Neurologic system

• optic II sensory: visual acuity, field of vision, pupillary response (afferent)
• oculomotor III. Motor: eyelid elevation, extraocular eye movement, pupil size, convergence, pupillary constriction (efferent)
• Facial VIII sensory: taste, motor: facial movement, muscle expressions lacrimal gland and salivary gland.
• Glossopharyngeal IX: Sensory: sensation of the throat, taste (posterior tongue). Motor: gagging and swallowing movements.
• • Neck must be stabilized
• Neck must be stabilized, if no collar available, use shirt, coat, or other material. KEEP NECK STRAIGHT.
• Rolled like a log, as one straight piece onto flat surface.
• Avoir flexion of the neck, no pillow or other kind of support under the head.
• Confusion

  Cause: brain tumors, head injuries and strokes. Accompanied by anxiety, agitation, and refusal to cooperate. In delirium may be hallucinations, delusions, and severe agitation, usually caused by fever or metabolic imbalance. Patient may become combative. A calm, consistent and orderly approach combined with a set daily routine. The use of distractions can calm the patient.
• Romberg test: the patient is asked to stand with their feet together and to close their eyes, if the sense of balance is normal, there will not be swaying from side to side.
• Thrill: palpate for vibration, gently put your fingers on the enlarged vessels.
• Bruit; auscultate for swishing sound, should coincide with patients pulse.
• Antihypertensives are not given the morning of dialysis. Nitroglycerin NTG patches, digitals, and anticoagulants are withheld. Invasive procedures after dialysis are postponed for 4 to 6 hours because heparin may cause bleeding.
• Arteriovenous fistula AVF: formed by joining an artery and vein. Takes 6 to 8 weeks for vessels walls to thicken. Not for patients with diabetes, prolonged IV drug use, peripheral vascular disease.
• Arteriovenous graft AV GRAFT: connected by synthetic material. S/S: muscle cramping, hypotension, nausea, vomiting, the access may clot off, infected or bleed.
• Chronic renal failure: most common causes, diabetes, and hypertension.

  Nephrosclerosis results from hypertension and causes atherosclerotic disease of the small arteries in the kidneys.

  Azotemia: accumulation of nitrogen, signaled by increase BUN and serum creatinine.

  S/S nausea, vomiting and changes in mental awareness and levels of consciousness.

  Uremic syndrome: retention in the blood of urea, creatinine, and nitrogenous wastes (azotemia), lead to dry skin with a pallid yellowish gray color.
• Chronic renal failure: oliguria led to hyperkalemia that can affect the heart and cause dysrhythmia and cardiac arrest.
• Remind CAN to report

  ·      Changes in wakefulness

  ·      Irritability

  ·      Speech

  ·      Eye appearance

  ·      Gait

  ·      Balance

  ·      Do not assign a patient who has already show sign of LOC
• Changes in blood pressure, particularly a rise in systolic pressure and a widening pulse pressure may indicate increase in ICP.
• Acute renal failure result from physical injury, secondary to hypoperfusion, infections, inflammation or damage from toxic chemicals.
• Oliguric phase: patient puts out 100 to 400 ml of urine in 24 hrs. Last about 10 to 14 days, it can go for weeks to months. High BUN, High creatinine, volume overload.
• Diuretic phase: kidney is unable to concentrate urine. Output can be 1000 to 2000 ml of urine per day. May cause dehydration, hyponatremia, hypokalemia. DX: urinalysis, creatinine, BUN, CBC and electrolyte.
• Cancer of the bladder; more common in men ( 60 to 80). Smokers have double risk, people living in urban areas, exposure to dyes, nitrates, leather processing or rubber. S/S: hematuria, frequency urgency or dysuria.

