Nursing Care of Patients with Neurological Disorders – Flashcards

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the most common causes of prolonged unconsciousness includes these four
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CVA Heady Injury Brain Tumor Drug Overdose
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Important Nursing Considerations to always take into account
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(1) Always assume that the patient can hear, even though they make no response. (2) Always address the patient by name and tell him what you are going to do. (3) Refrain from any conversation about the patient's condition while in the patient's presence.
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What to regularly observe and record
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Vital Signs and Level of consciousness!
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What to Do in regards to changes in vitals or consciousness
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report changes to charge nurse, Doctor, ARNP or PA
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Types of changes to be very aware of
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temperature consciousness response to stimuli protective reflexes (corneal gag)
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Normothermic interventions
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Take temperature regularly Feel the patient's skin with back of hand Adjust room temperature accordingly
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airway and breathing interventions
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-chin extended and lateral recumbent is the safest position. -suction secretions to prevent aspiration -reposition side to side to prevent pooling of secretions in lungs -administer oxygen as ordered -always have suction available to prevent aspiration of vomitus
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this is often referred to as the coma position
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lateral recumberant
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nutritional needs interventions
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observe patient carefully when administering savage feedings. Best position is the sitting position to reduce aspiration Fluids are maintained by IVF MUST keep accurate records of intake and output(urine) -Observe for signs of dehydration or fluid overload.
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skin care interventions
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-the unconscious patient should be given a complete bed bath every other day. -moisturize skin with lotion after bathing -keep nails short so that the patient does not scratch themselves
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skin care nursing interventions continued
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provide oral hygiene at least twice per shift (tongue, tooth surfaces, and soft tissue areas) unconscious patients are mouth breathers so pay attention area! Put petroleum on lips from drying.
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skin care interventions continued
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-keep nostrils free of crusted secretions with water soluble lubricant -put eye drops or corneal ointment to prevent abrasions -watch perineal area throughly after each incident
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bowel elimination interventions
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BM should be regular to prevent impaction keep ACCURATE record of BM. Note amount, color, consistency assess for signs of impaction administer laxatives and enemas Probiotics?
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sings of impaction
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-no incontinence however complete evacuation is not observed. Small frequent loos stools may be the first sign of impaction.
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urine interventions
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the bladder should be emptied regularly to prevent infection or stone formation adequate hydration is important. monitor urine output CAREFULLY. This should be reported provide catheter care at least once per shift and whenever to patient soils linens
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When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. The unconscious patient cannot tell you that he is __________ or is experiencing pressure on a body part.
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uncomfortable
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Limbs must be supported in a position of _________. Do not allow flaccid limbs to rest unsupported
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function
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When turning the patient, maintain _____________ and do not allow the arms to be caught under the torso.
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alignment
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Utilize a foot board or boots at the end of the bed to ________ the possibility of foot drop
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decrease
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When joints are not exercised in their full range of motion each day, the muscles will gradually shrink, forming what is known as a contracture. -___________ exercises must be provided for the unconscious patient to prevent contractures.
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Passive (thank you PT)
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Exercises with a range of motion (ROM) are performed under the direction of the ________ __________
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physical therapist.
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Precautions must be taken to prevent the development of __________ __________.
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pressure sores
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Utilize a ___________ mattress such as a flotation mattress, alternating pressure mattress, or eggcrate mattress.
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protective
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get the patient _____ and int o the chair
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OOB
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Definition. inflammation of the meninges. The severity of the disease is dependent upon the specific microorganism involved, the presence of other neurological disorders, the general health of the patient, the speed of diagnosis, and the initiation of treatment
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meningitis
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causes of meningitis
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Travel of infectious microorganisms to the meninges via the bloodstream or through direct extension from an infected area (such as the middle ear or paranasal sinuses).
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Common meningitis microorganisms include
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(a) Meningococcus. (b) Streptococcus. (c) Staphylococcus. (d) Pneumococcus. (2) Contaminated head injury. (3) Infected shunt. (4) Contaminated lumbar puncture.
