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Nursing 128 Test 3


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Name 5 changes related to aging
Recent memory loss
Decreased touch sensation
Change in perception of pain
Change in sleep patterns
Altered balance or coordination
Name some neurological problem symptoms.
dizziness, confusion, parasthesia, unsteady gait, seizures, visual problems, hearing problems
What is the first sign of a neurological problem?
Decrease in level of conciousness.
Name the 6 levels of conciousness
Alert (awake, responsive)
Lethargic(sleepy, yet arousable)
Arousable (can be woken up)
Stuporous (arousable w/ difficulty)
Obtunded(insensitive to painful stimuli)
Comatose (not arousable)
Test for remote/long term memory?
What is your birthdate?
Test for recent recall memory?
Who brought you here?
Test for immediate/new memory?
Tell the client 3 unrelated words. Have them repeat them 5 minutes later.
Test for attention span
Have client count backwards from 100 by 7
Test for cognition.
What is the name of the V.P.?
What are ipsilateral symptoms?
Symptoms on the same side as a brain injury. (injury on left, symptoms on left)
What are contralateral symptoms?
Symptoms are on the opposite side of the injury. (injury on right, symptoms on left)
Test for sensory function.
Use the edge of a paperclip on the hand with the client's eyes closed.
Test for sensory function
Touch discrimination.
Touch different parts of the body while the client's eyes are closed.
Some causes of peripheral nervous system involvemenet.
Diabetes, malnutrition, vascular problems, spinal cord or nerve injury.
Test for motor function
muscle strength.
Squeeze my two fingers, resist hand, push with legs.
What is the pronator drift test?
While standing, client closes eyes, holds hands out w/ palms up & arms extended. If there is a problem, one arm will drift down & the hand will pronate. Indicates a brain lesion.
Tremors, unintentional movements, changes in gait or posture, weakness or paralysis can all be signs of what?
Cerebral/brainstem problems
What are the superficial reflexes?
Achilles (back of ankle), Babinski (bottom of foot), Abdominal (near umbilicus), cremasteric (upper inner aspect of the thigh)
Rating scale for reflex activity.
0 absent
1 hypoactive/weaker than normal
2 normal
3 stronger than normal
4 hyperactive
Hyperactive reflexes may indicate these 3 problems
neurological disease, tetanus, hypocalcemia
Hypoactive reflexes may indicate these 6 problems
neurological disease, neuromuscular disease, muscular disease, diabetes, hypothyrodism, hypokalemia
PIH leads to eclampsia, then hyperactive reflexes, and then
seizure activity
Glascow coma scale measures these 3 assessments.
Eyes open, best verbal response, best motor response.
4 stages of eye responses
to sound/speech, on request
to pain
no response
5 stages of verbal response
1.oriented to person, place & time
2.engages in conversation, confused in content
3.inappropriate words spoken
4.incomprehensible sounds/groans response
6 stages of motor response
1. obeys verbal commands (raise arm)
2. localizes pain
3. normal flexion to painful stimuli
4. abnormal flexion
5. extension to painful stimuli
6. no response
early responses to pain
localize pain
withdraw from pain
3 late signs of pain (extensive damage has already occurred)
decorticate posturing
decerebrate posturing - related to brain stem problem
no response
What is decorticate posturing?
arms flex on the chest, hands internally rotated, legs may extend. indicates problem w/ corticospinal pathways.
What is decerebrate posturing?
arms stiffly extended, hands externally rotated, legs may extend.
Pupils that are pinpoint or dilated and do not react are a sign of...
neurological deterioration.
Pupil assessment - 5 items
Size estimated in mm
direct response
consensual response
Types of lab tests for neurologic disorders
C&S of blood or cerebral spinal fluid
When is a skull and spine xray used?
To detect injury that involves fractures or dislocations that may damage the nervous system. ex. vertebrae.
When is a cerebral angiogram used?
To show soft tissue. A picture of groups of vessels. May do carotid or vertebral angiograms to see blockages, leakage and aneurisms (ballooms).
