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Neurological Fundamentals High Fowlers dec ICP pressure on brain LOC most sensitive indicator of neuro status Pupil size 3 5 mm Often Confused Terms Dysphasia Aphasia impaired communication written language comprehension Dysphagia impaired swallowing Dysarthria muscle weakness to speak Apraxia impaired ability to perform a learned movement Glascow Coma Scale GCS 9 12 moderate 8 severe Babinski Sign normal toes point downward upon stroke abnormal great toe bend upward small toes fan out Decorticate vs Decerebrate Postures Decorticate nonfunctioning cortex s sx flexion of arms and extension of legs Decerebrate brainstem lesion manifestation of drowning pt s sx rigid extension and pronation of arms legs Cranial Nerves CN 3 4 6 extraocular movements Cerebral Cortex Diagnostic Testing CSF Assessment normal CSF clear and colorless abnormal CSF cloudy infection WBC protein buildup orange yellow inc CSF protein prev bleeding use dextrose testing to confirm Major Conditions Unconscious pt conditions that are highlighted in red indicates emergency s sx unarousable no response to pain altered respirations decreased response to cranial nerve test and reflex tests Priority 1 Emergency airway equipment bedside 2 Assess circulation 3 Suction as needed 4 Semi Fowlers and avoid Trendelenburg 5 Reposition q2h 6 Keep NPO and assess for gag reflex before resuming diet Basilar skull fracture s sx battle sign bruise behind ear CSF leakage from nose periorbital hematoma racoon eyes Priority 1 Support ABC 2 C spine immobilization 3 Neuro monitoring Cushing s Triad signs of increased ICP 1 irregular respirations 2 bradycardia 3 wide pulse pressure s sx change in LOC headache increased BP with widening pulse pressure bradycardia fever pupil changes Increased ICP complication Impedes on circulation to brain functioning of nerve cells can lead to brainstem compression death Priority 1 DECREASE ICP Keep HOB 30 degrees promotes venous drainage 2 IV mannitol osmotic diuretic to move fluid from brain into interstitial fluid plasma 3 Keep body midline straight flexion decreases drainage 3 Stool softeners prevents straining 4 Calm environment dim lights low noise etc to prevent stress on body 5 Suction if needed 6 Treat fever and body temp shivering can increase ICP 7 Teach pt about avoiding Valsalva maneuver coughing or deep breathing Seizures 1 Phases 1 Prodromal 2 Aural 3 Ictal active seizure 4 Postictal experience prolonged confusion headache while recovering Absence Seizure brief no loss change in muscle appear as though pt is daydreaming Tonic Clonic Tonic Stiffening of muscles followed by loss of consciousness Clonic hyperventilation jerking of extremities Status Epilepticus deadly seizures w o intervals of consciousness result in brain damage Epilepsy chronic seizures Priority 1 Assist pt to lie down 2 Position on side maintains patent airway allows for drainage of secretions and prevents tongue from occluding airway 3 Loosen restrictive clothing never put restraints 4 O2 as needed 5 Record time duration of seizure 6 Never abruptly stop antiseizure meds 7 Good oral care to prevent gingival hyperplasia from Phenytoin 8 Use suction after seizure Amyotrophic Lateral Sclerosis ALS degeneration of motor system no changes in sensory autonomic or mental status S S respiratory difficulty at the end of the disease resp muscles are affected leading to death muscle weakness dysphagia No cure Bell s Palsy Facial Paralysis in paralysis of one side of face Lower motor neuron lesion of CN 7 facial nerve resulting Note Does not affect vision balance or extremity motor function which means they are capable of performing various ADLs i e driving shopping recovery usually in a couple weeks Priority 1 Facial muscle exercises 2 Protect eyes from becoming dry artificial tears wear patch night 3 Have pt chew on unaffected side 4 Provide oral care Autonomic Dysreflexia Hyperreflexia SNS stimulation after injury T6 or higher neurological emergency Risk factors noxious stimulus distended bladder or constipation UTI restrictive clothing pressure injuries s sx vasodilation T6 site and above severe HTN headache diaphoresis bradycardia flushing JVD nausea vasoconstriction below T6 site pale cool no sweating Complication hypertensive stroke Priority 1 Assess for the noxious stimuli to prevent stroke palpate distended bladder assess for bowel impaction remove restrictive clothing 2 Raise HOB 45 degrees 3 Monitor BP and provide antihypertensives if needed Spinal Cord Injury Total transection of cord total loss of sensation movement and reflex below the level of injury If injury is between C1 C8 quadriplegia If injury is between T1 L4 paraplegia C2 C3 injury is usually fatal any injury C4 or above respiratory difficulty Priority 1 Always assume spinal cord injury with traumas until it s ruled out 2 Immobilize pt on backboard 3 Body midline with head in neutral position 4 Maintain patent airway 5 Logroll pt if needed 6 Monitor ABGs to assess respiratory status 1 Spinal Immobilization device to stabilize pt s spinal column after a suspected spinal cord injury NSAIDS N neurological examination focal deficits numbness decreased strength S significant traumatic mechanism of injury A alertness altered LOC I intoxication D distracting injury S spinal examination point tenderness over the spine Stroke risk factor uncontrolled HTN 140 mm Hg s sx hemiparesis one sided weakness new sudden arm drift aphasia impaired speech facial droop headache vomiting impairment of verbal written comprehension right side stroke left sided weakness neglect lack of impulsive control behavioral changes left side stroke right sided weakness neglect dysphasia language damage Golden hr 1 hr to treat pt time is brain Priority 1 Ensure patent airway 2 CT Scan STAT 3 Lower BP slowly above 170 mmHG for the first 1 2 days 4 High fowler s 1 Ischemic vs Hemorrhagic Stroke Ischemic embolic CLOT Low O2 blood flow blockage cause issue with brain tissue perfusion s sx HTN in order to maintain brain perfusion distal to the area of blockage Hemorrhagic brain bleed vessel ruptures INC INP Increased ICP avoid suctioning for 10 secs Priority TPA to be given 4 5 hour from onset of S S contraindicated in thrombocytopenia uncontrolled HTN head trauma within past 3 months major surgery within past 14 days s sx severe headache worst headache of life Seizure can occur due to high ICP dysphagia Ischemic embolic Priority 1 Seizure precautions NPO Neuro assessment 3 Prevent activities that

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HARVARD NEUROBIO 319 - Neurological Nursing

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