MS II Exam 4

Define agnosia.
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What is a norepinephrine deficit associated with? Excess?-D: depression -E: anxietyWhat is the function of GABA?-Inhibitory -Communicates messages to other neurons, helping to balance the offset of excitatory messages. Also allergies.What is associated with a GABA deficit? Excess?-D: Huntington's Disease (tremors, loss of motor control, & personality changes) -E: Sleeping & eating disordersWhat are the major functions of the frontal lobe? Parietal? Temporal? Occipital? Cerebellum? Brain Stem?•Frontal: thought, decision, personality, judgement, concentration •Parietal: right to left perception, depth perception, •Temporal: Hearing and language •Occipital: vision, and memory •Cerebellum: movement •Brain stem: HR, RR, BPWhat three aspects make brain circulation unique?-arterial and venous vessels are not parallel -collateral circulation through the circle of willis allowing blood to be redirected on demand -blood vessels have two rather than three layers making them more prone to rupture when weakened or under pressureThe bifurcations in the circle of willis are frequent sites of what?aneurysm formation *aneurysms are out-pouchings of the blood vessel due to vessel wall weakness. Rupture of an aneurysm causes a hemorrhagic strokeWhat do the veins of the brain help control?CSF levelsName the cranial nervesI. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Accessory XII. Hypoglossal * Oh oh oh to touch and feel very good velvet AHName the cranial nerves and tell if they are somatic, motor, or both.I. Olfactory: S II. Optic: S III. Oculomotor: M IV. Trochlear: M V. Trigeminal: B VI. Abducens: M VII. Facial: B VIII. Vestibulocochlear: S IX. Glossopharyngeal: B X. Vagus: B XI. Accessory: M XII. Hypoglossal: M *Some say marry money but my brother says big butts matter moreWhat is the function of cranial nerve I?Olfactory: sense of smellWhat is the function of cranial nerve II?Optic: Visual acuity and visual fieldsWhat is the function of cranial nerve III?Oculomotor: Muscles that move the eye and the lid, pupillary constriction, & lens accommodationWhat is the function of cranial nerve IV?Trochlear: muscles that move the eyesWhat is the function of cranial nerve V?Trigeminal: Facial sensation, corneal reflex, & masticationWhat is the function of cranial nerve VI?Abducens: Muscles that move the eyesWhat is the function of cranial nerve VII?Facial: Symmetry of facial expressions and muscle movement in upper and lower face, salavation, tearing up, taste, and sensation in the earWhat is the function of cranial nerve VIII?Acoustic: hearing & eqilibriumWhat is the function of cranial nerve IX?Glossopharangeal: Taste, sensation in pharynx & tongue, pharyngeal muscles, swallowing.What is the function of cranial nerve X?Vagus: muscles of pharynx, larynx, and soft palate; sensation in external ear, pharynx, larynx, thoracic & abdominal viscera; parasympathetic innervation of thoracic and abdominal musclesWhat is the function of cranial nerve XI?Accessory: sternocleidomastoid & trapezius musclesWhat is the function of cranial nerve XII?Hypoglosal: movement of tongueWhat is the function of the autonomic nervous system?functions to regulate activities of internal organs and to maintain and restore internal homeostasisWhat should a neurologic health history include?-Pain -Seizures -Dizziness -Vertigo -Visual disturbances -Weakness -Abnormal sensations -Hx (health, family, & social)What are the 5 components to a neurologic physical assessment?-Consciousness & Cognition -Cranial Nerves -Motor System -Sensory System -ReflexesWhat does the Consciousness and Cognition portion of a neurological assessment contain?-mental status -intellectual function -thought content -emotional status -language ability -lifestyleWhat are the four types of aphasia? Which area of the brain is involved in each?-Auditory receptive: temporal lobe -Visual receptive: parietal and occipital lobes -Expressive speaking: Inferior-posterior frontal areas -Expressive writing: posterior frontal areaWhat are the components of a motor system physical assessment?-Muscle size, tone, and strength -coordination & balance -Romberg testWhat are the components of a sensory system physical assessment?-Tactile stimulation -Superficial pain -Temp and vibration sense -ProprioceptionWhat reflexes are incorporated in a neuro physical assessment?-DTR -Bicep -Tricep -Brachioradialis -Patellar Achilles -Plantar (Babinski)Why may an older adults pupils not respond to light?Presence of cataractsDifferentiate between dementia and delirium.