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med surg unit 7 neuro
general review
70
Nursing
Undergraduate 1
03/14/2011

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Cards

Term

TWO MAIN BRANCHES of NEUROLOGICAL SYSTEM

Definition

CNS (CENTRAL NERVOUS SYSTEM)

PNS (PERIPHERAL NERVOUS     SYSTEM)

Term

CNS (CENTRAL NERVOUS SYSTEM)

CONSISTS OF 

Definition
BRAIN & SPINAL CORD
Term

CNS (CENTRAL NERVOUS SYSTEM)

function

Definition

RECEIVES, INTERPRETS & RESPONDS TO DATA

REASONING, ABSTRACT THOUGHT, EMOTION

DOES NOT REGENERATE   

Term

PNS (PERIPHERAL NERVOUS     SYSTEM)

CONSISTS OF

Definition

CRANIAL NERVES – 12 PAIRS

                                 SPINAL NERVES – 31 PAIRS

AUTONOMIC NERVOUS SYSTEM

Term

PNS 

FUNCTIONS

Definition

ENABLES CNS TO INTERACT WITH BODY

nMAY REGENERATE IF DAMAGE NOT TOO CLOSE TO SPINAL CORD OR TOO SEVERE    

Term

THE NEUROLOGICAL SYSTEM

BASIC FUNCTIONAL UNIT

 

Definition
The NEURON 
Term
AFFERENT
Definition
CONDUCT IMPULSES TOWARD THE CNS
Term
EFFERENT
Definition

CONDUCT IMPULSES AWAY FROM THE CNS

THE NEUROLOGICAL SYSTEM

Term
CELL BODY
Definition

nSITE OF METABOLIC ACTIVITIES

nFORMS GRAY MATTER IN THE CNS

nFORMS GANGLIA OUTSIDE THE CNS

Term
DENDRITES 
Definition
CONDUCT IMPULSES TO CELL BODY
Term
AXONS 
Definition

nCONDUCT IMPULSES AWAY FROM CELL BODY

MYELINATED FORMS WHITE MATTER   

Term

NERVE IMPULSE  TRANSMISSION

Definition

IMPULSE TRAVELS FROM ONE NEURON TO ANOTHER VIA THE SYNAPSE

Term

NEUROTRANSMITTERS

Definition

CHEMICALS WHICH ENABLE IMPULSES TO CROSS SYNAPSE

EXCITATORY – ENABLE TRANSMISSION (DOPAMINE, SEROTONIN ACETYLCHOLINE)

INHIBITORY – INHIBIT TRANSMISSION (GAMMA-AMINOBUTYRIC ACID = GABA)

Term
NEUROMUSCULAR JUNCTION (NMJ) 
Definition

WHERE THE IMPULSE MOVES FROM THE NERVE TO THE MUSCLE

Term
ACETYLCHOLINE
Definition

a neurotransmitter released at the nerve endings of parasympathetic nerve fibers, at some nerve endings in the sympathetic nervous system, and at nerve endings of skeletal muscles.

IMBALANCE = NEUROMUSCULAR DISORDER

NOT ENOUGH = NO ACTION POTENTIAL

TOO MUCH = MUSCLE FATIGUE

Term
ACETYLCHOLINESTERASE --
Definition

nFOUND IN NMJ -- INACTIVATES ACETYLCHOLINE TO RETURN THE MUSCLE TO ITS RESTING STATE

IMBALANCE = NEUROMUSCULAR DISORDER

NOT ENOUGH = MUSCLE FATIGUE

TOO MUCH = NO ACTION POTENTIAL

THE NEUROLOGICAL SYSTEM

Term

PROTECTIVE STRUCTURES

Definition

BONE, SKULL, VERTEBRAE (33)

Term

VERTEBRAE (33)

Definition

CERVICAL – 7THORACIC – 12LUMBAR – 5SACRAL – 5 [FUSED], COCCYX 4 – [FUSED]

Term
what CUSHIONs VERTEBRAE
Definition
INTERVERTEBRAL DISKS 
Term

MENINGES

Definition

DURA MATER -- “TOUGH MOTHER Fucker!!!!”