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diagnostic procedure for meningitis
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Lumbar puncture blood cultures Physical examination
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signs and symptoms of meningitis
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Hyperthermia chills Headache nausea and vomiting nuchal rigidity photophobia opisthotonos altered LOC Multiple petechiae over the body
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nursing management for meningitis
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administer IVF and meds as ordered Antibiotics should be started immediately corticosteroids should be used for the critically ill patient. drug therapy may be continued after the acute phase of illness.
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nursing interventions for meningitis
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record intake and output carefully to observe the patient for signs of dehydration due to insensible fluid losses. monitor vital signs and neurological status. monitor temperature every 4 hours and if there is any cooling or warming device, this will be every hour.
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nursing management for meningitis part 2
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if isolation is required, educate family and staff maintain dim lighting in the room
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is a disorder of the nervous system that affects peripheral nerves and spinal nerve roots. It is also called infectious polyneuritis.
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Guillain Barre syndrome
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the exact cause is unknown. Many patients give a history of a recent infection, especially of the upper respiratory tract. There is also evidence of a connection with the Swine flu vaccination.
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Guillain Barre syndrome
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diagnosis is made on history and symptoms. lumbar puncture will reveal increased protein in the cerebral spinal fluid
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Guillain Barre syndrome
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signs and symptoms of Guillain Barre syndrome
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motor weakness especially in the extremities. weakness usually ascends over period of hours to weeks. sensory disturbances, numbness, and tingling. cranial nerve involvement resulting in difficulty chewing and talking diminished deep tendon reflexes and low grade fever
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nursing management of patients with Guillain Barre syndrome
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treatment in nonspecific and symptomatic observed for adequacy of respiratory effort EKG monitoring after several weeks the paralysis will begin to disappear. This will usually start from the head down.
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chronic, progressive disease of the central nervous system characterized by the destruction of myelin. Myelin is the fatty and protein material that covers certain nerve fibers in the brain and spinal cord.
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multiple sclerosis.
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Multiple Sclerosis primarily affects adults between __________- years of age.
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20 and 40
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signs and symptoms of MS
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weakness visual disturbance nystagmus slurred speech intention tremor abnormal reflexes ataxia paraplegia urinary and bowel incontinence emotional labile
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nursing management of MS
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keep patient active and as functional as possible provide support to receive symptoms encourage exercises to strengthen and prevent contractures encourage frequent rest periods to prevent muscle fatigue administer muscle relaxants as ordered.
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nursing management of MS 2
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-avoid skin pressure and immobility -give special attention to sacral and perineal hygiene -support bladder -observe for retention -teach self catheterization -give urinary antiseptics -establish bowel regulation.
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nursing management of MS continued
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admin corticosteroids to reduce edema and swelling encourage bedrest with active stage effects of disease increase with each exacerbation support eye and speech defects use speech therapist assist patient and family to cope
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the patient with MS will experience behavioral changes such as
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euphoria, depression, denial, forgetfulness
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a progressive neurological disorder affecting the brain centers that are responsible for control of movement.
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Parkinsons
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signs and symptoms of parkinson's
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bradykinesia, tremor, rigidity, shuffling gait, muscle weakness, mask like face, depression, dementia
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nursing management of parkinson's
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drug therapy, physical therapy, encoring patient to be an active participant,
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an autoimmune disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body.
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myasthenia gravis
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There may be too much cholinesterase present, and acetylcholine is destroyed too quickly. or there my be too little released from the nerve or the motor end is not sensitive to ach.
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myasthenia gravis
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signs and symptoms of myasthenia gravis.
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anti cholinesterase drugs must be given at exact times. Teach symptoms of overdose. Have therapy coincide with mealtimes so that swallowing is at its best.
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Myasthenic crisis may result from
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natural deterioration of the disease, emotional upset, upper respiratory infection, surgery, or steroid therapy.