-Delirium: acute confused state that begins with disorientation -Dementia: Chronic & progressiveDefine akinetic mutismUnresponsiveness to environment; the patient makes no movement or sound but sometimes opens eyesDefine Cushing's response.the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICPDescribe abnormal body position associated with a severe brain injury characterized by extreme extension of extremitiesDescribe abnormal body position associated with a severe brain injury characterized by abnormal flexion of the upper extremities and extension of the lower extremitiesWhich posturing indicates worse condition?Decereberate posturing indicates deeper and more severe dysfunctionWhat is the most important indicator of a patient's condition?level of responsiveness and consciousnessDefine persistent vegetative stateState of unconsciousness in which wakefulness is present but awareness is lackingDefine locked-in syndromeinability to move or respond except for eye movements due to a lesion affecting the ponsWhat does progressive pupil dilation indicate?increasing ICPWhat does fixed dilated pupils indicate?injury at the level of midbrainWhat could a stiff neck indicate?subarachnoid hemorrhage or meningitisWhat is the criteria for the Glasgow Coma Scale?*Scoring: -Mild TBI: 13-15 -Moderate TBI: 9-12 -Severe TBI: 3-8What are some NANDA nursing diagnoses for altered level of consciousness?•Ineffective airway clearance related to inability to maintain an airway due to altered LOC •Risk of injury related to lack of adaptive and defensive resources due to decreased LOC •Deficient fluid volume related to inability to take fluids by mouth •Impaired oral mucosa related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake •Risk for impaired skin integrity and impaired tissue integrity of cornea related to diminished or absent corneal reflex •Ineffective thermoregulation related to damage of hypothalamic center •Impaired urinary elimination and bowel incontinence •Disturbed sensory perception •Interrupted family processes related to health crisisWhat are some collaborative problems associated with altered level of consciousness?-Respiratory Distress/Failure -Pneumonia -Aspiration -Pressure Ulcer -DVT -ContracturesWhat is the Monro-Kellie hypothesis?Because of the limited space in the skull, an increase in any one of the components of the skull (brain, tissue, blood) will cause a change in the volume of the othersWhat is the first sign of increased ICP? What are some other manifestations?-ALTERED LOC -Respiratory alterations -Posturing -Slow bounding pulse -Rise in SBP *0-10 mmHg is normal 15 mmHg is the upper limit of normalWhat are some causes of increased ICP?-Head Injury -Brain tumors -Subarachnoid hemorrhage -encephalopathies (toxic & viral)How is compensation to maintain a normal ICP accomplished?-shifting and displacing CSF -increasing the absorption or diminishing the production of CSF -decreasing cerebral blood volumeWhat does increased ICP cause?-reduces cerebral blood flow resulting in cell ischemia & death -stimulates further swelling -may shifts brain tissue causing herniation (dire and potentially fatal event)How does PaCO2 play a role in ICP?An increase in the partial pressure of arterial carbon dioxide cause cerebral vasodilation leading to increased cerebral blood flow and increased ICP -A decrease in PaCO2 has a vasoconstrictive effect, limiting blood flow to the brain *Decreased venous outflow may also increase cerebral blood volume causing increased ICPWhat is autoregulation?refers to the brain's ability to change the diameter of blood vessels to maintain a constant cerebral blood flow during alterations in systemic BP *can be impaired during increased ICPAt what ICP measurement can the body not compensate?20 mmHgWhat is CPP and how is it calculated-Cerebral Perfusion Pressure (estimate of cerebral blood flow) -MAP-ICP=CPP *Normal CPP: 70-100What does a CPP less than 50 result in?permanent neurologic damageWhat happens if ICP is equal to MAP?cerebral circulation ceasesWhat is Cushing's response/reflex?-When cerebral blood flow decreases significantly the brain triggers an increase in arterial pressure to attempting to overcome the increased ICP. -Manifestations: Increase in SBP with a widening of the pulse pressure and cardiac slowingWhat is Cushing's triad?-bradycardia, hypertension, bradypnea *The brain can not autoregulate at this point herniation of brainstem and occlusion of cerebral blood flow will happen without interventionWhat are the EARLY manifestations of increased ICP?-Changes in LOC (agitation, slowing in speech, delay in response rime) -Changes in condition (restlessness, confusion, drowsiness, increased respiratory effort, purposeless movements) -Pupillary changes and impaired ocular movements -One sided weakness -HeadacheWhat are the LATE manifestations of increased ICP?-Cushing's response -Cushing's Triad -Respiratory & Vasomotor Changes -Projectile Vomiting -Stupor/Coma -Hemiplegia, Decortication, Decerebration, or Flaccidity -Cheyne-Stokes breathing -Loss of brainstem reflexes: pupil, gag, corneal, and swallowingWhy is lumbar puncture avoided in patient's with increased ICP?sudden release of pressure can cause the brain to herniateWhat are the complications of increased ICP?