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This Document Description: Forsyth Technical Community College Health Care Concepts
STUDY GUIDE
FINAL EXAM
NUR 211
NUR 211 – Exam 4 Study Guide 1.Concept of Intracranial Regulation The major divisions of the nervous system are the central nervous system (CNS – brain and spinal cord), and the peripheral nervous system (PNS). These systems work together to control cognition, mobility, and sensory perception. Anatomy and Physiology Review:
Nervous System Cells: Structure and Function
- The basic unit of the nervous system is the neuron which
transmits impulses, or “messages.” o Motor neurons:
cause purposeful physical movement
Efferent neurons: motor neurons that carry signals away from the
CNS and to the cells in the PNS
o S ensory neurons: have the ability to perceive
stimulation through one’s sensory organs or sensory perception
Afferent neurons: sensory neuron that sends impulses toward the
CNS, and away from the PNS o Other neurons process information, and some retain information o When neurons receive information, the effect may be excitation (increasing action) or inhibition (decreasing action)
o Each neuron has a soma (cell body), dendrites
(branching processes that send impulses along the
efferent or afferent pathways), and a single axon
o Axons are covered by a myelin sheath which is a
white, lipid covering. Myelinated axons appear whiteish and therefore are also known
as white matter. These axons have gaps in them known as
Nodes of Ranvier which play a major role in impulse conduction.
When the brain is impaired, the impulses cannot travel from the brain to the rest of the body. For example, patients with MS.
Nonmyelinated axons have a grayish cast and are called gray
matter.
o The enlarged distal end of each axon has a
synaptic or terminal knob, and within these
synaptic knobs are the mechanism for manufacturing, storing, and releasing a transmitter substance. Each neuron produces a specific
neurotransmitter chemical (for example, serotonin)
that can either inhibit or enhance the impulses but cannot do both. o Impulses are transmitted to their destination
through synapses (space between neurons). There
are two types of synapses: Neuron to neuron
- Frontal lobe: primary motor area, Broca’s speech area on the dominant side, voluntary eye movement, access to current sensory data, access to past information or experience, affective response to a situation, behavior regulation, judgement, ability to develop longterm goals, reasoning, concentration, and abstraction
- Parietal lobe: understanding sensory input such as texture, size, shape, and spatial relationships. Three- dimensional (spatial) perception. Needed for singing, playing musical instruments, and processing. Perception of body parts and body position awareness. Taste impulses for interpretation.
- Temporal lobe: auditory center for sound interpretation, complicated memory patters, and Wernicke’s area for speech
- Occipital lobe: primary visual center
- Cerebellum: receives immediate and continuous information about the condition of the muscles, joints, and tendons. Enables a person to be able to control voluntary movement, maintain equilibrium, and predict distance gauges in relation to other objects. Cerebellar
control is ipsilateral (situated on the same side, so right
side controls the right side of the body), unlike other motor cortex functions.
- Brainstem: throughout the brainstem are special ells that
constitute the reticular activating system (RAS) which
helps control awareness and alertness.
o Medulla: cardiac-slowing center, respiratory center, cranial
nerve IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal), and parts of cranial nerves VII (facial) and VIII
(vestibulocochlear) o Pons: cardiac acceleration
and vasoconstriction centers, pneumotaxic center that helps control respiratory patter and rate, cranial nerve V (trigeminal), VI (abducens), VII (facial), and
VIII (vestibulocochlear) o Midbrain: contains the
cerebral aqueduct or aqueduct of Sylvius, location of periaqueductal gray, which may abolish pain when stimulated, cranial nerve III (oculomotor) and IV (trochlear) The brains circulation originates from the carotid and vertebral arteries. The internal carotid arteries branch into the anterior cerebral artery (ACA) and the middle cerebral artery (MCA), the largest ones.
