ALTERED NEUROLOGICAL FUNCTION
OUTLINE for this nursing lecture
- To determine if client will be able to do his ADLs
- Test for cerebral function
- LOC – most important single indication of cerebral function
- Level I: Conscious – normal awareness (oriented)
- Level II: Lethargy, Somnolence, or Obstundation – responds with confusion; falls asleep when left alone; responds briskly to painful stimuli
- Level III: Stupor – minimal physical & mental activity; reacts by reflex &/or making unintelligible sounds
- Level IV: Semi-coma – no spontaneous movement withdrawal from painful stimuli; verbal response is limited to groaning; cough & swallowing reflex may occur; incontinence
- Level V: Coma – no spontaneous movement; reflexes are very minimal to absent
- Assessment tool designed to note trends in response to stimuli
- Score Eye opening Verbal Response Motor
- 6 x x Obeys command
- 5 x oriented & converses Localizes pain
- 4 simultaneously opens confused, converses Withdraws fr. pain
- 3 verbal command Inappropriate Decorticate
- 2 Pain Incomprehensible Decerebrate
- 1 NO RESPONSE (GCS = 3)
- Scores: >11 = 86% chance of moderate disability or recovery
- 9+ = conscious
- 8 = 50/50condition
- 7↓ = lethargic
- <7>
- 3-4 = 85% chance of dying or vegetative state
- O lfactory (S) = test smell using odorous substances
- Hyperosmia – acute sense of smell
- Parosmia – abnormal sense of smell
- Anosmia – loss of sense of smell anosmia
- O ptic (S) = Snellen’s (3-6y/o =20/20vision)
- O cculomotor (M) eye movements = 6 gaze directions ( √ diplopia &
- T rochlear (M) strabismus, nystagmus)
- T rigeminal (B) (S) = facial sensations using pins/cottons
- A bducens (M) (M) = chewing & corneal reflex using cotton (+) blinking
- F acial (B) -> (S) = anterior tongue; (M) = facial expressions ( √ for Bell’s Palsy)
- A coustic (S) = hearing (tinnitus & vertigo) & balance -> Romberg’s test (+) means ataxia is present;
- G lossopharyngeal (B) -> (S) = posterior tongue; (M) = swallowing: √gag reflex
- V agus (B) -> √ gag reflex
- S pinal accessory (M) = head & shoulder movement
- H ypoglossal (M) = tongue movement
- Muscle strength
- Akinesia, hemiplegia, hemiparesis, paraplegia, quadriplegia
- 5-point Scale
- 5/5 = normal (full strength & ROM against gravity & applied resistance/pressure)
- 4/5 = full ROM but weakness upon against pressure
- 3/5 = move actively against gravity alone
- 2/5 = able to move with support
- 1/5 = contraction is palpable & visible; trace/flicker movements occur
- 0/5 = undetectable contraction & movement
- Muscle tone:
- Hypotonicity – soft, flabby, flaccid
- Hypertonicity – rigid, spastic
- Muscle coordination – Finger-to-nose test, heel Down Opposite Shin
- Babinski– normal for infants til 2y/o
- Brudzinski’s sign- flexion of hips & knees upon forward flexion of the neck
- Kernig’s sign – resistance or pain upon straightening the knees as the legs, hips, & knees are flexed
- Grading: 0 = absent
- +1= diminished
- +2 = normal
- +3 = brisker than ave.
- +4 = hyperactive
- Orientation
- Language / communication
- Aphasia – defect in using & interpreting symbols of language
- Receptive / sensory
- Motor / expressive
- Dysarthria / anarthria – imperfect articulation causing difficulty in speaking due to crani al nerve dysfunction
- Attention span – serial 3s / 7s
- Memory
- Immediate recall - 5-8digits then reverse 4-6digits
- Recent memory
- Remote memory
- ability to keep its body temperature within certain boundaries, even when temperature surrounding is very different
- Thermo-regulatory center = hypothalamus
- Physiologic adaptation:
- Vasodilatation and sweating are the primary modes to lose excess body
- Skin - assists in homeostasis by reacting differently to hot and cold conditions so that the inner body temperature remains more or less constant
- Heat loss
- Sweating is the only physiological way to lose heat - heat loss by evaporation
- Vasodilatation occurs, this is the process of relaxation of smooth muscle in arteriole walls allowing increased blood flow through the artery. This redirects blood into the superficial capillaries in the skin increasing heat loss by radiation and conduction
- Heat production
- Piloerection - lifting the hair follicle upright; makes our hairs stand on end which acts as an insulating layer, trapping heat
- Vasoconstriction - blood is rerouted away from the skin and tow ards the warmer core of the body; this prevents blood from loosing heat to the surroundings and also prevents the core temperature dropping further
- Seizures & Epilepsy nursinglectures.blogspot.com
- Paroxysmal uncontrolled abnormal discharge of electrical activity in the brain
- Malfunction of hypersensitive neurons in cerebral cortex & limbic centers
- A symptom rather disease in itself
- Classification according to etiology
- Primary / Unknown – assessment finding does not reveal a definite cause
- Secondary / Symptomatic – causes
- Hyperpyrexia
- CNS infection
- Cerebral hypoxia &/or trauma