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______ _______ may occur due to overmedication with anticholinergic drugs
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cholinergic crisis
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signs and symptoms of cholinergic crisis
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the muscles stop responding to the bombardment of ACh, leading to flaccid paralysis, respiratory failure, and other signs and symptoms reminiscent of organophosphate poisoning. Other symptoms include increased sweating, salivation, bronchial secretions along with miosis.
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with this acetylcholine disease the patient may require ventilation, intubation
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myasthenia gravis
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is a cranial nerve disorder characterized by facial paralysis. Peripheral involvement of the 7th cranial nerve (facial nerve) produces weakness or paralysis of the facial muscles.
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bell's palsy
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The cause of this condition is unknown, but the majority of patient's have experienced a viral upper respiratory infection 1 to 3 weeks prior to the onset of symptoms.
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bells palsy
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Complications associated with Bell's palsy include
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facial weakness, facial spasm with contracture, corneal ulceration, and blindness.
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nursing interventions for bell's palsy
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protect involved eye, install articicial tears, increase environmental humidity, tell patient to wear eye patch at night. wear protective glasses in the day time. facial massage to maintain tone, surgical decompression of facial nerve may be necessary
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also known as Tic Douloureux, is a disorder of the 5th cranial nerve (trigeminal nerve). It is characterized by sudden paroxysms of burning pain along one or more of the branches of the trigeminal nerve.
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trigeminal neuralgia
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signs and symptoms of trigeminal neuralgia
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(1) Sudden, severe pain appearing without warning. (Along one or more branches of trigeminal nerve.) (2) Numerous individual flashes of pain, ending abruptly and usually on one side of the face only.
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trigeminal neuralgia attacks can be provoked by
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shaving talking yawning chewing gum cold wind
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nursing interventions for trigeminal neuralgia
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avoid cold things give tegretol and dilantin to relieve pain serum drug levels will be needed eat easily chewed foods
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the disruption of the blood supply to the brain, resulting in neurological dysfunction.
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CVA
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causes of CVA
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thrombosis cerebral embolism cerebral artery stenosisi cerebral hemorrhage
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risk factors associated with CVA
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hypertension previous history of TIAs Cardiac disease advanced age diabetes mellitus
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signs and symptoms of CVA
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depends on lesions size and site hemiplegia (paralysis) hemiparesis (weakness) communication loss receptive or expressive aphasia vision loss bladder impairment LOC changes
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signs and symptoms of CVA continued
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BP may be elevated due to increased ICP sudden headache with nausea and vomiting patient may be comatose for hours or weeks
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the longer the coma the
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poorer to prognosis
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____ is a frequent complication resulting from hemorrhage or ischemia and subsequent cerebral edema.
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ICP
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nursing management for CVA acute phase
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keep patient alive ensure adequate oxygenation to the brain support airway frequently assess LOC, pupils, response to commands, movement and strength, patient's vital signs
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Be aware of changes in any of the above. _________- could indicate progression of the CVA.
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Deterioration
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nursing management for CVA acute phase continued
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continually reorient patient maintain proper alignment prevent complication of bedrest HOB at 30 degrees
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________ may be a result of simply regaining consciousness, or may be due to a neurological deficit.
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Confusion
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nursing management of CVA
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ensure adequate fluid and electrolytes fluids may be restricted to decrease ICP IVF are maintain until patient stabilizes and NG insertion can begin
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medication therapy for CVA
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antihypertensives antibiotics seizure control anticoagulants
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these drugs are not given to a patient with a CVA because they depress the respiratory center and obscure neurological observations
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sedatives and tranquilizers
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medical and nursing management of CVA
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maintain adequate elimination foley catheter stool softners include family in plan of care keep them informed
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is an abnormal electrical disturbance in one or more areas of the brain. An estimated 2 to 4 million persons in the United States are afflicted with epilepsy and more that half of those are under 20 years of age
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epilepsy
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The underlying disorder may be structural, chemical, physiological, or a combination of all three.
