176 exam 1 Flashcards
What are common cause of a head injury?
Head injury
MVA
Assault
Falls
What are some different types of brain injury?
Scalp injuries (hematoma)
Concussion/ TBI (falls, blasts, injury, sports, MVA)
Contusion (bruising/bleeding into brain)
Intracerebral hemorrhage (stroke or bleeding w/in brain tissue; spontaneous)
Penetrating injuries (surgical intervention; through skull and brain tissue)
sudden - progresses rapidly - critical
- Burr holes
Important relationship between BP, pulse, & ICP (cushing’s triad)
- Monro-kellie-doctrine
S/s:
- Headache, light sensitivity/ pupillary changes (early)
- Change LOC/speech/vision (early)
- Cushing’s triad, change in vitals (late)
- Motor/sensory, Flaccid (unable to move) (late)
Clinical management:
- Semi-fowlers/ 30*, straight alignment, comfortable
- Hyperventilation: Suction 10 seconds (decrease ICP, can cause anoxic brain injury), Ataxic breathing (Biot’s Breathing; unpredictable irregularity)
- Fluid management: increase fluids to increase perfusion
- Mechanical drainage: ICP monitor
- Drug therapy: Mannitol, Decadron (MS)
- avoid flexion of the hips, waist, neck and rotation of the head, enemas and laxatives, and valsalva maneuver
-administer oxygen via NC to improve cerebral perfusion
Increased Intracranial Pressure (IICP)
What are some Dx tests for IICP?
MRI (tumors), CT (bleeding)
Skull X-ray (fractures, abnorm bone)
EEG (brain waves, seizures)
Brain biopsy (stages tumors)
lumbar puncture/ spinal tap (tests spinal fluid, infection/ diseases)
Volume of cranium ( brain tissue, CSF, blood) is constant
Increase must be accompanied by decrease in one or the other
Fun Fact: Brain takes up 80% space
Monro-kellie-doctrine
Osmotic Diuretic
inhibits reabsorption of water and electrolytes
Use: Cerebral edema, TBI, encephalitis
Adverse: Seizure, tachycardia, HF, Circulatory overload
Nursing Considerations:
- Check vitals( for tachycardia)
- Monitor urine o/p (for dehydration)
- Monitor electrolytes (for electrolyte imbalance)
- BUN/Cr & liver panel
- May cause phlebitis at IV site
- Monitor neuro status
- Administer via a filter
Know it works when LOC, eye opening, urine o/p increase, & speech patterns all improve
Mannitol (Osmitrol)
Steroid - glucocorticoid - long acting
Decrease inflammation
use: Cerebral edema, allergic reaction, MS, meningitis
Side effect: Hypokalemia, hypotension
Adverse: HF, thrombocytopenia, angioedema
Monitor Bs, mood, & s/s of cushing’s syndrome, poor wound healing, liver panel, lipid levels, and cholesterol
Decadron (dexamethasone)
Hallmark symptoms of IICP
late sign and typically means brain is about to herniate
Rise in systolic BP, with unchanged diastolic BP, decreased HR & RR
- widening pulse pressure, bradycardia, and abnormal respirations
- cheyne-stroke RR (deep breaths)
Keep pressure at 20 (highest)
S/s:
- decreased BP
- increased Pulse
- Increased RR
Cushing’s triad
Where does most ICP issues occur?
Meninges
What are causes of intracranial complications?
Perfusion
- constant blood flow to the brain
Neurotransmission
- Adequate transmission of nerve function
- Stroke, seizure, MS, and dementia can impact
Glucose regulation
- constant glucose supply needed to maintain optimal brain function
- Blood brings glucose to brain
- Diabetes impacts
Pathology
- healthy brain tissue for optimal function
- MS, meningitis, & encephalitis impact
What are 3 types of medications usually administered to patients with IICP?
Osmotic Diuretics
- hyperosmolar drugs; draw water from the edematous brain tissue and reduces it in 15min for 5-6hrs
Corticosteroid
- need blood glucose levels closely monitored
Anticonvulsants
- Given to head injury patients
Would a lumbar puncture be performed if there is increased ICP present? Why?
No, brain herniation may be precipitated by increasing the pressure gradient between cranial vault and spinal cord
Mechanisms or conditions that impact intracranial processing and function
Need to maintain balance that promotes optimal brain function
Intracranial regulation
Who is at risk factors for intracranial issues?