Blood brain barrier: seems to exist because the
endothelial cells of the cerebral capillaries are joined tightly together. This barrier keeps some substances in the bloodstream out of the cerebrospinal circulation and out of the brain tissue. Substances that can pass through the blood brain barrier: Oxygen, glucose, carbon dioxide, alcohol, anesthetics, and water
Cerebrospinal fluid (CSF): circulates, surrounds, and
cushions the brain and spinal cord. Expanded areas of the subarachnoid space, where there are large
amounts of CSF, are called cisterns. The largest cistern
is in the lumbar region, which is the site for lumbar punctures (second lumbar vertebrae and the second sacral vertebra – L2-S2)
o Spinal cord: starts reflex activity and transmits impulses to
and from the brain. Controls mobility, regulates organ function, processes sensory perception information from the extremities, trunk, and many internal organs, and transmits information to and from the brain. Contains gray matter (neuron cell bodies) and white matter (myelinated axons).
Neurologic Changes that Occur with Aging:
Neurologic changes associated with aging often affect mobility and sensory perception.
- Slower processing times, memory loss, decreased sensory perception of touch, change in perception to pain, change in sleep patterns, altered balance and/or decreased coordination, increased risk for infection, and changes in sleep patters
- Many of these changes affect ADLs and safety
- Intellect doesn’t decline as a result of aging. However, a person with certain health conditions may have problems that decrease cognition. Cognitive decline is frequently cause by drug interactions or toxicity or by an inadequate oxygen supply to the brain.
- Elderly person needs as much sleep as a younger person but is more likely to nap in the afternoon
- Lack of sleep can worsen symptoms of dementia, interfere with normal immune functions, and wound healing
- Mental status may be impaired as a result of infection, hypoxia, and hypoglycemia/hyperglycemia. So during times of confusion always assess O saturation, serum glucose, and potential for infection
Health Promotion and Maintenance:
Prevention of neurologic health problems includes avoiding risky behaviors and practicing a healthy lifestyle.
- Young men are at increased risk for “risky behaviors”
- Advise patients to avoid excessive alcohol or other substances that can impair judgement and cause an accident
- Teach importance of smoking cessation because it causes vasoconstriction of vessels which leads to decreased perfusion to the brain
- Sleep and rest are necessary to promote health
- Teach proper nutrition and exercise are important in preventing neurologic impairment. The body needs adequate glucose to function properly, and skipping meals or poor nutrition can affect the function of the body’s neurons
Assessment:
Patient History:
- Obtain health problem history, drug therapy history, smoking/substance use history, occupation, and current lifestyle
- Note patient’s appearance an assess their speech, affect, and movement. If the patient has difficulty communicating or hearing, ask family member or significant other to stay during the interview to help obtain an accurate history.
- Ask about medical history to determine its associated with the current health problem. Inquire about patients ability to perform ADLs so you can establish a baseline to compare to if the patients status worsens
- Ask patient if they are right or left handed o Patient may be somewhat stronger on the dominant side, which is expected o Effects of cerebrospinal
injury or disease are more pronounced if the dominant hemisphere is involved
- Ask about family neurologic history (ex, stroke). A number of neurological conditions have a genetic basis, such as neurodegenerative disorders, migraine headaches, and epilepsy.
Physical Assessment:
- Compare each assessment with the patients baseline, between right/left sides, and between upper and lower extremities
- Complete neurologic assessment includes mental status, cranial nerves, mobility, and motor system function, deep tendon reflexes, sensory perception, and cerebellar function. During any neurological assessment, look for asymmetry, such as subtle unequal movement in the facial muscles.
- Generally, a nurse performs a focused assessment agreed upon with provider. The provider will do the complete assessment. But it is important for the nurse to note any changes from baseline.
o Mental status assessment: assessment of consciousness and cognition
Consciousness is the ability to be aware of the environment, an
object, and oneself. Level of consciousness (LOC) usually refers
to the degree of alertness or amount of stimulation needed to engage a patient’s attention, and can range from alert to coma.
