Comprehensive Neuro Assessment Guidelines for Nursing Students

Final Breakdown 12 math 45 Cristy 35 Leesa Neuro 20 Neuro assessment—need to do neuro assessment Need to do—head injury, stroke like symptoms, decreased LOC. Neuro exam can establish LOC, level of functioning, cranial nerve testing, rectal tone Expressive aphasia A deficit in language output or speech production. Inability to express oneself CVA—assessment, first priority Initial assessment focuses on airway patency, which may be compromised by loss of gag or cough reflexes and altered respiratory pattern Cardiovascular status—BP, cardiac rhythm, and rate Neurologic assessment—LOC, monitor symptoms, speech, eye symptoms Monitor for potential complications—musculoskeletal problems, swallowing difficulty, respiratory problems, s/s of increased ICP, meningeal irritation

Guillain Barr—ABG, causes that exacerbate Viral infection, cytomegalovirus, Epstein-Barr, mycoplasma pneumoniae, H influenzae, HIV are the associated infections associated with the development of GBS Respiratory acidosis Halo vest Halo ring that is fixed to the skull by 4 pins that are inserted into the outer table of the skull. The ring is attached to a removable halo vest, which is a device that suspends the weight of the unit circumferentially around the chest. A frame connects the ring to the chest. Provides immobilization of the cervical spine while allowing early ambulation for patients with adequate function IICP—mannitol, assessment of IICP Normal pressure = 0-15 Mannitol: given for IICP, osmotic diuretic—pulls fluid from the brain Assessment: decreased LOC, restlessness, nausea, vomiting, headache, pupillary changes, late sign—Cushing’s triad: increased pulse pressure, decreased heart rate, change in respiratory pattern Parkinson’s S/S : Tremor, rigidity, bradykinesia, postural instability, depression, dementia, autonomic symptoms, sleep disturbances

Pathophys: decreased dopamine levels, unknown cause, movements start to slow and the disease progresses Assessment: fall risk, gross motor skills—assess while they are doing something. Resting is the best time to assess for tremors—purposeful activities = tremor can stop Planning: maintain independence, improving mobility. Need a rigorous routine program with activity and rest periods Interventions: encourage socialization, recreation, and independence, use of assistive devices—plate guard/silverware TIA with a fib, discharge medication Anticoagulants—Apixaban (Eliquis), Warfarin Autonomic dysreflexia Massive sympathetic response to a noxious stimulus (full bladder, fecal impaction) S/S: extreme hypertension, bradycardia, facial flushing, headache Tx: Sit patient up; frequent vital signs q5 minutes; loosen clothing and restrictive devices; foley; fecal impaction—digital rectal exam, remove stool, laxative may be needed; antihypertensives; call for help if needed C7-C8 injury Tetraplegia—quadriplegic Lower cervical injury Monitor respiratory status, bowel/bladder control, sexual dysfunction

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Hypothalamus—what it does Major respiratory center, appetite, sex drive, temperature, heart rate, blood pressure, sleep, anterior and posterior pituitary gland regulation, coordination of autonomic nervous system, stress response, emotional status Homeostasis Hormones: serotonin, norepinephrine, endorphin Spinal cord injury—why we perform rectal exam To determine rectal tone—bowel control/function Frontal lobe lesion May produce hemiparesis and partial seizures on the opposite side of the body, or generalized seizures. Changes in emotional state and behavior—impulsive, inappropriate in speech, gestures, and behavior. Functions of frontal lobe: voluntary motor function; cognitive function—orientation, memory, insight, judgement, arithmetic, abstraction; expressive language—written and verbal Next gen—head injury—anticipated vs contraindicated C collar, neuro assessment, serial neuro assessments, hemodynamic monitoring, CT scan, surgery may be needed, management of ICP and adequate CPP, ensure adequate oxygenation, ICP monitoring, IV fluid therapy, management of body temperature, control environment, suctioning may be needed.

