Exam #3: Ch. 56-60 (Neurological System)

Ch. 56-Nursing Assessment: Nervous System
1. Review the functions of the cerebral lobes.
*frontal: higher cognitive function, memory retention, voluntary motor movement, voluntary eye movement, expressive speech
*temporal: receptive speech, integration of somatic, visual, and auditory data
*parietal: sensory cortex, control and interpret spatial information
*occipital: sight processing

2. Describe the effects of aging on the nervous system.
*CNS
-loss of neurons in certain areas of brainstem, cerebellum, and cerebral cortex
>enlargement of ventricles
>decreased brain weight
>decreased blood flow
>decreased CSF production
-glycosylated hemoglobin (Hb A1C): risk factor for accelerated cerebral atrophy
*PNS
-changes to anterior horn cells, peripheral nerves, and target organ muscle
-deteriorated myelin sheath, therefore decreased nerve conduction
-decreased neuromuscular activity
>slower BP response to position change and body temperature
*additional relevent changes
-decreased memory, vision, hearing, taste, smell, vibration/position sense, muscle strength, and reaction time
>decreased dietary intake
>increased perceptual confusion
>fall/fracture risk

3. Differentiate the effects of the sympathetic and parasympathetic nervous system.
*both are part of the autonomic nervous system which governs involuntary functions of cardiac muscle, smooth (involuntary) muscle, and glands
-sympathetic nervous system (T1-L2): “fight or flight” response
>release of norepinepherine and acetylcholine
>occurs throughout body
>imagine what the body would do if a bear was attacking you
-parasympathetic nervous system (S2-S4): conserves and restores energy stores of the body
>releases acetylcholine
>acts in localized and discrete regions of the body
>imagine what the body would do after thanksgiving dinner

4. Explain common neurological assessment abnormalities.
*mental status
-ALOC: unable to speak, obey commands, or open eyes appropriately with verbal or painful stimulus
-anosognosia: unable to recognize bodily defect or disease
*speech
-aphasia: loss of language faculty
-dysphasia: difficulty with use of language
-dysarthria: lack of coordination in articulating speech
*eyes
-aniscoria: unequal pupil size
-diplopia: double vision
-homonymous hemianopsia: loss of vision in one eye
*cranial nerves
-dysphasia: difficulty swallowing
-ophthalmoplegia: paralysis of eye muscles
-papilledema: “choked disc”; swelling of optic nerve head
*motor system
-apraxia: inability to perform learned movements
-ataxia: lack of coordination in movement
-dyskinesia: fragmentary movements due to impairment of power
-hemiplegia: one-sided paralysis
-nystagmus: jerking of eyes while tracking objects
-opisthotonus: arching of back with head retraction
*sensory system
-analgesia: loss of pain sensation
-anesthesia: absence of sensation
>hyperesthesia/hypoesthesia: increase/decreased in sensation
-astereognosis: inability to recognize object form by touch
*reflexes
-Babinski’s sign: upgoing toes with plantar stimulation
-Brudzinski’s sign: neck lesion results in neck pain and reflex flexion of hip and knee
-Kernig’s sign: reflex contraction and pain when in supine position and hips are flexed 90 degrees
*spinal cord
-bladder dysfunction
>atonic: no muscle tone/contractility
>hypotonic: decreased muscle tone/contractility
>hypertonic: increased muscle tone, but decreased capacity
-paraplegia: paralysis of lower extremities
-quadriplegia: paralysis of all extremities

5. Explain different types of diagnostic studies of the neurological system and appropriate nursing responsibilities.
*cerebral angiography: catheter inserted into femoral artery, when vascular lesions or tumors are suspected, then x-rayed
-observe for bleeding
-apply pressure dressing and ice to promote hemostasis and prevent swelling
*electroencephalography (EEG): monitors electrical activity of surface cortical neurons of the brain
-withhold stimulants
-inform patient it is similar to an ECG, no pain involved
*electromyography (EMG): records electrical activity associated with innervation of skeletal muscles
-inform patient of slight discomfort with needle insertion
*lumbar puncture (LP): CSF aspiration at L3-L4 or L4-L5 interspace to assess CNS disease
-monitor neurologic system and vital signs
-encourage fluids
-label specimen
-maintain strict asepsis
-patient should be flat lying after procedure
-assure there is no tumor which could be herniated with procedure
*computed tomography scan (CT): computer assisted x-ray on several thin cross sections of body parts
-elicit allergies to contrast media
-remain calm during procedure and explain scanner
-non-invasive if no dye is used
*magnetic resonance imaging (MRI): imaging using magnetic energy with greater contrast than CT scan
-screen body for metal parts
-be aware of contraindications
-the patient will need to lie still for about an hour
-administer sedatives if necessary
*myelography: detects spinal lesions by x-ray of spinal cord and vertebral column with contrast media
-pre-procedure sedation
-empty bladder
-table will move during test
-patient should lie flat for a few hours after procedure
-encourage fluids
-monitor neurological system and vital signs
-headache and n/v may occur
*positron emission tomography (PET): assess cell death or damage by using radioactive material to measure metabolic activity
-explain procedure and that there will be 2 IV lines required
-no sedatives or tranquilizers involved
-empty bladder pre-procedure
-different activities may need to be performed during test
-glucose monitoring is necessary due to injected venous scan material
*carotid duplex studies: combined ultrasound and doppler technology to evaluate stenosis of carotid and vertebral arteries
-explain procedure to patient