- Alert: awake, engaged, and responsive. Patients who are less than alert are
labeled as either lethargic, stuporous, or comatose o Lethargic: patient is
drowsy but is easily awakened o Stuporous: arousable only with vigorous or
painful simulation o Comatose: patient is unconscious and cannot be aroused
despite the vigorous or noxious stimulation
- Orientation: ask questions to determine orientation to person, place, and time. Remember that time of day, drug therapy, need for sleep, glucose, and oxygen demands can affect responses. Be sure to link any changes in orientation to possible treatments that might be affecting their orientation. Be alter to both subtle and sudden changes. Helpful questions: o The patient’s ability to relate the onset of symptoms (why are you in the hospital?) o The name of the HCP or nurse o The year and month o Home address o Name of the health care agency
- Cognition: if there is a change from baseline, this needs to be reported to provider urgently because it may indicate stroke, new onset of confusion, or other serious neurological conditions Perform assessment at the following care interactions: o On admission and discharge o On transfer from one setting to another o Q8-12 hours throughout hospitalization o Following major pharmacotherapy o With behavior that is unusual for the person and/or inappropriate for the situation. Assess and document (noting “sometimes”, “frequently,” or “always” as observed): o Does the patient respond to voice; require being shaken awake to communicate; doze off during a
o Ask patient to grasp and squeeze two fingers of each of your hands then compare the grasps for equality of strength. Should release grasps on command o Assess ability to follow commands o Assess and evaluate strength against resistance, and a five- point rating scale is usually used. Compare previous results and report all decreases
o Cerebral or brainstem integrity can be assessed by asking
the patient to close their eyes and hold the arms perpendicular to the body and palms up for 15-30 seconds. If there is cerebral or brainstem muscle weakness, the arm on the weak side will start to fall or “drift” with the palm
pronating (turning inward, aka pronator drift). The same can
be done with the patient lying on their stomach with legs bent upward at the knees.
o Decortication posturing (A): abnormal motor movement seen
in the patient with lesions that interrupt the corticospinal pathways. Patients arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs
o Decerebration posturing (B): abnormal movement with
rigidity characterized by extension of the arm and legs, pronation of the arms, plantar flexion, and opisthotonos (body spasm in which the body is bowed forward). All four limbs involved. Associated with brainstem dysfunction.
- Assessment of Reflex Activity:
o Deep tendon reflexes: biceps, triceps, brachioradialis, and
quadriceps muscles and of the Achilles tendon can be tested. Striking the tendon with a reflex hammer should cause contraction of the muscle. The appropriate muscle
contraction indicates intact reflex arc. o Cutaneous
(superficial0 reflexes: plantar reflexes and sometimes the
abdominal reflexes.
Plantar: tested with a pointed (not sharp) object and
the normal response is plantar flexion of all toes
Babinski’s sign: dorsiflexion of the great toe and
fanning of the other toes, is abnormal in anyone older than 2 years old and represents the presence of a CNS disease. Can occur with drug and alcohol intoxication,
after a seizure, or in patients with MS or liver involvement.
- Upgoing toes: abnormal response that indicates CNS involvement
- Downgoing toes: normal response
o Hyperactive reflexes: indicates possible upper motor neuron disease
(damage to the brain or upper spinal cord)
o Hypoactive reflexes: may result from lower motor neuron disease
(damage to the lower spinal cord) or neuromuscular disease
o Asymmetry of reflexes: important because it can indicate disease
process or injury o Clonus: sudden, brief, jerking contraction of a
muscle or muscle group seen in seizures
- Assessment of Sensory Function: findings are documented according to agency protocol and patients particular illness or condition. Some patients may need hourly check, q4h, or qshift.
o Pain and temperature: these are transmitted by the
same nerve endings, so it can safely be assumed that it one is intact, then the other is as well. Use a warm or cold reflex hammer to test sensation. Use a sharp or dull object, show the patient what will be done, and then ask them to keep their eyes closed and indicate whether the sensation is sharp or dull. Sharp and dull ends should be changed at random. Be sure patient isn’t on anticoagulation therapy before testing with a sharp object. Any abnormalities need to be reported.