Population
- elderly
- adolescence/ young adults
- young children
- athletes
Individuals
- depends of cause of injury/ pathology
- ex: pregnancies, HTN, meds, DM(2), stroke, Alz/dementia, genetics
What disorders affect Intracranial regulation?
Developmental/ genetic
Trauma (biggest)
inflammation/infection (meningitis, encephalitis, cerebral edema)
Neoplasms (brain tumor)
Degenerative process (MS, dementia)
Vascular disease (cell death d/t lack of blood flow)
Metabolic & endocrine disorders (glucose regulation)
used to assess level of consciousness in trauma patients
- not used under age 3
best eye, motor, and verbal response
- higher # = good, low # = bad
GCS
chronic, progressive, degenerative neurological disorder
- cause is unknown (mostly genetic predisposition)
usually affect ages 20-40 (women more affected than men)
Myelin sheath damaged by immune system and nerve signal is disrupted (demyelination)
S/s:
- Blurred vision/ vision changes
- Tinnitus, decreased hearing
- urinary retention (incontinence, superpubic cath)
- Paralysis, muscle spams, weakness
- Speech/ swallowing issues (peg tube)
Dx based off Hx
- MRI of spinal cord and brain to reveal plaques that characterize
- No Cure
Multiple Sclerosis (MS)
What are nursing interventions for MS?
Encourage mobility (ROM exercises, PT/OT)
Nutrition ( increase fiber, fruit/veg, well balanced diet)
Skin care (avoid breakdown, reposition q2h)
Activity (balance rest/ exercise)
Control environment (avoid hot baths & monitor for urine retention)
protect from opportunistic diseases ( C-diff, pneumonia)
“Brain attack” - medical emergency
- S/s appear suddenly
- occurs more in men
S/s:
-“worst headache ever” (Hemorrhagic)
- stiff neck (Hemorrhagic)
- loss of consciousness (Hemorrhagic)
- seizure (Hemorrhagic)
- depends on area affected (Ischemic)
- one sided weakness (unilateral; Ischemic)
- vision changes (Ischemic)
- confusion (Ischemic)
- headache (Ischemic)
- dysphagia (Ischemic)
2 types:
- Hemorrhagic: hemorrhage into brain; shows on CT
- Ischemic: formation on embolus/ thromboses that occluded an artery; does NOT show on CT
Stroke (CVA - Cerebrovascular Accident)
What does BEFAST stand for?
B - Balance: sudden loss of balance?
E - Eye: vision changes?
F - Face: droop? have smile
A - Arms: weakness?
S - Speech: strange/slurred
T - Time: LKW, TPA given
w/in 3 hr
What are modifiable/non-modifiable risk factors for a stroke?
Modifiable:
- DM, HTN, high cholesterol, heart disease
- smoker, alc.
- obesity, sedentary lifestyle
Non-modifiable:
- age (50-75), gender (men)
- race, hereditary (latino, AA d/t HTN)
- previous hx
What neurological deficits could occur after a stroke?
Aphasia, dysarthria (communication issue)
Dysphagia (aspiration, malnutrition, check gag reflex, swallow study)
hemiplegia
unilateral neglect (patient doesn’t believe or “forgets” that side doesn’t work)
sensory impairment
What are some diagnostic tests for a stroke?
CT (fastest, determines stroke type)
-w/o contrast
MRI, ECG/EKG
EEG (later)
Cerebral & carotid angiography
Blood studies ( lipid, PT/INR)
Deficient blood flow to the brain from a partial or complete occlusion of an artery
Causes:
- Thrombotic (atherosclerosis; coagulation disorder/ chronic hypoxia)
- Embolic (thrombus is endocardial layer of heart; rheumatic heart disease)
treatment:
- Thrombolytics such as tissue plasminogen activator (tPA, alteplase; acute ischemic stroke)
- digests fibrin and fibrinogen and thus lyses the clot
- platelet inhibitors and anticoagulants given if stroke is caused by thrombus or embolus (ischemic stroke) to prevent more clots (must be given after 24hrs if treated with TPA)
Ischemic stroke
Results from bleeding into the brain tissue or subarachnoid space
- the bleed causes damage by destroying and replacing brain tissue
an aneurysm is often the cause of hemorrhage
treatment:
- craniotomy: clipping the aneurysm/ removing the clot to prevent re-bleed
hemorrhagic stroke
Administered IV w/in 3hrs from onset stroke symptoms
breaks up clot causing stroke
- stronger than heparin
CT/MRI needed to confirm no hemorrhage exists in the brain
Monitor for bleeding - place on bleeding precaution
Thrombolytic (t-pa)
Infection of meninges, membrane around the brain and spinal cord, caused by a virus or bacteria
Vaccine given to prevent infection in people “living in crowds”
- travelers, military, dorms, ect
S/s (sudden; early recognition):
- fever, cold hands/feet,
- rash, pale, blotchy skin
- v/, headache, confusion/ changed LOC
- stiff neck (chin tuck), severe muscle pain
- light sensitivity
Dx tests:
- Lumbar puncture ( determines is bacterial or viral)
- CT/MRI (brain swelling, shows affect area, assesses for complications)
- Throat culture (detects/ identifies bacteria
Meningitis
What are two positive signs of meningitis?