- Toxic agents / poison; metabolic intoxication
- Brain defects
- Degenerative diseases
- anaphylaxis
- Generalized – usually begins bilaterally without local onset, EEG abnormalities
- Grand Mal / Generalized Tonic-Clonic Seizure
- Precede by an aura (strange feeling of sensation)
- Loss of consciousness
- Tonic phase – entire body stiffens in rigid contractions, fixed jaw, clenched fists, temporary interruption of respiration (30-60s duration)
- Clonic phase – rhythmic jerky contraction & relaxation of muscles (esp. extremities), may bite lip 7 tongue, may be followed by fatigue, confusion, depression, amnesia
- Petit Mal / Absence seizure
- No actual convulsive movement
- Vacant stare
- Childhood or early adolescence
- No recall of attack
- Partial / Focal Seizure – most common; depends on brain part involved
- Jacksonian / Simple Partial Motor Seizure
- Tonic-clonic convulsive movement in a localized body region opposite of lesion
- Usually without loss of consciousness
- nursinglectures.blogspot.com
- nursinglectures.blogspot.com Hypothermia, hypoglycemia, hypoxia, toxic substances Firing of neurons in increasing frequency & amplitude Threshold of intensity of electrical discharges Firing spreads to adjacent neurons Brain stem Cortex & basal ganglia Muscle contraction & loss of consciousness Slowing of neuronal firing Intermittent contraction-relaxation phase seizures
- Priorities: airway & safety
- Provide privacy
- Ensure patent airway
- Side-lying position
- Padded tongue depressor
- Prevent injury
- Raise padded side rails
- Do not leave client alone (stay with client until fully conscious)
- D not attempt to restrain
- Protect the head (slip a small pillow under; place on lap)
- Reorient client to surroundings upon waking
- Note position of eyeball & head at the beginning of attack
- Note duration of unconsciousness
- Observe for fecal or urinary involvement
- A brain disorder accompanied by periodic convulsions and loss of consciousness
- Causes:
- Head trauma – most common cause (closed head injuries)
- Brain tumors
- Risk factors:
- CVA
- CNS infections
- Toxic substances interfering with brain metabolism (O 2 & glucose supply) – lead, alcohol & substance abuse
- Genetic pre-disposition (cerebral dysrhythmia, monozygotic twins)
- Detailed Hx
- Neurologic assessment
- Mental status exam
- EEG (electroencephalogram) – determines existence & type of epilepsy
- Hair shampoo (Prior & after the test)
- Hold meds (sedatives, tranquilizers, stimulants) & foods with caffeine 2-3days prior
- Skull x-rays – reveals skull configuration
- Remove metallic objects
- Computerized Tomography (CT) scan – visualization of brain & its structures in successive layers; IV contrast medium may be used
- Secure consent
- NPO at least 4hrs prior
- √ for seafood allergy
- C/I: pregnant, obese, claustrophobic, unstable v/s , a llergy to the dye
- MRI
- Positron-emission Tomography (PET) – visualization of physiologic functions; client is given doses of strong radioactive tracers
- Secure consent
- NPO 4hrs prior
- If diabetic client, CBG <>
- Agitated clients may require sedation
- Pharmacologic management - to control or minimize seizure
- IV
- Phenobarbital (Sodium luminal)
- Phenytoin (Dilantin)– slow cardiac arrhythmias & prevent seizures
- Diazepam (Valium) – muscle relaxant
- Oral – maintenance dose
- Carbamazepine (Tegretol)- anti-convulsant
- Dilantin
- Nursing – refer to seizure management
- Help client identify precipitating factors (stress, lack of sleep, alcohol use)
- No alcoholic beverages
- Take meds religiously
- Caution in swimming, horse-back riding, & driving
- Provide support to clients to accept condition & live a life as normal as possible
- Psychosocial counseling
- Carry IDs stating client is epileptic
- Surgery – last resort; client does not respond to meds
- Cortical resection of anterior temporal lobe – safest & most effective
- Criteria: failure of medical approach & localization of a focus of abnormal electrical discharge
- Client must be awake the whole time
- Brain tumor surgery
- Status epilepticus – continuous seizures or rapid succession lasting for at least 30mins
- A medical emergency
- Client may remain comatose & have repetitive seizure for hours
- Precipitating factor: abrupt withdrawal of anti-convulsant meds
- Lorazepam (Ativan) slow IV – med of choice given until seizures stop (Valium or Dilantin may be used instead)
- Ventilation equipment must be ready
- General anesthesia may be used or Vecuronium bromide (Norcuron –neuromuscular blocker)
- Client must be on continuous EEG monitoring
No comments:
Post a Comment
Spammers are NOT Allowed on this site. Please do not waste your time leaving a comment that is not relevant with Nursing lectures, it will just be DELETED. If you want to offer Guest Posting or you have a blog related to Nursing lectures, then send it to me at nursingniches(at)gmail(dot)com and I'll include your site in the blogroll. Thanks!