-herniation -DI -SIADHHow is increased ICP treated?-Osmotic Diuretics (MANNITOL) -Fluid Restriction -CSF draining -Controlling fever -Maintaining BP & SPo2 -Steroids (Dexamethasone)What is the purpose of ICP monitoring?-Identify increased pressures -quantify the degree of elevation -initiate treatment -provide access to CSF for sampling and drainage -evaluate effectiveness of TXDescribe intracranial pressure waves.-A Waves (plateau waves): indicated cerebral ischemia -B Waves indicate intracranial HTN & variations in the respiratory cycle -C waves: relate to variations in systemic arterial pressure and respirationsOne of the goals for ICP Tx is to maintain oxygenation and metabolic demands. How can this be achieved?-Monitoring ABG's & SpO2 -Barbituates -Sedation (decreases cerebral O2 demand) -Nutrition interventionsWhat are some nusrsing Dx for a patient with Increased ICP?-Ineffective airway clearance related to diminished protective reflexes -Ineffective breathing patterns related to neurologic dysfunction -Risk for ineffective cerebral tissue perfusion -Deficient fluid volume related to fluid restriction -Risk for infection related to ICP monitoringWhat is a craniotomy? What is its purpose?•Craniotomy: opening of the skull •Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, control hemorrhageWhat is a craniectomy? Cranioplasty?•Craniectomy: excision of portion of skill •Cranioplasty: repair of cranial defect using a plastic or metal plateWhat are Burr holes? What are they used for?circular openings for exploration or diagnosis to provide access to ventricles or for shunting procedures, aspirate a hematoma or abscess, or make a bone flapWhat is postoperative care following intracranial surgery aimed at?•Detecting and reducing cerebral edema •Relieving pain •Preventing seizures •Monitoring ICP and neurologic statusWhat are seizures?-Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neuronsHow are seizures classified?-Focal: originates in one hemisphere -Generalized: occur and engage bilaterally -Unknown: epilepsy spasms -"Provoked" related to acute, reversible conditionWhat are some specific causes of seizures?-cerebrovascular disease -hypoxemia -fever (children) -head injury -HTN -CNS infections -metabolic & toxic conditions (kidney injury, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure) -drug/alcohol withdrawal -allergiesWhat can longterm phenytoin use cause??gingival hyperplasiaWhat is status epilepticus?a single epileptic seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between themWhat has the term status epilepticus been extended to inclue?include continuous clinical or electrical (on EEG) seizures lasting at least 30 minutes, even if consciousWhy is status epilepticus a medical emergency?Vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations. Some respiratory arrest at the height of each seizure produces venous congestion and hypoxia to the brain. Repeated episodes may lead to fatal brain damageWhat are some precipitating factors of status epilepticus?-interruption of anticonvulsant meds -fever -concurrent infection -illnessDefine aphasiainability to express oneself or to understand languageWhat is the primary cerebrovascular disorder in the US & leading cause of longterm disability?stroke (CVA)What are the 2 types of CVA?ischemic and hemorrhagicWhat is the tx window for thrombolytic therapy following a ischemic CVAWithin 3 hrs of onset (some facilities 4.5)What are the five subtypes of ischemic strokes?-Large Artery Thrombotic -Small penetrating artery thrombotic -cardiogenic embolic strokes -cryptogenic stroke -otherDescribe large artery thrombotic strokes.-Caused by atherosclerotic plaques in the large blood vessels of the brain -Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (tissue necrosis in an area deprived of blood supply) *Thrombotic- blood clot forming inside the artery (usually forms in vessel already narrowing by atherosclerosisDescribe small penetrating artery thrombotic strokes.-Affect one or more vessels. Usually deep in brain with fewer symptoms -Most common type of ischemic stroke -Also called lacunar strokes due to cavity created after the death of infarcted brain tissueDescribe cardiogenic embolic strokes.-associated with cardiac dysrhythmias (A-fib), valvular heart disease, and thrombi in the left ventricle -Can be prevented w/ anticoagulants for A-fibWhere does a cardiogenic emboli stroke usually occur?-Emboli originate in the heart and travel to cerebral vasculature, most commonly settling in left middle cerebral artery (MCA)What causes Cryptogenic strokes?no known causeWhat are some contributors to strokes in the "other" category?