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the spinal cord extends from the first cervical vertebra (C1) and terminates at which vertebra
second lumbar vertebra (L2)
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where does cerebral spinal fluid found (CSF) circulate
in the subarachnoid space in the meninges; between the arachnoid mater and pia mater
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CSF
- shock abosrber for the brain
- made of water, glucose, sodium, chloride and protein
- exchanges nutrients and wastes between the blood and CNS neurons
-
cranial nerves
- olfactory
- optic
- oculomotor
- trochlear
- trigeminal
- abucens
- facial
- vestibulocochlear
- glossopharyngeal
- vagus
- accessory
- hypoglossal
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sympathetic nervous system
- triggered by stress
- secretes epinepherine and norepinephrine
- increases heart rate, constricts peripheral blood vessels, increase BP
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what is the most accurate and reliable indicator of neuro status
level of consciousness
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which scale uses eye opening, verbal response and motor response to deterimine the level of the pt conciousness
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term for involuntary movement of the eyes
nystagmus
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what is PERRLA
- part of pupillary evaluation
- pupils, equal, round, reactive to light, reactive to accomodation
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what are late indicators of neurological deteriorationvi
vital signs
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what is a recommended after a pt has a lumbar puncture
- pt lies flat for 6 - 8 hrs with the head of the bed flat
- increase oral intake of fluids
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How is a spinal headache caused by a lumbar puncture treated
a blood patch; small amount of pt blood injected into puncture site which clots and prevents leakage
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inflammation of the brain and spinal cord that may be caused by either bacterial or viral infection
meningitis
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which form of meningitis can be spread by direct contact with discharge from the respiratory tract of an infected person
bacterial
-
pathophysiology of meningitis
- infection/inflammation of brain and spinal cord
- purulent exudate
- increased intracranial pressure
- cranial nerves may be affected
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of all the symptoms associated with meningitis which one is a tell tale sign
nuchal rigidity (pain and stiffness when the neck is moved)
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signs and symptoms of meningitis
- severe headache
- fever
- photophobia
- petechial rash
- nuchal rigidity
- positve kernigs and brudzinski's signs
- nausea and vomiting
- encephalopathy
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kernig's sign
flex the pt hip to a 90 degree angle and then extend the knee. pain in the hamstring indicates meningeal infection
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brudzinski's sign
flexion of both hips when pts neck is flexed indicates meningeal infection
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nursing care for a pt with meningitis
- monitor respiratory status, gag and swallow reflexes
- instruct pt to avoid couging and not hold breath during turning
- monitor for signs of increasing ICP
- measures to lower body temp to reduce the metabolic rate
- elevate HOB as ordered
- risk for seizure and fall precautions
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encephalitis
- inflammation of brain tissue
- nerve damage, edema, necrosis
- increased intracranial pressure
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signs and symptoms of encephalitis
- directly related to area brain involved
- fever, nuchal rigidty, headache, nausea, vomiting, tremors, photophobia, confusion, delirium, agitation and restlesness
- comatose or exhibit aphasia, hemiparesis, facial weakness
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what are the complications associated with encephalitis
- cognitive disabilities
- personality changes
- ongoing seizures
- motor deficits
- blindness
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what causes intracranial pressure to increase
increase in brain, blood or CSF usually caused by brain tumor, brain trauma or intracranial hemorrhage
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what is the monroe-kellie hypothesis
if the volume of brain, blood or CSF increases the other 2 must decrease to maintain normal ICP (0 - 15 mmhg)
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initial signs of increased ICP
restlessness, irritability and decreased level of consciousness
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classic late sign of increased ICP; characterized by bradycardia, htn and widening pulse pressure
cushings triad
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as ICP increases pupil becomes dilated and fixed; no longer responds to light. this is a late sign of increased ICP.
blown pupil
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How is ICP measured
- place a catheter into the ventricle of the brain, cerebral parenchyma, subdural space or subarachnoid space
- patients under ICP monitoring are usually pharmacologically paralyzed and sedated
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signs and symptoms of increased intracranial pressure
- vomiting
- headache
- dilated pupil on affected side
- hemiparesis or hemiplegia
- decorticate then decerebrate posturing
- decreased LOC
- increasing systolic blood pressure
- increasing then decreasing pulse rate
- rising temperature
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Will elevating the head of the bed to 30 degress help prevent increased ICP and possibly decrease pain?
yes
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Will placing a pt with a head injury in a low stimulus environment (ex. dim lights and low noise) help relieve pain?
yes. alternative comfort measures are known to aid in pt comfort and may help reduce headache
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pts with infections, brain or systemic, require their temperature to be monitored. How often should a pts temperature be assessed?