Ch. 57-Nursing Management: Acute Intracranial Problems
1. Explain factors that affect intracranial pressure and cerebral blood flow.
*ICP
-arterial pressure, venous pressure, intraabdominal/intrathoracic pressure, posture, temperature, and ABGs, particularly CO2
*CBF
-carbon dioxide, oxygen, hydrogen ion
>low CO2: relaxes smooth muscle, dilates cerebral vessels, decreased cerebrovascular resistance, and increased CBF
>high CO2: constricts cerebral vessels, increased cerebrovascular resistance, increases CBF, and increased O2 tension
>low O2 tension: causes lactic acid which leads to vasodilation and the accumulation of hydrogen ions
--acidosis: autoregulation is lost and CBF would then be directly influenced by systemic BP, hypoxia, and catecholamines

2. Use the NP to provide are to a patient with IICP.
*assessment
-subjective: obtain from family/friend familiar with patient
-objective: LOC, deviations from normal bodily functions, neurological assessment
-dx: CT or MRI

*diagnoses
-ineffective tissue perfusion (cerebral)
-decreased intracranial adaptive capacity
-risk for disuse syndrome

*planning
-maintain patent airway
-have ICP within normal limits
-demonstrate normal fluid and electrolyte balance
-no complications secondatry to immobility or decreased LOC

*implementation
-suction airway
-reposition from side to side
-elevate HOB
-NG tube for gastric distention unless contraindicated
-decrease environmental stimuli and hazards
-assess ABGs, F&E, and pain
-minimize actions which promote ICP

3. Use the NP to provide care for a patient with an acute head injury.
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET

*diagnoses
-ineffective tissue perfusion (cerebral)
-hyperthermia
-acute pain (headache)
-impaired physical mobility
-anxiety
-potential complication: increased ICP

*planning
-adequate cerebral oxygenation and perfusion
-remain normothermic
-control pain and discomfort
-free from infection
-maximal cognitive, motor, and sensory function

*implementation
-protective gear education
-safe driving education
-explain need for frequent neurological checks
-check for CSF leaks
-care for the immobile patient
-surgery consent from family if needed

4. Explain the types of head injuries and related complications.
*scalp lacerations
-external head trauma
-excessive blood loss
-risk for infection
*skull fractures
-linear, depressed, simple, comminuted, compound
>intracranial infection, hematoma, meningeal, and brain tissue damage
*minor head trauma
-concussion: sudden transient mechanical head injury
>repeated minor head trauma could lead to a more progressive, serious problem
*major head trauma
-contusion: bruising of brain tissue
-laceration: bleeding of brain tissue
>brain hemorrhage
*epidural hematoma
-bleeding between dura and inner brain surface
*subdural hematoma
-bleeding between dura mater and arachnoid layer
*intracerebral hematoma
-bleeding within the brain

5. Explain the indications for and types of cranial surgery
*stereotactic
-uses precision apparatus to drill Burr hole
-removes small brain tumors and abscesses, drains hematomas, ablative procedures for extrapyramidal diseases, and repair of arteriovenous malformations
-reduces surrounding tissue damage
-also ionizing radiation procedure
*craniotomy
-removal of brain part by sawing Burr hole

6. Use the NP to provide care to a patient post-cranial surgery
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET

*diagnoses
-ineffective tissue perfusion (cerebral)
-decreased intracranial adaptive capacity
-risk for disuse syndrome

*planning
-return to normal consciousness
-control pain and discomfort
-maximize neuromuscular functioning
-rehabilitate to maximal ability

*implementation
-therapeutic communication
-explain procedure
-prevent ICP
-suction airway
-reposition from side to side
-elevate HOB
-NG tube for gastric distention unless contraindicated
-decrease environmental stimuli and hazards
-assess ABGs, F&E, and pain
-minimize actions which promote ICP