-illicit drug use (cocaine) -coagulopathies -migraines -vasospasm -spontaneous dissection of the carotid or vertebral arteriesDescribe the pathophysiology of an ischemic stroke.What is the Penumbra region? How can it be saved-potentially viable brain tissue surrounding the core of infarction -early perfusion via t-PADescribe the ischemic cascade.Cerebral blood flow decreased to 25mL per 100g of blood per minute (normal 50mL per 100g) •Neurons can no longer maintain aerobic respiration (production of energy using oxygen) •Mitochondria switch to anaerobic respiration leading to increased lactic acid = changes pH •Neurons incapable of producing sufficient ATP •Electrolyte balances begin to fail, cells cease to functionWhat do the clinical manifestations of an ischemic stroke depend on?-Location of the lesion -Size of the area with inadequate perfusion -Amount of collateral blood flowWhat are some classic stroke manifestations?-numbness/weakness of the face, arm, or leg, especially on one side of the body -confusion or change in mental status -trouble speaking or understanding speech -difficulty walking, dizziness, or loss of balance and coordination -severe H/A (hemorrhagic)Differentiate the manifestation of a left and right hemispheric stroke.Many people may experience hemiplegia or hemiparesis during a stroke. Differentiate the two.-Hemiplegia: paralysis of one side of body or part of it -Hemiparesis: weakness of one side of body or part of itDifferentiate between muscle tone in early stroke and 48 hrs post stroke.-Early Stroke: flaccid paralysis, and loss of DTR's •DTR's reappear, & increased tone and spasticity (stiffness) on affected sideDefine the following dysfunctions of language and communication: -dysarthria -expressive aphasia -receptive aphasia -apraxia-dysarthria: difficulty speaking caused by the paralysis of the muscles responsible for producing speech -expressive aphasia: inability to speak fluently -receptive aphasia: inability to understand language -apraxia: inability to perform previously learned actionWhat area of the brain is affected if expressive aphasia is present? receptive?-E: Broca's -R: Wernicke'sWhat is hemianopsia?Not being able to see one half of the field of vision in one or more eyeWhat part of the brain is affected if a patient presents with the following types of aphasia? -Auditory Receptive -Visual receptive -Expressive speaking -Expressive writing-Auditory receptive: temporal lobe -Visual receptive: Parietal and occipital area -Expressive speaking: Inferior posterior frontal area -Expressive writing: Posterior frontal areaWhat is agnosia?difficulty in the ability to recognize previously familiar objects perceived by one or more of the sensesWhat is a TIA (transient ischemic attack)?Sudden loss of motor, sensory, or visual function lasting up to 2 hours *Results from temporary ischemia to a certain part of the brain but diagnostic images will not show ischemiaWhat is the initial Dx test for a stroke? When must it be done?-CT w/o contrast -25 mins or less from presentation in EDAfter the CT what other Dx tests are performed?-EKG (12 lead) -Carotid ultrasoundWhat are some ways to prevent a stroke?•No smoking •Healthy weight •Modest alcohol •Exercise •Control hypertension (screenings, meds, etc). •DASH diet (Dietary approaches to stop HTN) •Stroke screeningsWhat anticoagulants are given to people who have experienceed TIA or stroke?-Dabigatran (Pradaxa) -Rivaroxaban (Xarelto) -Warfarin (A-Fib) -Dipyridamole + ASA (Aggrenox) -Clopidogrel (Plavix)What is the goal INR for someone on warfarin with a-fib?2-3If anticoagulants are contraindicated for the patient what is the best option?ASAWhy would someone who experienced a stroke be put on statins?they reduce coronary events and ischemic strokesWhat drug is used for thrombolytic therapy? How does it work?-t-PA -binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the clot.What is the time goal for t-PA to be administered?60 mins after arriving at EDWhat are the benefits of t-PA admin within 3 hours of a stroke?-decrease in size of the stroke and increased overall improvement after 3 monthsWhy can you not receive t-PA 3 hours after the event?increased risk of cerebral hemorrhage and edemaHow long must you wait to give another anticoagulant after t-PA admin?24 hoursWhat is a major complication of t-PA admin?Intra-cranial bleedingWhat is the main surgical procedure for pt with TIAs or mild strokes?-Carotid Endarterectomy (CEA): Removal of the plaque or clot from the carotid artery to prevent future strokeWhat are some complications of CEA?-stroke -cranial nerve injuries -infection/hematoma at insertion site -carotid artery disruptionHow long must a stroke pt stay NPO?until dysphagia screening is doneWhat must the blood pressure stay below if t-PA is administered?less than 185/110Why must the nurse monitor the pt closely for hyperglycemia and fever after a stroke?