Neurological System Disorder- Nclex

Care for clients with Disorders of the Neurological System- Brain and Spinal cord
1- Olfactory
I- Smell- Identify common odors
2- Optic
II- Visual Acuity- Snellen Chart (central vision) and peripheral vision check.
3- Oculomotor
III- regulate eye movement- Check pupil constriction, check for strength of lids closure and reaction to objects moving towards eyes.
4- Trochlear
IV- responsible for inferior and medial eye movement- Check pupil constriction, check for strength of lids closure and reaction to objects moving towards eyes.
5- Trigeminal
V- Facial sensation; corneal reflex- identify the location of the stimulus; check jaw strength
6- Abducens
VI- responsible for lateral eye movement- Check pupil constriction, check for strength of lids closure and reaction to objects moving towards eyes.
7- Facial
VII- movement of facial muscles, facial expressions, Tear formation, salivation, Taste sensation- Check symmetry of facial expressions, muscle strength, Identify sweet, sour, salty on anterior tongue.
8- Acoustic (vestibulocochlear)
VIII- Hearing and equilibrium- Use Weber and Rinne Test for hearing loss.
9- Glossopharyngeal
IX- Taste sensation in post third of the tongue- Identify sweet, sour, and salty taste on posterior are of tongue.
10- Vagus
X-Pharyngeal contraction- Ask client to say "Ah", uvula should rise midline; check ability to swallow.
11- Spinal Accessory
XI-Movement of trapezius and sternocleidomastoid muscles- have client Shrug shoulders against resistance and neck turned against resistance.
12- Hypoglossal
XII-Tongue movement- have client stick out tongue, observe for deviations or tremors, check strength of tongue movement by pressing it against tongue blade.
Glasgow Coma Scale
assess neurologic status- motor, verbal, eye opening response. Lowest score (3= coma)- highest score (15= fully awake).
Normal ICP reading
10-20 mm Hg- Intracranial Pressure monitor device can also drain cerebrospinal fluid (most invasive).
Basilar Facture
facture at the base of the skull- avoid coughing or blowing nose to prevent an increase in intracranial pressure.- S/S: CSF leakage from the ear (otorrhea) or nose (rhinorrhea), blood stain that develops a yellowish circle around it (halo), Battle sign (ecchymosis behind ears), Racoon eyes. Coup (closed fracture).
Epidural Hematomas
Arterial bleed- spurts out blood every time heart beats- Collection of blood between skull and dura- S/S: pattern of consciousness to comatose.
Subdural Hematomas
Venous bleed- steady flow- Collection of blood between dura and arachnoid space. Acute:first 2 days, Subacute: 2-14 days, Chronic: 14 days to months.
Intracerebral Hematomas- Nursing Care
Occurs in the brain tissue due to tearing of arteries and veins with in the brain -frontal/temporal lobes- Tx: insertion of Burr Holes and craniotomy.
Increased Intracranial Pressure- S/S
results from an increase in intracranial content that occurs with tumor growth, edema, excess cerebrospinal fluid (CSF) or hemorrhage- S/S: Blurred vision, change in cognition, changes LOC, Cheyne-Stokes respiration, Coma, Decerebrate posture, Decorticate, Dolls eyes
Cheyne- Stokes respiration
repeated breathing pattern characterized by fluctuation in the depth of respiration, first deeply, then shallow, then not at all
Decerebrate posture
supine, legs straight with hands straight on side with pals/wrist upwards
Decorticate posture
supine, legs straight with hands at chest- deCORticate (hands at the core)
ICP vital signs
increased BP with widening pulse pressure, Decreased Pulse rate, Decreased Respirations
ICP in Infants S/S
Bulging fontanels, high-pitch cry, irritability, restlessness
ICP Nursing Care
HOB 30 degrees, give oxygen, frequent neuro checks, restrict intake, assess output to prevent overhydration, prevent seizures with anticonvulsants, treat N/V, pain meds can mask symptoms
Types of Glioma Brain Tumors
Astrocytomas, Glioblastomas, Oligodendrocytomas, Medulloblastomas, Ependymomas- Most common brain tumors.
Composed of Abnormal blood vessels- "Birthmark"- developed in Cerebellum- risk for brain attacks. Developing Tumors
Slow-growing tumor benign and encapsulated
Acoustic Neuromas
Tumors of 8th Cranial Nerve, Auditory meatus.
Pituitary Adenomas
Can cause pressure on the Optic Nerves, hypothalamus, or third ventricle.
Craniotomy Post-Op care
Monitor VS and neuro assessments, cardiac rhythm, perform passive ROM, turn, cough and deep breathe every 2 hours, use cold for edema, prevent DVT with stocking, Supratentorial Surgery (HOB 30 degrees), Intratentorial Surgery (Flat on either side for 2 days), avoid hip or neck flexion, wound suction drainage assessment.
Cerebrovascular Accident
Stroke- Ischemic (mild stroke TIA/ Hemorrhagic - blood in brain.
General: whole brain is attacked, Tonic Clonic (grand mal) :last up to 5 minutes, Aura, LOC, Absence (petit mal):little or LOC, blank stares (daydreaming affect), Partial seizures: Simple- no LOC,no movements, Complex- LOC, lots of movements but dont remember.
