Chap 56 - Neuro AssessmentWhat problems would you expect with a patient with a temporal lobe lesion? Temporal Lobe Lesion: disturbance of auditory sensation and perception - inability to pay attention to what they see or hear - impaired ability to comprehend language (Wernickes area) - impaired factual and long-term memory - emotional disturbance - altered sexual behaviors What problems would you expect with a patient with a frontal lobe lesion? Frontal lobe Lesion = impaired judgement - impaired reasoning - impaired problem-solving - impaired expressive speech (Brocas area)

What cranial nerve do we care the most about and why? IX/X - Glossopharyngeal/Vagus - gag reflex, swallowing = danger of aspiration

What do you know about the cerebellum? - Cerebellum = smallest part of the lesser brain Maintains balance, movement, coordination & posture = ^ Rx of falling

What do you know about the brainstem? - Brainstem 1) Pons (Pneumotaxic center) = controls rate, rhythm, and depth of respiration 2) Medulla Oblangata = lowest part - damage: most life threatening ** controls respiration, HR, swallowing, vomiting, hiccups, and vasomotor center ** When should we NOT do a lumbar puncture? - Thrombocytopenia ----> risk for bleeding - ^ ICP ----> can cause risk for herniation due to change in CSF pressure

What do we know about lumbar puncture? Lumbar puncture is done by a MD using strict aseptic technique in the patients room or in a procedure room on the floor, needle inserted into the subarachnoid space between the 3rd and 4th lumbar vertebrae - used to assess many CNS diseases - Indicated: get pressure readings, CSF labs. & injection of air, anesthetics or meds - Patient lies on side in lateral recumbent position/ can be seated (Usu. no sedation or NPO) - Put a bandaid over the site - Post: Lay flat for 4-8 hrs. to prevent CSF leakage from the puncture site - Pt. may have headache afterwards from decrease in CSF ----> ^ fluid intake

Med- Surg: Neuro

Think about LP, EEG, Evoked Potential, and EMG and think of the most common disorder each exam will be testing for.

What do you know about myelogram? Myelogram = Xray of spinal cord and vertebral column after injection of contrast medium into subarachnoid space (Check for allergy to iodine) = Used to detect spinal lesions (ie. herniated or ruptured disc, spinal tumor) - Test is done on a TILT TABLE - Post: Patient should lie flat for a few hours and drink lots of fluids (prevent headache)

What is the post-procedure care for a pt who has had cerebral angiography? - Monitor neurologic signs and VS every 15-30 min. for first 2 hrs., every hour for the next 6 hours, then every 2 hrs for 24 hours. - Maintain bed rest until patient is alert and VS are stable - Report any neurologic status changes - Monitor for risk of bleeding from groin site (insertion of catheter) - Assess for allergies for iodine

How do you test for sensation? Touch, pain & temp = start with light touch first Vibration sense = tuning fork Position sense= move finger up or down, pt should identify; Romberg test Coritcal Sensory function = two point discrimination graphesthesia (writing on hand) stereognosis (perceive form and nature of object) Motor system = pronator drift; muscle tone - hypotonia (flaccid), hypertonia(spasticity), tics, tremors, myoclonus (spasm), athetosis (slow movements), chorea (involuntary)

What is the Romberg test and what does it tell us? Romberg test = have them stand with feet together and then close their eyes - (+) fi they lose their balance when eyes are closed = ^ Rx of falls

LP (spinal tab) EEG Evoked Potential EMG

Diagnose: - Meningitis - Guillain-Barre

syndrome - MS - Brain/SC

cancers

Purpose: Electrical activity in the brain Evaluate: - Seizure disorders - Sleep disorders - CV lesions - Brain injury

Purpose: Look at electrical activity and nerve conduction in response to stimulation of sight, sound and touch .Diagnose: - Disease (ie MS) - local nerve damage - motor function intra-operatively

Purpose: looks for electrical activity in the muscles - VERY PAINFULDiagnose: muscle and peripheral nerve damage (unexplained muscle weakness) = M.G.