Preop for Angiogram
NPO for 24 hours, empty bladder
remove dentures, remove metal
vs,neuro checks before test
Postop for angiogram
vs, neuro checks, fluid encouraged to flush dye, bedrest w/affected extremity immobilized, pressure dressing on site, sandbag on pressure dressing, ice application
2 types of cerebral angiograms
contrast media method
digital subtraction method
precaution for contrast media method
Check allergies for shellfish, eggs, iodine.
Digital subtraction method (DSA)
dye is injected IV
images taken w/ computerized digital camera
safer than contrast media method
Digital subtraction method prep
Fluids are restricted
Digital Subtraction Method post op.
drink fluids
assess insertion site & extremity
no activity restrictions
What does a myelography show?1
Abnormalities of the spinal cord.
What does an Electroencephalography (EEG) do?
Measure the electrical activity of the brain w/ an electrode. Can be used to diagnose sleep disorders and pinpoint the site of seizure activity.
Preop for EEG
Outpatient. Shampoo hair, no cream, oil, spray. Avoid stimulants, depressants.
Contrast method of Angiogram
dye injected into brachial or femoral artery
may rarely use carotid artery
client will feel heat when dye is injected.
Risks of the contrast method of angiogram.
allergic reaction.
spasms of the blood vessels
(artery constricts - decreases blood supply)
What are MRI's used for?
to detect neuro disorders.
How is a brain scan done?
A radioactive isotope is injected and absorbed by the brain. Provides information about the structure of an organ. 2 hours after dye is injected, films are taken.
How is a PET scan done?
Radioactive substances are used to provide information about both the structure and the function of an organ.
What are some reasons for doing a lumbar puncture/spinal tap?
CSF examination
measurement of pressure
inject medication or anesthesia
withdraw fluid
to inject dye or air
contraindicated w/ inc. ICP
Assessment of CSF
appearance - clear and colorless
cell count - RBC's indicate bleeding, WBC's indicate infection.
Why is a C&S of the CSF done?
To identify bacteria, microorganisms.
Why is a glucose and protein gest done on CSF?
To diagnose neuromuscular disease and bacterial meningitis.
What does it indicate when LDH is found in CSF?
It is associated with bacterial meningitis.
Why is a cytology test of the CSF done?
To test cells to diagnose CNS tumors
What are the preop nursing implications for lumbar puncture?
empty bladder
lateral recumbent position (fetal)
label samples sequentially
needle is inserted between 3&4 vertebrae of the lumbar spine.
What are the postop considerations for lumbar puncture?
lie flat 4-8 hours-prevent CSF leakage
force fluids 24-48 hours to replace CSF
vs & neuro checks
assess for spinal headache (from excessive loss of CSF)
What are causes of increased ICP?
increased intracranial bulk (brain tissue, blood, CSF)due to trauma, hemorrhage, tumors, abscesses, edema, inflammation.
What happens with increased ICP?
impedes cerebral circulation, absorption of csf, function of nerve cells.
What is a fatal consequence of increased ICP?
The brain herniates downward toward the brainstem causing irreversible brain damage or death.
What is the most common cause of death with head trauma?
Increased ICP.
What is normal ICP?
10-15 mm Hg
80-180 mm H2O
How is ICP measured?
A catheter is inserted into the spinal column or into the ventricles of the brain.
Factors that increase ICP?
increased PCO2, Decreased PO2, valsalva maneuver, isometric muscle contraction, coughing/sneezing/vomiting, emotional upset, supine or trendelenburg position (head down, suctioning.
What is the most sensitive indicator of increased ICP?
Assess LOC!
4 Assessments for increased ICP
LOC, headache, projective vomiting
pupillary changes, assess motor function, assess vital signs, diagnostic tests.
Motor functions that indicate increase ICP.
weakness, hemiplegia, positive Babinski, decorticate or decerebrate posturing, seizure activity.
