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COTAC II Exam 5 Key Concepts

Terms in this set (268)

What does an Ophthalmoscopy examine?
Examines cornea, lens, retina (indirect & direct)
What does a Slit-lamp examination do?
Magnifies 10-40X, binocular microscope mounted on table
What's tonometry?
measures intraocular pressure, tests for glaucoma

TONometry measures to see if there's a TON of intraocular pressure
What's color vision testing?
Ishihara polychromatic plates (primary color dots integrated into background of secondary colors). Central vision identifies colors.
What's the Amsler grid?
Geometric grid of identical squares with central fixation point, used for macular degeneration
What's ultrasonography? What is it used for?
Clear picture if retina, for tumor and retinal detachment
What's angiography? What's it used for?
Injection of dye IV, macular degeneration.

Patient teaching: well hydrated, brief warm feeling, may turn skin/urine gold tone, nausea/vomiting, check for iodine allergy.
What's Perimetry testing?
Evaluates field of vision.

Scotomas: blind or partially blind areas in the visual field.



Remember PERIMETRy checks to see if someone can see the whole PERIMETER of the field of vision
What's the Snellen Chart used for?
Used to test vision.

20/30 is great vision. 20/20 or less is worsening vision
What's a refractory error?
Can be corrected by lenses that focus light rays on the retina (glasses & contacts)
What's Emmetropia?
20/20 vision, normal vision


Remember Emme has perfect vision!
What's Myopia?
Nearsighted and have blurred distance vision
What's Hyperopia?
Farsighted, have excellent distance vision but blurry near vision
What's Astigmatism?
Distortion due to curvature of the cornea
What parameters need to be met to be considered legally blind?
20/400, absence of light perception. Legally blind. Ranges from inability to perceive light to having some vision remaining.
What causes someone to become legally blind?
Diabetic retinopathy, macular degeneration, glaucoma, cataracts.
What's nursing management for someone who's legally blind?
Promote coping efforts: acceptance of permanence of blindness, fear, process through the stages of grieving.
Promote spatial orientation and mobility: adapt to environment, keep items within clients reach, orient client to location of meal tray (use a clock method to orient patient to food, etc.). Knock before entering client's room.

Promote home care: Braille, Guide dog
What's the patho of Glaucoma?
Pathophysiology: increase in intraocular pressure (IOP) caused by congestion of aqueous humor. Aqueous production & drainage are not in balance. Pressure builds up in the eye. Increased IOP causes irreversible mechanical or ischemic damage.

Normal IOP is 10-21 mm/hg. More prevalent in ages 40+. Common cause of blindness, early diagnosis and treatment is essential to prevent vision loss.
When should you check for Glaucoma?
Before age 40: every 2-4 years
40-54: every 1-3 years
55-64: every 1-2 years
65 and older: every 6-12 months
What are risk factors for Glaucoma?
family history, African American, older age, DM, cardiovascular disease, migraines, myopia (nearsighted), trauma to eye, steroid use, thin cornea, infection, tumors, hypertension, retinal detachment.
What are the different types of Glaucoma?
i. Primary open angle(POAG): most common form, aqueous humor outflow is decreased due to blockage in the drainage system. Gradual rise in IOP (22-32). Silent thief.

ii. Primary angle-closure: angle suddenly closes, IOP increases suddenly (30 or higher)
What are the signs and symptoms of Primary open-angle glaucoma?
gradual loss of peripheral vision, decreased accommodation, mild eye pain, blurry vision, halos around lights, headache.
What are the signs and symptoms of Primary Angle-closure glaucoma?
Severe eye pain, nausea/vomiting, photophobia, headache decreased or blurry vision, colored halos around lights, red eyes, hazy cornea, pupils nonreactive to light. Requires immediate treatment.
What's included in nursing management for patients with glaucoma?
monitor for increased IOP, monitor for decreased vision & light sensitivity. Treat severe pain & nausea w/analgesic antiemetics. Focus on maintaining the therapeutic regimen for lifelong control of a chronic condition. Emphasize the need for adherence to therapy and continued care to prevent future vision loss.
What should be taught to a patient with glaucoma regarding medications?
Prescribed eye med is beneficial if used EVERY 12 HOURS. Instill 1 drop in each eye twice daily. Wait 5-10 minutes between eye drops if more than one is prescribed. Avoid touching the top of the application to the eye, always wash hands before and after use, use the punctal occlusion technique after eye drop is instilled.
What are treatment options for Glaucoma?
Goal is to prevent further optic nerve damage, maintain IOP within range unlikely to cause damage. Lifelong therapy.

Medications:
Timolol (Betablocker, first line therapy).
Pilocarpine (Cholinergic).
Apraclonidine (Adrenergic antagonist).
Surgery

i. Glaucoma surgery client education: Laser trabeculectomy, Iridotomy, or placement of shunts improve flow by opening the channel out of the anterior chamber of the eye.
What should the patient with glaucoma be educated on when it comes to glaucoma surgery?
i. Glaucoma surgery client education: Laser trabeculectomy, Iridotomy, or placement of shunts improve flow by opening the channel out of the anterior chamber of the eye.

Client education: wear sunglasses while outside or in brightly lit areas, report manifestations of infections like yellow/green drainage.

Avoid activities that increase IOP: bending at the waist, sneezing, coughing, straining, head hyperflexion, restrictive clothing, sexual intercourse. Use stool softener daily (Colace), don't lift anything over 15 pounds.

Limit activities: tilting head back to wash hair, cooking, housekeeping, rapid/jerky movements (Vacuuming), driving & operating heavy machinery, playing sports.

General: do not lie on operative side, report severe pain or nausea as this can indicate possible hemorrhage, final best vision occurs 4-6 weeks after surgery
What is cataracts?
An opacity or cloudiness of the les that impairs vision, leading cause of blindness in the world, increased incidence with aging. By age 80, more than half of Americans have cataracts, a leading cause of disability in the US.
What are the risk factors for Cataracts?
aging, Myopia (nearsighted), retinal detachment, infection, long-term steroid use, smoking, poor nutrition/obesity, heredity, dehydration, blunt trauma, excessive exposure to sunlight, DM, down syndrome, renal disorders, musculoskeletal disorders.
What are the clinical manifestations of Cataracts?
PAINLESS and progressive, blurry vision, sensitive to glare. Reduced visual acuity: prescription changes, reduced night vision, decreased color perception.

Myopic shift: return of ability to do close work. Astigmatism, Diplopia (double vision), color shifts as lens becomes more brown. Opacity of the lens (visible behind the pupil)
What's part of nursing care for a patient with Cataracts?
Check visual acuity with the Snellen chart, determine the client's functional capacity, increase the amount of light in the room.

Provide adaptive devices for reduced vision: magnifying lens, large print, talking devices.
What's a part of surgical management for a patient with cataracts?
If reduced vision does not interfere with normal activities, surgery is not needed. Surgery is performed on an outpatient basis w/local anesthesia. Surgery usually takes less than 1 hour; patient is discharged soon after.

Surgical removal of the lens: small incision is made; lens is removed whole or in pieces (sound waves used to break into pieces). A replacement or intraocular lens is inserted, replacement lenses can correct refractive errors which result in improved vision.
What's included in pre-op care for someone with Cataracts?
Pt should avoid taking alpha-antagonists (Flomax) "floppy iris syndrome", Dilating eye drops (anticholinergic agents), Antibiotic eye drops, Anti-inflammatory eye drops.
What's included in post-op care for someone with Cataracts?
Monitor for infection & bleeding, eye drops, prevent an increase of IOP & limit certain activities (bending at the waist, straining).

Infection: report yellow or green discharge (white and crusty is normal), increased redness or pain, increased tear production.

Bleeding: immediately report any sudden change in visual acuity or increase in pain.

When to call MD: vision changes, continuous flashing lights or floating shapes, redness or swelling increases, type & amount drainage increases, pain with nausea/vomiting can indicate IOP or hemorrhage, significant pain.
What's included in patient teaching for someone with Cataracts?
final best vision occurs 4-6 weeks after surgery, protective eye patch for 24 hours, eyeglasses during the day, eye shield at night, washing of hands, cleaning of eye, shampoo hair cautiously, decrease intraocular pressure, avoid lying on side of affected eye the night of surgery.
What's the patho behind Retinal detachment?
Separation of the sensory retina & the retinal pigment epithelium (RPE). Hole or tear develops in the retina. Liquid vitreous seeps thru & causes retina to detach.
What are the signs and symptoms of Retinal detachment?
Sensation of a shade or curtain coming across the vision of one eye, bright flashing lights, sudden onset of floaters. This is a true ocular emergency!!
What's the surgical treatment for Retinal detachment?
Scleral Buckle: band compresses the sclera & brings 2 layers of retina together, HIGH SUCCESS RATE.

Pars plana vitrectomy: removal of vitreous, locating the incision at the pars plana, frequently used in combination with other procedures.

Pneumatic Retinopexy: injecting gas bubble, liquid, or oil is used to flatten the sensory retina. Post op positioning is critical: Patient must remain prone to keep gas bubble overlying the area of detachment & providing consistent pressure to reattach the sensory retina.
What's nursing management for a patient having a surgery for Retinal detachment?
Promoting comfort with positioning.

Patient teaching: increased IOP, cataracts, further detachment.
What's the patho behind Macular degeneration?
NO CURE. central loss of vision that affects the macula of the eye, the most common cause of vision loss in people older than age 60.

