Med-surg exam 3 / Neuro study guide
Brain
Role: coordinate and organize the functions of all other body systems.
2 main divisions: CNS (brain
... [Show More] and spinal cord) + PNS (cranial and spinal nerves and autonomic system)
Neuro Assessment
Health History
o Common symptoms: assess OLDCARTS
Pain, dizziness/vertigo, seizures, muscle weakness, abnormal sensation, visual
disturbances, visual changes (double vision, flashing lights)
Past health history (head trauma), family history, and social history (elicit drug use) (recall from HA)
Physical Exam
o Mental status (LOC)
o Motor ability + muscle strength
*Be aware of the normal aging process the nervous system undergoes*
Common Neuro Diagnostic Tests
Imaging studies
o Computed tomography (CT) scan
Gold standard for strokes
o Magnetic resonance imaging (MRI)
o Positron emission tomography (PET)
o Skull and spinal x-rays
Angiographic studies
o Cerebral angiography
Electrophysiologic studies
o Electroencephalography (EEG)
Gold standard for seizures
o Electromyography (EMG)
Look at diagram on this slide for diagnostic tests.
Altered LOC
Altered LOC is not a disorder, it’s a change in function due to different phenomenon’s we experience due to
a neurologic issue.
o LOC can be impaired by any disorder that affects cerebral hemisphere of brain: stroke, head
injury, trauma, drug OD
Gauged on a continuum from full cognition to coma
o Used the Glasgow Coma Scale: eye opening, motor response, and verbal response
o Range 3-15
3: severe impairment
<9: coma levels
15: no impairment
Clinical manifestations
Nursing Interventions
o Maintain airway: elevate HOB, suction, oral hygiene (risk for aspiration), tracheostomy (trach
care), ventilator
o Safety: padded side rails, low boy beds, bed alarms, sitter in the room
o Fluid and nutrition status: IV fluids, especially if in coma, monitor I/O, feeding tube if LOC does
not increase.
o Skin integrity: turn client, inspect skin, assess for urine leakage and stool leakage.
Repositioning: lift patient to prevent shearing.
Increased Intracranial Pressure
Normal ICP: 0-10 mm Hg; 15 mm Hg is the upper limits. *Anything over 15 is TOO HIGH*
Inverse relationship: As ICP increases, cerebral blood flow decreases.
Most often associated with head injury, but also caused by brain swelling, epilepsy, and meningitis.
Increased ICP results in:
o Decreased cerebral perfusion
o Cerebral edema
o Displace brain tissue: also called herniation.
o Destroy brain cells
Continual ICP leads to impaired neuro function leading to altered LOC: drowsy and slurred speech.
o Abnormal posturing occurs = decorticate and decerebrate positioning seen. This is an
EMERGENCY!
Osmotic diuretic will be ordered to quickly reduce edema. i.e. Mannitol
Also, restrict fluids, drain CSF, control fever because fever and shivering can increase
ICP due to cellular metabolic demands. Also, maintain BP and O2.
Once stable, look for underlying cause.
o If not corrected, client will become comatose.
Seizures
Seizure: sudden abnormal electrical discharge [Show Less]