-Fever associated with poor neurological outcome. -hyperglycemia exacerbates neurologic injury. Blood Sugar should range from 80-140. High PriorityWhat are some important nursing interventions post-stroke?-positioning -ambulate ASAP -Prevent shoulder pain (never lift by affected shoulder) -Maintain skin integrity -Enhance self-care -Swallow studies -speech therapy -nutrition -bowel and bladder training -improve thought process (don't finish their thoughts)What is a hemorrhagic stroke?A stroke primarily caused by intracranial or subarachnoid hemorrhage leading to bleeding into the brain tissue, ventricles, or subarachnoid spaceWhat are 80% of hemorrhagic strokes caused by?small vessel ruptures from uncontrolled HTNWhat is the primary culprit of subarachnoid hemorrhage?ruptured intracranial aneurysmWhat is AVM? What are they typically caused by?-arteriovenous malformation -Abnormality in embryonal development leading to a tangle of arteries and veins that lack a capillary bed - no bed leads to dilation and rupture *most common cause of strokes in young peopleWhat are the clinical manifestations of a hemorrhagic stroke?-SEVERE H/A -Early Symptoms: vomiting, sudden change in LOC, focal seizures *May have visual disturbances, tinnitus, nuchal rigidity, dizziness, and hemiparesisWhy may a pt with a AVM show little/no neuro deficits?a clot may seal the site of rupture *If this doesn't happen coma and death may occur rapidlyWhat type of stroke has significant morbidity and mortality rates?subarachnoid hemorrhageWhy should. pt with a suspected stroke get a CT or MRI?to determine the type of stroke, size, & location of hematoma, and the presence or absence of ventricular blood, & hydrocephalusWhat dx test confirms the presence of a hemorrhagic stroke?cerebral angiographyWhy would a lumbar puncture be performed?A confirmed subarachnoid hemorrhagic stroke with no evidence of increased ICPWhat does the medical managament of a hemorrhagic stroke consist of?•Allow the brain to recover from initial incident •Prevent or minimize risk of re-bleeding •Prevent or treat complications •Bed rest with sedation to avoid agitation •Mgmt of vasospasm •Reverse bleeding if anticoagulant induced •Treat seizures •Treat hyperglycemia •DVT prevention after bleed has stopped •Analgesics for painWhat does the surgical management of a hemorrhagic stroke consist of?-primary intracerebral hemorrhage is not treated surgically unless the pt has worsening neurological exams, increase ICP or signs of brainstem compression, then surgical evacuation is recommended for the pt with cerebellar hemorrhage. -May have aneurysm clipped or repaired if stable -May be stentedWhat are some nursing interventions for hemorrhagic stroke?-relieve anxiety and reduce stimuli -NO activity that increases BP -Ant-embolism stockings to prevent DVTDefine autonomic dysreflexiaa life-threatening emergency in patients with spinal cord injury that causes a hypertensive emergencyDifferentiate between blunt and penetrating traumatic brain injury.-blunt: head collides with another object and brain tissue is damaged but there is no opening in the skull or dura -penetrating: object penetrates the skull, enters the brain and damages the soft tissueWhat is the most common type of TBI?Concussion *pt usually recovers in a few days/weeksWhat patients may have slower recovery following a concussion?-older than 65 -young children -hx of 1+ concussionsWhat are some symptoms of a concussion/mild TBI?-H/A -Sleep problems -Cognitive deficits -Irritability -Dizziness -Anxiety -NauseaWhat is second impact syndrome?a 2nd concussion before the 1st concussion is resolved that causes cerebral edema, increased ICP, and possibly deathName a few TBI red flags.•Altered consciousness, persistent •Progressively declining neurological examination •Pupillary asymmetry •Seizures •Repeated vomiting •Double vision •Worsening headache •Cannot recognize people or is disoriented to place •Behaves unusually or seems confused and irritable •Slurred speech •Unsteady on feet •Weakness or numbness in arms/legsWhat are some nursing dx for TBI?-Ineffective airway clearance and impaired gas exchange RT brain injury -Risk for ineffective cerebral tissue perfusion RT ↑ ICP and possible seizures -Imbalanced nutrition: less than body requirements RT ↑ metabolic demands, fluid restriction, and inadequate intake -Risk for injury (self-directed and directed at others) RT seizures, disorientation, restlessness, or brain damageAn important nursing intervention for a pt with a TBI is maintaining a patent airway. How can this be achieved?-Keep HOB 30 degrees to facilitate drainage of secretions and decrease ICP -Suction -Monitoring ABGs -Pulmonary assessment -Oral hygiene to prevent pneumoniaWhat are primary spinal cord injuries due to? Secondary?-Primary injuries result of the initial insult or trauma and permanent if transection (severing) -Secondary: edema and hemorrhage which destroy myelin and axonsWhat do experts believe about secondary SPI?