XVI.

NEURO

A. Neurological Assessment
1. Glasgow Coma Scale:

a. Define: A scale that measures the degree or level of ______________________.

b. Used to assess the level of consciousness in a client who already has

_______________ consciousness or has the potential of altered consciousness.

c. Three responses of the Glasgow Coma Scale:

1) ________ Opening
2) Motor Response
3) __________ Response
Rule: We like a high number ranging from 13 to 15 for the Glasgow Coma scale.
Glasgow Coma Scale
Eye Opening:
Spontaneous - 4
To verbal command - 3
To pain - 2
No response 1 Critical Thinking Exercise:
Motor Response: Assessment data
To verbal command - 6
To localized pain - 5 1. Opens eyes when talked to
Flexed/withdraws - 4 but goes back to sleep
Flexes abnormally - 3 between questions.
Extends abnormally - 2 2. Answers with mumbles and
No response 1 moan and gives no reliable
Verbal Response: data.
Oriented/talks - 5 3. Slaps your hand away with
Disoriented/talks 4 pressure on nail beds.
Inappropriate words 3
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Incomprehensible sounds 2 Score: ________________

No response - 1

*LOC is always #1 with neurological assessment

2. Pupillary changes (normal pupil size is 2-6 mm) PERRLA

3. Hand grips/lifts legs/pushing strength of _______________ (strength, equality)
Also assessing if they can follow a command.

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 4. Reflex assessment
a. Babinski Reflex:
Normal in a child up to ______ year.
Abnormal in the __________. Babinski Reflex

The adult or child greater than one year should have a ____________ reflex or
curling of the toes when the bottom of the foot is stroked.

What does it mean if the adult has a present Babinski reflex or fanning of the toes
when you stroke the bottom of the foot?

A severe problem in the ________________ nervous system.

(Tumor or lesion on the brain or spinal cord, Multiple sclerosis, Lou Gehrigs
disease)

b. Reflexes: (0) = absent, (1+) = present, diminished, (2+) = normal, (3+) =

increased but not necessarily pathological, (4+) = hyperactive
Grading Responses:
0 = No response
1+ = Sluggish or diminished
2+ = Active or expected response
3+ = More brisk than expected. Slightly hyperactive
4+ = Brisk, hyperactive, with intermittent or transient clonus

Ankle clonus- a series of abnormal reflex movements of the foot,

induced by sudden dorsiflexion.

A normal reflex response would be documented as___________.

B. General Diagnostic Tests:

1. CT:
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a. With/without contrast (dye)
Will you need the client to sign a consent form prior to the test when using
dye? ____________________

b. Takes pictures in _____________

c. Keep __________________ still
d. No ____________________

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 2. MRI (Magnetic Resonance Imaging):
a. Which is better CT or MRI? ___________
b. Is dye used? _____________
Is radiation used? _____________
A _____________is used

c. Will be placed in a tube where client will have to lie flat.

d. Remove ______________________
e. No credit cards
f. No ______________
g. Do fillings in teeth matter? _____________
h. Do tattoos matter? _____________
i. Will hear a thumping sound
j. What type of client cant tolerate this procedure? _____________________
k. Can talk and hear others while in the _______________

3. Cerebral Angiography
Will a consent form be needed? __________ Why?_________________________

X-ray of cerebral circulation

Go through the _____________________ artery.

a. Pre:
1) Well hydrated/void/peripheral pulses/groin prepped
Anytime an iodine based dye is used the client will need to be well
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hydrated to promote excretion of the dye.

Watch:
BUN and Creatinine? ____________
Output? ___________
Hold metformin (Glucophage)? _________________
2) Explain they will have a warmth in face and a metallic taste;
3) Allergies? _________ __________
An iodine base dye is used.

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 b. Post:
1) Bed rest for 4-6 _______________

2) Watch for bleeding at the femoral artery site (BLEEDING/HEMORRHAGE)

3) Embolus
An embolus can go lots of different places:
Arm, Heart, Lung, Kidney
Since we are performing a test on the brain.if the embolus goes to the
brain the client will have a change in _____________, one-sided
weakness, and ______________________, motor/sensory deficits.

4. EEG: (Electroencephalography)
a. Records electrical activity of the brain
b. Helps diagnose ________________ disorders and evaluate the types of seizures
occurring

c. Evaluates loss of consciousness and dementia

d. Screening procedure for __________________

e. Indicator of __________________________death
f. Used to diagnose sleep disorders like narcolepsy, cerebral infarct, brain tumors or
abscesses.

g. Pre procedure:
Hold sedatives. Why? _________________________
No caffeine
Not ___________________________________(drops blood sugar)

h. Beginning of the procedure

Will get a baseline first with client lying quietly (normal EEG) Neuro

May be asked to hyperventilate to assess brain circulation; assess photo

stimulation for seizures, or sedate for sleep study.

If you have someone who is completely unconscious. A pain response or

noxious stimuli may be introduced to stimulate a brain wave. This can be
anything from a strong smell like ammonia to a bright light.