Appearance of Drusen: clusters of debris or waste material. Tiny, yellowish spots beneath the retina.
What are the signs and symptoms of macular degeneration?
Lack of depth perception, objects appear distorted, blurred vision, loss of central vision, blindness.
What are the types of macular degeneration?
Dry Macular Degeneration: most common type. Caused by gradual BLOCKAGE in retinal capillary arteries which lead to ischemia & necrosis.

Wet Macular Degeneration: less common. Caused by new growth of blood vessels of thin walls which lead to vessels LEAKING BLOOD AND FLUID. Can occur at any age.
What is the treatment for macular degeneration?
laser therapy to seal leaving vessels, ocular injections.
What's important patient information regarding the treatment of macular degeneration?
Consume foods high in antioxidants, carotene, Vit E, B 12. May be prescribe a supplement high in carotene and Vit E. As loss of vision progresses, patient will be challenged with ADLs, along with their ability to eat, drive, write, and read. Refer client to community organizations: assist with transportation, reading devices, & large-print books. consume foods high in antioxidants, carotene, Vit E, B 12. May be prescribe a supplement high in carotene and Vit E. As loss of vision progresses, patient will be challenged with ADLs, along with their ability to eat, drive, write, and read. Refer client to community organizations: assist with transportation, reading devices, & large-print books.
What's the patho of Diabetic Retinopathy?
caused by damage to the blood vessels in the tissue at the back of the eye (retina).
What are risk factors for Diabetic Retinopathy?
Poorly controlled blood sugar.
What are symptoms for Diabetic Retinopathy?
floaters, blurriness, dark areas of vision, difficulty perceiving colors.
What are treatments for Diabetic Retinopathy?
Mild cases may be treated w/careful diabetes management, need strict diet. Advanced cases may require laser treatment or surgery.
What's Conjunctivitis?
Pink eye
What are symptoms of Conjuctivitis?
burning, scratching, itching sensation, photophobia. Can easily spread from one eye to the other.
What are the classifications/causes of Conjunctivitis?
Bacterial, viral, fungal, parasitic, allergic, toxic.

Viral conjunctivitis is HIGHLY contagious.
What's Enucleation?
(Removal of eyeball (Globe) from the orbit)
What's Evisceration?
removal of contents through an incision
What's Extenteration?
removal of entire contents.
What's Ocular Prothesis?
Will have large ocular pressure dressing removed after a week. Ophthalmic topical antibiotic ointment is applied in the socket 3 times daily. Client has loss of depth perception, extra caution with ambulation. Client is advised conformers may accidentally fall out of the socket, if this happens... wash, dry, place back in.
What's the Weber Test?
Uses bone conduction to test lateralization of sound. Tuning fork checks to see if patient can hear equally on the right and left ear (ringing noise).
What's the Rinne Test?
Is held behind the ear, CONDUCTIVE. Useful for distinguishing between conductive and sensorineural hearing loss.
What's the Audiometer?
Noninvasive test of hearing ability, frequency, pitch, intensity. The client indicates when a tone is herd through earphones. Usually done in an audio room.
What's the Tympanogram?
Measures mobility of the tympanic membrane & middle ear structures relative to sound.
What's an Otoscopy?
examines the external auditory canal, tympanic membrane, & malleus bone.

Indications: audiometry indicates impairment or ear pain.
Pull up and back on auricle for adults, pull down and back for children up to age 3.

Tympanic membrane should be pearly gray color & intact.

Light reflex should be visible from center of the tympanic membrane anteriorly.

Tympanic membrane can become inflamed & bulge due to pressure of exudate & displaces light reflex (fluid or bubbles behind the tympanic membrane).
What's an Electronystagmography?
Detects involuntary eye movements (nystagmus). Assess for disease of the vestibular system. Electrodes are taped near the eyes & recorded when the ear canal is stimulated with cold water instillation or injection of air.

Nursing actions: keep client alert during procedure. Client should maintain bedrest & NPO until vertigo subsides.

Client education: fast before procedure. Restrict caffeine, alcohol, sedatives, & antihistamines several days before the test. Contraindicated in patients' w/pacemakers.
What's Caloric Testing?
Can be done concurrently w/ENG. Water (warm or cold) is instilled in effort to induce nystagmus (involuntary eye movement). The eyes response to the instillation of water is diagnostic of vestibular disorders. Nursing actions & client education are same as ENG.

Using warm water in the right ear, an ocular nystagmus is evoked in which the slow phase is towards the left side, and conversely the fast phase is towards the right.
What are the risk factors of hearing loss?
family history, congenital malformations,

Ototoxicity (chronic use of salicylates, furosemide, gentamycin, azithromycin, chemo meds, NSAIDs).

Infections, exposure to loud noises, perforation of tympanic membrane.
What's Conductive hearing loss?
Due to external or middle ear problem, often caused by otitis media, otosclerosis, & foreign bodies.
What's Sensorinerual hearing loss?
due to damage to the cochlea or vestibulocochlear nerve.
What's Mixed hearing loss?
both conductive & sensorineural.
What's functional hearing loss?
psychogenic, due to emotional reaction.
What are clinical manifestations of hearing loss?
Tinnitus (ringing in ears), abnormal repetitive sounds, difficulty hearing in a group, turning up the volume on the TV. Impairment may be gradual & not recognized by the person experiencing the loss.

As hearing loss increases: Deterioration of speech, fatigue, indifference, social isolation or withdrawal.
How should you communicate with someone who is hearing impaired?
Use low-tone normal voice, speak slowly & distinctly. Reduce background noise & distractions, face the person & get their attention. Speak into the less-impaired ear, use gestures & facial expressions. If necessary, write out the info or use a sign language translator.
What is a Cerumen inspection?
removal may be by irrigation, suction, or instrument. Gentle irrigation should be used with lowest pressure, directing stream behind the obstruction. Glycerin, mineral oil, half-strength H2O2 or peroxide in glyceryl may help soften cerumen. Candles could be used as well.
What's External Otitis?
Inflammation of the external auditory canal (swimmers' ear, trauma, systemic conditions). Inflammation is most commonly due to the bacteria staphylococcus or pseudomonas, or fungal infection.
What's Malignant external otitis?
Severe bone infection. Rare, debilitating & occasionally fatal. Progressive. Effects external auditory canal, surrounding tissue, & skull.
What's tympanic membrane perforation?
Usually caused by infection or trauma (skull fracture, explosion, severe blow to ear). Heal spontaneously in weeks to several months.

Otorrhea: CSF from the ear. Clear watery drainage.

Rhinorrhea: CSF from the nose.

Surgery: Tympanoplasty. Tissue is placed across the perforation to allow healing & improves hearing.
What are causes of Acute Otitis Media?
Acute viral or bacterial infection of the middle ear. Lasts less than 6 weeks.
What are the signs and symptoms of Acute Otitis Media?
Otalgia (sensation of fullness or pain in ear). Drainage from the ear (purulent or blood drainage, bacterial**). Fever, headache, conductive hearing loss.
What's the medical management for Acute Otitis Media?
systemic antibiotics for middle ear infection, analgesics, apply heat & decongestants.
What's a part of surgical treatment for a patient with Acute Otitis Media?
Myringotomy: surgical opening of the eardrum, placement of equalizing tubes (eustachian tubes) to equalize pressure. Eustachian tubes stay in place for 6-18 months & fall out on their own.
What are considerations when administering t-PA?
Administer within 3-4.5 hours of initial manifestations. Only given for ischemic strokes.
What are contraindications of t-PA?
Must be 18 or older, verified ischemic stroke, SBP not >185, DBP not >110. No seizure activity, no blood thinners. Platelet count >100,000, no major surgery within 2 weeks. No GI or urinary bleeding within 21 days.
What are therapeutic procedures for a patient suffering from a stroke?
Carotid artery angioplasty w/stenting (CAS): stent placed to open blockage, performed withing 6 hours of onset of manifestations.
Carotid Endarterectomy: removes atherosclerotic plaque in the carotid artery, recommended for patients' w/ blockage over 50-70% if other factors are present (TIAs).
Post op: assess for headache, neck swelling, hoarseness.
What are nursing interventions for patients suffering from a stroke?
Monitor vitals every 1-2 hours. Notify provider of a BP over 180/110 (can indicate ischemic stroke). Monitor & treat fever. Maintain Oxygen over 92% if patient has decreased LOC. Monitor ECG for cardiac arrythmias. Conduct cardiac assessment to detect murmurs & irregularities. Monitor for change in LOC. Monitor for hyperglycemia due to poor neuro outcomes. Elevate HOB at least 30 degrees, prevent extreme flexion/extension of head. Institute seizure precautions.
Assist patient w/communication if speech is impaired: supply w/picture board of commonly requested items/needs. Speak slow/clearly. Use one step commands, maintain eye contact, work w/speech therapist, give patient time to communicate.
Assist w/ safe feedings: swallow study before feeding, completed 4-24 hours upon ED arrival. (4 liquid consistencies will be recommended following the study. Thin, nectar-like, honey-like, spoon-thick). Eat in upright position, swallow w/ head slightly flexed forward. Place food in the back of mouth on unaffected side, suction at the bedside.
Prevent complications of immobility: ambulate asap, ROM every 2 hours, change position every 2 hours, elevate affected extremities, work closely w/Physical Therapy.
Care for one-sided neglect: observe & protect from injuries of the affected extremities. Teach patient to protect & care for affected extremity. Apply arm sling, dress affected side first, place affected extremity to midline & protect from danger, instruct patient to overlook the affected side periodically.
Maintain safe environment: use assistive devices during transfers.
If patient has homonymous hemianopsia: instruct patient to use a scanning technique when eating/ambulating, put items in the room within patients view.
Assist w/ADLs/OT/PT: OT to assess for adaptive aids. Provide frequent rest periods. Patient typically leans to the affected side; provide support. Shoulder subluxation can occur if the affected arm is not supported. Instruct patient to use the unaffected side to exercise the affected side. Don't pull on affected arm, promote self-care, add a task each day.
What's the patho of Ménière's disease?
abnormal inner ear fluid balance, genetic predisposition.
What are the signs of symptoms of Ménière's disease?
fluctuating, progressive hearing loss (unilateral hearing loss), tinnitus, feeling of pressure or fullness, episodic, incapacitating vertigo that may be accompanied by nausea and vomiting.
What are the treatments for Ménière's disease?
Diet: low sodium diet (1000-1500 mg/day), sodium & fluid retention disrupts the balance of fluid in the inner ear. Meclizine (Antivert), tranquilizers, antiemetics, diuretics.
What's part of surgical management of Meniere's Disease?
Endolymphatic sac procedures & vestibular nerve section. Pressure points treatment: inserting a tympanostomy tube, which applies micropulses at intervals to relieve vertigo by displacing fluid of the inner ear. Hearing loss, tinnitus, fullness can continue; aimed at eliminating vertigo.
What's Tinnitus?
Ringing in the ear. Roaring, buzzing, hissing sound in one or both ears (if hearing something weird or off, notify the provider)
What's Vertigo?
the illusion of motion or a spinning sensation. (Reduce exposure to bright lights, move head slowly when changing positions, plan evenly spaced daily fluid intake, avoid foods containing caffeine).
What's Ototoxicity?
related to medications, Gentamycin, Erythromycin, Furosemide, Ethacrynic acid, NSAIDs, Chemo agents (Cisplatin). Can result in irreversible hearing loss, monitor blood levels, teach client about adverse effects, routine audiometry is indicated with use of ototoxic IV antibiotics.
What's Benign Paroxysmal Positional Vertigo?
Caused by debris (small crystals of calcium carbonate) located within the semicircular canal. Sudden onset can last a few weeks or years.