-Experts believe secondary injury is the principal cause of spinal cord degeneration and can be reversed in first 4-6 hours after injury *Early treatment is essentialWhat are the major risk factors for SCI?-young -male -drug/alcohol useDifferentiate between paraplegia and tetraplegia.-Paraplegia: paralysis of lower body -Tetraplegia (formerly quadriplegia): paralysis of all four extremitiesDifferentiate between complete and incomplete SCI-Complete injury: nerve damage obstructs all signals coming from the brain to the body below the injury -Incomplete injury: some sensory or motor function below the level of injuryWhat is the most common SCI?incomplete tetraplegiaWhy is respiratory function a major concern of SCI?-C4 innervates the diaphragm -T1-T6 innervates the intercostals -T6-T1 innervate the abdominal musclesWhat does emergency management of SCI include?-Immobilization of head/neck in a neutral position -Designated person to control head and keep it stabilized during transferWhy is keeping the head in a neutral position so important w/ SCI?-Twisting movement of the spine may irreversibly damage the cord by causing bony fragments of vertebra to cut into, crush, or completely sever the cordHow is SCI medically managed in the acute phase?-O2 therapy to maintain high PaO2 *if ET is placed the MD must avoid flexing or extending neckWhat is Halo Traction?it immobilizes the cervical spine when a cervical fracture occurs while allowing a pt to ambulate earlier *•Fixed in the skull by 4 pins. Ring attached to halo vest that suspends the weight of the unit equally around the chestWhat nursing interventions must be performed with Halo traction?•Clean pin sites daily, observe for loosening •Keep torque screwdriver available to tighten screws if needed •Inspect skin under vest especially on bony prominences, no powder, change liner periodically •Detailed instructions to family on discharge if vest to be worn for extended timeIn what instances is surgery indicated for SCI?•Compression of the cord •Injury results in fragmented or unstable vertebral body •Wound that penetrates the cord •Bony fragments in the spinal cord •Deteriorating neurologic status •Early surgical stabilization improves outcomes •Promotes neurologic functioning by removing pressure from the cord and provide stabilityWhat is spinal shock?Transient physiological reaction to depression of the reflex activity below the SCI level. Associated with muscle flaccidity, absent reflexes, altered bowel and bladder function, and paralytic ileus.What is Neurologic Shock?-Loss of autonomic nervous function below lvl of injury -associated with decreased BP, heart rate, cardiac output, venous pooling in extremities and peripheral vasodilation *Pt does not sweat in paralyzed part of the bodyIf injuries to cervical and upper thoracic cord respiratory problems develop. Name a few.-Decreased vital capacity -retention of secretions -increased PaCO2 -decreased PaO2 -respiratory failure -pulmonary edemaVTE is an acute complication of SCI. How can this be prevented?-Low dose anticoagulant therapy -SCD's or TED hose -Permanent filters may be placed in vena cava to prevent emboli from reaching lungs (PE)Why should you monitor BP when turning an SCI pt?Some have problems with vasomotor response and hypotension and tolerate changes in position poorlyWhat are some ways to improve motility in a SCI pt?-splint to prevent footdrop -trochanter rolls to prevent external rotation of the hips -Passive ROM to prevent atrophy and contracture of musclesWhat nursing intervention can be performed to relieve GI compression, distention, and prevent vomiting and aspiration?NGTWhat diet should an SPI pt be placed on when bowel sounds are present (first week)?high calorie, high fiber, high protein diet and gradually increase amount of foodVTE is a complication of SCI. When can these pts be put on anticoagulants?once head injury ruled out and other systems assessedThe first 2 weeks after SCI, blood pressure is usually unstable and low which interferes with normal reflex arcs that produce vasoconstriction when standing (orthostatic hypotension). What are some nursing interventions associated with this complication?-Promote venous return, meds, and close monitoring of vital signs, very slow progression to sitting/uprightWhat is autonomic dysreflexia? What pts is it more common in?-occurs as exaggerated autonomic responses to stimuli after spinal shock has resolved -Severe pounding HA with HTN, diaphoresis (forehead), nausea, nasal congestion, bradycardia -It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine at or above (T6 or above).What measures MUST be performed in autonomic dysreflexia occurs?1. Pt put in sitting position to lower BP 2.Rapid assessment to ID and alleviate cause 3. Empty bladder immediately (cath) 4. Check for impaction 5. Assess for skin breakdown 6. Remove other stimuli - cold drafts, objects next to skin, etc.) 7. Administer anti-hypertensive slow IVP 8. Pt. education about event and possibility of recurrence (anyone with T6 and above lesion)What are the chronic complications of SCI?