NR 325 - Neuro
- patent airway
- sabilize C spine
- O2
- iv access
- intubate if GCS < 8
- control ext. bleeding
- remove patients clothing - ANS-Tx of hematoma
- w/in 24-48 hrs of injury
- HA
- nausea / vommitting
- sx rt increased ICP
- decreased LOC
- ipsilateral pupil dilated and fixed (severe) - ANS-s/sx of hematomas
-voluntary movement and reflexes - ANS-SNS
+ glucose reading
blood present - use halo sign
no blood - dextrostix test - ANS-diagnostics for CSF leak
1 - ANS-no eye opening
1. loss of brain function
2. severe brain damage
3. increased ICP - ANS-abnormal posturing causes
1. systolic htn (220/80)
2. bradycardia (<60)
3. irregular respiration's (cheyne stokes) - ANS-cushings triad
,13-15 pts - ANS-minor brain injury scale
2 - ANS-eyes open to pain
2nd to other d/o
fever
hypoglycemia
cerebral edema
infection
toxin exposure
hypoxia
alcohol/drug w/d
F/E imbalance; dehydration acidosis - ANS-secondary seizures
3 - ANS-eyes open to verbal command, speech, or shout
3-8 pts - ANS-severe brain injury scale
4 - ANS-eyes open spontaneously
4 ventricles fluid filled cavities
extends through the spinal cord
produced by choroid plexus
circulates in the subarachnoid space
surrounds the brain, brainstem, spinal cord
cushions for the brain and SC
functions:
- protection
- nutrients
- remove waste
- measure to detect bacteria, protein
- meaure ICP - ANS-CSF
5-15 mmHg - ANS-normal ICP
9-12 pts - ANS-mod brain injury scale
a dipstick test of nasal fluid that checks for CSF after a brain injury
determines presence of glucose - ANS-dextrostix test
, abx agressively: PCN ceftriaxone
analgesics: acetominophen/ NSAIDs
antipyretics: acetominophen / NSAIDs
anti-convulsants - phenytoin - ANS-medications for meningitis
ACh
miosis
stims saliva flow
decreased HR
bronchoconstriction
stims peristalsis
secretions increase
stims bile release
bladder contraction - ANS-parasympathetic NS
acute facial paralysis
inflammatio of facial nerve
CN VII
unknown causes
viral infections: HSV-1, HZV
autoimmune - ANS-Bell's Palsy
acute reversible d/o that causes confusion and decreased awareness of ones environment
response to a specific condition - ANS-what is delirium
always assess bilaterally side to side
biceps
triceps
brachioradialis
patellar
achilles
babinski - ANS-reflex assessment
Alzheimer's disease - ANS-Most common cause of dementia
- patent airway
- sabilize C spine
- O2
- iv access
- intubate if GCS < 8
- control ext. bleeding
- remove patients clothing - ANS-Tx of hematoma
- w/in 24-48 hrs of injury
- HA
- nausea / vommitting
- sx rt increased ICP
- decreased LOC
- ipsilateral pupil dilated and fixed (severe) - ANS-s/sx of hematomas
-voluntary movement and reflexes - ANS-SNS
+ glucose reading
blood present - use halo sign
no blood - dextrostix test - ANS-diagnostics for CSF leak
1 - ANS-no eye opening
1. loss of brain function
2. severe brain damage
3. increased ICP - ANS-abnormal posturing causes
1. systolic htn (220/80)
2. bradycardia (<60)
3. irregular respiration's (cheyne stokes) - ANS-cushings triad
,13-15 pts - ANS-minor brain injury scale
2 - ANS-eyes open to pain
2nd to other d/o
fever
hypoglycemia
cerebral edema
infection
toxin exposure
hypoxia
alcohol/drug w/d
F/E imbalance; dehydration acidosis - ANS-secondary seizures
3 - ANS-eyes open to verbal command, speech, or shout
3-8 pts - ANS-severe brain injury scale
4 - ANS-eyes open spontaneously
4 ventricles fluid filled cavities
extends through the spinal cord
produced by choroid plexus
circulates in the subarachnoid space
surrounds the brain, brainstem, spinal cord
cushions for the brain and SC
functions:
- protection
- nutrients
- remove waste
- measure to detect bacteria, protein
- meaure ICP - ANS-CSF
5-15 mmHg - ANS-normal ICP
9-12 pts - ANS-mod brain injury scale
a dipstick test of nasal fluid that checks for CSF after a brain injury
determines presence of glucose - ANS-dextrostix test
, abx agressively: PCN ceftriaxone
analgesics: acetominophen/ NSAIDs
antipyretics: acetominophen / NSAIDs
anti-convulsants - phenytoin - ANS-medications for meningitis
ACh
miosis
stims saliva flow
decreased HR
bronchoconstriction
stims peristalsis
secretions increase
stims bile release
bladder contraction - ANS-parasympathetic NS
acute facial paralysis
inflammatio of facial nerve
CN VII
unknown causes
viral infections: HSV-1, HZV
autoimmune - ANS-Bell's Palsy
acute reversible d/o that causes confusion and decreased awareness of ones environment
response to a specific condition - ANS-what is delirium
always assess bilaterally side to side
biceps
triceps
brachioradialis
patellar
achilles
babinski - ANS-reflex assessment
Alzheimer's disease - ANS-Most common cause of dementia