Status Epilepticus
Continuation of Tonic-Clonic Seizures without normal recovery period
Parkinson's Disease- Nursing Care
Degenerative Nuerological disorder- S/S: Hypokinesia, Microghraphia, Dysphonia, Dysphagia, sweating, urinary retention, Dementia, Stooped posture, slow tremors, abnormal movements.- Tx: Give MAOI- Maintain Joint mobility, high fiber diet, avoid thin liquids, speech therapy.
Meningitis- Nursing Care
infection of the Meninges of brain and spinal cord- S/S: Nuchal rigidity, Postive Kernigs/Brudzinski sign, Photophobia, LOC, IICP.- Tx: Droplet precaution-
Kernig Sign
Sign of meningitis; positive when the leg is fully bent at the hip and knee, and subsequent extension of the knee leads to pain
Brudzinski Sign
pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine
Multiple Sclerosis
No Cure- a progressive autoimmune disorder of the central nervous system marked by damage to the myelin sheath. S/S: Plaques occur in the brain and spinal cord causing tremor, weakness, incoordination, paresthesia, and disturbances in vision and speech.
Multiple Sclerosis Nursing Care
Muscle streching, frequent rest periods, prevent skin impairment, risk for aspiration, eye patch for double vision.
Myasthenia Gravis
progressive decrease in muscle strength; activity resumes and strength returns after a period of rest- S/S: weak muscles, loss of facial expression, and risk for respiratory failure. -
Myasthenic Crisis
an acute exacerbation of disease caused by inadequate amount of meds, infection fatigue, stress, or hot temperature
Cholinergic Crisis
Too much medication-N&V, diarrhea, cramps hypotension. TX: Tensilon to distinguish from Myasthenia Crisis, Atropine to reverse, Respiratory support may be needed
Myasthenia Gravis Nursing Care
Give medication ON TIME, Frequent rest periods, soft foods, pureed diet, (Crisis): Respiratory function is priority, suction and postural drainage, I & O, Wt. daily.
Guillain- Barre
Rapidly ascending progressive paralysis or weakness that leads to respiratory failure- starts from legs to face.
a brain disorder in which there are memory impairments plus other cognitive disturbances
Lou Gehrigs Disease/ Amyotrophic Lateral Sclerosis (ALS)
a degenerative disease which patients become progressively weaker until they are completely paralyzed- S/S: facial twitching, loss of coordination, voice change, repetitive movements.- Enteral feedings, Rehab
Huntington's Disease- Nursing Care
genetic disorder that causes progressive deterioration of brain cells.- S/S:emotional instability, involuntary movements, difficulty chewing, loss of bowel/bladder control, mental deterioration.- 10 to 20 yrs to live after symptoms occur.
Trigeminal Neuralgia- Nursing Care
a condition characterized by sudden, intense, severe lightning-like pain in face due to an inflammation of the fifth cranial nerve- pain when chewing, brushing teeth, washing face. Tx: Glycol Rhizotomy (damage nerve to prevent pain), Ice, artificial tears, eye patch.
Bell's Palsy- Nursing Care
temporary paralysis of the seventh cranial nerve that causes DROOPING only on the affected side of the face- S/S: Dystonia, Loss of tearing, one-sided facial pain.- Tx: Use heaet to area, protect eye with artificial eye drop and eye patch, use dark sunglasses.
condition of abnormal muscle tone that causes the impairment of voluntary/repetitive muscle movement
Spinal Cord Injuries- S/S
occurs at 5th-7th Cervical or 12th Thoracic or 1st Lumbar- if above C4, loss of respiratory function.-
Harrington Rod Placement
stainless-steel rod with a ratchet and a hook at each end allowed the safe placement, on the back of the spine, a metal strut, which could be lengthened to pull out a C-shaped curve with spinal fusion—bone grafting—to solidify the spine in the straightened position. Without this fusion, constant movement would loosen the rod and it would either break or rattle free.
Gardner- Wells Traction
U-shaped tongs for spine- having pressure--controlled pins that are inserted into the skull at opposite ends to permit application of a longitudinal force to the axis of the spinal column. -Tx: Log Roll as one unit.
Vinke Tongs
used to exert skeletal traction on the skull, as in surgery for fractures or cervical vertebrae- Spine- Tx: Log roll as one unit
Halo vest
A lightweight vest that an attaches halo that stabilizes the cervical spine.
Autonomic Hyperreflexia
Caused from bladder distention- Sudden and dangerous increase in blood pressure
Autonomic Dysreflexia
emergency situation-hypertensive crises (elevated systolic pressures of 260-300mm Hg), bradycardia, severe headache and possibly stroke or seizure activity- S/S: full bladder, fecal impaction, wrinkle in clothing, cramps, ingrown toenail, etc. Drug of choice is nitroprusside sodium (Nipride) or Nifedipine (procardia)
Intervertebral Disk disease
neurological deficits and sometimes paralysis that results when one or more intervertebral disks degenerates -Herniated Disk
Herniated disk
rupture of the intervertebral disk cartilage, which allows the contents to protrude through it, putting pressure on the spinal nerve roots- 4th-5th Lumbar or C5-C7.- Tx: Use Log Roll, Avoid sitting, driving, avoid heavy lifting for 4 months.
Diabetes Insipidus- Nursing Care
deficit in secretion of ADH- S/S: Polyuria, nocturia, wt. loss, dehydration, thirst, dilute urine, Tx: Give Desmopressin.
Expressive Aphasia
Disturbance of speech in which understanding remains but ability to speak is grossly impaired.
Receptive Aphasia
Damage to Wernicke's area can cause this condition in which a person hears a sound, but it has no meaning