•Premature aging •Disuse syndrome •Autonomic dysreflexia •Bladder and kidney infections •Spasticity •Depression •Pressure ulcers (10%) with associated osteomyelitis, sepsis, fistulas Heterotrophic ossificationWhat is heterotrophic ossification?the presence of bone in soft tissue where bone normally does not exist. The acquired form of HO most frequently is seen with either musculoskeletal trauma, spinal cord injury, or central nervous system injury.What is disuse syndrome?deterioration of body systems as a result of musculoskeletal inactivityDefine ataxialack of coordinated movements with or without spasticity or paresisDefine priona protein that causes infections or diseasesWhat is meningitis? What is septic meningitis caused by? Aseptic?-Inflammation of the meninges -bacteria -viral (usually secondary to a weakened immune system ex: cancer, HIV)What are the clinical manifestations of meningitis?-H/A -Fever -Neck immobility due to muscle spasm -Positive Kernig's & Brudzinkisigns -Photophobia -Rash -Disorientation -SeizuresWhat is Kernig's sign?When the patient is lying with the thigh flexed on the abdomen the leg can not be completely extendedWhat is Brudzinski's sign?After forced flexion of the neck there is a reflex flexion of the hip and knee and abduction of the leg.When testing CSF after a lumbar puncture what are some indications of infection?-yellow/pink/green color -protein greater than 45 mg/dl -more than 5 leukocytes per microliter -Less than 50 mg/dl of sugarHow is meningitis tx?-Penicillin G & a cephalosporin IV 30 mins of hospital arrival -Dexamethasone adjunct txWhat nursing interventions should be performed with meningitis?-Infection control /Isolation -Pain management -Keep room dark and quiet -Keep fever down -Hydration -Neurologic monitoringWhat is multiple sclerosis?-an immune-mediated, progressive demyelinating disease of the CNS.What is demyelination?-the destruction of myelin—the fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord; it results in impaired transmission of nerve impulses.What are the three courses of MS?-relapsing-remitting (RR) course: With each relapse, recovery is usually complete; however, residual deficits may occur and accumulate over time, contributing to functional decline. Over time, most patients with the RR course of MS progress to a secondary progressive course, in which disease progression occurs with or without relapses. -primary progressive course, in which disabling symptoms steadily increase, with rare plateaus and temporary minor improvement. May result in tetraparesis, cognitive dysfunction, visual loss, and brain stem syndromes. -progressive-relapsing course: It is characterized by relapses with continuous disabling progression between exacerbationsWhat are the clinical manifestations of MS?-Fatigue -Depression -Weakness -Numbness -Difficulty in coordination (ataxia) -Loss of balance, spasticity -Pain -Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness.Fatigue is often the most disabling symptom of MS. How can it be avoided??-Avoiding hot temperatures, effective treatment of depression and anemia, and occupational and physical therapies may help control fatigue. *Additional strategies include a balance of rest and activities, good nutrition to avoid being overweight and obese, and a healthy lifestyle including avoidance of alcohol and cigarette smokingWhat are some complications of MS?-Urinary tract infections -Constipation -Pressure ulcers -Contracture deformities -Dependent pedal edema -Pneumonia -Depression -Osteoporosis -Emotional, social, marital, economic, and vocational problems may also occurHow can injury be prevent for MS pts with ataxia?•Walk with feet apart to widen the base of support •Use of assistive devices (walkers, canes, etc.) •Wheelchair, motorized scooterWhat is myasthenia gravis?Autoimmune disorder characterized by varying degrees of weakness of the voluntary musclesWhat is the patho of Myasthenia Gravis?normal communication between the nerve and muscle is interrupted at the neuromuscular junction. Antibodies produced by the body's own immune system block, alter, or destroy the receptors for acetylcholine at the neuromuscular junction, which prevents muscle contraction from occurring.What are the clinical manifestations of MG?-Diplopia & Ptosis**** -weakness of muscles of face and throat (causing bland facial expression, dysphonia, and dysphagia) -generalized weaknessHow is MG Dx?