10-Neuro-11-16-17

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X. NEURO
A. Neurological Assessment:
1. Glasgow Coma Scale:
a. Definition: 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.
*LOC is always #1 with neurological 
assessment
d. Factors that can alter the 
 Glasgow Coma scale:
• Drug use 
• Alcohol intoxication
• Shock 
• Hypoxia
GLASGOW COMA SCALE
Eye Opening (E): 
 Spontaneous - 4 
 To verbal command - 3 
 To pain - 2 
 No response – 1
Motor Response (M): 
 To verbal command - 6 
 To localized pain - 5 
 Flexed/withdraws - 4 
 Flexes abnormally - 3 
 Extends abnormally - 2 
 No response – 1
Verbal Response (V): 
 Oriented/talks - 5 
 Disoriented/talks – 4 
 Inappropriate words – 3 
 Incomprehensible sounds – 2 
 No response - 1
Total = E + M + V
CRITICAL THINKING EXERCISE:
Assessment data
1. Opens eyes when talked to but goes back to sleep between questions.
2. Answers with mumbles and moans and gives no reliable data.
3. Slaps your hand away with pressure on nail beds.
 
Score: ________________
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 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
 
4. Reflex assessment 
a. Babinski Reflex: 
• Normal in a child up to ______ year 
• Abnormal in the __________ 
• The adult or child greater than one year should 
 have a normal reflex or curling of the toes when 
 the bottom of the foot is stroked. 
• What does it mean if the adult has a positive 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 Gehrig’s disease) 
b. Reflexes: 
GRADING REFLEX RESPONSES:
0 = No response (absent)
1+ = Present, but sluggish or diminished
2+ = Active or expected response (normal)
3+ = More brisk than expected. Slightly hyperactive, but not necessarily 
 pathological
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 _______________.
Negative Babinski
Positive Babinski
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B. General Diagnostic Tests:
1. Computerized Tomography (CT): 
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 ____________________
2. Magnetic Resonance Imaging (MRI):
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 can’t 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. 
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a. Pre - procedure: 
1) Well hydrated/void/peripheral pulses/groin prepped
• Anytime an iodine based dye is used, the client will need 
 to be well hydrated to promote excretion of the dye.
Watch:
BUN and Creatinine
Urinary Output
Hold metformin (Glucophage®)
2) Explain that they will have warmth in the face and a metallic 
 taste; 
3) Allergies? ________________ or __________________
• An iodine based dye is used. 
b. Post - procedure:
1) Bed rest for 4-6 _______________ 
2) Watch for bleeding at the femoral artery site 
 (BLEEDING/HEMORRHAGE) 
3) Possible complication: Embolus
• An embolus can go to a lot 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 
 ______________________, and motor/sensory deficits. 
4. Electroencephalography (EEG):
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 
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d. Screening procedure for __________________
e. Indicator of __________________________ death 
f. Used to diagnose sleep disorders like narcolepsy, cerebral infarct, 
 and brain tumors or abscesses 
g. Pre procedure:
• Hold sedatives. Why? _________________________
• No ____________________________
• Not ___________________________________ (drops blood 
 sugar)
h. Beginning of the procedure:
• Will get a baseline first with client lying quietly (resting EEG) 
• 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. 
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 pressure readings 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) 
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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. 
• Meningitis
Can bacteria get into the puncture site? ________
Can bacteria get into the spinal fluid? _________
What would that cause? ____________________
C. General Care for Any Client with Increased Intracranial Pressure:
1. Signs and Symptoms of  ICP: 
a. Early Signs: 
 1) Earliest sign? Change in________________ 
 2) Speech? ____________________ or ___________________ 
 3) Delay in response to _________________ suggestion. 
 Slow to respond to commands 
 4) Increasing drowsiness 
 5) Restless with no apparent reason 
 6) Confusion 
b. Late Signs:
 1) Marked change in LOC progressing to stupor, then____________. 
NORMAL LAB VALUE:
ICP: 0 -15 mm Hg
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 2) Vital sign changes: 
 Called Cushing’s Triad and requires ____________________ ________
 intervention to prevent brain ischemia. 
 Cushing’s Triad:
• Systolic hypertension with a ____________________ pulse 
pressure.
• Slow, full, and bounding pulse
• ____________________ respirations. Look for a change in 
pattern, like Cheyne Stokes or ataxic respirations. 
 3) Posturing: A response to ______________ or noxious stimuli. 
 