Vital signs that indicate increased ICP.
widening pulse pressure (large gap between sys & dias.), bradycardia, abnormalities in respirations, especially periods of apnea, elevated temperature.
Diagnostic tests for increased ICP
MRI, CT scan, EEG
No lumbar puncture!
Management of increased ICP
decrease ICP & prevent damage to brain cells by maintaining adequate blood flow w/ sufficient O2 & glucose & to reduce the buildup of CO2.
Medications used for increased ICP
steroids - to decrease edema (antiflammatory effects)
diuretics to decrease edema by excreting large volumes of water.
What is a potential complication of using diuretics to decrease ICP?
Fluid and electrolyte imbalance, especially sodium and potassium.
Nursing interventions to decrease ICP
normalize body temperature
maintain fluid balance
elevate hop 30 degrees
administer O2, decrease stimuli
prevent straining, medications
pulmonary clearance, patent airway
Comparison of ICP and shock
Increased ICP - inc. temp, inc. BP, pulse pressure widens, dec. pulse, irreg. respirations, apnea.
Shock - no temp change, dec. BP, inc. pulse, inc. resp.
When treating increased ICP with medications, what is contraindicated?
morphine and other narcotics that alter neuro status.
Some assessments of the comatose client.
neurological status
respiratory status
cardiac status
skin status
bowel and bladder
Nursing interventions of the comatose client.
pulmonary clearance
I&O and bowel elimination
nutritional requirements
maintain skin integrity
hygiene needs
Nursing interventions of the comatose client
protect eyes
provide uninterrupted rest
provide auditory, visual and tacile stimuli
profide family support
Some causes of confusion in a client
vascular problems
alcohol - chronic
trauma, infection
sundown syndrome
metabolic disorders (diabetes)
medication side effects
Nursing diagnosis of a confused client.
alteration in thought processes related to decreased memory/lack of orientation...
Interventions for the confused client with decreased memory.
repetition of instructions
written memory aids
appeal to several senses
small steps; simple to complex
Interventions for the confused client with lack of orientation.
window view, social interaction, clock, calendar, photographs, television, structure environment, face to face contact, short sentences, simple commands.
Interventions for the confused client with aggressive behavior.
maintain calm, firm attitude.
rotate care among staff
avoid overstimulation
provide a structured environment
set limits on behavior
reinforce appropriate behaviors.
Nursing diagnosis of the aphasic (inability to communicate) client.
alterations in communication related to expressive or receptive aphasia or dysarthia.
Expressive aphasia is...
The client understands people, but can't form the words to respond.
Receptive aphasia is...
The client can talk, but can't understand what is being said.
Interventions for the client with aphasia.
Use alphabet or picture board
Treat the client as as adult
Present one thought at a time
Ask simple questions/one word answers
Keep familiar routine for client.
Nursing diagnosis of a client with dysphagia
Alteration in nutrition related to dysphagia...
Assessment of a client with dysphagia.
Gag reflex
ability to chew
condition of mouth
deviation of uvula
ability to suck
Interventions for a client with dysphagia
Feed from good side
offer thickened liquids only
offer semisolid foods
offer small amounts frequently
Examples of food for dysphagic client.
custard, jello, mashed potatos, ice cream, canned fruits.
Nursing diagnosis of the immobile client.
Alteration in mobility related to ...
Complications of the immobile client.
Pneumonia, Thrombosis
Constipation/fecal impaction
Urinary tract infection
Skin breakdown
Contractures/Muscle wasting
Examples of acidic fruit juices to prevent UTI's.
Cranberry, prune
(Orange is not acidic)
Nursing diagnosis of the incontinent client.
Altered urinary elimination or bowel incontinence...
Interventions for bowel incontinence
establish schedule for evacuation
administer stool softeners
Interventions for bladder incontinence.
Schedule use of bathroom
Foley clamping routine
Crede method (pressure to pubic area)
Intermittent self catheterization
Incontinence pads
Kegal exercises
Incontinence surgeries
What medication is given for a bladder with poor muscle tone?