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epilepsy
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factors that predispose a patient to epilepsy
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(a) Trauma to the head/brain. (b) Brain tumor. (c) Circulatory disorder, stroke. (d) Metabolic disorder (such as hypoglycemia, hypocalcemia, or cerebral anoxia). (e) Drug/alcohol toxicity. (f) Infection (meningitis/brain abscess).
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this phase of grand mal seizure consists of vague emotional changes (depression, anxiety, nervousness). Lasts for minutes to hours. Followed by an "aura." Aura is usually a sensory "cue" (odor or sound) or sensation "cue" (weakness, numbness). It is related to the anatomical origin of the seizure, and warns the patient that a seizure is imminent. this phase may not be present in all patients
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preictal phase
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this phase of granola includes: loss of consciousness, skin is cyanotic and breathing is spasmodic, jaws are clenched tight, tongue may be bitten, urinary and equal incontinende usually occur. may last minutes
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tonic-clonic phase
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______activity is characterized by rigid contraction of the muscles.
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tonic
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__________ activity is characterized by alternate contraction and relaxation of muscles, causing jerking movements of the arms and legs.
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Clonic
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this phase of grand mal seizures will vary in symptoms. Some patients will fall into a deep sleep. patients may experience headache, fatigue, confusion and nausea
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post ictal phase
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Characterized by brief loss of consciousness, or "blank spells." (2) Individual stares blankly, eyelids may flutter, and there is slight movement of head and extremities. (3) More common in children. (4) May occur dozens of times per day.
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petit mal seizures
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Different forms of seizure activity often appearing as irrational or odd behavior, such as removing one's clothing or purposeless behaviors such as smacking one's lips. (2) Last only a few moments and individual has no recall of behavior. (3) Auditory, visual, or olfactory hallucinations may also occur.
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psychomotor seizure
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Seizures may start in one part of the body and move to another. Consciousness may not be lost. (2) May be followed by a grand mal seizure. Status Epilipticus. this is a extreme neurological emergency.
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Jacksonian seizure or also call focal/ marching seizure
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nursing management of epilepsy
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prevent cause and recurrence reinforce importance of drugs to control not cure
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nursing management of seizure
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place oral airway by bed set up suction equipment
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essential steps to protect a patient during a seizure.
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turn the patient on their side to provide drainage for oral secretions do not restrain patient during seizure remove objects that may obstruct breathing or cause injury. protect the patient's head from injury.
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nursing managment of epilepsy
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keep bed flat, turn patient on side, dim room lighting and noise kept to a minimum. loosen restrictive clothing, check vital signs, check lips and tongue for injury
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a localized intracranial lesion which occupies space with the skull and tends to cause a rise in intracranial pressure.
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brain tumor
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The most common brain tumors are _______, which begin in the glial (supportive) tissue. There are several types , including the following: Astrocytomas arise from small, star-shaped cells called astrocytes. They may grow anywhere in the brain or spinal cord.
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gliomas
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signs and symptoms of brain tumor
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depend on location decreased LOC or confusion. Headache, lethargy, vomiting, papilledema, alterations in mentation, aphasia, hemiparesis, visual field defects, sensory defects, seizures
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nursing management of brain tumors
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diagnostic test to determine location and size of lesion monitor and record vital signs use measure to decrease ICP initiate sz precautions
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medications for brain tumors
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steroids and anti-eleptic agents
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withholding a patients steroids can result in
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adrenal crisis
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withholding antiepileptic agents frequently precipitates ____
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seizures
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post op nursing care
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goal is to prevent complications accurately monitor and record vitals and neurological signs
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post operative cerebral edema peaks between
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48 to 60 hours following surgery. Patient may be lucid during first 24 hours, then experience a decrease in level of consciousness during this time.
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post operative nursing interventions
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do not turn patient on operative side of brain. this can cause irreversible damage in the first 72 hours. normothermic goal seizure precautions monitor I & Os cough and deep breath continually reorient patient
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increased body temperature in a neuro patient may be due to swelling around the
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hypothalamus.