o Touch discrimination: likely to be normal if pain and
temperature are intact. Patient closes eyes and practitioner touches the patient with a finger and asks the patient to point to the area that was touched. Might also touch two different areas at the same time. o CNS problems in the brainstem, thalamus, and cortex generally result in loss of sensation on the
the lowest score possible indicating total neurologic unresponsiveness. Decrease of 2 or more points in GCS total in clinically significant and should be reported immediately. Other findings that require immediate notification to the provider:
- Abnormal flexion or extension, particularly of the upper extremities (decerebrate or decorticate)
- Pinpoint or dilated nonreactive pupils
- Sudden or subtle change in mental status
- Change in LOC is the earliest sign of neurologic deterioration Start with least noxious irritation or pressure and proceed to more painful stimulation if the patient doesn’t respond Begin each assessment by speaking in a normal voice, if not response, use a louder voice, if no response, gently shake the patient, if no response, apply painful stimuli using one of these methods:
- Supraorbital (above the eyes) pressure
- Trapezius muscle squeeze
- Mandibular pressure
- Sternal rub
- Pressure on the base of the nail bed …no nipple pinching!
- Apply for no more than 20-30 seconds
- Psychosocial Assessment: varies among patients and the severity of their neurologic impairment. Depression can result in cognitive and behavioral changes that are similar
to delirium or dementia. Depression is quite common. Consider screening patients.
o Laboratory Assessment:
Fluid, electrolyte, and glucose abnormalities can cause neurologic impairment BMP is evaluated Anemia and malnutrition can contribute to neurologic impairment CBC Albumin Vitamins and minerals (particularly vitamin B) Arterial blood gases
Cultures to rule out infection o Imaging Assessment:
X-rays: can determine fractures, curvatures, bone erosion, bone
dislocation, and possible calcification of soft tissues. In head trauma and multiple injuries, after assessing ABCs, one of the first priorities is to rule out cervical spine fracture
Cerebral Angiography: done to visualize the cerebral circulation
to detect blockages in the arteries or veins of the brain, head, neck, that impair perfusion. Gold standard for diagnosing intracranial vascular disease. Done to identify aneurysms, traumatic injuries, strictures/occlusions, tumors, blood vessel displacement from edema, and arteriovenous malformations.
- Risk factors: some patients may have sensitivity reaction to contrast dye, and may need steroids prophylactically. Seafood allergies are no longer considered an indicator of iodinated contrast allergy. To prevent aspiration, assess for any N/V, and ensure NPO 4-6 hours before test.
- Patients head is immobilized during procedure
- Do not move during procedure
- Contrast dye is injected through a catheter placed in the femoral artery. You will feel a warm or hot sensation when the dye in injected; this is normal
- You will be able to talk to the physician; let them know if you begin to experience and pain
- Follow-up care: assess dressing for bleeding and swelling at the site, apply an ice pack to the site, keep the extremity straight and immobilized, maintain the pressure dressing for 2 hours. Check extremity for adequate circulation (color, temp, distal pulses, cap refill)
- Monitor for contrast reaction (hives and flushing), thrombosis, and bleeding at the entry site. If bleeding is present, maintain manual pressure on the site and notify the physician immediately.
- Increase IV fluid intake
Computed tomography (CT): picture of tissues - spinal cord,
brain, and peripheral neuromuscular system
- CT Angiography: administer contrast dye IV before scan
abnormal brain waves that are seen only when sleeping, such as with frontal lobe epilepsy o Test may take 45-120 minutes but they do allow 5 minute breaks
- Follow-up care: wash patients hair to remove gel/glue used on electrodes. Acetone or witch hazel can help dissolve the paste. Sleep deprived patients may need a ride home.
Evoked potentials: aka evoked response. Measure the electrical
signals to the brain generated by sound, touch, or light. Assess sensory nerve problems and confirm neurologic conditions such as MS, brain tumor, acoustic neuroma (small tumors of the inner ear), and spinal cord injury.