Chapter 58 - Stroke What is the most important risk factors to address to prevent strokes? HTN = most important risk factor & Tight Diabetes control - Most strokes are caused by atherosclerosis which leads to thrombus and emboli formation - No smoking - Limit alcohol intake

How do you know if someone has had TIAs? What is the purpose of treating TIAs with daily aspirin? Transient Ischemic Attach (TIA) = initial warning sign of CVA ---> mini stroke - helps determine the type of stroke the pt. is having - can have a variety of symptoms depending on where the blockage is - Symptoms usually last tPA

Which are the cardinal symptoms /history of ischemic stroke? Common treatment? Ischemic = inadequate blood flow d/t arterial occlusion (80% of strokes) Types: 1) Thrombotic (blood clot) - c/b an atherosclerosis 2) Embolic (traveling blood clot) - c/b an occlusion - usu. have a cardiac hx (HTN/CAD) or history of TIAs Tx: = only lower BP if MAP > 130 or Systolic > 220 (use IV metoprolol)

- watch for increased ICP in first 72 hrs

= keep HOB up, maintain head/neck alignment, no hip flexion, avoid

hyperthermia

- will usu. go home on Warfarin or Plavix (anticoagulants)

- NO heparin b/c it increases risk for intracranial hemorrhage - Give tPa within 3-4.5 hrs. of onset of symptoms (given IV; check vitals freq.) - given STAT (GIVE FIRST)

Which are the cardinal symptoms /history of hemorrhagic stroke? Common treatment? Hemorrhagic = bleeding into the brain tissue itself, or into the subarachnoid space - much worse if pt. is already taking Warfarin Types: 1) Subarachnoid - usu. c/b aneurysm - s/s headache, N/V 2) Intracranial - usu. c/b HTN Tx = higher chance of death (silent killer)

** HTN is big cause ----> primary tx is for HTN

- absolutely NO anticoagulants (^ Rx of bleeding)

- watch for seizures (give Dilantin or Kepra)

- vasospasm can happen 1-2 weeks after the stroke with a subarachnoid

hemorrhage

Surgery = aneurysm ---> clipping

HTN ---> drain of fluid (lots of blood)

What type of stroke should we keep the BP slightly elevated and why?

ISCHEMIC strokes

- d/t a blockage = need to keep blood flowing to maintain cerebral perfusion.

Which type of strike should NOT be given aspirin, heparin, or tPA?

HEMORRHAGIC

= ^ Rx of bleeding more into the brain

How do you recognize right stroke vs. left stroke? What are the expected nursing diagnoses for each type of stroke? (pg. 1393 - Fig 58-3)

Left-brain damage (stroke on right side of the brain)

*Paralyzed right side; hemiplegia * Impaired speech/ language

aphasias* Impaired right/left discrimination * Slow performance, cautious* Aware of deficits: depression,

anxiety * Impaired comprehension related

to language, math

Righ-brain damage (stroke on left side of the brain)

*Paralyzed left side; hemiplegia * Left-sided neglect * Spatial- perceptual deficits * Tends to deny or minimize

problems * Rapid performances, short

attention span (^ Rx of injury) * Impulsive, safety problems * Impaired judgement * Impaired time concepts

What does Plavix do and what are the risks?

- Plavis = anti-platelet drug

Risk = ^ bleeding

What is a one sentence description of each of the procedures used to treat ischemic strokes?

- tPA is given FIRST

- Stenting - done during angioplasty to keep the artery open

- have a risk of releasing small emboli (watch for stroke symptoms to increase

after the procedure) = Frequent Vitals and LOC checks - postop - Transluminal angioplasty balloon via a catheter in the groin

- Carotid endarterectomy open the carotid artery to remove the plaque

How can we help the patient with a stroke communicate?

- Ask yes/no questions

- Give pt. plenty of time to respond

- Speak in normal volume and tone (as an adult)

- Use picture boards, gestures or demonstrations as an acceptable alt. form of speaking

How can we help the patient with homonymous hemianopsia?

- from Right-sided stroke Place objects on UNAFFECTED side

- on the Left

How can we help a patient with dysphagia (difficulty swallowing?

Teach the pt. the chin tuck and double swallow methods.

- make sure GAG-REFLEX is (+)

How do we help a patient with bladder training?