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head injuries are categorized into these 2 categories
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direct and indirect
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This phenomenon is a combination of direct and indirect injury. A direct blow to one side of the skull causes the brain to be jarred inside the skull, causing an indirect injury on the side opposite the direct blow.
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Coup-contrecoup
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Brain damage resulting from a head injury is dependent upon these 3 things
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(1) The force of impact. (2) The type of impact. (3) The location of impact.
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________- skull fractures are potentially serious injuries due to the proximity of the brain stem.
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Basilar
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__________ skull fractures may be open or closed. In either case, the underlying brain tissue may be damaged.
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Depressed
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________ skull fractures are "cracks." They may be dangerous if they overlie vascular structures.
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Linear
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are a result of bleeding within the closed compartment of the skull. They may cause compression of brain tissue.
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hematomas
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_______ hematoma is caused by bleeding between the skull and the dura.
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epidural
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________ hematoma is caused by bleeding between the dura and the arachnoid membrane.
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subdural
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______hemorrhage/hematoma is caused by bleeding into the subarachnoid space.
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subarachnoid
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results from violent jarring of the brain against the interior of the skull. The patient experiences a brief loss of consciousness followed by confusion, headache, and irritability. Complete recovery is usual
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concussion
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This injury is more serious than a concussion. The severe jarring of the brain causes bruising of the brain. (This bruising is the result of blood vessel rupture.) Permanent damage may result.
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contusion
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causes of increased ICP
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edema, bleeding, trauma, or space-occupying lesions.
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signs and symptoms of increased ICP
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change in LOC may occur over minutes, hours, days diminished response to stimuli confusion, restlessness, disorientation, and drowsiness, headache vomiting
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ways that ICP is increased
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coughing, sneezing, straining
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clinical signs and symptoms of increased ICP
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papilledema pupils may be non reactive, dilated, pinpoint, non reactive, elevation of BP with a widened pulse pressure increased pulse initially and then brady out bradypnea
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Edema and pressure of both the optic nerve and the oculomotor nerve at the point at which they enter the globe is caused by venous congestion resulting from increased intracranial pressure.
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papilledema
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Pupil on the affected side may be ___________.
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nonreactive
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nursing managment for increased ICP
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monitor vital signs closely accurately assess and document neuro status maintain airway intubation and hyperventilation place patient on side do not simulate coughing... elevate HOB, promote venous return, seizure precautions
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evaluation of _____ is crucial in the neuro ICU since symptoms progress rapidly!
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consciousness
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_________ may be indicated to provide adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced vascular spasm.
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Intubation and hyperventilation
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If patient is not intubated, position the patient on his ______ to decrease the possibility of airway occlusion use oral or nasopharyngeal airway, prn.
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side
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Be aware that stimulation of coughing when suctioning increases intracranial pressure and may precipitate _____ activity.
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seizure
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medication for increased ICP
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mannital, corticosteroids, dilantin, antibiotics, hypertonic IVF ,
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_______ fluids such as Dextrose in water crosses the blood-brain barrier and increase cerebral edema and intracranial pressure.
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hypotonic
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______ will be restricted to reduce intracranial pressure.
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Fluids. so accurate I and O must be kept
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seizure precaution for ICP
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pad side rails, secure tongue blade to head of bed, maintain normal body temperature, monitor rectal temperature frequently, place hypothermia blanket as ordered for temperature over 102.
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Flexion-extension injuries are commonly located at ________ ("whiplash").
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C4 - C7
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_____________- are frequent sites of spinal cord injury resulting rom falls.
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T11, T12, and L1
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signs and symptoms of spinal cord injury,
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total sensory, motor loss below the level of ijury
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______ spinal cord injuries will produce quadriplegia--loss of function of all four extremities.
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Cervical
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Injuries to the thoracic spinal cord below the level of ______ will produce paraplegia--paralysis of the lower extremities.