Lumbar Puncture: aka spinal tap, is the insertion of a spinal
needle into the subarachnoid space between the third and fourth (sometimes fourth and fifth) lumbar vertebrae. LPs are used for:
- Obtain CSF pressure readings with manometer
- Obtain CSF for analysis
- Check for spinal blockage by spinal cord lesion
- Inject contrast medium or air for diagnostics
- Inject spinal anesthetics or selected drugs
- Patient prep: contraindicated for patients with increased intracranial pressure because of the danger of sudden release of CSF pressure. Also, not done in patients with skin infections at or near the puncture site. It is VERY important that the patient not move during this procedure. If the patient is restless or cannot cooperative, two people may need to assist. Patient may need sedative to decrease movement – consider these needs before the procedure.
- Procedure: patient is in fetal side-lying position, site is cleaned thoroughly, local anesthetic is applied, needle is inserted, and instruct patient to alert to any shooting pain or a tingling sensation. After needle is removed, slight pressure is applied, and an adhesive bandage strip is placed over the insertion site o CSF should be clear, odorless, and contain only a few cells. Confirmation of CSF is the presence of glucose.
- Follow-up: obtain VS and perform frequent neuro checks. Follow protocol on how long patient should be on bed rest and remain flat. Increase fluid intake. o Monitor for complications such as increased intracranial pressure - headache, nausea, vomiting, photophobia, and change in LOC. Other serious complications are brainstem herniation, infection, CSF leakage, and hematoma formation. o Observe site for leakage and
notify HCP if it occurs o May prescribe meds for HA if ordered
Transcranial Doppler Ultrasonography: uses sound waves to
measure blood flow through the arteries 2.Exemplars: Traumatic Brain Injury/ Increased Intracranial Pressure/ Hydrocephaly
Traumatic brain injury (TBI) is damage to the brain from an external mechanical
force and not caused by neurodegenerative or congenital disorders. TBI can lead to temporary and permanent impairment in cognition, mobility, sensory perception, and/or psychosocial function.
- Direct injury: force produced by a blow to the head
- Indirect injury: force applied to another body part with a rebound effect to the brain
- The brain responds to these forces by movement within the rigid cranial vault. It may also rebound or rotate on the brainstem, causing diffuse nerve axonal injury (shearing injuries). The brain may be contused (bruised) or lacerated (torn) as it moves over the inner surfaces on the cranium, which are irregularly shaped and sharp.
- Movement or distortion within the cranial cavity is possible because of multiple factors: o Brain is supported by CSF within the cranial cavity. When external force is applied to the head, the brain can be injured by the internal surfaces of the skull. o Brain tissue is very fragile and prone to injury
- Acceleration injury: caused by an external force contacting the head, suddenly placing the head in motion
- Deceleration injury: occurs when the moving head is suddenly stopped or hits a stationary object
Primary Brain Injury: occurs at the time of injury and results from the physical stress
(force) within the tissue caused by blunt or penetrating trauma.
- Focal brain injury: confined to a specific area of the brain and causes localized damage that can often be detected with a CT/MRI
- Diffuse brain injury: damage throughout many areas of the brain. Initially at a microscopic level and not initially detectable by CT. MRI has greater ability to detect microscopic damage, but these areas may not be imaged until necrosis occurs
- Open traumatic brain injury: occurs when the skill is fractures or when it is pierced by a penetrating object.
- Closed traumatic brain injury: integrity of skull is intact, but damage to the brain tissue can still occur as a result of increased intracranial pressure
- TBI can also be further defined as mild, moderate, or severe. Generally, the determination of severity of TBI is the result of the Glasgow Coma Scale.