Treatment: bedrest, Meclizine
What's Labrynthitis?
(Infection of the labyrinth): Often secondary to otitis media, sudden onset of severe vertigo, nausea/vomiting, hearing loss and tinnitus.

Treatment: bedrest, darkened room, Meclizine or Dimenhydrinate, systemic antibiotics.
What's Ostoscelerosis?
Bones in the middle ear fuse together. Leads to conductive hearing loss.

Treatment: Stapedectomy (the stapes is removed & replaced w/ a prosthesis.
What's involved in nursing care for patients with inner ear conditions?
Nursing care: Monitor functional ability & balance, fall risk precautions, assess home safety (clear path, walker). Assist w/ENG & caloric testing as needed, administer antivertigo & antiemetic meds as needed.
What are medications that can help with inner ear conditions?
Meclizine (Dramamine, helps w/ vertigo & nausea): antihistamine & anticholinergic effects, treats vertigo from inner ear problems.
Adverse effects: sedation, dry mouth, urinary retention

Antiemetics (Ondansetron, Zofran)
Diphenhydramine & Dimenhydrinate: antihistamines treat vertigo & nausea from inner ear problems.
Adverse effects: sedation, dry mouth, urinary retention.

Scopolamine patch: anticholinergic treats nausea associated with inner ear problems. Transdermal.
Adverse effects: sedation, dry mouth, urinary retention, increases IOP (Not good for patients with glaucoma**).

Diazepam (Valium): Benzodiazepine that decreases stimuli to the cerebellum.
Adverse effects: sedation, increases IOP (not good for patients with glaucoma**), dependency.
What's Vestibular Rehab?
for patients with vertigo, exercises that help them adapt better and minimize effects of vertigo. Combination of biofeedback, PT, & stress management. Postural education to avoid positions & learn helpful positions that can terminate a vertigo attack.
What are Vertigo reducing activities?
restrict movement of the head, change position slowly, avoid caffeine & alcohol, rest in a quiet dark place. Use assistive devices such as a cane or walker to assist with balance. Maintain a safe clutter-free environment, space intake of fluids evenly throughout the day, decrease intake of salt/sodium.
What are Cochlear Implants?
Auditory prostheses. Consists of a microphone, speech processor, a transmitter & receiver that convert sounds into electric impulses & electrodes that are attached to the auditory nerve. The implants transmitter is located outside the head behind the ear & connects via magnet to the receiver located immediately below it, under the skin. Those who were born totally deaf adapt more slowly. Intense prolonged language training is needed for those who didn't develop speech.

Client education: immediately after surgery, the unit is not turned on. The external unit is applied, & the speech processor is programmed 2-6 weeks after surgery. Avoid MRIs**.
What's part of a neurological assessment?
Pain, seizures, dizziness (abnormal sensation of imbalance or movement), vertigo (illusion of movement, usually rotation), visual disturbances, weakness, abnormal sensations, past health/family/social history.

Conscious and cognition: mental status, intellectual function, thought content, emotional status, language ability, impact on lifestyle.

Motor system: muscle size, muscle tone & strength, coordination & balance, Romberg test.

Sensory system: tactile sensation, superficial pain, temperature, vibration & position sense (proprioception).

Reflexes: DTRs, biceps, triceps, brachioradialis, patellar Achilles, superficial, pathologic, plantar (Babinski).
What are the cranial nerves?
I. Olfactory
II. Optic
III. Oculomotor
IV. Trochlear
V. Trigeminal
VI. Abducens
VII. Facial
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Accessory
XII. Hypoglossal
What are Dermatomes?
a specific segment of skin supplied by a single pair of spinal nerves
CT scan including nursing interventions?
Cross sectional view, variations in tissue density, with or without contrast, noninvasive.

Nursing interventions: lie quietly, address claustrophobia (possible need for sedation).

Contrast concerns: allergies to shellfish/iodine. Assess BUN & Creatinine, metformin medication. NPO 4 hour before contrast, monitor for allergic reactions. Flushing out contrast by increasing oral fluids (hydration is key for excretion of dye).
What are PET and SPECT?
Nuclear imaging exams. 3D images of static (Depicting vessels) or (functional brain activity). Determines tumor activity and or response to treatment. Determines dementia (the brain does not respond to the tracer).

PET: Glucose based tracer is injected into the bloodstream prior. Initiates regional metabolic activity, documented by PET scanner.

SPECT: uses a radioisotope to initiate metabolic activity, uses radiation.

Nursing actions for PET & SPECT: if patient has history of diabetes mellitus; adjust medications to avoid hyperglycemia or hypoglycemia before and after the procedure. Patient lies flat with head secured; sedation is rarely needed. If radioisotopes are used, assess for allergic reaction. Contraindications are pregnancy & breastfeeding.
What's the purpose of an MRI?
cross section images, images are obtained using magnets (not radiation). Safe for pregnancy. Not compatible with some artificial devices, use MRI approved equipment to obtain vital signs and provide ventilation/oxygen. With or without contrast. Clearer images, capable of discriminating soft issue from tumor or bone (determine size and blood vessel location).
What are contraindications of an MRI?
pacemaker, orthopedic joints, artificial heart valves, aneurism clips, IUD.
What are pre-procedural nursing actions for an MRI?
remove transdermal patches w/foil backing, remove jewelry, patient should wear a hospital gown. If sedation is planned, NPO for 4-8 hours prior. Determine history of claustrophobia. Explain the tight space and noise. Determine if the client has metal implants. All people should remove jewelry/electronics/phones to prevent damage. Use pillows to position the client, secure the clients head.
What are intra-procedural nursing actions for an MRI?
Ensure client remains supine, offer earplugs, sedation may be provided.
What are post-procedural nursing actions for an MRI?
if contrast media, check site to ensure clotting occurred & monitor for allergic reaction. If sedation, monitor until client is stable.
What's a cerebral angiogram?
Nursing Actions: NPO 4-6 hours prior, assess BUN/Creatinine, determine history or bleeding or anticoagulation use. Hydrate before procedure, void immediately before procedure, mild sedation for relaxation can be used. Warmth in face, behind eyes, or in mouth & metallic taste w/dye injection. Assess puncture site (bleeding/hematoma) and circulation. Activity restriction, icepack to insertion site.
What are indications for an EEG?
assess the electrical activity of the brain, most done to assess seizure disorders, used to evaluate sleeping disorders, behavioral changes, tumors, abscesses, clots. Determines brain death.
What are pre-procedural nursing actions for an EEG?
review medications. Client education: wash hair, stay awake the night before the test (to achieve sleep-deprivation which can induce a seizure), during the exam you might be exposed to flashing lights or asked to hyperventilate for 3-4 minutes. Avoid sedating or stimulant meds 24 hours prior.
What are intra-procedural nursing actions for an EEG?
procedure takes 45-120 minutes, small electrodes are placed on the scalp, notations are made when stimuli is present.
What are post-procedural nursing actions for an EEG?
Resume normal activities.
What are indications for a lumbar puncture?
Spinal tap (L3/L4, L4/L5) as spinal cord ends L1. Can determine disease (MS, Syphilis, Infection, malignancies). Used to reduce ICP, instill contrast or administer chemotherapy.
What's a CSF analysis?
clear vs pink tinged, cell count, culture, glucose, protein
What are nursing actions for a Lumbar Puncture?
Assist patient in a "Cannonball" position while on one side (lateral/ hunched forward). Manometer can be used to determine the opening pressure of the spinal cord. Monitor puncture site. Bedrest & flat for at least 4-8 hours to prevent CSF leak that can lead to post lumbar puncture headache. Headache could be mild to severe, few hours to several days after. Administer analgesic agents. Epidural blood patch to seal the hole in the dura if headache persists. Hydrate**.
What are complications of a Lumbar Puncture?
Brain herniation, spinal hematoma leading to paralysis, infection if CSF leak.
What is Akinetic Mutism?
Unresponsiveness to the environment. Patient makes no movement/sound, but eyes can open.
What's a Persistent Vegetative State?
patient is devoid of cognitive function but has sleep wake cycles. No cognitive function remaining.
What's Locked-in Syndome?
patient is unable to move/respond except for eye movements related to lesions of pons. Communication is key*
What's the Glasgow Coma Scale?
Score ranges from 3-15. Best response 15, worst response 3.