What medications are given for spastic bladder?
Ditropan, Pro-banthine
Two types of neurological problems of the CNS-Brain
Seizure disorders, epilepsy
What is a seizure disorder?
A physical manifestation of rapid paroxymal and abnormal electrical firing of neurons
What is epilepsy?
A chronic disorder characterized by recurrent unprovoked seizure activity.
Who has the highest incidence of epilepsy?
Older adults.
Can epilepsy be inherited?
What are the causes of epilepsy?
Primary (idiopathic)- cause unknown
Secondary - underlying lesion d/t brain tumor, trauma, metabolic, electrolyte disturbance, infection, drug/alcohol withdrawal, hyperthermia.
What is the diagnostic test for epilepsy?
Name four types of seizures
Tonic-clonic (grand mal)
Atonic (without muscle tone)
Name the stages of a tonic-clonic (grand mal) seizure.
Cry Out
Tonic - body stiffens
Clonic - rhythmic jerking
What are some types of auras in a tonic/clonic seizure?
smell, sound, taste, hallucination, weakness, numbness.
What types of things happen during the clonic stage of a grand mal seizure?
loss of consciousness
respirations may stop (apnea)
What happens during the postictal stage of a tonic-clonic seizure?
no memory of the seizure (may last hours, days)
Nursing management for seizures
Protection from injury
Support respiratory function
Assessments for seizure management
time of onset, type of motor movement, incontinence, pupil reaction and eye movement, respiratory status, skin color, moisture, pre and postictal state.
Ways to protect the seizure patient from injury.
Clear environment
pad side rails
loosen restrictive clothing
protect clients head (pillows)
stay with client throughout seizure
Ways to support respiratory function for the seizure client.
Place client on side
insert airway
administer oxygen
suction as needed
Post seizure care
quiet environment, decrease stimuli
side rails up
vs and neuro checks
check mouth for injuries
check for incontinence
administer meds as ordered
reorient patient
maintain seizure precautions
What are seizure precautions?
Prevent injury
O2 and suction equipment
IV access
padded side rails
bed in low position
airway available
no padded tongue blade!
Describe absence seizures
Brief loss of consciousness
common in children
easy to miss
Describe myoclonic seizures
brief jerking or stiffening of extremities - singly or in groups
last a few seconds
Describe atonic/akinetic seizures
sudden loss of muscle tone causing the person to drop to the floor
may be followed by confusion
What are 2 types of partial seizures?
Complex partial (with loss of consciousness)
Simple partial (no loss of consciousness)
50% of seizures are ...
unclassified - not in any category
What is status epilepticus?
Continuous seizure activity lasting longer than 10 minutes or repeated seizures over the course of 30 minutes.
What are the usual causes of seizures?
Sudden withdrawal from anticonvulsant medication, infections, head trauma, cerebral edema, metabolic disturbances.
Interventions for the management of seizures.
Vagal nerve stimulation
Surgical procedures
Client and family education
Risk factors for stroke.
Heredity, gender (males), >65, race (African American), HTN, coronary artery disease, diabetes, hyperlipidemia, obesity, sickle cell anema, phenylpropanolamine (PPA), smoking, alcohol, cocaine, IV drug use.
Cranial nerve involvement in stroke patients
CN V - chewing
CN VII - facial paralysis, drooping
CN IX & X - swallowing, gag reflex
CN X11 - tongue movement
Test for cranial nerve V for stoke patient.
Trigeminal. Clench teeth, lightly touch anterior skull, paranasal sinus area, jaw area. (both sides)
Test for cranial nerve VII for stroke patients.
Facial paralysis. 6 facial movements - raise eyebrows, smile, puff out cheeks, purse lips and blow out, show teeth, squeeze eyes shut while you try to pry them open.
Test for cranial nerve IX and X for stroke patients.
swallowing and gag reflex. IX movement of posterior pharynx when client says AHhh. X gag reflex (touch tongue blade to posterior pharynx.