Cardiac 11 AAA—surgical ileus—how to prevent Start nutrition early Peptic ulcer prophylaxis Ambulate early Anterior wall MI—nursing diagnosis Goal is to restore oxygen to tissues— impaired tissue perfusion Decreased cardiac output Acute pain Chest pain—priority action 12 lead EKG, telemetry, vitals, labs—troponin elevation, patient history Aspirin, Nitro CHF—labs to report BNP over 100—key diagnostic finding in HF, CBC DCM—CVP Increased CVP related to jugular vein distention Right sided heart failure—late sign Echo—ejection fraction less than 40%

Mitral regurgitation—s/s Dyspnea, weakness, fatigue, palpitations, SOB on exertion, cough Murmur during systole—high pitched/blowing Low cardiac output, pulmonary edema Manifests as severe congestive heart failure Telemetry reading—PR interval Normal: 0.12-0.20 Represents time between atrial depolarization and ventricular depolarization Cardiac diet Low cholesterol, low fat, low sodium Small, frequent snacks versus large meals Fish, lean meats, eggs, fruits, vegetables, whole grains, legumes, nuts PTCA—discharge instructions Increase fluid intake to flush dye Stop smoking Diet restrictions, weight loss Maintain bed rest for 24 hours, no hip flexion, no sitting up in bed Keep extremity extended for 4-6 hours post op

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Cirrhosis 3 Ascites—what causes it Portal hypertension Movement of albumin into the peritoneal cavity Increase in capillary pressure and obstruction of venous blood flow Albumin given IV—desired effect Pulls fluid back into the vascular space If effective, increased urine output and increased hemodynamics Paracentesis—SAA Removal of fluid from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall Assess puncture site for bleeding, apply pressure if needed Informed consent Empty bladder Measure abdominal girth Assess for s/s of hypovolemia Renal failure 2 Diuretic phase Usually, 1-2 weeks

Urinary output gradually increases—hypovolemia can occur Non-oliguric ATN does not do this Complications—hypovolemia, hypokalemia, hyponatremia Renal angiogram—priority intervention Pulses—palpated and compared to the uninvolved extremity Apply pressure to puncture site Knee on affected side bent for 6 hours Endocrine 4 Insulin administration Check blood glucose levels Cloudy, clear, cloudy Monitor for s/s of hypoglycemia Know peak, onset, duration -Rapid acting: lispro (Humalog), aspart (Novolog); onset—5-15 min. Peak—1 hour, duration—2-4 hours -Short acting: regular insulin (Humulin R, Novolin); onset—30-60 min. Peak—2-3 hours, duration—4-6 hours -Intermediate acting: NPH; onset—2-4 hours, peak—4-12 hours, duration—16-20 hours -Very long acting: glargine (Lantus), determir (Levemir); onset—1-6 hours, peak— continuous, duration—24-36 hours

DKA—interventions Rehydration with IV fluids—0.9% NS—large volume crystalloid first Continuous infusion of regular insulin Monitor: blood glucose, urine output Telemetry—hyperkalemia if too much insulin -insulin pushes potassium back where it needs to go Daily electrolyte panels Vitals, lung assessments, signs of fluid overload Hypothyroidism—s/s Fatigue, weakness, decreased bowel sounds, decreased appetite, weight gain Myxedema coma—seen in older patients in winter months Decreased T3 and T4, increased TSH Hyperkalemia, hyponatremia Addison’s—s/s Weakness and fatigue, anorexia, hypotension, emaciation, dark pigmentation of the mucous membranes and the skin, metabolic acidosis, hypoglycemia, hyponatremia, increased BUN Leadership 5 Delegation

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Prioritization Respiratory ABGs—plan of action, interpreting pH: 7.35-7.45—decreased = acidosis, increased = alkalosis PCO2: 35-45—decreased = alkalosis, increased = acidosis HCO3: 22-26—decreased = acidosis, increased = alkalosis Respiratory acidosis: improving ventilation—blow off CO2 Respiratory alkalosis: slow breathing ABGs—interventions Acidosis: improving ventilation, bronchodilators, antibiotics, pulmonary hygiene, supplemental oxygen Alkalosis: slow breathing, breathe into a closed system (paper bag), antianxiety agents Ventilator—high pressure alarm intervention Related to the patient—decreased compliance, increased dynamic pressures Action: auscultate breath sounds, suction, sedate if patient is biting the ETT or bucking the vent Chest tube—bubbling—bad and tidaling good Intermittent bubbling can be normal, continuous bubbling is not normal—air leak Tidaling is normal