every 4 hrs and prn
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Measures to prevent increased ICP
- keep head of bed eleveated at 30 degrees
- avoid flexing the neck; keep head and neck in midline position
- give anitemetics and antitussives a necessary to prevent vomiting and cough
- adminsiter stool softeners
- minimize suctioning
- avoid hip flexion
- prevent unnecessary noise and startling the pt
- space care activities to provide rest between each disturbance
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decorticate posturing
- abnormal flexion of upper extremities with extension of lower extremities
- pressure exerted in the cerebral tissue above the midbrain
-
decerebrate posturing
- abnormal extension of upper extremities with extension of lower extremities
- increasing pressure exerted on the midbrain or upper pons
-
tension headache
- can be caused by persistent contraction of the scalp and facial, cervical and upper thoracic muscles
- associated with PMS or psychosocial stressors such as anxiety, emotional distress, or depression
- pain described as pressure, aching, steady and tight
-
migraine
- believed to be caused by cerebral vasoconstriction followed by vasodilation
- may or may not begin with an aura
- often hereditary
- pain described as throbbing, boring, vise-like, and pounding
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what are some common triggers for a migraine
specific foods, noise, bright light, alcohol and stress
-
prodromal phase of a classic migraine
- preheadache phase
- pt may experience visual disturbances, difficulty with speaking and/or numbness or tingling
- common migraines do not have a prodromal phase
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medicinal treatments for migraines
- prophylactic: nifedipine (calcium channel blocker), propranolol (beta blocker); both lower blood pressure and may help prevent the vasoconstriction and vasodilation
- amitriptyline (tricyclic antidepressant)
- acute: NSAIDs, ergot, triptans and opiods
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does controlled hyperventilation help decrease ICP
- yes
- elimination of carbon dioxide causes blood vessels to constrict and ICP to fall
-
cluster headaches
- caused by vascular disturbance, stress, anxiety, and emotional distress
- occur in clusters spanning from several days to weeks
- NSAIDs and tricyclics may be prescribed
- pain described as throbbing and excruciating
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epilepsy
- idiopathic epilepsies occur before age 20
- new seizures after 20 are caused by an underlying disorder
-
partial seizure
- repetitive, purposeless behaviors (automatisms) are classic symptoms
- pt appears to be in a dream like state while picking at his or her clothing, chewing or smacking his or her lips
-
absence seizure
- aka petit mal seizure
- occur most often in kids
- staring that last for several seconds
-
tonic-clonic seizures
- tonic phase: lasts 30 to 60 seconds and is characterized by muscular rigidity
- clonic phase: contraction and relaxation of all muscles in a jerky, rhythmic fashion
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postictal period
- recovery period following a seizure
- pt is exhausted and may sleep deeply for 30 minutes to several hours
-
mannitol
- hyperosmolar diuretic used to decrease ICP
- draws fluid from tissue into blood stream
- urination is increased since it is a diuretic
-
what do corticosteroids do for a person with ICP or cerebral edema
dexamethasone helps decrease ICP and cerebral edema
-
status epilepticus
- 30 minutes of repetitive seizure activity without a return to consciousness
- usually caused by abrupt cessation of anticonvulsant therapy
- valium and ativan given to stop seizures
-
seizure precautions the nurse can implement
- pad side rails of bed
- keep call light within reach
- assist pt with ambulation
- keep suction and oral airway at bedside
-
nursing care during a seizure
- stay with pt
- do not restrain pt
- protect from injury
- loosen tight clothing
- turn on side to prevent occlusion of airway or aspiration
- suction if needed
- monitor vitals when able
- document progression of symptoms
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what is documented when a pt has a seizure
- behavior before seizure
- length of seizure
- associated behaviors
- incontinence
- lingering effects
- time before recovery
-
concussion
- mild brain injury
- characterized by headache, dizziness, nausea and vomiting
- may have amnesia of events before or after trauma
- loss of consciousness for 5 minutes or less
-
contusion
- bruising of brain tissue
- brainstem contusions affect level of consciousness
-
subdural hematoma
- acute: develops within 24 hrs of injury
- subacute: more than 24 hrs and less than 1 week
- chronic: occurs within weeks or month of injury; associated with low impact injuries that cause slow bleeding
-
who are particularly prone to chronic subdural hematomas
-
epidural hematoma
- results from arterial bleeding
- pt loses conciousness right after injury
- regains consciousness and is briefly coherent
- rapidly deteriorates
- airway management and control of ICP must be initiated immediately
-
autonomic dysreflexia
- occurs at or above T6
- normally caused by distended bladder
- noxious stimuli below the spinal cord injury causes activation of the sympathetic nervous system
- b/p goes up to 300 systolic
- vasodilation, flushing and diaphoresis above the lesion and bradycardia as low as 30 bpm
- cool, pale skin , gooseflesh and vasocontstriction below the spinal lesion
- pounding headache and nasal congestion secondary to dilated blood vessels
-
what is likely if a pt has an injury at or above C5?
respiratory impairment
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what is the purpose of crutchfield and gardener-wells tongs
keeps the head and neck immobile while fusion and healing take place
-
common causes of autonomic dysreflexia
- bladder distention (most common)
- UTI
- ingrown toenails
- pressure ulcers
- pain
- labor in a pregnant woman
- bowel impaction
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if a pt is at risk for or you suspect that a pt has autonomic dysreflexia what can you do?
- take the pt blood pressure and continue to monitor it every 5 minutes
- place pt in high fowlers; utilizes the effect of orthostasis to control blood pressure
- remove elastic stocking or any other garment that could prevent blood from pooling the periphery; allowing blood to pool can help reduce blood pressure
- monitor blood pressure when catheterizing
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signs of autonomic dysreflexia
- sudden high blood pressure
- bradycardia
- headache
- pale skin below the injury
- gooseflesh
-
spinal shock
- immediately after injury the sympathetic nervous system function is disrupted
- symptoms: vasodilation, hypotension and bradycardia
- hypothermia is caused by vasodilation
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