Term
DURA MATER 
Definition

nOUTERMOST COVERING (NEXT TO THE BONE)

nHAS RICH BLOOD SUPPLY

nFOLDS OVER ON ITSELF CREATING FISSURES WHERE THE VENOUS SINUSES ARE LOCATED

Term
ARACHNOID 
Definition

MIDDLE LAYER

DELICATE (SPIDER WEB-LIKE), VASCULAR


CONTAINS ARACHNOID VILLI WHICH PROJECT INTO THE VENOUS SINUSES TO DRAIN THE CSF

Term
PIA MATER 
Definition

‘GENTLE MOTHER’

MOST DELICATE LAYER, 

  INNERMOST LAYER

ADHERES CLOSELY TO THE SURFACE OF THE BRAIN & SPINAL CORD

Term

CEREBROSPINAL FLUID (CSF)

Definition

PROVIDES CUSHIONING FROM SUDDEN OR ABRUPT MOVEMENT TO CNS

 CONSTANTLY FORMED IN CHOROID PLEXIS OF LATERAL VENTRICLES

 CIRCULATES THROUGH THE SUBARACHNOID SPACE

 CONSTANTLY REABSORBED INTO VENOUS SINUSES VIA ARACHNOID VILLI

DIRECT PATHWAY TO ELIMINATE WASTE PRODUCTS

Term

 

NEUROLOGICAL  ASSESSMENT

 I    

 

Definition

 

  OLFACTORY

ASSESSMENT TECHNIQUE-Ask client to occlude each nostril separately and close the eyes. Present familiar odors, such as vinegar, lemon, coffee, and ammonia.

norm-Client identifies odors correctly.


 

Term

 

NEUROLOGICAL  ASSESSMENT

II

 

Definition

OPTIC

ASSESSMENT TECHNIQUE- Help client cover each eye separately; test visual acuity using a Snellen. 

Client and examiner cover an eye, and examiner moves an object from the periphery toward client's nose from superior, inferior, medial, and lat¬ eral positions while both fix their gaze straight ahead. Examiner then tests opposite eye. Inspect optic nerve with an ophthalmoscope.

 

norm-Client names letters or reads words accurately. 

Client and examiner see object at the same time in the visual field. Optic nerve appears round and lighter than surrounding retina.

Term

 

NEUROLOGICAL  ASSESSMENT

III

 

Definition

OCCULOMOTOR

ASSESSMENT TECHNIQUE-In a darkened room, shine a bright light in each pupil; ask client to look at a near and far object Ask client to follow an object you move in horizontal, vertical, and oblique directions

norm- Pupil constricts briskly in response to light and dilates when looking far away. Eye movement is coordinated in all directions. 

Term

 

NEUROLOGICAL  ASSESSMENT

IV

 

Definition

TROCHLEAR      

ASSESSMENT TECHNIQUE-See assessment for motor function of oculomotor nerve.

norm-Eyes move interiorly and medially.                                

Term

 

NEUROLOGICAL  ASSESSMENT

V

 

Definition

TRIGEMINAL

ASSESSMENT TECHNIQUE-Observe for jaw symmetry while client opens mouth. 

Instruct client to clamp jaws tightly together. Stroke forehead, cheeks, and jaw with a wisp of cotton, sharp object (e.g., pin), cold and warm objects, and a vibrating tuning fork. 

Touch each cornea with a wisp of cotton. 

Tap center of chin with a reflex hammer while client slightly opens the mouth.

norm-Appearance is symmetric. 

The muscles contract bilaterally. Client shows bilateral sensitivity and correctly identifies sensory experience. 

Client blinks. 

Jaw closes suddenly and slightly.

Term

 

NEUROLOGICAL  ASSESSMENT

VI

 

Definition

ABDUCENS

ASSESSMENT-See assessment for motor function of oculomotor

norm-Client moves eyes in lateral directions.

 

Term

 

NEUROLOGICAL  ASSESSMENT

VII

 

Definition

FACIAL

ASSESSMENT TECHNIQUE-Ask client to wrinkle the forehead, smile, frown, raise eyebrows, look at ceiling, and whistle. 

Instruct client to close eyelids and resist examiner's efforts to open them. 

Apply sweet, sour, salty, and bitter flavors to both sides ofthe anterior tongue.

norm-Facial movements are symmetrical. 

Both eyes equally resist efforts to open them. 

Client accurately identifies tastes.

Term

 

NEUROLOGICAL  ASSESSMENT

VIII

 

Definition

ACOUSTIC (AUDITORY, VESTIBULOCOCHLEAR)

ASSESSMENT TECHNIQUE-Test hearing acuity and perform the Rinne and Weber tests with a tuning fork. Have client stand with both feet close together; note for swaying with eyes open and

then shut.

norm-Client repeats whispered words correctly; sound is lateralized equally and heard longer by air than by bone conduction. Client maintains balance or sways slightly.