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T1
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The diaphragm is innervated by the phrenic nerves which arise from cervical nerve roots______
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C3 to C5
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nursing management of spinal cord injury
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reduce fracture and obtain immobilization of spine to prevent further damage. continuously assess breathing pattern
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patient with ___ will have some form of skeletal traction.
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cervical
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Continuously observe patient for motor and sensory changes due to ______ edema or hemorrhage, which may further compromise cord function.
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cord
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Test patient's motor ability by asking him/her to
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spread fingers, grip your hands, shrug shoulders, etc.
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Test sensory level by
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gently pinching the skin at shoulders and progressing down sides ascertain level at which patient can no longer feel pinch.
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Carefully record findings in patient's clinical record report changes in patient's motor/sensory level immediately to
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HCP
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Be on high alert for signs of
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spinal shock
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signs and symptoms of spinal shock
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complete loss of motor, sensory, reflex, and autonomic activity below the level of injury. this is temporary but may last for several weeks
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with spinal cord injury If turning is allowed and patient is not on a turning frame or turning bed, the patient must be carefully________ with the spine maintained in alignment.
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log-rolled
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(1) Sensory nerve. (2) Transmits smell impulses from receptors in the nasal mucosa to the brain.
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CN 1 olfactory
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(1) Sensory nerve. (2) Transmits visual impulses from the eye to the brain.
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CN 2 optic
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Motor nerve. (2) Contracts the eyeball muscles.
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CN 3 oculomotor nerve
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(1) Motor nerve. (2) Contracts the eyeball muscles.
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CN 4 trochlear nerve
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(1) Mixed nerve. (2) Transmits pain, touch, and temperature impulses from the face and head to the brain (sensory function). (3) Contracts the muscles of chewing (motor function).
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CN 5 Trigeminal nerve
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(1) Motor nerve. (2) Contracts eyeball muscles.
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CN 6. abducens nerve
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Mixed nerve. (2) Transmits taste impulses from the tongue to the brain (sensory function). (3) Contracts the muscles of facial expression and stimulates secretion of salivary and lacrimal glands (motor function).
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CN 7 Facial
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(1) Sensory nerve. (2) Transmits hearing and balance impulses from the inner ear to the brain.
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CN 8 Vestibulocochlear Nerve (VIII).
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(1) Mixed nerve. (2) Transmits taste impulses and general sensations from the tongue and pharynx (sensory function) to the brain. (3) Contracts the swallowing muscles in the pharynx and stimulates secretions of the salivary glands.
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CN 9 Glossopharyngeal Nerve (IX).
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(1) Mixed nerve. (2) Transmits sensory impulses from the viscera (heart, smooth muscles, abdominal organs), pharynx, and larynx to the brain. (3) Secrets digestive juices, contracts the swallowing muscles of the pharynx and larynx, slows down the heart rate, and modifies muscular contraction of smooth muscles.
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CN 10 vagus
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(1) Mixed nerve. (2) Transmits sensory impulses from the pharynx and larynx to the brain. (3) Contracts the muscles of the pharynx, larynx, and the neck.
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CN 11 spinal accessory nerve
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(1) Motor nerve. (2) Contracts the muscles of the tongue.
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CN 12 Hypoglossal nerve
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this scale is used to assess subarachnoid hemorrhages or aneurysms
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Hunt hess scale
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what is worse, grade 1 or grade 5?
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grade 5
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asymptomatic or mild headache with minimal nuchal rigidity is this grade on the hunt hess scale
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grade 1
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moderate to severe headache with nuchal rigidity and non neurological deficit is this grade on the hunt hess scale
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grade 2
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drowsiness or confusion with mild focal neurological deficit is this grade on the hunt hess scale
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grade 3
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stupor with moderate to severe hemiparesis is this grade on the hunt hess scale
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grade 4
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coma with decerebrate posturing is this grade on the hunt hess scale
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grade 5
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