7. Use the NP to provide care to a patient with bacterial meningitis.
*assessment
-subjective: how injury was inflicted, anticoagulant usage, use of alcohol or drugs, risky behaviors, headache, mood changes, impaired judgement, fear, denial, anger, agression
-objective: ALOC, type of laceration and bruising, patency of airway, fluid leakage, Cushing’s triad, vomiting, incontinence, uninhibitied sexual expression, pupil dysfunction, neurological function, muscle strength
-dx: CT, MRI, PET

*diagnoses
-decreased intracranial adaptive capacity
-disturbed sensory perception
-acute pain
-hyperthermia

*planning
-maximize return of neurologic function
-resolve infection
-control pain and discomfort

*implementation
-darken room and cool towel for photophobia
-manage fever
-assess for dehydration
-respiratory isolation
-therapeutic communication

Ch. 58-Nursing Management: Stroke
1. Differentiate the pathophysiology of each type of stroke.
*anatomy of cerebral circulation
-internal carotid arteries: anterior circulation
-vertebral arteries: posterior circulation
*regulation of cerebral blood flow
-cerebral autoregulation: changes to vessel diameter to compensate for systemic BP changes
-systemic BP, CO, and blood viscosity all affect brain blood flow
-collateral circulation: compensation for decreased cerebral blood flow
-ICP
*artherosclerosis: hardening and thickening of arteries can lead to thrombus formation and contribute to emboli
*ischemic stroke: inadequate blood flow to brain from partial or complete artery occlusion
-thromobotic stroke: injury to vessel wall and blood clot fomration
>narrowing of vessel by plaque
-embolic stroke: clot blocks blood flow
*hemorrhagic stroke: bleeding into brain tissue itself or into subarachnoid space or ventricles
-intracerebral hemorrhage: bleeding within the brain by a ruptured vessel
>hypertension
-subarachnoid hemorrhage: bleeding into CSF-filled space between arachnoid and pia mater on brain surface

2. Using a system’s approach, identify the complications resulting from an acute stroke.
*motor function
-impairment of mobility, respiration, swallowing/speech, gag reflex, and ADLS
*communication
-aphasia, dysphasia, dysarthria
*affect
-uncontrolled exaggerated emotional responses related to loss of functions
*intellectual function
-impaired memory and judgement
>right brain stroke: impulsive decisions and memory problems related to language
>left brain stroke: cautious decisions
-difficulty making generalizations; difficulty learning
*spatial-perceptual alterations
-right side stroke: decreased perception of self and illness, decreased sensory input form affected side, decreased object recognition by sight, touch, sound and decreased ability to carry out learned sequential movements on demand
*elimination
-initial and temporary
>secondary result

3. Use the NP to provide care to a patient with stroke.
*assessment
-subjective: description of current illness, hisotyr of similar symptoms, current medications, risk factors such as HTN and family history
-objective: LOC, cognition, motor ability, cranial nerve function, deep tendon reflexes (all should be monitored continuously)
-dx: non-contrast CT scan for confirmation and cause

*diagnoses
-ineffective tissue perfusion (cerebral)
-ineffective airway clearance
-impaired physical mobility
-impaired verbal communication
-unilateral neglect
-impaired urinary elimination
-impaired swallowing
-situational low self esteem

*planning
-maintain or improve LOC
-attain maximum physical functioning
-maximum self-care abilities and skills
-stable body functions
-maximal communication skills
-adequate nutrition
-avoid further complications
-effective coping

*implementation
-focused prevention on risk factors
-respiratory patency and function
>positioning, suctioning, oxygenation, gag reflex
-monitor neurological signs
-monitor cardiac rhythm and vital signs
-monitor IV and I&O
-monitor lung sounds and heart sounds
-ROM exercises
-observe lower extremity edema
>TEDs and SCDs
-elevation to avoid dependent edema
-hygiene care
-bladder training or foley care
-mouth care
-therapeutic communication
-monitor possible changes to senses and perceptions
-familial support
-patient education regarding home care

Ch. 59-Nursing Management: Chronic Neurologic Problems
1. Explain the pathophysiology and types of seizures
*abnormal neurons spontaneously fire
*generalized seizures: involve both sides of the brain
-tonic-clonic: loss of consciousness, stiffening of body, then subsequent jerking
-typical absence seizure: staring spell may be resulting from hyperventilation or flashing lights
>children
-atypical absence seizures: staring spells accompanied by peculiar behavior or confusion
*partial seizures: begin at one side of brain and can evolve to both
-simple partial seizure: no loss of consciousness and short lasting
-complex partial seizures: ALOC, longer than one minute, involves emotional, behavioral, cognitive, and affective function followed by confusion