Bladder training program consists of:

1) Adequate fluid intake with most of it given between 7am & 7pm

2) Scheduled toileting q2hrs. using bedpan, commode or bathroom

= encourage usual position for urinating

3) Observation for signs of restlessness (may indicated need for urination)

4) Assessment of bladder distention by palpation

Chapter 59 - Chronic Neuro ProblemsWhat is the treatment for migraines?

** Triptan (Sumatriptan) = affect seritonin and cause vasoconstriction (migraines -

vessels are dilated ab)

* take as soon as headache starts

* can take aspirin at the same time

Prevents Meds:

Topamax & Depakote = antiseizure drug

* may have to take for several months for them to be effective at

prevention

Topiramate = antiseizure medications - effective therapy for migraine prevention

Antihypertensives and antidepressants (affect seritonins)

**CLUSTER = 100% O2***

** Tension - Tylenol, Motrin (Non-opioids) **

What assessment data would you expect to find with a cluster headache? How do you treat cluster headaches?

Assessment data:

S/S = sufferer has between 1-3 attacks/day over a 4-6 wk, period usu. at the same

time of day

- Pain is sharp, stabbing, radiates from eye up or down (lasts mins. to 3 hrs.)

- Can cause: tearing, nasal congestion, pupil constrict , facial flushing/pallor

- Pt. can become suicidal

Tx:

* inhalation of 100% O2 delivered at a rate of 6-8 L/min. for 10 minutes

DRUGS are NOT helpful - Cluster headaches are SHORT lasting

* Wine sometimes triggers migraines

What should the nurse do when a patient is seizing? What medications should they preparer for?

SUPPORT

- Ensure patent airway (turn head to side to prevent aspiration)

- Protect from injury (but DONT restrain)

- Prepare for meds

= Dilantin, Phenobarbital = Long acting

= Valium, Ativan = Short acting ------> Give FIRST!!!! (Fast Acting)

- Suction PRN

- Reassure and Re-orient AFTER seizure

- VERY IMPORTANT TO RECORD DETAILS OF THE SEIZURE!!!! ****

- ***** Seizure precautions: - Suction

- Ambu bag

- Oxygen at bedside

- Padded Bedrails

- FIRST time seizure = EMERGENCY!!!

What do you know about phenytoin (Dilantin)?

- Phenytoin is widely used to treat seizure disorders

Watch for: Gingival hyperplasia & hirsutism ----> GOOD ORAL CARE

(Use soft toothbrush)

What are interventions for a patient with MG?

- Maintain patent airway and adequate ventilation ---> 00 for resp. insufficiency

* assist in mechanical ventilation

* assess PFT

- Monitor VS, I/O, NVS motor grading scale (muscle strength)

- Maintain side rails

- Institute NGT feeding to prevent aspiration (semisolid foods)

- Prevent complications of immobility (turn q2hrs, q1 w/elderly)

* perform physically demanding activity early in the AM

- Schedule drugs so peak action is @ mealtimes

- Distinguish between myasthenic and cholinergic crisis

What is a risk/complication of MG?

-

- Respiratory insufficiency (^ RX)

- Aspiration

What causes a myasthenic crisis? What causes a cholinergic crisis? What is the expected treatment for each?

- Myasthenic Crisis = UNDERMEDICATION ----> Neostigmine (cholinergic)

- Cholinergic Crisis = OVERMEDICATION ----> Atropine (ANTIcholinergic)

What are the symptoms of ALS as compared to HD?

- Myasthenic Crisis - Cholinergic Crisis

Cause: undermedication - stress - infection

Cause: overmedication (^ ACh)

S/S: CANt - see, swallow, speak or breath = myasthenia gravis

S/S: PNS, - ^ salvation ---> aspiration - ^ muscle WEAKNESS

Tx: admin CHOLINERGIC drugs (Neostigmine)

Tx: ANTICHOLINERGIC drugs (Atropine sulfate)

ALS HD

- limb weakness- dysarthria - dysphasia

- chorea - worsening gait - risk of aspiration/malnutrition - cognitive deterioration - loss of speech and ability to eat

What can a nurse (interventions) do for a patient with ALS?

1) Facilitating communication

2) Reducing risk of aspiration

3) Facilitating early identification of respiratory insufficiency

4) Decreasing pain secondary to muscle weakness

5) Decreasing risk of injury r/t falls

6) Providing diversional activity ---> reading & companionship

What can a nurse do for a patient with HD?