<8 indicates severe head injury and/or coma.
9-12 indicates moderate head injury.
>13 indicates minor head injury.
Helps determine neuro changes. Used in clients with head injuries, brain tumors, strokes, & encephalitis. If patient is intubated, eye & motor response can be assessed with modification noted (GCS 5tScore ranges from 3-15. Best response 15, worst response 3.
<8 indicates severe head injury and/or coma.
9-12 indicates moderate head injury.
>13 indicates minor head injury.
Helps determine neuro changes. Used in clients with head injuries, brain tumors, strokes, & encephalitis. If patient is intubated, eye & motor response can be assessed with modification noted (GCS 5t).
What's Decorticate Posturing?
not as severe of posturing.
What's Decerebrate Posturing?
Severe posturing, not a good sign!
What are complications of Altered Level of Consciousness?
Respiratory failure, pneumonia, pressure ulcers, aspiration, DVT, contractures.
What are medical management interventions of Altered Level of Consciousness?
Airway- oral, nasal intubation, trach.
Circulatory status-blood pressure, heart rate.
Nutritional support-feeding tube/gastrostomy tube.
What's part of nursing management for someone who has an Altered Level of Consciousness?
Airway: frequent monitoring of respiratory status including auscultation of lung sounds. Position the patient to minimize aspiration. HOB elevated 30 degrees, never supine. Lateral or semi-prone position. Suctioning, oral hygiene, chest physiotherapy & postural drainage, mechanical ventilation/intubation.


Mouth and Cornea Care: clean eyes with cotton balls moistened w/saline. Use artificial tears as prescribed. Implement measures to protect eyes; use eye patches cautiously as the cornea may contact patch.


Skin Integrity: assess skin frequently, especially areas with high potential for breakdown. Turn patient frequently. Carefully position patient in correct body alignment, perform passive range of motion to prevent contractures. Use splints, foam boots, trochanter rolls, and specialty beds as needed.


Thermoregulation: adjust environment & cover patient appropriately. Administer antipyretics as ordered. Use hypothermia blanket if needed. Give a cooling sponge bath, monitor temp frequently & use measures to prevent shivering.


Bowel and Bladder Function: assess for urinary retention & urinary incontinence. May require indwelling or intermittent catheterization. Initiate bladder-training program. Assess for abdominal distention, potential constipation, & bowel incontinence. Monitor bowel movements. Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated. Diarrhea may result from infection, meds, or fluid administration.



Sensory Stimulation and Communication: talk to touch patient & encourage family to talk to & touch the patient. Maintain normal day-night pattern of activity. Orient the patient frequently. Note: when arousing from coma, a patient may experience a period of agitation; minimize stimulation at this time (no crying family members, loud noises). Initiate programs for sensory stimulation. Allow family to ventilate feelings/concerns & provide support. Reinforce & provide consistent information to family. Referral to support groups & service for family.

Absence of complications: assess patient frequently, pay attention to minor changes, report changes to HCP in timely manner, communicate needs to healthcare team. Educate family. It is the nurse's responsibility to communicate with other healthcare providers (respiratory therapy, occupational therapy).
What's the patho behind increased ICP?
Normal range is 10-15 mm Hg with 15 mm Hg being the upper limit of normal. The skull prevents the brain from expanding. Brain compensates by displacing CSF or blood volume. If this compensation fails, ICP will increase. Brain tissues may shift thru the dura and result in herniation = death!
What are actions to increase ICP?
Hypercarbia (elevated carbon dioxide) CO2= vasodilation. ETT or oral tracheal suctioning, Coughing, extreme neck or hip flexion/extension. Maintaining the HOB at less than 30 degrees. Increase intra-abdominal pressure (clothing, Valsalva maneuver (bearing down).
What are actions to decrease ICP?
Elevate HOB to at least 30 degrees. Avoid extreme flexion/extension or rotation of the head, maintain middle neutral neck position, Mechanical ventilation. Maintain PaO2 greater than 60 mm Hg. Avoid constipation/Valsalva maneuver. Calm restful environment (limit visitors, minimize noise). Hyperventilation (brief periods, after the first 24 hours following injury.
What is the CPP equation?
Normal CPP is 70-100. A CPP of less than 50 results in permanent damage. 3/SBP+(DBP)2=MAP
What are early manifestations of increased ICP?
changes in LOC, change in condition (restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements). Double vision (optic nerve/pressure increasing). Weakness in one extremity or one side. Headache (constant, increasing in intensity, or aggravated by movement or straining).
What are late manifestations of increased ICP?
respiratory or vasomotor changes, projectile vomiting, fixed dilated pupils (loss of brainstem reflexes). Seizures, coma, posturing. Changes in vital signs (increase in SBP, decrease in HR, rapid fluctuation from tachycardia to bradycardia, Cheyne-strokes respiration (death is coming!), fever, Cushing's triad.
What is Cushing's Triad?
Bradycardia, Hypertension, Bradypnea**
What is pharmacological management for increased ICP?
Mannitol (osmotic diuretic): treats cerebral edema, increased ICP, medication draws fluid from the brain into the blood.

Nursing actions: administer IV to treat acute cerebral edema, insert indwelling urinary catheter, monitor serum electrolytes and osmolality.

Phenytoin: used prophylactically to prevent or treat seizures, check therapeutic blood levels.
What's part of medical management for increased ICP?
Monitor ICP, drainage of CSF, maintain cerebral perfusion (Dobutamine, Levophed), Control fever (fever increases cerebral metabolism & rate and cerebral edema forms). Maintain oxygenation (ABGs, elevated CO2 increases ICP, Pulse oximetry). Reduce metabolic demands (sedation, no movement of patient decreases metabolic demands).
What are complications of increased ICP?
Infection due to break in the skin (ICP monitoring). Brain stem herniation related to increase in ICP. Diabetes Insipidus, decreased secretion of ADH, client is dehydrated. SIADH, increased secretion of ADH, client is overhydrated.
What is a craniotomy?
surgical opening into the skull
What should you know about nursing care for a patient that's had a Supratentorial craniotomy?
Maintain HOB of at least 30 degrees with proper body positioning to prevent increased ICP.
What should you know about nursing care for a patient that's had a Infratentorial craniotomy?
Keep patient flat and on either side for 24-48 hours to prevent pressure on the neck incision site.
What should you know about nursing care for a patient that's had a Transsphenoidal craniotomy?
Monitor urine output, urine specific gravity, and level of consciousness
What are Burr holes?
Circular openings. Assess cerebral swelling, injury, size, and position of ventricles.
What are nursing actions for a craniotomy?
administer mannitol & dexamethasone every 6 hours for 24-72 hours post op. Administer phenytoin or diazepam to prevent seizure activity. Monitor ICP. Maintain calm environment, provide emotional support (brain surgery is an extremely
What's a tonic clonic seizure?
breathing can stop, cyanosis, biting, incontinence. Period of confusion & sleepiness follows the seizure.
What's a tonic seizure?
Sudden increased muscle tone, loss of consciousness & autonomic manifestations (vomiting, incontinence, salivation)
What's a clonic seizure?
muscles contract and relax
What's a Myoclonic seizure?
brief jerking or stiffness of the extremities
What's an atonic/akinetic seizure?
Muscle tone is lost, frequently fall. Confusion follows the seizure.
What's a complex partial seizure?
Associated with automatisms (unaware of lip smacking or picking at clothes). Can cause a loss of consciousness or black out for several minutes. Amnesia can occur immediately before & after.
What's a simple partial seizure?
Consciousness is maintained. Can cause unusual sensations (sense of déjà vu, pain, offensive smell)
What are risk factors for seizures?
Genetics, CVA, hypoxemia, fever, head injury, cerebral edema, hypertension, central nervous system infections, metabolic & toxic conditions, brain tumor, drug/alcohol withdrawals, allergies, abrupt cessation of antiepileptic drugs (must be tapered, taken at same time every day), toxins, stroke, heart disease,
What are seizure precautions?
protect patient from injury, move furniture away from patient, hold head in lap if on the floor, position client to provide patent airway. Turn patient to side to prevent aspiration, loosen restrictive clothes, raise & pad side rails, bed in lowest position, suction set-up. DO NOT: restrain, attempt to open jaw, insert airway, use padded tongue blades.
What's medical management for seizures?
medications control, don't cure. 70-80% effective.
Side effects: skin reactions (idiosyncratic or allergic disorders). Acute toxicity (when med initially prescribed). Chronic toxicity (late in course of therapy). Do not stop meds suddenly!!
Surgery: tumors, abscesses, cysts, vascular anomalies
What's included in client education for seizures?
Reducing fear of seizures: help patient understand how to control seizure activity, take meds as ordered, identify causative factors, moderate routine/lifestyle, avoid excessive exercise, Ketogenic diet (for patients' w/seizures), photic stimulation, stress management, ETOH.
What are complications of seizures?
Status epilepticus: repeated seizure activity within a 30-minute time frame or a single, prolonged seizure lasting more than 5 minutes. A medical emergency!

