio waves Used to ID: – Edema – Hemorrhage – Tumors

52. Magnetic Resonance Imaging: MRI Nursing Considerations Remove all metal Relaxation techniques / Claustrophobia Duration: – 45-60 min Lay flat & motionless

53. Nervous System Controls and coordinates all parts of the body By transmission of electrical impulses

54. Cerebral Cortex / Cerebrum CNS produces electrical waves

55. Electroencephalography (EEG) Measures electrical impulses of the brain – brain waves Electrodes applied to the scalp Used to diagnosis – Seizures – Coma – Brain death Obtain an baseline – Quiet & dark Stimulation – Flashing lights

56. Electroencephalography (EEG) Duration: 1 hour  seizures – sleep deprivation Hold meds – anti seizure meds – Tranquilizers – Stimulants – depressants No caffeine OK to eat

57. Lumbar Puncture Description Into Subarachnoid space @ L 3-4 level Used to – Extract CSF – Test Spinal fluid pressure – Introduce antibiotics dyes anesthesia

58. Lumbar Puncture Nursing Considerations Pre-procedure – Side lying with legs pulled close to chin – Do not move – Painful – pressure – Shooting pain down leg – 10 minutes

59. Lumbar Puncture Post-procedure – Bed rest –  Fluid (unless…) – Observe for S/E

60. I-ICP I-ICP Cycle – I-ICP  –  pressure –  cerebral perfusion  – Ischemia  –  edema  – Death

61. I-ICP Early S&S – #1 Alt LOC  restlessness or confusion – H/A – Pupil changes – Weakness on one side

62. I-ICP - Late S&S Stupor  coma Pulse –– Resp –  & Erratic BP –– Temp –– Projectile vomiting

63. I-ICP Late S&S – Abnormal posturing – Loss of protective reflexes

64. Goals of I-ICP management Decrease the Pressure –  edema

65. I-ICP management Decrease Edema – Osmotic diuretic

66. I-ICP management Decrease edema – Corticosteroids Anti-inflammatory

67. I-ICP management Decreasing edema – Fluids  – HOB  – Oxygen 

68. Seizures Definition – Abnormal motor, sensory autonomic or psychic activity resulting from sudden excessive discharge from cerebral neurons

69. Seizure video in bed http://www.youtube.com/w atch?feature=player_detailp age&v=Nds2U4CzvC4 http://www.youtube.com/w atch?feature=player_detailp age&v=Nds2U4CzvC4 http://vimeo.com/3428474 http://www.google.com/url ?url=http://www.healthgur u.com/content/video/watch /100663/10_Truths_About_ Epilepsy%3FHG_Google_Vid eo_Sitemap%3D&rct=j&sa= X&ctbm=vid&ei=PZbITt7cLs 3diAKU_PzADw&ved=0CGc QuAIwBDge&q=seizure+ton ic+clonic&usg=AFQjCNGdre dGS6dFX9kRopvQ9nC91kBK rw&cad=rja

70. Seizures Classification – Partial – Seizure that begins in one part of the brain Simple – Awareness – Memory – Consciousness

71. Seizures Classification – Partial Simple Complex – Loss of » Awareness » Memory » Consciousness

72. Seizures Classification – Generalized – Seizure that involves electrical discharges in the whole brain Absence Seizure – Period of staring Tonic-Clonic Seizure

73. Seizures Seizure activity – Tonic Phase Rigidity – Clonic phase Jerking

74. Seizures Characteristics – Post-seizure / postictal Recover period Deep sleep Head ache Weak Nausea Muscle soreness Depression Tired

75. Seizures Medical management – Anti-convulsants

76. Seizures Nrs Management w/ anticonvulsants – Do not stop abruptly  seizures – Monitor levels – Take regularly – Alcohol only in moderation

77. Seizures Before Seizure – At risk for injury Padded side rails Suction machine in room

78. Seizures During a seizure Safety – Ease to floor – Protect the head – Turn to side – Loosen clothing – In bed? Remove pillow Side rails up – Do not Insert anything in mouth restrain – Stay with pt Support client – Privacy

79. Seizures Observe & document – 1 st – Movement – Duration – Unconsciousness – Post seizure behavior

80. Seizures After a seizure – Document – At risk for Aspiration Vomiting

81. Seizures –VS –Check mouth –Clean client –Allow to “sleep it off” Post Seizure Nursing care – Side lying – Padded side rails –  stimulation Dim lights Noise 