2. Use the NP to provide care to the patient with seizure disorder, multiple sclerosis, myasthenia gravis and Parkinson’s disease
**seizure disorder
*assessment
-subjective: history of seizures, current compliance with medications, family history of seizures, changes before seizure, anxiety, depression, changes in sexual drive
-objective: bitten tongue, soft tissue damage, abnormal RR or breath sounds, HTN, tachycardia, bradycardia, GI/GU incontinence, type of seizure, weakness, paralysis
-dx: toxiclology screen, serum levels, LP

*diagnoses
-ineffective breathing pattern
-risk for injury
-ineffective coping
-ineffective therapeutic regimen management

*planning
-free of injury during seizure
-optimal mental/physical health while taking anti-seizure drugs
-satisfactory psychosocial functioning

*implementation
-identify precipitating events
-promote safety measures
-good general health habits
-record details of seizure
-maintain airway and safety
-therapeutic communication
-medic alert bracelet

**multiple sclerosis
*assessment
-subjective: past infections or vaccines, use/compliance to current medications, family history, malaise, weight-loss, dysphagia, decreased GI/GU function, generalized muscle weakness, numbness, tingling, muscle spasms, blurred/lost vision, anger, depression, euphoria
-objective: apathy, inattentiveness, pressure ulcers, scanning speech, impaired hearing, muscular weakness
-dx: CSF analysis, MRI

*diagnoses
-impaired physical mobility
-sexual dysfunction
-impaired urinary elimination pattern
-interrupted family processes

*planning
-maximal neuromuscular function
-independent ADLs
-optimal psycho-social well-being
-adjust to illness
-decrease precipitating factors

*implementation
-therapeutic communication
-prevent complications of immobility
-bladder training/ foley care
-maintain strong immune system

**Parkinson’s Disease
*assessment
-subjective: CNS trauma, encephalitis, fatigue, dysphasia, weight loss, decreased GI/GU function, excessive sweating, loss of dexterity, difficulty initiating movements, muscle soreness and cramping, mood swings, hallucinations
-objective: blank face, slow monotonous speech, infrequent blinking, ankle edema, postural hypotension, drooling, tremor, poor coordination, rigieity, stooped posture, shuffling gait

*diagnoses
-impaired physical mobility
-impaired verbal communication
-deficient diversional activity
-imbalanced nutrition: less than body requirements

*planning
-maximal neurological function
-maintain ADLS as long as possible

*implementation
-physical exercise
-well balanced diet
-encourage independence
-avoid secondary complications

**myasthenia gravis
*assessment
-subjective: fatigue level, affected body parts, severity, coping abilities
-objective: RR and depth, SpO2, and muscle strength
-dx: ABGs, pulmonary function tests
*diagnoses
-ineffective breathing pattern
-ineffective airway clearance
-impaired verbal communication
-imbalanced nutrition: less than body requirements
-disturbed sensory perception (visual)
-activity intolerance
-disturbed body image

*planning
-return of muscle endurance
-manage fatigue
-avoid secondary complications
-maintain quality of life

*implementation
-adequate ventilation
-drug therapy and monitor side effects (drug-drug interactions)
-daily planning
-balanced diet

Ch. 60-Nursing Management: Alzheimer’s Disease and Dementia
1. Explain the pathophysiology of dementia and Alzheimer’s disease
*dementia: neurodegeneration and vascular disorders
*Alzheimer’s Disease: plaque of the brain, abnormal protein threads inside nerve cells and loss of neuron connections

2. Use the NP to provide care for a patient with dementia and Alzheimer’s Disease.
*assessment
-subjective: repeated head trauma, family history, malnutrition, incontinence, poor personal hygiene, disturbed sleep pattern, impaired coping, forgetfulness
-objective: disheveled appearance, loss of recent memory, disorientation, agitation, confusion, inability to do simple tasks
-dx: diagnoses by exclusion

*diagnoses
-disturbed thought process
-self-care deficit
-risk for injury
-wandering

*planning
-maintain functional ability as long as possible
-safe environment and minimal injuries
-meet personal care needs
-maintain dignity

*implementation
-assess for depression and suicide ideation
-work with caregiver to monitor ongoing changes
-consistency to reduce anxiety or disruptive behavior

3. Explain the general categories of drug therapy for Alzheimer’s Disease.
*drugs for…
-decreased memory and cognition: block cholinesterase to improve functional abilities
-depression: improve cognitive ability
-behavioral problems: atypical anti-psychotics with uncertain side effects
-sleep disturbances

4. List general nursing care instructions for the caregiver.
-provide a safe environment
-stop potentially dangerous behavior early
-reinforce routine and continue communication
-monitor diet
-reduce stress triggers
-know when caring for the patient is too much