Usual causes: ETOH withdrawal, sudden withdrawal from antiepileptic drugs, head injury, cerebral edema, infection, metabolic disturbances.

Complications: decreased oxygen levels, inability to return to normal functioning, continued assault on neuronal tissue.

Treatment: IV diazepam or lorazepam followed by IV phenytoin or fosphenytoin
What is status epilepticus?
Status epilepticus: repeated seizure activity within a 30-minute time frame or a single, prolonged seizure lasting more than 5 minutes. A medical emergency!

Usual causes: ETOH withdrawal, sudden withdrawal from antiepileptic drugs, head injury, cerebral edema, infection, metabolic disturbances.

Complications: decreased oxygen levels, inability to return to normal functioning, continued assault on neuronal tissue.

Treatment: IV diazepam or lorazepam followed by IV phenytoin or fosphenytoin
What's a migraine with aura?
Pain aggravated by physical activity. Unilateral, pulsating pain. One or more manifestations (photophobia, phonophobia, nausea and or vomiting). Persists for 4-72 hrs.
What are stages of a migraine?
1. Prodromal phase: patient has specific symptoms such as food cravings or mood changes

2. Aura phase: may not be present; involves vision changes, flashing lights, or diplopia (double vision)

3. Headache phase: may last a few hours to a few days

4. Termination phase: intensity of the headache decreases
What's an atypical migraine?
Status migrainous- headache lasts longer than 72 hours.

Migrainous infarction: neuro manifestations that persists for 7 days. (imaging indicates ischemic infarct).
What are abortive medications for headaches?
Mild migraines: NSAIDs, acetaminophen, OTC formulations for migraines, antiemetics.

Severe migraines:
Triptan (Sumatriptan, Mitrex): Educate the client to notify the provider for continuous or severe chest pain. Contraindicated for those who have a history or are at risk for MI.

Ergot Alkaloids (Ergotamine): adverse effects: GI discomfort. Toxicity: muscle pain, paresthesia in fingers and toes, peripheral ischemia. Not for long-term use to avoid physical dependence. Pregnancy Category X.
What are preventative medications for headaches?
NSAIDs with beta blocker, calcium channel blocker, beta-adrenergic blocker, antiepileptic drugs.

Beta blocker (Propranolol): adverse effects: extreme tiredness, fatigue, depression, asthma exacerbation. Nursing actions: monitor HR, and BP, take apical pulse before dosing. Contraindicated: heart block, bradycardia, asthma, HF.

Onabotulinumtoxin A (Botox): injections into head/neck up to 5 treatment cycles
What is important client education for migraines?
Keep diary to record headache patterns & triggers. Remain in a cool dark and quiet place. Avoid triggers: Tyramine foods, MSG, preservatives (Pickles, caffeine, beer/wine, aged cheese, artificial sweeteners). Manage stress/anger, get adequate rest/sleep, avoid light glare or flickering lights. Avoid intense odors/perfumes/tobacco smoke.

Complementary & alternative therapies: yoga, meditation, massage, acupuncture. External trigeminal nerve stimulator (don't use more than 20 minutes a day).
What are cluster headaches?
brief episode of intense, unilateral, non-throbbing pain that lasts 15 minutes to 3 hours. Pain radiates to the forehead, temple, or cheek. Occurs daily 1-8 times. Followed by period of remission.

Signs and symptoms: tearing of the eye with runny nose & nasal congestion, facial sweating, eyelid drooping & edema, miosis (pupil constriction), facial pallor or flushing, bradycardia, Nausea/vomiting.

Treatment: migraine headache meds, home oxygen (12 L/min for 15-20 minutes at onset. Can provide relief in 15 minutes.
What are risk factors for strokes?
Non-modifiable risk factors: over 55 years old, male gender, African American race.

Modifiable risk factors: hypertension, cardiovascular disease, elevated cholesterol, obesity, smoking, DM, sleep apnea.
How can you prevent a stroke?
Modify these risk factors - hypertension, cardiovascular disease, elevated cholesterol, obesity, smoking, DM, sleep apnea.
What's an Ischemic stroke?
87% of strokes, decreased oxygen in brain due to vascular occlusion from thrombotic or embolic event.
What's a Thrombotic stroke?
Occurs secondary to a blood clot on an atherosclerotic plaque.
What's a Hemorrhagic stroke?
13% of strokes, bleeding into skull from a ruptured artery of aneurism. Poorer prognosis, significant ischemia & increased ICP.
What are clinical manifestations of a left cerebral hemisphere stroke?
responsible for language, math, analytical thinking.

Expressive & receptive aphasia (inability to speak & understand language). Agnosia (unable to recognize familiar objects).
Alexia (reading difficulty).
Agraphia (writing difficulty).
Right hemiplegia (paralysis) & hemiparesis (weakness).
Hemianopsia (loss of visual field). Slow cautions behavior. Depression, anger, frustrated easily.
What are clinical manifestations of a right cerebral hemisphere stroke?
Responsible for visual & spatial awareness & proprioception. Altered perception of deficits, unilateral neglect syndrome 9more common in R). Loss of depth perception, poor impulse control & judgement. Left hemiplegia or hemiparesis, hemianopsia.
What's a Transient Ischemic Attack (TIA)?
temporary neuro deficit resulting from temporary impairment of blood flow. Warning of an impending stroke. Diagnostic work up required to treat & prevent irreversible deficits.
What's a TBI?
traumatic brain injury
What are diagnostic procedures for a stroke?
Non contrast CT scan: performed within 25 minutes of ED visit, used to determine type of stroke & whether the patient is a candidate for thrombotic therapy.

MRI: can identify edema, ischemia, necrosis.
Cerebral angiography, Lumbar puncture.
What's a part of medical management for a hemorrhagic stroke?
Control of hypertension.

Care is mostly supportive: (INR correction, DVT prevention, analgesics for head/neck pain, antipyretics, antihypertensive prevention, bedrest w/sedation. Oxygen.

Surgery: evacuation or unruptured aneurism repai
What criteria would need to be met for t-PA?
Ischemic stroke!

Administration: administer within 3-4.5 hours of initial manifestations. Only given for ischemic strokes.

Contraindications: must be 18 or older, verified ischemic stroke, SBP not >185, DBP not >110. No seizure activity, no blood thinners. Platelet count >100,000, no major surgery within 2 weeks. No GI or urinary bleeding within 21 days.
What's a part of medical management for an ischemic stroke?
Anticoagulants (Warfarin): used for patient who have A Fib or cardioembolic strokes. INR therapeutic range 2-3. Don't use in hemorrhagic strokes. Alternative to warfarin is Novel oral anticoagulants (Rivaroxaban).

Antiplatelet (Aspirin, Clopidogrel): low dose aspirin given within 24-48 hours to prevent further clot formation.

Antiepileptic med (Phenytoin): given if patient develops seizures.
What are therapeutic procedures for an ischemic stroke?
Carotid artery angioplasty w/stenting (CAS): stent placed to open blockage, performed withing 6 hours of onset of manifestations.

Carotid Endarterectomy: removes atherosclerotic plaque in the carotid artery, recommended for patients' w/ blockage over 50-70% if other factors are present (TIAs).

Post op: assess for headache, neck swelling, hoarseness.
What are important nursing interventions for stroke patients?
Monitor vitals every 1-2 hours. Notify provider of a BP over 180/110 (can indicate ischemic stroke). Monitor & treat fever. Maintain Oxygen over 92% if patient has decreased LOC. Monitor ECG for cardiac arrythmias. Conduct cardiac assessment to detect murmurs & irregularities. Monitor for change in LOC. Monitor for hyperglycemia due to poor neuro outcomes. Elevate HOB at least 30 degrees, prevent extreme flexion/extension of head. Institute seizure precautions.

Assist patient w/communication if speech is impaired: supply w/picture board of commonly requested items/needs. Speak slow/clearly. Use one step commands, maintain eye contact, work w/speech therapist, give patient time to communicate.

Assist w/ safe feedings: swallow study before feeding, completed 4-24 hours upon ED arrival. (4 liquid consistencies will be recommended following the study. Thin, nectar-like, honey-like, spoon-thick). Eat in upright position, swallow w/ head slightly flexed forward. Place food in the back of mouth on unaffected side, suction at the bedside.
Prevent complications of immobility: ambulate asap, ROM every 2 hours, change position every 2 hours, elevate affected extremities, work closely w/Physical Therapy.

Care for one-sided neglect: observe & protect from injuries of the affected extremities. Teach patient to protect & care for affected extremity. Apply arm sling, dress affected side first, place affected extremity to midline & protect from danger, instruct patient to overlook the affected side periodically.

Maintain safe environment: use assistive devices during transfers.
If patient has homonymous hemianopsia: instruct patient to use a scanning technique when eating/ambulating, put items in the room within patients view.

Assist w/ADLs/OT/PT: OT to assess for adaptive aids. Provide frequent rest periods. Patient typically leans to the affected side; provide support. Shoulder subluxation can occur if the affected arm is not supported. Instruct patient to use the unaffected side to exercise the affected side. Don't pull on affected arm, promote self-care, add a task each day.
What's the patho behind a TBI?
Primary Injury: consequence of direct contact to head/brain during instant of initial injury. (Contusion, laceration, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal injury).

Secondary Injury: damage evolves over hours or days after initial injury. (Cerebral edema, ischemia, chemical changes associated w/trauma.)
How can you prevent a TBI?
Seatbelt/helmet, children sit in the back seat, prevent falls, secure firearms, don't drive under the influence of drugs/alcohol.
What are clinical manifestations of a TBI?
Scalp wound: heavy bleeding , portals for infection.