Test for cranial nerve XII for stroke patients.
Tongue movement - stick tongue out.
Nursing management for patient with meningeal irritation.
vs, neuro checks, assess for signs of ICP, cranial nerve testing 3,4,6,7,8; seizure precautions, IV antibiotics, isolation precautions, people in close contact are tested.
Nutrition for a stroke patient.
Count calories, weigh patient, give supplements, foods high in fiber, adequate fluids.
Neuro checks for ICP
assess LOC, headache, motor function, vital signs, projectile vomiting, pupilary changes
diagnostic tests
Pupilary changes in ICP
unilateral pupil dilation
bilaterally dilated and fixed pupils
slow pupil reaciton to light
papilledema with opthalmoscopic exam
Difference between bacterial and viral meningitis.
Bacterial - fall & winter, s. pneumonia,common in dorms, most common
Viral - after virus (measles, mumps, herpes simplex, herpes zoster), complete recovery
Signs of meningeal irritation
Nuchal rigidity
Kernig's sign
Bridzinski's sign
Alzheimer's Disease warning signs
Recent memory loss, difficulty performing familiar tasks, problems with language, disorientation to time and place, impaired judgment, wandering.
Risk factors of Alzheimers Disease.
Genetic disposition, chemical imbalance, environment, immunologic causes.
Nursing responsibilities for treating MS with prednisone.
Monitor fluids, electrolytes, glucose levels, K, GI Bleeding, personality changes and protect from exposure to infections.
Antiepileptic drug that causes impaired liver function.
Antiepileptic drug that causes body hair increase and slurred speech.
Why are antihistamines given for Parkinson's disease?
To enhance anticolinergic drying action
Post op care for spinal nerve root decompression.
Deep breathing w/o coughing, rest the back, narcotic analgesics, assess for resp distress w/ cervical fusion, assess donor site, back brace or collar, logrolling day of surgery, support head, assess dressing, assess voiding, nv checks of extremities
Clinical management of multiple sclerosis.
PT, OT, Corticosteroids, immunosuppressive therapy, adjunctive therapy, bee sting therapy, nutritional supplements.
Two types of Autonomic Nervous System Syndromes
Neurogenic/Spinal shock
Autonomic Dysreflexia
What is neurogenic/spinal shock
Sudden depression of sympathetic reflex activity below the level of injury.
What is autonomic dysreflexia?
a later complication of spinal injury.
Symptoms of neurogenic/spinal shock
hypotension, bradycardia, flaccid paralysis, paralytic ileus, loss of reflexes. Symptoms appear 30-60 min. after injury, last several months. Tx-medication.
Symptoms of Autonomic Disreflexia
sever hypertension, bradycardia, flushing and sweating, blurred vision, nausea, cool mottled skin below injury.
Cause of autonomic disreflexia
overstimulation of the autonomic nervous system, i.e, distended bladder or color - emptying will reverse the problem.
Assessment for spinal nerve root decompression
Assess for pain, posture/gait, paresthesia, deep tendon reflexes.
Nonsurgical management for spinal nerve root decompression
assess pain, motion & sensation in extremities, Williams position(HOB elevated, knees flexed), firm mattress, exercise, medications for pain and inflammation, heat/ice, weight control.
Mechanisms of spinal cord injury
hyperflexion of neck, hyperextension of neck, axial loading (jump off roof), penetrating injuries (stab, gunshot)
Degrees of spinal cord injury
cord concussion (blow)
contusion (bruising)
laceration (Tear in spinal cord)
transection (complete severing of cord)
Effect of high cervical damage to the spine (C2-3)
Respiratory failure - often immediate death.
Effect of low spinal damage
loss of motor function, sensation, reflex activity, bowel & bladder function
What is the priority assessment in spinal cord injury?
Assess Airway!
What is the next nursing priority after assessing airway in spinal cord injury?
Immobilization of the head, neck and back; maintain proper alignment of the spine at all times.

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