| increased ICP occurs in patients with acute neurological conditions such as | brain tumor, hemorrhage, anoxic brain injury, and toxic or viral encephalopathies |
| ICP is most commonly associated with | head injury |
| subjective data for a diagnosis of ICP include the patients understanding of the condition, and | any visual changes such as diploia (double vision) |
| the earliest sign of ICP is | change in LOC |
| nursing interventions for ICP to reduce venous volume include: | elevate the head of the bed 30-45 degrees to promote venous return & place the neck in a neutral position |
| types of seizures | generalized tonic clinic (grand mal)
absence (petit mal)
psychomotor (automatisms)
jacksonian (focal)
miscellaneous (myoclonic and akinetic) |
| seizures are followed by a rest period of variable length called the | postictal period |
| aura is | a sensation (of light or warmth) or emotion (such as fear) that may precede an attack of migraine or epileptic seizure |
| types of strokes | ischemic stroke
thrombotic stroke
embolic stroke
hemorrhagic stroke
transient ischemic attack |
| a TIA should be considered a | forerunner of a stroke |
| central nervous system is made up of the | brain and spinal cord |
| the peripheral nervous system includes | all the nerves that lie outside the CNS |
| the 2 broad categories of cells within the nervous system are | 1. neurons
2. neurolglia or glial cells |
| nerve 1: | olfactory |
| 1. olfactory impulses and functions | from nose to brain
sense of smell |
| nerve 2: | optic |
| 2. optic impulses and functions | from eye to brain
vision |
| nerve 3: | oculomotor |
| 3. oculomotor impulses and functions | from brain to eye muscles
eye movements, extraocular muscles, pupillary control |
| nerve 4: | trochlear |
| 4. trochlear impulses and function | from brain to external eye muscles
down and inward movement of eye |
| nerve 5: | trigeminal |
| 5. trigeminal impulses and functions | from skin to mucous membranes of head to brain, from teeth to brain, from brain to facial muscles
sensations of face, scalp, teeth, and chewing movements |
| nerve 6: | abducens |
| 6. abducens impulses and functions | from brain to external eye muscles
outward movement of eye |
| nerve 7: | facial |
| 7. facial impulses and functions | from taste buds of tongue to brain, from brain to facial muscles
sense of taste, contraction of muscles of facial expression |
| nerve 8: | acoustic |
| 8. acoustic impulses and functions | from ear to brain
hearing, sense of balance |
| nerve 9: | glassopharyngeal |
| 9. glassopharyngeal impulses and functions | from throat and taste buds of tongue to brain, from brain to muscles and salivary glands
sensations of throat, taste, swallowing movements, gag reflex, sense of taste, secretion of saliva |
| nerve 10: | vagus |
| 10. vagus impulses and functions | from throat, larynx, and organs in thoracic and abdominal cavities to brain from brain to muscles of throat and to organs in thoracic and abdominal cavities
secretions of throat, larynx, and thoracic, and abdominal organs, swallowing, voice production, slowing of heartbeat, acceleration of peristalsis |
| nerve 11: | spinal accessory |
| 11 spinal accessory impulses and functions | from brain to certain shoulder and neck muscles
shoulder movements and turning movements of head |
| nerve 12: | hypoglossal |
| 12. hypoglossal impulses and functions | from brain to muscles of the tongue
tongue movements |
| glasgow coma scale eye-opening response | 4- spontaneous
3- to verbal stimuli
2- to pressure
1- no response |
| glasgow coma scale verbal response | 5- oriented
4- confused but able to answer questions
3- words
2- sounds
1- no response |
| glosgow coma scale motor response | 6- obeys commands for movement
5- movement to stimulus
4- withdraws in response to pain
3- flexion in response to pain
2- extension in response to pain
1- no response |
| post procedure for lumbar puncture | patient should lie flat in bed for several hours, assess site for leakage, pain numbness or tingling in extremities |
| assess for CT scan if use of contrast medium and without use of contrast medium | if use of contrast medium check for allergies to iodine and seafood and without contrast medium pt may be NPO for 4-6 hours before |
| primary goals for a patient having a seizure | protection from aspiration and injury and observation and recording of the seizure activity |
| during the demylelination process, the myelin sheath and the sheath cells are destroyed, causing | an interruption or distortion of the nerve impulse so that it is slowed or blocked |
| clinical manifestations for multiple sclerosis have a variety of s/s such as | visual problems, urinary incontinence, fatigue, weakness or in coordination of an extremity, sexual problems such as impotence in men, and swallowing difficulties |
| stoke is an abnormal condition of the blood vessels of the brain characterized by | hemorrhage into the brain or the formation of an embolus or thrombus that occludes an artery, resulting in ischemia of brain tissue |
| the major importance of TIAs is that they | warn the patient of an underlying pathologic condition |
| approximately 40% of pts who experience TIAs will have a stroke in | 2-5 years |
| most frequently used antiplatelet agent | aspirin |
| hemorrhagic stoke vs ischemic stoke | hemorrhagic stoke results from bleeding into the brain and an ischemic stoke results from deficient blood flow to the brain from a partial or complete occlusion of an artery |
| pts with an acute ischemic stoke can benefit from throbolytics such as ______________ that do what | tissue plasminogen activator (tPA, alteplase [Activasel]) which digests fibrin and fibrinogen and thus loses the clot |
| for stoke patient problem insufficient nutrition related to impaired ability to swallow, what are the nursing interventions | thicken liquids with a commercially available thickening agent, do not use a straw |
| the most frequent long-term disabilities following a stroke are | he i paresis, inability to ambulate, aphasia, depression, and complete or partial dependence on ADLs |
| with Bell’s palsy clinical manifestations what differentiates it from a stroke | the inability to wrinkle the forehead |
| two abnormal signs that occur with meningitis are | Kernig’s sign (inability to extend legs without extreme pain) and Brudzinski’s sign (flexion of hip and knee when neck is flexed) |
| s/s of meningitis | severe headache, stiffness of neck, irritability, malaise, and restlessness |
| autonomic dysreflexia is an abnormal cardiovascular response to | stimulation of the sympathetic division of the autonomic nervous system |
| autonomic dysreflexia s/s | bradycardia, hypertension (up to 300mmhg), diaphoresis, “goose flesh”, flushing, dilated pupils, blurred vision, restlessness, nausea, severe headache, and nasal stuffiness |