   

  Cancer of the bladder treatment: BCG (TB vaccine), solution is instilled into bladder via catheter, is clamped for 2 hours, and the patients is repositioning every 15 to 30 minutes. Standard precautions for 6 hours after BCG, the patient should be disinfected with bleach, do not splash.
• Renal stones common causes; bariatric surgery, inadequate intake of fluids, sluggish flow of urine (bed rest/immobility), diabetes, obesity gout and hypertension. Prevention: 2500 urine/24 hrs. Prevent UTIs. Cranberry juice, prunes, or lemon juice. S/S: flank pain  over affected kidney and ureters, that radiates downward toward genitalia, nausea and vomiting
• Autonomic dysreflexia (AD)


  Uninhibited and exaggerated reflex response of autonomic system
• Autonomic dysreflexia (AD)


  • Occurs in 85% of all patients have spinal cord injury at or above T6
  • Dangerous to patients because causes vasoconstriction of the arterioles with immediate elevation of blood pressure
  • Sudden hypertension causes retina hemorrhage, seizures or stroke
  • Less serious effects include severe headache, changes in pulse rate, sweating and flushing above level of spinal injury
• Stimulations that can precipitate AD

  • Tight clothing around the waist
  • Distended bladder
  • Rectal suppositories
  • Sudden changing of position
• Most stimulations that can precipitate AD are related to the bladder, bowel, and skin of the patient
• Autonomic dysreflexia; keep bladder from become overdistended, check catheter and drainage every hour, monitor output and time, palpate bladder for distention. When AD occur call 911, lower blood pressure, place the patient in sitting position or HOB to 45 degrees, if stimulation is known should be removed.
• Myelography is to detect spinal lesions, intervertebral disk problems, tumors, or cysts. No for ICP patients. Placed prone and strapped to x ray table for the spinal puncture. Patient is kept in bed with HOB at 60 degrees or flat. Warm flush contrast, bowel evacuation the night before, NPO for 4-8 hours before procedure, withheld medications before and 48 hours after procedure, assess allergy to shellfish and iodine, needs a signed consent form,obseve for signs of meningitis, monitor urinary output, assess pulse and sensation in extremities.
• Altered physical mobility due to CNS deficits, weakness, paralysis or fatigue.
• Patient will maintain mobility of all joints, no evidence of contractures, regain optimal physical mobility that is neurologically possible.
• Passive ROM or supervise active ROM aid, position flaccid extremities in anatomically correct position during rest, teach ROM patient and family, teach transfer techniques to hemiplegic patient and family, collaborate with PT to maximize activity.
• Bladder training for patients with neurologic disorders including strokes, spinal cord injury, and tumors and lesions of the spinal. Purpose is to prevent renal calculi, UTIs, and allow patient freedom from fear of embarrassment. 2 hours schedule, 2000 to 3000 ml between morning and 6 pm, coffee, tea, alcohol, and soda should be avoided after dinner. Toileting before going to bed. A trial of 6 weeks is needed. Crede maneuver in patient with spinal injury at L2 or below. Self-catheterization for paraplegia patients.
• Cerebral angiography; to visualize the structure of the cerebral arteries to determine the presence of stricture, tumors, aneurysm, bleeding or hematoma. Requires signed consent form, allergy to iodine and shellfish, discontinue anticoagulants, administered medications to prevent reaction to dyes, assess for bleeding, sedative may be given, NPO for 8-12 hours.
• Concussion; a coup-contrecoup injury. Symptoms; headache or pressure, dizziness, memory loss, loss of balance, foggy, hazy, groggy, sluggish, nausea and vomiting, confusion. Rest and sleep to allow the brain to heal. Sustaining another concussion within 10 days can cause long-term problems. Not allow resumption of activities for 1 to 2 weeks.
• Positron emission tomography (PET): to assess cell function, damage in the brain tissue caused by Alzheimer, Parkinson’s, tumors, strokes, seizure focus. Signed consent form, iv will be inserted, avoid sedatives or tranquilizers, avoid intense activity 24 hours before test, empty bladder before.
• Lumbar puncture (spinal tap) to determine whether the CSF pressure is elevated, there is blockage to the flow of CSF, obtain fluid for chemical analysis. Puncture into arachnoid space between L3 and L4 or L4 and L5, fluid is aspirate and placed in tubes, check color, pH, cell count, protein, chloride, glucose. Signed consent form back bowed, head flexed on chest, knees to abdomen, patient may be sitting. Keep patient flat for 1 hour to reduce headache. Encourage fluids and assess drainage and inflammation.
• Hemiplegia paralysis and loss of sensation in an extremity. Taught to become aware of arm or leg placement when turning or transferring to a chair to prevent injury to the affected extremity.  
• Hemiplegia paralysis and loss of sensation in an extremity. Tauch to become aware of arm or leg placement when turning or transferring to a chair to prevent injury to the affected extremity.