 Posturing indicates that the motor response centers of the brain are 
 compromised.
• Decorticate posturing: Arms flexed ______________ and bent in 
toward the body and the legs are extended. 
• Decerebrate posturing: All __________ extremities in rigid 
extension; WORST.
• Client will be rigid, tight, and burning ___________________. 
c. Miscellaneous Signs:
1) Headaches 
2) Changes in _______________ and pupil response. (In profound 
 coma - fixed and dilated) 
3) Projectile ___________________ can occur because the vomiting 
 center in the brain is being stimulated. 
2. 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. 
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3. Treatment of  ICP:
a. Maintain ________________________. 
• Decreased O2 levels and high CO2 levels cause cerebral 
 vasodilation which increases ICP. 
b. Maintain adequate cerebral perfusion.
• Don’t want _______________________ or bradycardia because 
 that would ________________ brain perfusion.
• Isotonic saline and inotropic agents: dobutamine (Dobutrex®) 
 and norepinephrine (Levophed®)
c. Keep temperature below ______________________________.
1) An increased temperature 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 head midline so the jugular veins can ______________. 
f. Watch the ICP monitor with __________________, etc. 
g. Avoid __________________, bowel/ bladder distention, hip 
 flexion, Valsalva, and isometrics. No sneezing and 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. 
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k. Monitor vital signs for Cushing’s Triad. 
l. Barbiturate induced coma-________________ cerebral metabolism: 
 phenobarbital (Luminal®). 
m. Osmotic diuretics: mannitol (Osmitrol®)  ___________ fluid from 
 brain cells and filters it out through the kidneys. 
 
 This ______________ the ICP. 
n. Steroids: dexamethasone (Decadron®) – decreases cerebral 
 _____________ 
o. ICP monitoring devices:
• Ventricular catheter monitor or subarachnoid screw
• Greatest risk? _____________________
• No loose connections
• Keep dressings __________. (Bacteria can travel through 
something that is wet much easier than something that is dry.)
D. Neurological Alterations:
1. Meningitis: 
a. Definition: Meningitis is ___________________ of the spinal cord 
 or brain. 
b. Causes: Can be either viral or ___________________ 
 Bacterial is primarily 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
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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 
 ________________________ are recommended 
 for college aged students. 
5) Viral meningitis is usually transmitted by feces and requires 
 ________________ precautions. 
• Commonly seen in infants and children 
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.
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2) Generalized Seizure:
• Involves the ______________ brain
• Called non-focal seizures.
• Loss of consciousness is the ________________ manifestation.
INTERNATIONAL CLASSIFICATION OF SEIZURE DISORDERS:
Tonic /Clonic – formerly known as grand mal
Myoclonic – sudden, brief contractions of a muscle or group of muscles
Absence – formerly called petit mal and characterized by a brief loss of 
consciousness.
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) Don’t forget the basics of _______________ and safety during 
 a seizure.
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 is ______________
• Closed fracture  dura is _________ torn
• With basal skull fractures, you see bleeding where? 
 __________________
• Battle’s 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 fractures 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 
 occur: 
 Difficulty awakening/speaking, confusion, 
 severe headache, vomiting, pulse changes, 
 unequal pupils, one-sided weakness
All of these are 
signs that the 
ICP is going 
______________!
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b. Hematomas:
A small hematoma that develops rapidlymay be fatal, while a 
massive hematoma that develops slowly may allow the client to 
_________________________.
1) Epidural Hematoma:
• Pathophysiology:
This is rupture of the middle meningeal artery (fast bleeder 
under high pressure).
Injury  Loss of consciousness  Recovery period  Can’t 
compensate any longer  Neuro changes 
• Treatment:
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) 
• Treatment:
Chronic: imitates other conditions; 
Bleeding & compensating
Neuro changes = maxed out
Acute or Chronic: immediate craniotomy and remove 
________: control ___________
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3. Spinal Cord Injury:
Autonomic	dysreflexia:
a. Pathophysiology:
• With __________ spinal cord injury (above T6), the major 
 complication to look for is autonomic dysreflexia or 
 hyperreflexia. 
b. Signs/Symptoms:
• It is a syndrome characterized by: severe _____________ 
 and headache, bradycardia, nasal stuffiness, flushing, 
 sweating, blurred vision, and ____________________.
• Sudden onset. It is a neurological emergency. If not treated 
 promptly, a hypertensive _______________ could occur. 
c. Causes:
• What can cause it? Distended ________________, constipation, 
 or painful stimuli. 
d. Treatment:
• First, sit the client up to lower _____________ _______________.
• Treat the cause: Put in catheter, ________________ impaction, 
 look for skin_______________, painful stimuli, or a cold draft 
 breeze in the room.
• Teach prevention measures.
 
Autonomic	dysreflexia	is the result of a faulty response from the sympathetic nervous 
system to a stimulus that occurs below the spinal cord lesion.
NCLEX® CRITICAL THINKING EXERCISE:
Which shoes would you buy for a Parkinson’s client?
1. Hot pink furry slippers
2. New Balance tennis shoes
 
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NCLEX® CRITICAL THINKING EXERCISE:
Which home health client would you go see first?
1. The Alzheimer’s 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
 
 
 
NCLEX® CRITICAL THINKING EXERCISE:
Your client has been diagnosed with an ischemic stroke. Signs and symptoms: right side 
paralysis, trouble swallowing, 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