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Neuro Exam #1-Med Surg

Terms in this set (57)

Clinical manifestations:
-As the pressure increases within the cranial cavity, it is first compensated for by venous return and CSF displacement.
-As the pressure continues to rise, the cerebral blood flow decreases and inadequate perfusion of the brain occurs.
-This cycle causes Pco2 to increase and the Po2 and Ph to decrease.
-These changes cause vasodilation and cerebral edema which leads to increased compression of neural tissue and increased ICP
-When the pressure buildup is greater than the brain's ability to compensate, pressure is exerted on surrounding structures where the pressure is lower
-This movement of pressure is called Supratentorial shift and can result in herniation
-This can lead to alteration in the life-sustaining mechanisms such as Blood pressure, respirations, tempeerature, pulse
-Late signs:There is a rise in systolic pressure with unchanged diastolic causing a widening pulse pressure, bradycardia, abnormal respirations which indicate that there is herniation in the brain.

Subjective data:
-Visual changes such as Diplopia-double vision
-Changes in personality and ability to think
-Nausea, pain, headache that increases in intensity with coughing, straining, stooping. Usually present in the early morning and may awaken the pt. from sleep.

Objective data:
-Earliest sign: Changes in LOC (disorientation, restlessness, lethargy)
-Pupillary signs, sluggish reaction, the oculomotor nerve (III) is compressed
-Fixed and dilated pupil-called blown pupil-Ominous sign that must be reported to the physician ASAP.
-Ipsilateral pupil that is unable to constrict and remains dilated
-Changes in BP and pulse. Rising systolic and widening pulse pressure
-Cushing's response-widening pulse pressure, increased systolic BP and bradycardia together.
-Respiratory problems (Cheyne-Stokes or deep and stertorus). Ataxic breathing may also occur leading to respiratory paraysis.
-High, uncontrolled temperature, resulting in hyperthermia
-progressive muscle weakness
-Babinski's reflexes, hyprflexia, rigidity, characteristic posturing
-Vomiting (unexpected, projectlie) and singultus (caused by compression of the Vagus nerve cranial nerve X)
-Papilledema (choked disk). The optic disk is edematous and the retina is compressed.
Multiple sclerosis is a chronic, degenerative, neurologic and progressive disease with an unknown cause.
Patients with the first signs and symptoms of MS have a proliferation of immune cells gamma delta T cells in their spinal fluid.
Those T cells attack the body and myelin damage occurs.
The onset is usually between the ages of 15 to 50 with women being affected more than men.

Clinical manifestations:
-insidious and gradual onset with vague symptoms
-visual problems
-urinary incontinence
-weakness or incoordination of extremities
-sexual problems
-swallowing difficulties
-chronic, progressive deterioration with episodes of remission and exacerbation
-exacerbations may be related to chilling, fatigue, or emotional disturbances
-scarring of myelin sheath and progressive neurological damage

Subjective data:
-diplopia, blindness
-scotomata (spots before the eyes)
-numbness, fatigue
-emotional instability
-bowel and bladder problems
-loss of joint sensation
-ataxia and tremor (with involvement of the cerebellum)
-impotence is significant in male patients

Objective data:
-muscle weakness and spasms
-changes in coordination
-spastic and ataxic gait
-cerebellar signs include ataxia, dysarthria and dysphagia
-behavior changes such as euphoria, emotional lability, mild depression
-urinary incontinence
-intention tremors of upper extremities

Diagnostic test:
-No definitive diagnosis, based on history and physical examination.
-MRI, CT scan, CSF

-Adrenocorticotropic hormone
-Corticosteroids such as Prednisone or Dexamethasone
-Immunomodulating drugs
-Pro-Banthine or Urecholine for the urainary frequency and urgency
-prophylactic drugs to prevent infections such as Bactrim, Sptra, Macrodantin, Cranberry juice
-Encourage po fluid intake of at least 2000ml/day and stool softener if constipation is present.
Myasthenia Gravis is an autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups. it is unpredictable neuromuscular disease with lower motoneuron characteristics. MG can occur at any age, but most commonly between the ages of 10 and 65, with peak at 20 to 30.