Term

 

NEUROLOGICAL  ASSESSMENT

IX

 

Definition

GLOSSOPHARYNGEAL

ASSESSMENT TECHNIQUE-Touch palate with a tongue blade. 

Ask client to say "ah."

norm-Blade elicits a gag response. 

Uvula remains in midline.

Term

 

NEUROLOGICAL  ASSESSMENT

X

 

Definition

VAGUS

ASSESSMENT TECHNIQUE-Have client say "la, la, la."

norm-Client speaks clearly and distinctly, with no hoarseness.

Term

 

NEUROLOGICAL  ASSESSMENT

XI

 

Definition

 

ACCESSORY (SPINAL)

ASSESSMENT TECHNIQUE-Instruct client to shrug the shoulders as you apply resistance.

norm-Client raises shoulders.

 

Term

 

NEUROLOGICAL  ASSESSMENT

XII

 

Definition

HYPOGLOSSA

ASSESSMENT TECHNIQUE-Tell client to stick out the tongue.

norm-Tongue remains in midline with no lateral deviation.

Term

NEURO ASSESSMENT

n   OBJECTIVE DATA

Definition

 GENERAL APPEARANCE, POSITION & POSTURE

MOVEMENT OR NONMOVEMENT OF ALL EXTREMITIES & FACE

SENSATION – SHARP & DULL – FACE, ARMS, LEGS

SWALLOW INTACT?, GAG WHEN SUCTIONED? -- (#9-GLOSSOPHARYNGEAL)

SPEECH PATTERN      APHASIA -- EXPRESSIVE, RECEPTIVE, GLOBAL (BOTH)

BEHAVIOR/MENTAL STATUS

  INTELLECT – SERIAL 7'S; SPELL “WORLD” BACKWARD

Term

assess

MEMORY

Definition

n   TELL THEM 3 OBJECTS TO REMEMBER

n   SHORT TERM

n   LONG TERM (SEVERAL MIN. LATER)

Term

 

NEURO ASSESSMENT

n   GLASCOW COMA SCALE

 

 

Definition

   EYE OPENING- SPONTANEOUSLY (4), n  TO SPEECH (3)n  TO PAIN (2)n  NO OPENING (1)

n   BEST VERBAL RESPONSEn  ORIENTED (5)n  CONFUSED (4)n  INAPPROPRIATE WORDS (3)n  INCOMPREHENSIBLE (2)n  NO RESPONSE (1)

n   BEST MOTOR RESPONSEn  OBEYS COMMANDS (6)n  LOCALIZES PAIN (5)n  FLEXION WITHDRAWL TO PAIN (4)n  ABNORMAL FLEXION (3)n  EXTENSION TO PAIN (2)n  NONE (1)

n   SCORES 3-15n   < 10 = EMERGENT SITUATION

n   SCORE < 7 = COMA

Term

DECORTICATE (FLEXOR)

Definition

INDICATES CEREBRAL DYSFUNCTION      SPINE RIGID      ARMS ADDUCTED & FLEXED, LEGS EXTENDED & PLANTAR FLEXED

Term

n   DECEREBRATE (EXTENSOR POSTURING)

Definition

n  INDICATES BRAINSTEM DYSFUNCTION

      SPINE RIGID , POSSIBLY OPOSTOTONUS

      ARMS EXTENDED & INTERNALLY ROTATED

LEGS EXTENDED & PLANTAR FLEXED

Term

n   BABINSKI (PLANTAR) 

Definition

if present in adult = brain dysfunction

adult refelxes should protect the foot not flare

Term

n   PAINFUL STIMULATION

Definition

TRAPEZIOUS PINCH, INNER ARM PINCH, FINGERNAIL PINCH

Term

NEURO ASSESSMENT

FOR HEAD INJURY PT

Definition

n   MAINTAIN HEAD & NECK IMMOBILIZATION UNTIL CERVICAL SPINE X-RAY READ BY MD & “NECK CLEARED”

