Med- Surg: Neuro

Chap 56 - Neuro Assessment

What 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

Think about LP, EEG, Evoked Potential, and EMG and think of the most common
disorder each exam will be testing for.
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 PAINFUL
Diagnose: muscle and
peripheral nerve
damage (unexplained
muscle weakness)
= M.G.

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

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 <1hr. should go to ER in case they really do have a stroke
- NO INFARCTION
ASPRIN (anti-platelet)/ Plavix = prevent the development of a thrombus or an embolus
What diagnostic test is most important for a suspected strokes and why?
- NON-CONTRAST CT SCAN = see if stroke is ischemic or hemorrhagic
What should be the priority assessments for the patient with suspected stroke?
NURSING HX: 1) description of the current illness with attention to initial
symptoms, particularly symptom onset and duration, nature (intermittent or
continuous), and changes
- time can affect treatment decisions ====> 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 Problems

What 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?


- 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)

- 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?
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?


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

** 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 *

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)?
Mild
- 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

Moderate
- 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
- 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

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