Medical management:
-treatment with Anticholinesterase drugs such as Neostigmine (Prostigmin) and Pridostigmine (Mestinon). these medications promote nerve impulse transmissions and alleviate symptoms.
-Corticosteroids may be used as adjunct therapy
-Immunosuppressive medications (Imuran, Sandimmune, Cytoxan)
-Plasmapheresis-removes antibodies produced by the immune system via separation of plasma from blood in a cell separator.
-Thymectomy-indicated for almost all patients with thymoma
-IV immune globulin administration to reduce production of acethylcholine antibodies
-Intubation and mechanical ventilation during acute exacerbation when the respiratory status is compromised

Nursing Interventions and Patient teaching:
-Prevent aspiration/pneumonia
-prevent/manage respiratory problems
-teach patient airway protective techniques during swallowing (chin tuck, double swallow)
-Suctioning prn
-Feeding tube placement if swallowing becomes impaired
-Promote rest and preserve energy
-ROM and PT to maintain muscle function
-Teach importance of medication administration and taking them on time
-Explain how to adjust medication dosage
-Caution which medications need to be avoided (anesthetics, antidyysrhytmics, antibiotics, quinines, antipsychotics, barbiturates, sedatives, hypnotics, tranquilizers, opioids, thyroid preparations)
-Advise to seek medical attention with first signs of URI
-Advise to eat only while sitting upright in order to prevent aspiration
-Caution to avoid crowds in flu and cold season
-Explain need for rest periods and activities
-Advise to wear medical-alert bracelet

-If the client is having a seizure, maintain a patent airway
-Do not force the jaws open or force anything in their mouth
-place the client onto their side on the floor and protect the head and body
-remove furniture or items that mayy cause injuty
-support the ABC's-airway, brething, circulation
-administer oxygen
-note time and duration of the seizure
-Assess behavior at the onset of the seizure, note presence of aura, changes in facial expression, or cry or sound
-prepare to suction secretions from the airway
-remain with the client
-do not restrain the client
-loosen restricitve clothing
-note the type, character and the progression of the movements during the seizures
-monitor for incontinence
-Administer IV medications to stop the seizure
-Document the characteristics of the seizure
-Provide privacy, if possible
-Monitor behavior after the seizure, such as the state of conciousness, motor ability, and speech ability
-Instruct the patient about tne need of life-long medication and follow-up with blood levels
-Instruct the client to avoid alcohol, stress, fatigue and strobe lights
-Encourage the patient to access community resources and too wear a midic-alert bracelet.

Adult Health:
-The primary goal is to protect from aspiration and injury and observation and recording of the seizure activity
-Never leave the patient alone
-If patient is sitting or standing, lower to the floor and away from equiment/furniture
-Support and protect the head
-Turn head to the side to maintain airway and prevent aspiration
-loosen constrictive clothing, especially around the neck
-do not restrain the client
-do not try to open the jaw or place a padded tongue blade (no object should be placed in the mouth)
-Suctioning and oxygen after the seizure may be required
-seizure precautions-padded siderails
-observe and record details of the event
-note all aspects of the seizure: events before, when did it occur, how long, aura, ictal, postictal? what occurred after each phase?

Nursing Dx: Ineffective airway; Risk for Injury
Adult Health:
Nursing Interventions:
-well-balanced diet with high-fiber foods and adequate fluid intake. High-protein diet with supplemental vitamins is recommended
-obese patients should be referred to dietician counseling

Skin care:
-frequent turning to avoid skin impairment
-use of special devices such as eggcrate and air matresses
-because of sensory involvement, the patient may not feel the need t change the position

-encourage regular exercise, but prevent fatigue
-exercise increases coordination and decreases muscle spasticity
-encourage daily rest periods
-teach how to stabilize the affected side b leaning toward the less affected side.

