HEAD (NEUROLOGICAL/ PSYCHIATRIC)

I. Cerebrovascular accident: sudden loss of brain functioning A. Types: 1. Ischemic: Decrease blood supply to brain vessels 2. Hemorrhagic: Intracranial bleeding B. Symptoms: Slurred speech, unilateral movement, drooped face, blurred vision, numbness C. Interventions: 1. Maintain airway function 2. Provide neuro-checks every hour and vital signs 3. Assess gag reflex related to aspiration risks 4. Perform a Glasgow Coma Scale every 30min-hour D. Glasgow Coma Scale (Normal 8-15 or <7 indicates coma)
Spontaneous; open with blinking at baseline Opens to verbal command, speech, or shout Opens to pain None Obeys verbal commands Purposeful movement to painful stimulus Flexion: withdraws from pain Flexion: abnormal (spastic) decorticate Extension: abnormal (rigid) decerebrate None Orientedx3 (person, place, time) Confused conversation Speech (Inappropriate) Speech (Incomprehensible) None 4 3 2 1 6 5 4 3 2

Eye Opening Response

Motor Response

1
5 4 3 2 1

Verbal Response

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Seizure or Epilepsy: A seizure results from a chaotic or excessive discharge of neurons. It is considered a symptom that has many underline causes such as head injury, drugs, intoxication, feveretc. Epilepsy is a clinical diagnosis, which is characterized as recurring seizures. A. Types 1. Generalized: Involves both sides of the brain i.e. tonic-clonic (formerly grand mal) or absence (petit mal) 2. Partial: Involves a specific part of the brain or one hemisphere; loss consciousness (complex) or no loss of consciousness (simple) 3. Status Epilepticus: Life-threatening condition in which the seizure lasts longer than 30min. Treatment should begin within 5min. Airway management and benzodiazepines are

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imperative. The longer the seizure occurs, the more the brain is damage and should be treated promptly B. Documentation (COLD) 1. Character: What was the seizure activity occurring? Document the body parts involved, the activities beforehand 2. Onset: When did start? What was happening? Note any incontinence or trauma that occurred. 3. Location: Where did the activity start? 4. Duration: How long did the seizure last and its post-ictal stage? C. Interventions: 1. Place the patient in seizure precautions 2. Obtain capillary blood sugar so hypoglycemia is not confused with the person post-ictal phase 3. Obtain blood samples: Used to assess medication, alcohol levels Spinal Cord Injury: A disruption of nerve tracts that cause sensory loss, paralysis, or nervous system dysfunction A. Types of injury 1. Cervical: Quadriplegia a. Ventilated dependent related to diaphragm paralysis b. All four extremities paralyzed c. Injury above C3 is usually fatal 2. Thoracic: Paraplegia a. Paralysis of lower extremities b. Bladder and bowel incontinence c. Increased risk of having autonomic dysreflexia: A complication occurring above T6, symptoms include severe hypertension (systolic<200), headache, diaphoresis 3. Lumbar: Decrease control or paralysis of lower extremities and loss bowel/bladder function B. Interventions 1. Immobilized the client or place a c-collar on him/her until cleared by the attending physician, usually after x-ray and CT scan results 2. Maintain respiratory function 3. Assess vital sign hourly Meningitis is an infection of the meninges, a protective membrane that cover the brain and spinal cord. There are different types of meningitis, however, bacterial meningitis is life threatening that has a very high mortality rate if left untreated

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A. Three Classic Symptoms: Change in LOC, nuchal rigidity neck stiffness, and a sudden high fever B. Interventions 1. Anticipate a lumbar puncture to isolate the organism 2. Promptly administer IV antibiotics, hydration, oxygen Suicidal Ideation: To have thoughts or a plan of committing suicide A. Identify High Risk Groups: adolescents, elderly, stressful life events i.e. sexual orientation conflicts, chronic illnesses, substance abusers B. Interventions 1. Initiate suicide/safety precautions a. Stay with the patient or implement using a sitter b. Use restraints as ordered and document the incident accordingly c. Remove sharp or dangerous objects 2. Anticipate psychiatric services; the patient may be cleared of threatening behavior and sent home with follow-up/ outpatient treatment 3. If discharged make sure the patient is aware of resources readily available 4. Psychotic episodes should follow similar interventions