n   CHECK SCALP FOR WOUNDS & BLEEDING & SWELLING

n   CHECK EARS & NOSE FOR BLEEDING OR CSF LEAK

Term

n   HOW TO CHECK FOR  CSF LEAK

Definition

n   CHECK DRAINAGE FOR GLUCOSE 

n  NEG = NOT CSF

n  POS = CSF OR BLOOD PRESENT

n   IF POS. FOR GLUCOSE CHECK FOR HALO SIGN

n  ALLOW DRAINAGE TO DRIP ONTO 4X4

      RED CENTER = BLOOD

      YELLOW RING = CSF

Term

NEURO ASSESSMENT

REPORT 

Definition
ANY NEURO CHANGES TO MD STAT
Term

NEURO ASSESSMENT

PUPIL CHANGES 

Definition
ARE VERY LATE – MAYBE TOO LATE
Term

NEURO ASSESSMENT

LOC

Definition

n   PAY ATTENTION TO LOC

n   LOC WILL CHANGE FIRST

Term

NEURO ASSESSMENT

  VITAL SIGNS

Definition

n   AFFECTED BY NEURO DISORDERS

n  SBP INCREASES WITH ­ICP

n  PULSE DECREASES WITH ­ICP

n  TEMP      CAN BE HIGH & REFRACTORY TO TYLENOL

      VERY LOW USU. MEANS DEATH SOON

Term

n   CT (CAT) [COMPUTERIZED AXIAL TOMOGRAPHY

Definition

 ID, EVALUATE, DIFFERENTIATE & F/U  ABNORMALITIES OF    CRANIAL STRUCTURES  GOOD  FOR VASCULAR LESIONS, SMALL LESIONS, TO SHARPLY DEFINE LESION BORDERS.  MAY BE UNENHANCED, ENHENCED (USE IV DYE), OR BOTH      UNENHANCED DONE 1ST

Term

CAT sacn

 NURSING roll

 

Definition

      TELL PT. HE MUST LIE STILL

      ASSESS SHELLFISH/ IODINE ALLERGY

      MAY NEED WRITTEN CONSENT IF ENHANCED    

Term

n   MRI (MAGNETIC RESONANCE IMAGING)

Definition

n   USES A MAGNET & RADIOFREQUENCY SIGNALS & COMPUTER MAKES A PICTURE

CAN REVEAL SUBTLE CHANGES IN SOFT TISSUES IE BRAIN, SPINAL CORD, BLOOD VESSELS

Term
MRI Nusring Roll
Definition

n  PT. MUST LIE STILL      EARPLUGS & MAY NEED SEDATION

  NO METAL IN ROOM

n  FACILITY CHECK LIST FOR PACER, VALVES, NEW STENTS, AICD, HARDWARE, ETC.   

Term

PET SCAN (POSITRON EMISSION TOMOGRAPHY)

Definition

n   SHOWS METABOLIC FUNCTION

n   CAN COMBINE WITH MRI & HAVE COMPUTER GENERATED 3D PICTURE 

Term

   LP (LUMBAR PUNCTURE)

n   USES

Definition

n  MEASURE CSF PRESSURE (80-180 MM H2O)

      OPENING – AT BEGINNING; CLOSING – AT END

Term
LP-OBTAIN SAMPLES
Definition

   DX. MENINGITIS, SUBARACHNOID HEMMORHAGE, GUILLIAN BARRE’

n  CHECK FOR GLUCOSE, PROTEIN, CELLS, C&S

Term
LP-  MEDICATION ADMINISTRATION
Definition

      SPINAL ANESTHESIA (NOT EPIDURAL)

      ANTIBX (NEED TO GIVE DIRECTLY INTO CSF R/T BLOOD BRAIN BARRIER WON’T LET MANY MEDS ACROSS)

CHEMOTHERAPY

Term
LP-
Definition

n   CONTRAINDICATED IN ­ICP

n   MD INSERTS NEEDLE BETWEEN L3-L4 OR L4-L5  

Term
LP- NURSING
Definition

n   OBTAIN SUPPLIES (USU.DISPOSABLE TRAY ON SUPPLY CART OR FROM MATERIAL SUPPLY)

n   OBTAIN INFORMED CONSENT

n   MAINTAIN PT. POSITIONn  MUST BE STILL

n  PREFERRED – SIDELYING WITH KNEES DRAWN UP & CHIN ON CHEST

n  SUPPORT PT. THROUGHOUT PROCEDURE 

Term
LP- MANAGE SPECIMENS
Definition

 NOTE ORDER THEY WERE COLLECTED IN &

LABEL IF CONTAINERS NOT ALREADYLABELED (#1, #2, #3)

n  KEEP STERILE FOR C&S

TAKE TO LAB STAT

Term

LP- 

n   POST CARE

Definition

n   LIE FLAT X 6-8 HRS AFTER

n   CHECK VITAL SIGNS & NEURO’s & COMPARE TO BASELINE (Q2H THEN Q4H X 24 HRS.)