PALLIATIVE care

= try to provide the most comfortable environment possible for the patient

and caregiver by maintaining patient safety, treating the physical symptoms,

and providing emotional and psychologic support

End-of-life issues: care int the home or long term care

- artificial methods of feeding

- advance directives and CPR

- use of abx to tx infections

- guardianship

What are the symptoms of Parkinsons Disease? - d/t low dopamine

Triad: 1) Temors

2) Rigidity

3) Bradykinesia (Shuffling gait = festination)

Also: depression, anxiety, short-term memory probs ---> dementia

What is a common side effect of treatment for PD?

- Dyskinesia (uncontrolled movements)

What are the interventions for a PD patient with bradykinesia?

- Levodopa + Carbidopa ---- treat symptoms; not a cure

- PT & OT

- Diet = lots of time to eat

Semisolid foods (easy to eat)

- Prevention of falls = teach to step over a line

- rocking motion to promote movement

- lift toes up when walking (prevent shuffling)

- Remove rugs and anything that may promote falls

Chapter 60 - Alzeimgers Disease, Dementia & Delirium What are the assessment differences between delirium and dementia?

** key difference is SUDDEN change in cognitive abilities or disorientation **

What are the treatments/testing differences between delirium and dementia?

Delirium = Confusion Assessment Method (CAM)

- looks at acute changes in the patients status

Is that pt. having trouble maintaing focus/attention?

Is it a fluctuating course (better at times, severity changes)?

Is the pt. incoherent or illogical?

Is the pt.s LOC changing?

Dementia = Mini-Mental Status Exam (MMSE)

= looks at cognitive functioning

* Need: Quiet room and NO anti-anxiety meds *

Dementia Delirium

- Insidius onset- Slow progression- Duration of months to years - Difficulty with abstract thinking impaired judgement, words difficult to find - Misperceptions ofter present -- delusions

and hallucinations - May pace or be hyperactive (as dx

progresses pt. may NOT be able to perform ADLs)

- Sleeps during the day - Frequent awakenings at night - Fragmented sleep

- Rapid onset - Abrupt progression - Duration of hours to weeks - Disorganization - Disoriented - Slow or accelerated incoherent speech - Distorted: Delsuions & hallucinations- Variable --- can by hyperactive or

hypoactive, or mixed psychomotor functions - Disturbed sleep - Reversed sleep cycle

What are the interventions for patient with dementia?

- Provide structure and consistency

- Prevent control or agitation

- Prevent injury

- Prevent overstimulation

What are the progressing symptoms of dementia (ie symptoms of moderate to severe dementia)?

Is AD inherited? How do you diagnose AD?

AD is GENETIC ----> MC with early-onset AD

Dx Studies = CT & PET

CT = may show brain atrophy

PET = may show a decrease in brain activity

What do you do to prevent wandering?

Put them in a room near the nurses desk

Place Medic Alert ID bracelets

Alarms on beds and doors

Provide space for safe pacing

What do you do to prevent sundowners syndrome? - Open blinds/turn on lights during the day - Limit naps and caffeine intake - Provide sleeping medications to solve sleeping problems- Keep the pt. very active during the day - Create a bedtime ritual

What should you do first when a dementia patient has restlessness and agitation?

- Redirect - give them a task (ie sweeping, cleaning, etc)

- Distract - talk to them, listen to music, look at pictures, go somewhere, ask them why

- Reassure - remind them that they are safe and you will be there for them

Mild Moderate Severe

- Forgetfulness beyond what is seen in a normal person

- Impaired short term memory

- Lose of initiative/interests- Forgetful - Small personality changes - Lose of ability to problem

solve, plan or organize

- Memory loss and confusion - Trouble organizing, planning and

following directions - Forgets how to do simple tasks - Trouble recognizing family and

friends - Agitation and restlessness - Lack of judgement - Wanders - Trouble sleeping - Delusions, hallucination, paranoia

- Severe impairment of all cog. functions

- Little memory, unable to process new info

- Unable to perform ADLs - Unable to speak or

understand words - May become immobile and

incontinent - May have difficulty eating/

swallowing food