Skull fractures: usually localized, persistent pain, swelling. Brain may be damaged as a result.

Fractures of base of the skull: bleeding from nose, pharynx, ears.

Battle signs: ecchymosis behind ear

Halo sign: indicates CSF leak, ring of fluid around blood stain from drainage.
What's a open head injury?
integrity of skull is compromised by a penetrating or blunt force trauma, high risk of infection.
What's a closed head injury?
occurs from blunt trauma that causes acceleration of the head & then deceleration or hits a stationary object.
How can you document the severity of a head injury?
Depends on GCS & length of time unconscious
What's a concussion?
Change in neuro function, no identified brain damage, usually resolves within 72 hours. Post-concussion syndrome: persistent cognitive & physical manifestations. Patient may be admitted for observation or sent home. Observation of patient after head trauma; report immediately. (Observe for changed in LOC, difficulty awaking, lethargy, dizziness, confusion, irritability, anxiety, difficulty speaking/moving, severe headache, vomiting). Patient should be aroused & assessed frequently.
What's a contusion?
bruised brain, a period of unconsciousness associated w/stupor or confusion. More severe than concussion, unconscious, may lie motionless, faint pulse, shallow breathing, pale skin, bladder & bowel incontinence. Presents similar to shock (low BP) Varying outcomes.
What's a diffuse axonal injury?
widespread shearing injury, results in coma, severe head trauma.
What are signs and symptoms of an epidural hematoma?
Signs and symptoms: blood collection in space between the skull & the dura. Patient may have a brief loss of consciousness with return of ludic state. As hematoma expands, increased ICP reduces LOC. Emergency situation!
What's the treatment for an epidural hematoma?
measures to reduce ICP, remove the clot, stop bleeding. (Burr holes or craniotomy). Patient will need monitoring & support of vital body functions & respiratory support.
What's an acute subdural hematoma?
Acute: symptoms develop over 24-48 hours. Changes in LOC, pupillary signs, hemiparesis. Coma, increasing BP, decreasing HR, slowing respiration result in expanding mass=intervention needed asap!
What's a subacute hematoma?
Symptoms develop 48 hours to 2 weeks, requires immediate craniotomy & control of ICP.
What's a chronic hematoma?
Develops over weeks to months. Causative injury may be minor or forgotten. Clinical signs and symptoms may fluctuate. (severe headache that's intermittent, alternating focal neuro signs; personality changes, mental deterioration, focal seizures).
Treatment: Evacuation of clot.
What's a intracerebral hemorrhage?
hemorrhage occurs into the substance of the brain. May be due to trauma or a nontraumatic cause. (Hypertension, aneurism, tumors, bleeding disorders, anticoagulant therapy).
How can a hemorrhage be treated/ managed?
Supportive care, control of ICP, administration of fluids, electrolytes, and antihypertensive meds. Craniotomy or craniectomy to remove clot & control hemorrhage unless area is inaccessible.

Management: Always assume cervical spine injury until it is ruled out**

Treatment of increased ICP: adequate oxygenation, elevate HOB, maintain normal blood volume, drain CSF if needed.

Supportive measures: ventilator, seizure prevention, fluid & electrolyte maintenance, nutritional support, management of pain & anxiety.
What are nursing interventions for a patient with a hemorrhage?
Respiratory status: brain injury or death occurs within 3-5 minutes of hypoxia. Changes in LOC using the GSC provide the earliest indication of neuro deterioration.

Cranial nerve function: eye blink response, gag reflex, tongue & shoulder movement.
-Assess pupils for size, equality, & reaction to light. Bilateral sensory & motor response.
-Calculate CPP using ICP monitor if in place. Maintain C-spine precautions until cleared by x-ray. Report presence of CSF from the nose or ears to the provider. Monitor fluid/electrolytes/osmolality to detect change in sodium regulation (DI or SIADH). Provide adequate fluids to maintain cerebral perfusion pressure. When giving large amounts of IVF you must monitor for fluid overload & cerebral edema. Maintain safety & seizure precautions. Support client's family (coping can be hard). If brain death occurs, support the family when deciding whether to donate organs.
What is brain death?
Organ donation: nurse assist w/exam for determination of brain death & help w/process of organ donation.

3 cardinal signs: coma, absence of brain-stem reflexes, apnea.
What are risk factors for a spinal cord injury?
young age, male gender, alcohol/drug use.
What are causes of a spinal cord injury?
car accident, violence (gunshot), falls, sport injuries.
What are level of injury consequences?
-C-spine injury result in quadriplegia
-T1 or below injuries result in paraplegia
-C4 or above result in impaired ventilation due to involvement of phrenic nerve
-Complete lesion result in complete loss of all voluntary movement & sensation below the level of injury.
What is spinal shock?
sudden but temporary loss of all reflexes & autonomic function below the level of spinal injury. Muscle weakness & lack of sensation/reflexes. Paralytic ileus from loss of autonomic function. Hypotension & bradycardia can occur. Response from inflammation caused by injury. Keep MAP at least 85 mm Hg can prevent further damage; administer plasma expanders (Dextran). Could last days-weeks.
What is neurogenic shock?
Sudden loss of communication withing he sympathetic nervous system (fight/flight), blood pressure & HR decrease, Cardiac output decreases.

Venous pooling occurs due to peripheral vasodilation=edema. Paralyzed portions of the body don't perspire because sympathetic activity is blocked so watch for early detection of fever. Can occur within 24 hrs of injury & can last for weeks.

Nursing actions: stabilizing the spinal cord w/proper positioning. Monitor Vitals/temp/dependent edema. Treat w/appropriate meds (vasopressors like norepinephrine/dopamine or atropine) & IV fluids. Patient is at greater risk for VTE (monitor for manifestations of swelling, decreased pulses, areas of warmth & or tenderness. Administer anticoags as prescribed for DVT prophylaxis).
What is autonomic dysreflexia?
-Stimulation of the SNS & an inadequate compensatory response by the PSN. Acute emergency. Occurs after spinal shock has resolved & may occur years after the injury. Occurs in a person w/ a SC lesion above T6.
What are the main causes of autonomic dysreflexia?
Distended bladder (most common cause, check foley patency). Distention or contraction of visceral organs (Constipation). Stimulation of the skin.
What are the symptoms of autonomic dysreflexia?
Symptoms: extreme HTN, severe pounding headache, pallor below the level of spinal cord lesions dermatome. Flushing & profuse diaphoresis above spinal level lesion. Blurred vision, nausea, nasal congestion, bradycardia.
What are nursing actions when caring for a patient with autonomic dysreflexia?
Nursing actions: place patient in sitting position immediately! Notify provider.

-Determine & treat the cause: check patency of urinary catheter or insert catheter for distended bladder, remove fecal impaction, assess for injury (skin, fractures, infection), remove tight clothes, adjust room temp & block drafts, monitor vitals, administer antihypertensives (nitrates or hydralazine).
What is someone's respiratory status like if they have a spinal cord injury?
monitoring respiratory status is 1st priority!! Respirations can be affected from spinal cord injury at or below C4. Provide oxygen & carefully suction as needed. Assist w/intubation & mechanical ventilation as needed, assist client to cough by applying abdominal pressure when attempting to cough, encourage use of IS and cough & deep breathing regularly.
What does orthostatic hypotension have to do with a spinal cord injury?
common complication of spinal cord injury. Caused by interruption of functioning of the ANS & pooling of blood in lower extremities when in an upright position.

Nursing actions: change positioning slowly, use a reclining wheelchair, use thigh-high hose or elastic wraps to increase venous return, may extend all the way up the clients leg & include the abdomen.
What will muscle strength and tone look like in someone with a spinal cord injury?
determine baseline & monitor for increased loss of muscle strength. Encourage active ROM & assist if the client lacks all motor function.
-Upper motor neuron injuries (above L1, L2): spastic muscle tone after neurogenic shock, if severe they can develop pressure injuries. Can be painful if sensation is intact. Administer muscle relaxants (Baclofen, Dantrolene) for severe spasticity; monitor for drowsiness & muscle weakness.
-Lower motor neuron injuries (below L1, L2): flaccid type of paralysis.
What will mobility look like in someone with a spinal cord injury?
Use braces if incomplete injury. Wheelchair provides best functional mobility. Patients w/high level injuries may experience postural hypotension when sitting upright. Avoid footdrop & contractures. Use of specialty beds.
Wheelchair transfer stages:
1: raise HOB (lower the angle if patient reports dizziness)
2: transfer patient into reclining wheelchair w/the back of the wheelchair reclined
3: be ready to lock & lean the wheelchair back onto the knee to a fully reclined position if the patient reports dizziness
4: do not attempt to return the patient to the bed.
How will the bowel and bladder function be affected in a patient with a spinal cord injury?
Spastic neurogenic bladder: upper neuron injury, males use a condom catheter & micturition reflex stimulation (tugging on the pubic hair). Females use an indwelling urinary catheter due to unpredictable urine release. Administer cholinergic (bethanechol) to decreased spasticity of the bladder.
Flaccid neurogenic bladder: lower neuron injury, males & females interventions include intermittent catheterization & Crede's method (downward pressure placed on bladder to manually express urine).
Bowel function: daily use of stool softeners or bulk-forming laxatives. Stimulate a bowel movement daily or every other day with bisacodyl suppositories or digital stimulation. Developing a schedule is critical in preventing complications.
How will a spinal cord injury affect I's + O's?
patient may be NPO for days, nutritional support necessary, maintain soft stools.
How will a spinal cord injury affect neurological status?
determine baseline & monitor for further loss of function.
How will a spinal cord injury affect the GI system?
Ileus can develop, monitor bowel sounds.
How will a spinal cord injury affect skin integrity?
change position every 2 hours, every 1 hour if in wheelchair, pressure ulcers can develop within 6 hours, cervical collars (skin breakdown under chin, on shoulders, at the occiput), use pressure relief devices continuously.
What is a halo traction?
Provides traction or immobilizes the spinal column.

