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Neuro nclex

Terms in this set (39)

INCREASED ICP: maintain respiratory status and prevent hypoxia; avoid administration of morphine to prevent hypoxia; maintain mechanical ventilation as prescribed. If PaCO2 at 30 to 35 , will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decreased ICP
Client positioning following removal of a bone flap for decompression: turn client from the back to the non-operative side. Positioning after a posterior fossa surgery: position the client on the five, with a pillow under the head for support, and not on the back
Client positioning following Infratentorial surgery: involves surgery below the tentorium of the brain; the HCP may prescribe a flat position without head elevation or may prescribe the head of the bed the elevated at 30 to 45°. Do not elevate head of bed in acute phase following surgery without HCP's prescription
Client positioning following supratentorial surgery: HCP may prescribe the head of bed elevated at 30° to promote venous outflow through the jugular veins. Do not lower head of bed in the acute phase of care after surgery without a HCP's prescription
Cervical Injury at C2 to C3 is usually fatal. C 4 is the major innervation to the diaphragm by the phrenic nerve. Involvement above C4 causes respiratory difficulty and paralysis of all four extremities. Client may have movement in the shoulder if the injury is at C-5 through C8, and may also have decreased respiratory reserve
Thoracic level injuries: loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury.
Autonomic dysreflexia: lesions or injuries above T 6 and in cervical lesions may occur. Symptoms include sweating, bradycardia, hypertension, nasal stuffiness, and gooseflesh
Lumbar and sacral level injuries: loss of movement and sensation of the lower extremities may occur. S 2 & S 3 center on my micturation; so below this level, the bladder will contract but not empty, neurogenic bladder
Injury above S2 in males allows them to have an erection, but are unable to ejaculate because of sympathetic nerve damage. Injury between S2 and as for damages the sympathetic and parasympathetic response, preventing erection and ejaculation
Tetraplegia, quadriplegia: injury occurring between C1 and C8; paralysis involving all four extremities
Paraplegia: injury occurring between T1 and L4; paralysis involving only the lower extremities
neurogenic shock occurs most commonly and injuries above T6 and usually is experienced soon after injury. Massive vasodilation occurs, leading to pooling of the blood in the blood vessels, tissue hypoperfusion, and in paracellular metabolism
Symptoms with autonomic dysreflexia: sudden onset, severe throbbing headache; severe hypertension and bradycardia; flashing above the level of the injury; pale extremities below the level of the injury;
Nasal stuffiness, nausea, dilated pupils or blurred vision, sweating, piloerection, restlessness and a feeling of apprehension
Interventions for autonomic dysreflexia: notify HCP and raise the head of bed in a high Fowlers position, loosen tight clothing on the client; check for bladder distention or other nauseous stimuli, if a fecal impaction is present, this impact the clients if necessary; ensure it is not too cool or two drafty and also monitor vital signs every 15 minutes, especially BP; administer antihypertensive medication; document
Cerebral aneurysm precautions: maintain bed rest and a semi Fowler's or a side lying position; maintain a darkened room without stimulation; provide quiet environment, a telephone in the room is not usually allowed;
Reading, watching television, and listening to music are permitted, provided that they do not overstimulate; limit visitors; maintains fluid restrictions; provide diet as prescribed and avoid stimulants;
Revent any activities that initiate the Valsalva maneuver; administer care gently; limit invasive procedures; maintain normothermia;
Prevent hypertension, provide sedation, provide pain control, administer prophylactic anticonvulsant medications, provide DVT prophylaxis
Usually a BP of 150/100 is maintained during the acute phase of a stroke to ensure cerebral perfusion
Interventions and post acute phase of stroke: position client two hours on unaffected side and 20 minutes on affected side. Position client in the prone position if prescribed for 30 minutes three times daily
Myasthenia Gravis: neuromuscular disease with considerable weakness and abnormal fatigue of voluntary muscles; a defect of transmission of nerve impulses at myoneural junction
Causes of myasthenia : secretion of acetylcholine, excessive secretion of cholinesterase, and unresponsiveness of the muscle fibers to Acetylcholine
Symptoms: weakness, fatigue, difficulty chewing and swallowing, dysphagia, the ptosis, diplopia, week horse voice, difficulty breathing, diminished breath sounds, respiratory paralysis and failure
Interventions for myasthenia gravis: monitor respiratory status and ability to cough and deep breathe adequately: and for respiratory failure; maintain suctioning and emergency equipment at bedside; monitor vitals and speech and swallowing abilities to prevent aspiration
Encourage to sit up when eating, assess muscle status, instruct to conserve strength, plan short activities that coincide with times of maximal muscle strength, monitor for Mayasthenuc and cholinergic crisis,
Administer anticholinesterase meds, avoid stress, infection, fatigue, and OTC meds , where a medic alert bracelet, informed about services from myasthenia gravis foundation
Myasthenic crisis: and acute exacerbation of the disease caused by a rapid, unrecognized progression of the disease, in adequate amount of medication, infection, fatigue, or stress
Assessment: increased Pauls, respirations, and BP; dyspnea, and Oxsee, and cyanosis; bowel and bladder incontinence; decreased urine output; absent cough and swallow reflex
Cholinergic crisis: results in deep polarization of the motor and plates; caused by overmedication with anti-cholinesterase
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