Secondary Brain Injury: includes any processes that occur after the initial injury and
worsen or negatively influence patient outcomes. Secondary injuries result from physiologic, vascular, and biochemical events that are an extension of the primary injury. Most common secondary injuries: hypotension and hypoxia, intracranial
Weakness, due to illness Unhealthy lifestyle choices Violent behaviors Prematurity in infants with cerebral intracranial hemorrhage from fragile cranial blood vessels Hydrocephalus Participation in sports without proper equipment Advanced age High A1C (elevated glucose)
Number one risk factor is falls o Causes of IICP: Head Trauma
Hemorrhage Cerebral edema (most common cause of sustained IICP) Tumors Inflammation Brain attack Abscesses
Hydrocephalus o Diagnostics:
ICP monitoring, CT scan of head, MRI, X-rays, Echoencephalogram, EEG, Ultrasonography of brain, Brain echogram, Cerebral angiography, PET, Nerve conduction studies, Serum electrolytes, glucose, protein o IICP is the leading cause of death from head trauma in patients who reach the hospital alive. It occurs when compliance no longer takes place, and the brain can no longer accommodate further volume changes. As ICP increases, cerebral perfusion decreases, leading to brain tissue ischemia and edema. If edema remains untreated, the brainstem may herniate downward through the Foramen of Monro or laterally from a unilateral lesion within on cerebral hemisphere,
causing irreversible brain damage and possible brain death ( brain
herniation syndromes). o Three types of edema may contribute to IICP:
Vasogenic edema: caused by abnormal permeability of the walls
of the cerebral vessels, which allows protein-rich plasma infiltrate to leak into the extracellular space of the brain. Fluid primarily collects in white matter.
Cytotoxic edema: occurs as a result of a hypoxic insult, which
causes a disturbance in cellular metabolism and active ion transport. Damage to cells membranes results in cell edema, cell dysfunction, and cell death. May lead to vasogenic edema.
Interstitial edema: occurs with fluid accumulation between the
cells of the brain. Associated with increased blood pressure and increased CSF pressure. Develops rapidly and is controlled by
reducing BP and CSF pressure. o Assessed by using the Glasgow
Coma Scale and baseline neuro assessments Pulse - may be thready, irregular & rapid Remember Cushing’s Triad-always late sign Respiratory Cheyne–Stokes Ataxic (irregular) Temperature: elevated as brainstem fails
Pupils Pinpoint Unilaterally dilated Sluggish to Fixed Blurred vision Diplopia
Papilledema o Treatment: for all diuretics monitor BP, I&O, and
fall risk (orthostatic hypotension)
Mannitol (osmotic diuretic) helps pull fluid off of the edematous
brain and back into the vascular system
- Given IV and use a filtered needle! Can crystalize
Acetazolamide given to promote excretion of fluid
- More commonly given to children
Furosemide or Ethacrynic acid inhibit Na and Cl reabsorption
which decreases CSF production
Fentanyl, Lorazepam, or MS
- Can be given to calm the agitate patient Paralytics are also neuromuscular blocking agents used to control restlessness and agitation
Barbiturates such as pentobarbital can induce coma
Antipyretics such as acetaminophen can treat hyperthermia
(may be given rectally)
Anti-seizure/anticonvulsants manage seizures o Monitor:
Continue to monitor VS and monitor for signs of Cushing’s Triad:
- Severe HTN with a widening pulse pressure (systolic – diastolic = pulse pressure)
- Decreased pulse rate (bradycardia)
- Decreased and irregular respirations o Cushing’s is a late sign that can lead to brain herniation without treatment o You want to keep BP <180/ Avoid suctioning, it can increase ICP Stool softeners should be given to prevent Valsalva maneuver o
Clinical Therapies for IICP:
Maintain airway Monitor neurologic status Monitor IICP monitor and ventilator Decrease stimuli Raise bedrails and pad bed in case seizures occur (2 siderails only) Elevate HOB 15-30 degrees to prevent decreased blood flow to brain and improve oxygenation Monitor arterial blood gases
- pH: (acidic) 7.35-7.45 (alkalotic)
- CO2: (alkalotic) 35-45 (acidic)
- HCO3: (acidic) 22-26 (alkalotic)
- PaO2: 80- Prevent immobility complications (no passive ROM, turn them from side to side, TED hose or SCD) Monitor fluid and electrolytes