Nursing care: maintain body aliment & ensure weight hangs freely, monitor skin integrity (assess under the vest), provide pin care. Do not use device to turn or move the patient. Good skin care (dry, no powder). Teach vest care (liner should not get wet, liner should be changed periodically).
What should be include in pin care for someone with halo traction or cervical tongs?
clean each pin site using one cotton tipped applicator per site (to avoid risk of infection or infecting other sites).
How can spinal surgery help with a spinal cord injury?
Assess for airway compromise from swelling or hemorrhage w/cervical fusions. Assess neuro status & vitals every hour for the first 4 hours post-op.
What is aseptic meningitis?
Viral & most common form that usually resolves without treatment. Measles, Mumps, Herpes, West Nile virus.
What's fungal meningitis?
common with AIDS. Cryptococcus Neoformans
What's septic meningitis?
bacterial & is a contagious infection w/a high mortality rate. Otitis media, Pneumonia, Sinusitis. Neisseria meningitides, streptococcus pneumonias, or haemophilus influenzae.
What are vaccines for meningitis?
Hemophilus Influenza type b (Hib): infants, 4 doses starting at 2 months of age.

Pneumococcal polysaccharide vaccine (PPSV): intended to prevent respiratory infections. For adults who are at risk (immunosuppressed or crowded living conditions).

Meningococcal (MCV4): adolescents prior to living in college dorm or military base. Recommended at age 11 or 12 w/ booster at age 16.
What are signs and symptoms of meningitis?
excruciating, constant headache, nuchal rigidity (neck stiffness), altered LOC, positive Kernig's sign (thigh flexed on abdomen, can't fully extend). Positive Brudzinski's sign (neck flexed, flexion of knees & hips is produced). Fever & chills, nausea/vomiting, behavioral changes, photophobia, hyperactive DTRs, tachycardia, seizures, red macular rash, restlessness, irritability.
What does a CSF analysis have to do with meningitis?
most definite diagnostic procedure for meningitis.
Results: appearance of CSF is cloudy =bacterial, clear=viral. Elevated WBC, elevated WBC, elevated protein, decreased glucose due to bacteria, elevated CSF pressure.
What's included in nursing care for a patient with meningitis?
Nursing care: isolate patient as soon as meningitis is suspected*, droplet precaution*; continue precautions until antibiotics have been administered for 24 hours. Those with bacterial meningitis may need precautions continuously, follow hospital policies. Monitor vitals/assess for septic shock, implement fever reduction measures. Bedrest w/HOB at 30 degrees. Monitor for increased ICP, avoid increasing ICP, seizure precautions, provide calm environment w/dim lights, report meningococcal infection to the public health department.
What are medications for meningitis?
Ceftriaxone or cefotaxime in combination with Vancomycin given until culture & sensitivity results available, early administration of high doses of appropriate IV antibiotics for bacterial meningitis.

Phenytoin: anticonvulsant if ICP increases or the client has a seizure.

Acetaminophen, Ibuprofen: analgesic for headache & or fever, prefer nonopioids to avoid masking changes of LOC.

Prophylactic antibiotics (Ceftriaxone, Ciprofloxacin, Rifampin): for those in close contact with the patient.
What are complications of meningitis?
Increased ICP: leads to brain herniation & death, monitor signs of increased ICP & treat w/mannitol.

SIADH: monitor blood & urine labs, provide interventions such as Demeclocycline & restrict fluids, daily weight.

Septic emboli: can occur in the hands & feet, lead to gangrene & DIC.
What's a brain abscess?
Collection of infectious material within brain tissue, risk is increased in immunocompromised patients, prevent by treating otitis media, mastoiditis, sinusitis, dental infections, & systemic infections promptly. Diagnosis by MRI or CT. CT-guided aspiration is used to identify the causative organisms.
What are signs and symptoms of a brain abscess?
headache that is worst in the morning, fever/vomiting, neuro deficits (weakness, decreasing vision), signs & symptoms of increased ICP (decreasing LOC & seizures).
What should be done regarding medical and nursing management for a patient with a brain abscess?
b. Medical management: control ICP, drain abscess, antibiotic therapy, treat cerebral edema w/corticosteroids.

c. Nursing management: conduct frequent & ongoing neuro assessments & responses to treatment, ensure patient safety & protect from injury, provide supportive care, monitor for neuro deficits.
What is encephalitis?
acute inflammation of the brain tissue
What are the causes of encephalitis?
viral infections (HSV, west Nile, St. Louis), fungal infections.
What are the signs and symptoms of encephalitis?
headache, fever, confusion, change in LOC, Vector-borne rash, flaccid paralysis, Parkinson's-like movement.
What's included in the medical and nursing management for a patient with encephalitis?
c. Medical management: Acyclovir for HSV infection, Amphotericin B & or other fungal agent for fungal infection, control seizures, control ICP.

d. Nursing management: frequent & ongoing assessment, dim lights, limit noise, PRN pain meds (use cautiously, may mask neuro symptoms). Monitor I & O (alert for presence of renal complications from antiviral therapy, monitor for seizures.
What's the patho of Multiple Sclerosis?
chronic progressive immune-related demyelination disease of the CNS (interrupts flow of nerve impulse). Plaques can occur on axon (unable to regenerate & causing irreversible damage, most common areas include the optic nerve, cerebrum, brainstem, cerebellum, & spinal cord. Different possible courses (relapsing-remitting MS is most common type. After relapse they may not return to baseline, eventually progress to the point of quadriplegia). Aggressive forms can shorten lifespan.
What are risk factors of Multiple Sclerorosis?
most common by the age of 20-40 years old, more common in women (twice as often), family history, researching the cause, associated w/interleukin (IL)-7 & IL-2 receptor genes.
What are the signs and symptoms of Multiple Sclerosis?
fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain or paresthesia, visual disturbances, difficulty w/speech, muscle spasticity, bowel & bladder dysfunction, cognitive dysfunction, sexual dysfunction.
What are diagnostic procedures for Multiple Sclerosis?
CSF: reveals elevated protein level & a slight increase in WBC.

MRI: reveals plaques of the brain & spine.
What's a part of the nursing care for a patient with Multiple Sclerosis?
Monitor: visual acuity, speech patterns, swallowing, activity intolerance, skin integrity.
Discuss coping mechanisms & resources, encourage fluid intake & other measures to decrease risk of UTI, assist w/bladder elimination. Establish a voiding time schedule (every 1.5-2 hours). Monitor cognitive changes, plan interventions to promote cognitive function (reorient as needed, place objects used in routine places). Use a communication board as needed.

Apply eye patches to treat diplopia: alternate eyes every few hours, teach scanning technique.

Exercise & stretch affected muscles, balance activity & rest.

Maintain a safe environment: high fall risk, walk w/feet apart & widen base of support, watch the feet while walking.
What medications will help a patient with Multiple Sclerosis?
Interferons beta-1 a & beta-1 b: start early in the course of the disease, used to prevent & treat relapses. Adverse effects: flu-like symptoms.

Corticosteroids (prednisone, dexamethasone, methylprednisolone): reduce inflammation in acute exacerbations. Adverse effects: infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, GI bleeding, personality changes.

Antispasmodics (Dantrolene, Baclofen, Diazepam): for muscle spasticity.

Anticonvulsants (Carbamazepine): to treat paresthesia.

Anticholinergics (Propantheline): is used for bladder dysfunction.
What is Myasthenia Gravis?
Impaired transmission of impulses across the myoneural junction, considered a motor disorder (varying degrees of weakness of the voluntary muscles). Women affected more than men. Ages for women (20-40 years old), for men (60-70 years old).
What are signs and symptoms of Myasthenia Gravis?
diplopia (double vision), ptosis (droopy eyelid), weakness of facial muscles. Dysphonia (abnormal voice) caused by laryngeal involvement. Dysphagia which increases choking & aspiration. Generalized weakness affects extremities & intercostal muscles which lead to respiratory failure.
What is the Tensilon Test?
Administration of tensilon will do nothing to a normal patient. Will cause a temporary improvement of muscle weakness in a patient w/myasthenia gravis. There is a risk for V Fib or cardiac arrest. Antidote: atropine sulfate.
What's included in medical and nursing management for a patient with Myasthenia Gravis?
Pharmacologic therapy: anticholinergic meds inhibit breakdown of acetylcholine.
Therapeutic plasma exchange (plasmapheresis): exchange of plasma, reduces the number of antibodies circulating in the bloodstream, temporary relief from symptoms (few weeks).
Surgery: Thymectomy, removal produces antigen-specific immunosuppression & clinical improvement.


d. Nursing management:
Med management: understand action of meds & schedule of taking them.

Conserve energy: identify times for rest throughout the day.

Risk of aspiration: meals should correlate with peak effects of anticholinesterase meds.

Impaired vision: tape eyes closed for short periods of time, artificial tears, eye patches.

Avoid factors that exacerbate symptoms: emotional stress, infections, rigorous activity, heat.

Support groups.
What's a Myasthenic Crisis?
result of disease exacerbation or a precipitating event, most commonly a respiratory infection (the common cold). Severe generalized muscle weakness w/respiratory & bulbar weakness, patient may develop respiratory compromise failure. Patient admitted to ICU & closely monitored.