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 5. Lumbar Puncture:
a. Puncture site: lumbar subarachnoid space
b. Purpose:
1) To obtain _____________fluid to analyze for __________, infection, and
tumor cells.

2) To measure pressures reading with a manometer

3) To administer drugs intrathecally (brain, spinal cord)
c. How is the client positioned and why? __________________________________
___________________________________________________

d. Inspect the surrounding skin at the puncture site for any infection.
e. CSF should be clear and colorless (looks like water)
f. Post-procedure:
Lie flat or prone for 2-3 hrs.

Increase ____________to replace lost spinal fluid.

What is the most common complication? _________________

The pain of this headache______________________ when the client sits up

and ________________ when they lie down.

How is this headache treated? Bed rest, fluids, pain med, and a
________________ patch
g. Life threatening complications:
Brain Herniation: With known increased ICP, a lumbar puncture is
contraindicated.
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Meningitis
Can bacteria get into the puncture site? ________

Can bacteria get into the spinal fluid? _________

What would that cause? ____________________

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 C. General Care for Any Client with Increased Intracranial Pressure
1. Signs and Symptoms of ICP: Normal Lab Value:
ICP: 0-15 mm Hg
Early Signs:

a. Earliest sign? ________________

b. Speech? ____________________

c. Delay in response to _________________ suggestion. Slow to respond to

commands

d. Increasing drowsiness
e. Restless with no apparent reason
f. Confusion
Late Signs:

g. Marked change in LOC progressing to stupor then____________.

h. Vital sign changes:
Called Cushings Triad and requires ____________________intervention to
prevent brain ischemia.

Cushings Triad:

1) Systolic hypertension with a ____________________ pulse pressure.

2) Slow, full and bounding pulse

3) ____________________ respirations. Look for a change in pattern, like

Cheyne Stokes or Ataxic Respirations.

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i. Posturing: A response to ______________ or noxious stimuli. Posturing indicates
that the motor response centers of the brain are compromised.

1) Decorticate posturing: Arms flexed ______________ and bent in toward the

body and the legs are extended.

2) Decerebrate posturing: all __________ extremities in rigid extension;

WORST.

3) Client will be rigid and tight and burning ___________________________

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 Miscellaneous Signs:

j. Headache

k. Changes in _______________ and pupil response. (fixed and dilated)

l. Projectile ___________________ can occur because the vomiting center in the

brain is being stimulated.

1. Complications of Increased ICP

a. Brain Herniation: This herniation obstructs the blood ___________to the brain
leading to anoxia and then brain_____________.

b. DI and SIADH: Can be either so you must assess for both.

2. Tx of ICP:
a. Maintain ________________________.
Decreased O2 levels and high CO2 cause cerebral vasodilation which
increases ICP.

b. Maintain adequate cerebral perfusion.

Dont want _______________________ or bradycardia because that

would________________ brain perfusion.

Isotonic saline and inotropic agents: dobutamine (Dobutrex) and

norepinephrine (Levophed)

c. Keep temperature below ______________________________

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1) An increased temp will increase cerebral metabolism which increases ICP.

2) The hypothalamus may not be working properly and a cooling blanket may be
needed.
3) Hypothermia is used as a treatment to decrease cerebral _______________ by
decreasing the metabolic demands of the brain.

d. Elevate the _________________________.

e. Keep ____________in midline so jugular veins can drain.

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 f. Watch the________________monitor with turning, etc.

g. Avoid __________________/ bowel/ bladder distention/ hip flexion/

Valsalva/ isometrics/ no sneezing/ no nose ________________

h. Limit ____________________ and coughing

i. _______________ nursing interventions

Anytime you do something to your client, ICP increases.

j. Monitor the Glasgow coma scale

Rule: If the Glasgow Coma score is below 8, think intubate.

k. Monitor vital signs for Cushings Triad.

l. Barbiturate induced coma-________________ cerebral metabolism:

phenobarbital (Luminal).

m. Osmotic diuretics: mannitol (Osmitrol) pulls ____________ from brain cells

and filters it out through the kidneys. This ______________ the ICP.

n. Steroids: dexamethasone (Decadron) decreases cerebral _____________.

o. ICP monitoring devices

1) Ventricular catheter monitor or subarachnoid screw

2) Greatest risk? _____________________
3) No loose connections

4) Keep dressings __________. (Bacteria can travel through something that is

wet much easier than something that is dry). Neuro

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 D. Neurological Alterations:

1. Meningitis:

a. Definition: Meningitis is ___________________ of the spinal cord or brain.

b. Causes: Can be either viral or ___________________. Bacterial is transmitted

through the respiratory system.

c. Signs and Symptoms:

1) Chills and Fever

2) Severe ___________________.

3) Nausea and Vomiting

4) Nuchal rigidity (stiff neck)

5) Photophobia

d. Treatment:

1) Steroids

2) Antibiotics if _________________

3) Analgesics

4) Droplet ______________________ for bacterial meningitis.

Bacterial meningitis is a very contagious, medical emergency. It has a

high mortality and________________________ is recommended for
college aged students.
Neuro

5) Viral meningitis is transmitted by feces and requires________________

precautions.