PE—why we give coumadin—maintain therapeutic levels Heparin at first, then go to coumadin—easier to maintain the therapeutic levels; INR 2-3 PE—s/s Sudden onset of SOB, chest pain, tachypnea, sustained hypotension, mild fever, cough/rales/wheezing, hypoxemia, tachycardia Low pressure alarm—machine malfunction Related to machine disconnection, loss of delivered tidal volume, ventilator leaks Reconnect, listen for leaks, check ETT placement ARDs—indirect causes Not caused by the lungs Sepsis, burns, trauma, blood transfusion, drug/alcohol overdose, drug reaction Intubation—CO2 detector to check placement CO2 detector is best indicator to determine correct placement of the ETT Shock 2 questions: hypovolemic shock—s/s

Hypotension, tachycardia, tachypnea, decreased urine output, cool/clammy skin, weak/thready pulse, altered mental status, lethargy DIC—transfuse blood products, what will we look at/how we know it’s effective Increase in platelets, hemoglobin, fibrinogen Decrease in PT, PTT, d-dimer Neurogenic shock Loss of sympathetic tone—vasodilation and decreased tissue perfusion S/S: hypotension, bradycardia, decreased CVP, decreased CO, warm extremities, cool core, hypothermia Crystalloids, vasopressors, dopamine Bradycardia—atropine = blocks parasympathetic effect External pacing Position flat with extremities elevated Role of ADH in hypovolemic shock Promotes sodium and water retention, helps fluid stay in the vascular space ADH is increased when low BP is detected At risk for DIC—sepsis Sepsis, trauma, shock, cancer, abruptio placenta, toxins, allergic reactions, HELLP syndrome

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Oncological Superior vena cava syndrome Mediastinal malignancy, causing compression Cerebral anoxia S/S: early : periorbital swelling, signs occur in the morning, Stokes sign—skin tight around the collar; late: vein distention, cough, dyspnea, increased respiratory rate, hoarseness Can cause right sided heart failure Protect airway, heparin, steroids, semi-fowler’s, elevate arms and legs Extravasation—give the antidote, stop infusion Can destroy the vein—necrotic tissue Stop the infusion Warm or cold compress depending on situation Not chemo certified—charge nurse Do not administer chemo without being chemo certified Radiation therapy—instructions for patients Oral care—stomatitis: assess oral cavity, lip moisturizer, no floss, soft toothbrush, saline solution oral rinse Low residue diet—low fiber, diarrhea—splashing hazard No pregnant women/children, visitors—limited time visits

High protein, high carb, high fluid diet Avoid soaps, lotions, powders, etc. to area Lukewarm water to bathe Avoid rubbing or scratching, no straight edged razors Avoid applying heat to area Avoid sunlight and cold weather Avoid tight clothing; cotton clothing better Vitamin A and D ointment to area SIADH—fluid restriction Hyponatremia Fluid restriction Seizure risk if sodium is increased too quickly Tumor lysis syndrome—what to monitor, interventions, Allopurinol Uric acid occurs in the serum Allopurinol to decrease serum uric acid Phosphate-binding agents Hydration Monitor urine output Sodium polystyrene (Kayexalate) Electrolyte balance Calcium carbonate

Amputations Interventions for amputations SAA—wrapping, positioning Stop bleeding Check pulses, capillary refill Pain relief, phantom limb pain—propranolol Figure 8 wrapping technique Prone position, do not elevate ROM exercises Amputation—therapeutic response Pressure on distal artery, proximal to the patient Special senses Lacrimation—contact lenses—remove them Cataract—s/s after surgery—when to call doctor—increased pain Drop down—1 st : ototoxicity, 2 nd : aminoglycoside level, meclizine, ondansetron, 3 rd : gentamicin, furosemide Medications for eye—tetracaine hydrochloride Transplant

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Renal—s/s of rejection Fever, decreased urine output, increased creatinine, weight gain, hypertension, hyperkalemia, mental status change, tenderness 0.9% normal saline with blood—isotonic Always normal saline with blood transfusions, isotonic solution Discharge—medication adherence Immunosuppressants, need to take for life Burns Circumferential burns—escharotomy—why? Releases the constriction of underlying tissue, restores tissue perfusion Assess pulses, respiratory effort, assess patient hourly Sterile procedure Interventions for burns SAA Lactated ringers NPO—NG tube Oliguria—test urine for myoglobin Irrigate if chemical burns Wrap each finger/toe separately, then wrap all together

Do not use ice Protective isolation Remove clothing, clean sheets Increase room temperature Humidified oxygen PROM—reduce contractures

Final Breakdown

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