82. Cerebrovascular accident AKA CVA Stroke Brain attack

83. CVA: Pathophysiology Disruption of blood flow to part of the brain  Ischemia  Infarction   ICP

84. CVA: Common Causes Ischemic – Thrombi – Emboli

85. CVA: Etiology Hemorrhage – Rupture of the cerebral blood vessel D/T: – HTN

86. CVA: Risk Factors Changeable Smoking Obesity HTN Sedentary life Stress  fat diet  Na diet Substance abuse Diabetes mellitus Non-changeable Age Gender Family history Race

87. CVA: Risk Factors Which is the most important risk factor for a stroke? A.Smoking B.Weight C.Diet D.HTN E.Stress F.Substance Abuse

88. CVA: Risk Factors What is the number one cause of CVA in a younger patient? A.Smoking B.Weight C.Diet D.HTN E.Stress F.Substance Abuse

89. CVA: Clinical manifestations S&S depend on: 1.Location 2.Size

90. CVA: Clinical Manifestations Alt. LOC H/A Aphasia Seizures Vision disturb Labile emotion Hemiparesis – Weakness Hemiplegia – Paralysis

91. Hemorrhagic Stroke Usually more severe with a longer recovery period than ischemic stroke

92. Hemorrhagic Stroke Common Cause – HTN

93. CVA: diagnostic findings CT / MRI

94. CVA: Medical Management Focus on Cause & Control #1 cause = – Hypertension – Anti-hypertensives

95. CVA: Rx - HTN Beta-blockers – Action Block sympathetic response

96. CVA: Medical Management Diet – Sodium  – Fat  – Potassium  – Stimulants  – Fluids 

97. CVA: Medical Management Prevent clot formation – Meds / anticoagulants

98. CVA: Medical Management Prevent clot formation – Non-Rx Ted hose ROM Isometric exercise

99. CVA: Medical Management Thrombolytic agents – Action Break down thrombi – S/E Hemorrhage

100. CVA: Medical Management Prevent Seizures – Anti-convulsants – Precaution –  stimuli

101. CVA: Medical Management  ICP – O2  – Position HOB  – Activity Rest – Meds Diuretics Glucocorticoids – Monitor BP

102. CVA: Medical Management Nutrition – NGT

103. CVA: Medical Management Monitor for complications – VS – I&O – Labs Na & K Glucose PT/PTT – Pulse oximetry

104. CVA: Medical Management Prevent complications ROM Isometric exercise Pain Control

105. CVA: NRS management Risk for injury r/t seizures r/t repeat CVA r/t unilateral neglect r/t falls – Padded side rails – Call light – Assist w. amb. – Suction – Items w/in reach – Clear path – H2O temps – Turn & position q2hr

106. CVA: NRS management Alt. nutrition r/t impaired swallowing Motor deficits Impaired judgment – SLP – Swallow eval – HOB high fowlers – Straws – no – Thick liquids – Swallow twice –  pocketing food – Talk & eat – NO – Unaffected side of tongue –  gag – Small meals – High texture food

107. CVA: NRS management Alt. Mobility r/t neuro deficits – Begin on admit – Turn q2hr – ROM – Splints – Footboards – Built-up utensils – Raised toilet – Exercises

108. CVA: NRS management Impaired Communication r/t aphasia – SLP – Give the client Time – Anticipate needs – Call bell – Face patient – Eye contact – Yes/No ? – ID methods – Gestures – Visual aids

109. CVA: NRS management Self-Care Deficit Eating – Non-skid mats – Stabilizer plates – Plate guards – Wide grip utensils

110. CVA: NRS management Self-Care Deficit Bathing & Grooming – Long handle sponge – Grab bars – Non-skid mats – Hand held showers – Electric razor – Shower seat

111. CVA: NRS management Self-Care Deficit Toileting – Raised seat – Grab bars

112. CVA: NRS management Self-Care Deficit Dressing – Velcro – Elastic shoelaces – Long-handle shoehorn

113. CVA: NRS management Self-Care Deficit Mobility – Canes – Walkers – Wheelchair – Transfer devices

114. CVA: NRS management Unilateral neglect Unaffected side – Personal items – Approach – Door face

115. TIA: Transient Ischemic Attack Short reversible ischemic event Duration – < 24 hrs No permanent neuro deficit Warning!