n   PUSH PO FLUIDS TO PREVENT HA

n   MONITOR FOR COMPLICATIONS- INFECTION-  NERVE DAMAGE- HEADACHE (MOST COMMON

Term
POST LP HA
Definition

n   10% PT. GET IT R/T CSF LEAKAGE AT SITE & TRACTION ON MENINGES

n   LASTS HOURS TO DAYS, MILD TO SEVERE, HARMLESS BUT REALLY MISERABLE, THROBBING FRONTAL OR OCCIPITAL, AGGRAVATED BY SITTING OR STANDING

n   TREATMENT: BEDREST IN DARK, QUIET ROOM, NARCOTIC ANALGESICS IE CODIENE, BLOOD PATCH

Term

n   EMG (ELECTROMYOGRAPHY)

Definition

n   STUDIES ELECTRICAL POTENTIAL OF MUSCLES & THE NERVES SUPPLYING THEM

n   USES NEEDLE ELECTRODES PLACED INTO SKELETAL MUSCLES & GRAPH IS MADE (LIKE AN EKG FOR SKELETAL MUSCLE)

n   USED TO DX. NEUROMUSCULAR DISEASES IE MYASTHENIA GRAVIS 


Term
CEREBRAL ANGIOGRAM
Definition
LIKE CORONARY ANGIOGRAMS EXCEPT CATHETER THREADED TO CAROTID & DYE IS INJECTED SO IT GOES TO THE HEAD
Term

n   CEREBRAL ANGIOGRAM

n   NURSING CARE-PRE-PROCEDURE

Definition

      OBTAIN INFORMED CONSENT & ASSESS  FOR IODINE/SHELLFISH ALLERGY

      NPO X 8 HRS.

      GET BASELINE VITAL & NEURO SIGNS

      HAVE PT. VOID BEFORE & REMOVE JEWELRY  

Term

CEREBRAL ANGIOGRAM

n   NURSING CARE- POST PROCEDURE

Definition

n   SITE CARE SAME AS CORONARY ANGIOS BUT FOCUS ON NEURO

n   PUSH PO FLUIDS TO CLEAR DYE

n   OBSERVE FOR COMPLICATIONS (MAY BE MANIFESTED AS BEHAVIOR, MOTOR, SENSORY, OR LANGUAGE DYSFUNCTION)

n  DYE ALLERGY

      DYSPNEA, ITCHING, RASH

n  VASOSPASM, THROMBOSIS, HEMORRHAGE, HEMATOMA, EMBOLISM, CVA, RENAL FAILURE 

Term

 EEG (ELECTROENCEPHALOGRAM)

Definition

n   MEASURES ELECTRICAL IMPULSES OF THE BRAIN

n  PT. CAN HAVE SEIZURES WITHIN THE BRAIN THAT WE CAN’T SEE

n   NEEDLES OR STICKY ELECTORODES PLACED ON UNSHAVEN SCALP

n   USED IN DX.

n  SEIZURES, BRAIN TUMORS, HA, SLEEP DISORDERS, HEAD INJURY, CONFIRM BRAIN DEATH

Term
EEG: 4 states
Definition

n   REST (BASELINE)

n   HYPERVENTILATE

n   PHOTIC (MAY CAUSE SZ.)

n   SLEEP (MAY SEDATE)

n  MAY ALSO DO SLEEP DEPRIVED

Term
EEG- NURSING
Definition

n   INSTRUCT PT.

n  PAINLESS, NONINVASIVE, DOESN’T PUT ELECTRICITY IN BRAIN, CAN’T READ THOUGHTS

n  ASK MD WHETHER TO HOLD ANTICONVULSANTS R/T THEY MASK SEIZURE ACTIVITY

      IF HELD GIVE MEDS IMMEDIATELY AFTER

n  HOLD STIMULANTS IE COFFEE, TEA R/T THEY INFLUENCE IMPULSES 

Term
CAROTID DOPPLER STUDIES
Definition

n   ULTRASOUND OF CAROTID ARTERIES

n   SHOWS BLOOD FLOW & VISUALIZES VESSELS

n   STENOSIS, OCCLUSIONS WHICH WILL LEAD TO CVA

n   NONINVASIVE, PAINLESS, NO PRE OR POST CARE

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