Management of Myasthenic Crisis: patient teaching of signs and symptoms ensure adequate ventilation (intubation & mechanical ventilation may be needed).
-Assessment & supportive measures: ensure airway & respiratory support, take ABGs, serum electrolytes, I&O, daily weight. If patient can't swallow, then NG may be needed.

Avoid sedatives & tranquilizers; aggravate hypoxia & hypercapnia. Cause respiratory & cardiac depression.
What is Guillain-Barre Syndrome?
An autoimmune disease in which the peripheral nerves become inflammed. Results in numbness and paralysis in the legs, upper body, and face. Level of independence depends on extent of paralysis.
What is the patho behind Guillain-Barre Syndrome?
Autoimmune disorder w/acute attack of peripheral nerve myelin, rapid demyelination, ascending weakness. May produce respiratory failure & autonomic nervous system dysfunction w/cardiovascular instability. Most often follows a viral infection. Could be related to influenza vaccine? Most common in males ages 16-25 & 45-60 years old. 5% will die.
What are the signs and symptoms of Guillain-Barre Syndrome?
weakness, paralysis, paresthesia, pain, diminished or absent reflexes that start in the lower extremities & progress upward. Bulbar weakness (lower cranial nerves). Cranial nerve syndromes. Change in vital signs (Vagus nerve affected, tachycardia, bradycardia, hypertension, orthostatic hypotension).
What are considerations for medical and nursing management when caring for someone with Guillain-Barre Syndrome?
Medical emergency, requires intensive care management w/continuous monitoring & respiratory support. TPE (plasmapheresis) & IVIG are used to reduce circulating antibodies.

Maintain respiratory function, enhancing physical mobility, providing adequate nutrition, improving communication, decreasing fear & anxiety, monitoring & managing potential complications, promoting home care.
What are signs and symptoms of a Brain Tumor?
Localized or generalized neuro symptoms, symptoms of increased ICP, headache (most common in the morning), vomiting, visual disturbances (edema on cranial nerve 3). Seizures, hemiparesis, mental status change, nystagmus (involuntary eye movement), tinnitus (ringing ears), personality changes.
What are diagnostic tests a Brain Tumor?
CT, MRI, PET scan, Cerebral angiogram: determines size, location, & extent of the tumor.

Lumbar puncture: should not be done if patient has manifestations of increased ICP to prevent brain herniation (DEATH).

Cerebral biopsy: usually guided by CT or MRI scan. Abnormal cerebral tissue is sent to pathology.

-Benefits: minimally disruptive to the rest of the brain, decreased recovery time, not associated w/risk of an open craniotomy.

-Negatives: does not remove or debulk the tumor, results can be inconclusive, & possible misdiagnosis.
What should be included in the medical and nursing management of a patient with a Brain Tumor?
maintain ABCs, monitor neuro status/monitor & treat increased ICP. Maintain safety, implement seizure precautions, monitor for complications (SIADH/DI).
What are medications for a patient who has a Brain Tumor?
Non-opioid analgesics: avoid opioids as they can decrease LOC.
Corticosteroids: reduce cerebral edema, relieves Headaches, improves LOC.
Osmotic diuretics: decrease fluid content of the brain, decreases ICP.
Anticonvulsant meds: control & prevent seizures.
H2-antagonist: decreases the risk of stress ulcers.
Antiemetics, Radiation/Chemotherapy/Craniotomy.
What's Bell's Palsy?
inflammation of viral infection of facial nerve causing one sided weakness of face
What causes Bell's Palsy?
facial paralysis caused by unilateral inflammation of the seventh cranial nerve.
What are the signs and symptoms of Bell's Palsy?
Unilateral facial muscle weakness or paralysis w/facial distortion, increased lacrimation, painful sensations in the face, may have difficulty w/speech & eating.
What's a part of medical and nursing management for a patient with Bell's Palsy?
Corticosteroid therapy may be used to reduce inflammation & diminish severity of the disorder.

provide & reinforce info & reassurance that stroke has not occurred, protection of the eye from injury; cover eye w/shield at night, instruct patient to close eyelid, use of eye ointment & sunglasses. Facial exercise & massage to maintain muscle tone.
What is Parkinson's disease?
A disorder of the central nervous system that affects movement, often including tremors.
What's the patho behind Parkinson's Disease?
Slowly progressing & debilitating disorder of movement, decreased levels of dopamine which allows acetylcholine to dominate. Most common in men, genetic predisposition, chronic use of antipsychotic meds. No definitive diagnostic procedures; rule out other diseases.
What are the signs and symptoms of Parkinson's Disease?
4 primary findings (tremor, muscle rigidity, bradykinesia, postural instability). Fatigue, stooped posture/postural instability, slow monotonous speech, masklike facial expression, difficulty chewing/swallowing. Drooling, dysarthria (slurred speech), mood swings, cognitive impairment, autonomic findings (orthostatic hypotension, flushing, diaphoresis).
What's a part of medical and nursing management when caring for someone with Parkinson's Disease?
c. Medical and nursing management: monitor swallowing.
Maintain adequate nutrition & weight: may need high calorie/high protein diet, document patients' weight at least weekly, keep diet intake log, small frequent meals.
Consult w/speech therapy if patient demonstrates a risk of choking.
Consult w/occupational therapy for eating devices.
Maintain mobility: encourage daily exercise/ROM, balance activity & rest, consult w/PT.
Promote communication: facial muscle strengthening exercises, encourage patient to speak slowly & pause frequently.
Monitor mental & cognitive status: observe for manifestations of depression & dementia, provide a list of community resources, assess for personal & family coping.
Provide a safe environment: no throw rugs, use an electric razor.
What are medications for a patient with Parkinson's Disease?
Levodopa (dopaminergic): converted to dopamine in the brain.
Carbidopa: protects levodopa from being metabolized before it reaches the brain. Allows for smaller doses & less adverse effects. Nursing actions: monitor for the wearing off, dose needs to be adjusted or needs a medication holiday. Aids in muscle function. Monitor for toxicity: muscle twitching, facial grimacing, spasmodic eye winking.
Dopamine agonists (pramipexole): combine w/dopaminergic for better results. Adverse effects: orthostatic hypotension, dyskinesias, & hallucinations.
Anticholinergics (Benztropine): decrease tremors & rigidity. Adverse effects: anticholinergic effects.
COMT inhibitors (Entacapone): decrease the breakdown of levodopa. Adverse effects: dark urine, diarrhea.
MAO-B inhibitors (Selegiline): reduce the wearing off phenomenon, avoid foods high in tyramine (can cause hypertensive crisis).
What are therapeutic procedures to help someone with Parkinson's Disease?
Stereotactic pallidotomy or thalamotomy: when patients are unresponsive to other therapies. Causes destruction of a small portion of the brain. Nursing actions: post op, assess for neuro impairment & brain hemorrhage.
Deep brain stimulation: electrode is implanted in the thalamus; current is delivered through a small pulse generator implanted under the skin of the upper chest. Decreases tremors & involuntary movements. Nursing actions: post op, assess for infection, brain hemorrhage, & stroke-like findings.
What's Huntington's Disease?
A chronic progressive hereditary disease that results in choreiform movement & dementia. Patho involves premature death of cells in the striatum of the basal ganglia (control of movement) & the cortex (thinking, memory, perception, judgement). Occurs at midlife.
What are the signs and symptoms of Huntington's Disease?
chorea (jerky involuntary movement), intellectual decline, emotional disturbances, uncontrollable movement, tics & grimaces, speech problems (slurred, hesitant, explosive), dysphagia (aspiration risk), disturbed gait w/eventual bedrest, impaired judgement & memory. Anger, dementia, & psychosis eventually occur.
What's a part of medical and nursing management for someone with Huntington's Disease?
medications to reduce chorea. Monitor for akathisia (motor restlessness) because it may be mistaken for the restless fidgeting of the disease itself when the patient is overmedicated. Depression, suicide prevention.
What's Amyotrophic Lateral Sclerosis (ALS)?
Unknown cause, progressive illness, loss of motor neurons in the anterior horn of the spinal cord & loss of motor nuclei of the lower brainstem, occurs between ages 40-60.
What are signs and symptoms of Amyotrophic Lateral Sclerosis (ALS)?
fatigue, progressive muscle weakness, cramps, fasciculations (twitching), incoordination, difficulty talking, difficulty swallowing, difficulty breathing.
What are ways to manage a patient with Amyotrophic Lateral Sclerosis (ALS)?
no specific therapy. Control symptoms (improve quality of life, wellbeing). Delay progression of disease, average survival time is 2 years, enteral feeding, suctioning, mechanical ventilation, decisions about life support, suicide risk.
How do you manage a patient with Muscular Dystrophies?
supportive care, prevent complications. Orthotic jacket (prevent spinal deformity & supports cardiovascular status). Spinal fusion, pulmonary function decreases due to disease progression or deformity of thorax secondary to severe scoliosis.

Muscular dystrophy association: research, patient services, clinical care, professional & public
What is Degenerative Disc Disease?
degenerative changes occur with aging or are the result of previous trauma, continued pressure may produce degenerative changes in the perves w/resultant changes in sensation & motor responses.

Treatment is usually conservative: rest & medication. Surgery may be required.
How do you manage a Disc Herniation?
Medical management:
Medications: analgesics, NSAIDs, muscle relaxers, corticosteroids.
Surgery: discectomy with or without fusion.
Nursing management: relief of pain, improve mobility, monitor for bleeding/hematoma, frequent neuro checks (spinal cord compression may produce rapid or delayed onset of paralysis), monitor for dysphagia.
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