Commonly seen in infants and children.

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 2. Seizures:

a. Define:

Should be thought of as a ______________of an underlying disorder

rather than a disease.

Seizures are not considered ___________________if they discontinue when

the disease has gone away

b. Classifications:
1) Partial Seizure:
A partial seizure is limited to a specific _______________ area of the
brain.

An aura may be the only manifestation

Called _______________ seizures.

Symptoms can range from simple to complex.

Simple means _______________ loss of consciousness, will see

numbness, tingling, prickling or ____________.

Complex means that they have impaired consciousness and may be

confused and unable to respond.

2) Generalized Seizure:
Involves the ______________ brain.

Called non-focal seizures.

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Loss of consciousness is the ________________ manifestation.

International Classifications of Seizure Disorders:

Tonic Clonic formerly known as grand mal
Myoclonic sudden, brief contractures of a muscle or group of muscles

Absence formally called petit mal and characterized by a brief loss of

consciousness.

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 c. Complications of Seizures:

1) Status epilepticus: a continuous seizure without returning to consciousness

__________________ seizures.

2) Trauma: Protect the client

d. Treatment:

1) Neurological examination including lab and X-ray

2) Anticonvulsants:

Can be ___________ or short term therapy.

Rapid acting: lorazepam (Ativan) and diazepam (Valium)

Long Acting: phenytoin (Dilantin) or phenobarbital

Rule: The NCLEX lady only uses the generic name of a drug in an NCLEX question.

Have ____________ side effects.

Monitor drug levels for toxicity through lab values.

Abrupt _____________________ can cause a seizure.

3) Dont forget the basics of _______________ and safety during a seizure

Neuro

Rule: Do not put anything in the mouth of a seizing client.

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 E. Neurological Injuries:

1. Skull Injury
May/may not damage ___________.

Open fracture dura ______________

Closed fracture dura _________ torn

With basal skull fractures you see bleeding where? __________________

Battles sign: bruising over ________________.

Raccoon eyes (peri-orbital bruising)

Cerebrospinal rhinorrhea- leaking spinal fluid from your ____________________

How do we tell CSF from other drainage? Positive for _______________ and the
halo test.

Non-depressed skull fractures usually do not require surgery; depressed do require

surgery.

2. Brain Injury
a. Concussion

Temporary loss of neurologic function with _________________ recovery

Will have a short (maybe seconds) period of unconsciousness or may just get
dizzy/see spots

Teach caregiver to bring client back to ED if the following occurs:

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Difficulty awakening/speaking, All of these are
confusion, severe headache, vomiting, signs that the ICP
pulse changes, unequal pupils, one-sided weakness is going
______________!

b. Hematomas
A small hematoma that develops rapidly may be fatal, while a massive hematoma
that develops slowly may allow the client to _________________________.

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 1) Epidural Hematoma:
Pathophysiology:

This is rupture of the middle meningeal artery (fast bleeder under high
pressure).

Injury Loss of consciousness Recovery period Cant compensate

any longer Neuro changes.

Tx:
Burr Holes and remove the clot; control the _____________.
Ask questions to ID the type of injury and the treatment needed:
Did they pass out and stay out?
Did they pass out and wake up and pass out again?
Did they just see stars?

Epidural hematoma is an ___________________

2) Subdural Hematoma
Pathophysiology:

Usually a ___________________ bleed

Can be acute (fast), subacute (medium), or chronic (slow)

Tx:

Chronic: imitates other conditions;

Bleeding & compensating
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Neuro changes= maxed out

Acute or Chronic: immediate craniotomy and remove

________:control___________

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 3. Spinal Cord Injury
Autonomic dysreflexia

a. Patho:
With __________ spinal cord injury (above T6), the major complication to
look for is autonomic dyreflexia or hypereflexia.

b. Signs and Symptoms

It is a syndrome characterized by:
severe _____________ and headache, bradycardia, nasal stuffiness,
flushing, sweating, blurred vision and anxiety.
Sudden onset, it is a neurological emergency if not treated promptly a
_______________ stroke could occur.

c. Cause:
What can cause it? Distended ________________, constipation, painful
stimuli.

d. Treatment:
First, sit the client up to lower _________________ ________________.

Treat the cause: Put in catheter, ________________ impaction, look for skin
pressure or painful stimuli, a cold draft breeze in the room.

Teach prevention measures. Why?

Critical Thinking Exercise:
Which shoes would you buy
for a Parkinsons client?
1. Hot pink furry slippers
2. New Balance tennis shoes
Critical Thinking Exercise:
Which home health client would
you go see first?
1. The Alzheimers client who
fell yesterday and confusion
has increased a little
2. The Type 2 diabetic client
who has been out of
medicine for three days
Critical Thinking Exercise:
Your client has been diagnosed
with an ischemic stroke. Signs
and symptoms: right side
paralysis, trouble swallowing
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and difficulty speaking. What is
the priority intervention for this
client?
1. Prevent aspiration
2. Assist with range of motion
exercises
3. Promote self-care
4. Provide a communication
board

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