Control of environment:
-Advise to avoid hot baths due to increased weakness
-summer travels should be planned in the coolest part of the day
-maintain peaceful and relaxed environment
-provide emotional support (sudden crying episodes or laughing outbursts may occur)
-provide patient teaching to both the client and significant others/caregivers
-stress importance of spacing activities and avoiding temperature extremes
-refer patient to support groups

Nursing Dx:
-Risk for powerlessness, r/t physical limitations imposed by progressive physical deterioration, loss of body control and threat to physical integrity
-Bathing/feeding/hygiene/self-care deficit r/t limitations in physical mobility imposed b disease process
-Encourage self-care
-Provide oral hygiene
-Catheterize intermittently as indicated
-Provide bladder dysfunction program
-Institute bowel control program
-Assist in dressing/grooming
-Provide nutritious/attractive meals

-Provide bed rest during exacerbation
-Protect from injury by instituting safety precautions
-place an eye patch on the eye for diplopia
-monitor for potential complications such as UTI's, calculi, pressure ulcers, respiratory tract infections and contractures
-provide regular elimination by bledder/bowel training and catheterization prn
-encourage independance
-assist with establishing regular exercise routine
-encourage to balance moderate activity with rest
-assess the need and provide assistive devices
-initiate physical and speech therapy
-instruct to avoid fatigue, stress, infection, overheating, and chilling
-encourage increased fluid intake and balanced diet (low-fat, high-fiber, high-potassium)
-safety measures related to sensory loss 9regulating bath temperature
-encourage the use of safety measures
-instruct on self-medication addministration
-provide information about the National MS Society
ALS stands for Amyotrophic Lateral Sclerosis aka Lou Gehrig's disease.
Loss of both lower and upper motoneurons is the major pathologic change associated with ALS.It is a rare, progressive neurologic disease that leads to death in 2 to 6 years. The onset is between 40 and 70 years of age and twice as common in men than women.
The cause is unknown. Electrical and chemical messages originating in the brain do not reach the muscles to activate them.
Primary symptoms:
-weakness of the upper extremities with the hands often being affected first
-muscle wasting and fasciculation (muscle twitching)
-death usually results from respiratory tract infection secondary to compromised respiratory function

There is no cure for ALS. A drug called Rilutek (riluzole) slows the progression of ALS adding 3 or more months to the patient's life.
This illness is devastating because the patient remains cognitively intact while wasting away.
Nursing management:
-guide through exercise, rest and reducing s/s of spasticity and wasting of muscles
-provide emotional support, provide cognitive activities, socialization, reading and human companionship
-guide and assist patient and family through the grieving process

-progressive degenerative disease involving the motor system
-the sensory and autonomic systems are not involved and mental status changes do not result from the disease
-cause may be related to excess glutamate, a chemical responsible for relaying messages between motor neurons
-as the disease progresses, muscle weakness and atrophy develop until a flaccid quadriplegia develops
-eventually, the respiratory muscles become affected, leading to respiratory compromise, pneumonia and death
-no cure is known and the treatment is symptomatic

Data collection:
-fatigue (including while talking)
-respiratory distress
-muscle weakness and atrophy
-tongue atrophy
-weakness of the hands and arms
-fasciculations of the face (twiching)
-nasal quality of speech

-care is directed towards the treatment of symptoms
-monitor respiratory status and provide respiratory treatments
-prepare to initiate respiratory support
-assess for complications of immobility
-provide emotional support to patient and family
Huntington's disease is a genetically transmitted autosomal dominant disorder that affects both men and women of all races. Onset of the disease is between the ages 30 to 50.
Diagnosis is based on family history, clinical symptoms and the detection of the characteristic DNA pattern from blood sample. The disease involves the basal ganglia and the extrapyramidal motor system with overactivity of the dopamine pathway, which leads to symptoms that are the opposite of the ones associated with Parkinson's disease.
Clinical manifestations:
-abnormal and excessive involuntary movements (chorea)-writhing, twisting movements of the face, limbs and body
-the movements get worse as the disease progresses
-facial movements involving speech, chewing and swallowing are affected and may lead to aspiration and malnutrition
-the gait deteriorates and ambulation eventually becomes impossible
-mental function deteriorates (the most devastating deterioration), intellectual decline, emotional lability, psychotic behavior
-death usually occurs in 10-20 years after the onset of symptoms
-there is no cure, therapeutic management is palliative
-antipsychotic, antidepressants and antichorea medications are prescribed (do not alter the course of the disease)
-caloric intake is as high as 4000-5000 calories per day due to excessive chorea movements
-Nutritional intake presents a great challenge as the disease progresses and the patient has difficulty swallowing and holding the head still.

Nursing goal is to provide the most comfortable environment for the patient and family by maintaining physical safety, treating the physical and emotional symptoms and providing psychological and emotional support.
-Genetic counseling is important part of care