-Tensilon Test (Edrophonium chloridedescribe the tensilon test-Positive if 30 seconds after administration of edrophonium chloride facial weakness and ptosis resolves for 5 minutesWhat is it called if symptoms worsen after a tensilon test?Cholinergic crisisWhat should always be available at the bedside of someone getting a tesilon test?ATROPINE SULFATE AND LIFE SAVING EQUIPMENT *Bradycardia, asystole, bronchconstriction, sweating and cramping are indications for useWhat are the treatment for MG?-anticholinesterase meds (Pyridostigmine bromide) -IVIG -therapeutic plasma exchange -thymectomyWhat are the specific effects of pyridostigmine bromide?-decreasing the heart rate, increasing the tone of GI smooth muscle, and stimulating the salivary glands by increasing secretions. It also increases tone and contractility of smooth muscle in the urinary bladder and relaxes the sphincter and bronchial smooth muscles.What is a myasthenic crisis?-exacerbation of MG causing severe generalized weakness and may lead to respiratory failure. -Symptoms include: *Respiratory distress *Dysphagia-difficulty swallowing due to muscle weakness *Dysarthria-difficulty speaking due to muscle weakness *Ptosis *Diplopia *Prominent muscle weaknessWhat is a cholinergic crisis?-Drug induced overstimulation of the parasympathetic nervous system, requiring discontinuation of any anticholinesterase drug the patient is taking. *Antidote: Atropine sulfateHow can pts with MG lessen their risk for aspiration?-Mealtimes should coincide with the peak effects of anticholinesterase medication to decrease the risk of aspiration. -Rest before meals is encouraged to reduce muscle fatigue. -The patient is advised to sit upright during meals, with the neck slightly flexed to facilitate swallowing. -Soft foods in gravy or sauces can be swallowed more easily.What is Guillain-Barre syndrome?-Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias. *Often occurs after a viral illness.What viruses usually preceed guillain-barre syndrome?-Campylobacter jejuni (implicated in 24% to 50% of cases) -cytomegalovirus -Epstein-Barr virus -Mycoplasma pneumoniae -H. influenzae, -HIVHow does Guillain-Barré typically begin?-muscle weakness and diminished reflexes of the lower extremities. Hyporeflexia and weakness may progress to tetraplegia.What are the life-threatening complications of Guillain-Barré?-respiratory failure -cardiac dysrhythmias -venous thromboembolismWhat is Bell's Palsy?Inflammation or viral infection of the facial nerve that causes one sided weakness or the entire faceWhat is trigeminal neuralgia?a nerve disorder that causes a stabbing or electric-shock-like pain in parts of the face.Define bradykinesiaabnormally slow voluntary movement and speechDefine choreaInvoluntary, rapid, irregular and jerky movements of the extremities or facial muscles; including facial grimacingDefine papilledemaedema of the optic nerve usually due to increased ICPWhat are the manifestations of brain tumors?•Localized or generalized neurologic symptoms •Symptoms of increased ICP •Headache •Vomiting •Visual disturbances •Seizures •Hormonal effects with pituitary adenoma •Loss of hearing, tinnitus, and vertigo with acoustic neuromaHow are brain tumors medically managed?-Radiation*** -Surgery -Chemo -CorticosteroidsWhat is Parkinson's disease?•Slow, progressive neurologic movement disorder associated with decreased levels of dopamineWhat are the manifestations of Parkinson's disease?•Cardinal: tremor, rigidity, bradykinesia/akinesia, postural instability •Autonomic: sweating, drooling, flushing, orthostatic hypotension, gastric and urinary retention •Dysphagia •Psychiatric changes: depression, anxiety, dementia, delirium, hallucinationsHow is Parkinson's treated?-Treatment directed toward controlling symptoms and maintaining functional independence -LevadopaWhat are some surgical procedures for Parkinson's?•Stereotactic Procedures •Thalamotomy •PallidotomyWhat is Huntington's disease?A chronic progressive hereditary disease that results in choreiform movement and dementiaWhat is the patho of huntington's?premature death of cells in the striatum of the basal ganglia (control of movement) and the cortex (thinking, memory, perception, judgment)What is the triad of Huntington's disease?-chorea -cognitive impairment -apathy and blunted affectWhat is the number 1 cause of dementia?Alzheimer'sWhat may play a role in the patho of Alzheimer's?oxidative stressWhat is oxidative stress?an imbalance between the production of free radicals and the ability of the body to counteract or detoxify their harmful effects through neutralization by antioxidantsWhat meds are given for Alzheimer's?-Donepezil -Riverstigamine -Galantmine -memantineWhat is ALS?-amyotrophic lateral sclerosis -Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei of the lower brainstemWhat are the manifestations of ALS?•Progressive weakness and atrophy of muscles cramps, twitching, and lack of coordination •Spasticity, deep tendon reflex brisk and overactive Difficulty speaking, swallowing, breathing