Kernig’s sign
- resistance of leg while hip flexed 90* then raise foot
Brudzinski sign
- Head to chest w/ knees flexed
Most severe for of meningitis
- medical emergency
Can have seizure or neurological defects
- show s/s of swelling on brain
person to person contacts / contagious
- droplet isolation
- enters through nose & pharynx
Tx:
- Droplet isolation
- prompt recognition
- broad spectrum antibiotics
Bacterial meningitis
Least severe form of meningitis
- most common
not usually deadly
- recovery w/in 1-2 weeks
Tx:
- Rest
- Increase fluids (oral/IV)
- Meds to decrease fever and headache
Viral meningitis
Inflammation of the brain itself
- Usually viral - slower/ gradual onset
- resembles meningitis
- fatal if untreated
May be from HIV, ticks, mosquitoes, measles, pox or mumps
S/s:
- Neuro damage
- N/V/H/Fever
- Seizure, aphasia, paralysis
- stiff neck, muscle weakness
- Abd. pain
- Increased BP/ cushing’s triad
Tx:
- Safety precaution ( increase seizure & fall risk)
- meds for comfort
- therapy to increase strength, speech & ADLs
- Monitor vitals & neuro status
Encephalitis
What are some complications that you may see in encephalitis?
Change LOC, IICP
Sensory/ motor changes
Change in speech
Sudden change in behavior d/t electrical hyperactivity in the brain
can lead to permanent neuro damage d/t depletion of O2 & glucose stored in the brain
Causes:
- Trauma, infection, epilepsy
- reduced cerebral perfusion
- Electrolyte disturbance ( hypoglycemia, acidosis, dehydration, metabolic panel)
- tumors, stress, drugs
- genetic tendencies
Dx:
- Rule out specific problems (aura)
- EEG (detects brain wave activity)
4 types:
- focal, generalized, acute symptomatic seizure, & unprovoked seizure
Anticonvulsant drug therapy
- DONT STOP TAKING MEDS
Seizure
Affects one area of the cortex affected during onset seizure
- most commonly occurs with epilepsy
Retained or impaired awareness
- may appear awake but usually do not respond to instructions or questions
Can tell when seizure is about to begin
- seizure typically lasts < 3 min
- Aura typically precedes the seizure
Focal Seizure
Affects the whole brain
- most common
-Loss of consciousness
tonic clonic
- fall/ slumped, stiffness, jerking, frothing, cyanosis
- post-ictal stage
- injury risk
- about 1 min long
Myoclonic
- brief jerking/ stiffness
Absent
- “staring spells”
- eye blinking, lip smacking
- 5-10 seconds long
Generalized seizure
Type of seizure caused by TBI, & drugs/ alc. withdrawal
Acute symptomatic seizure
Seizure of unknown cause, nervous system disorder, or older brain injury
unprovoked seizure
Medical emergency d/t continuous seizure for over 30 min
- depletes O2 and glucose from the brain resulting in permanent brain damage
IV anticonvulsants, neuromuscular blocks or general anesthetics used to stop/ slow activity
Tx:
- resolve underlying cause
- dose of meds gradually increase until therapeutic level achieved
- Combination of anticonvulsants may b e needed to help control activity
- DO NOT STOP TAKING (can lead to severe seizure activity)
- Ask when last seizure was
Management:
- safety precautions (do not leave client)
- padded side rails, side lying position
- move from harmful objects
- Remove loose fitting clothing, don’t restrain
- provide privacy, note time and duration
- provide education on stress, alc/caffeine, and meds (keppra, lorazepam, ect)
- if aura = find safe place
Status epilepticus
inhibits seizure activity (antiseizure)
- reduces pain
Use: generalized tonic-clonic seizures; status epileptic
Side effects:
- Hypotension
- Slurred speech
- Agranulocytosis
- Skin rash
- N/V/Constipation
adverse reactions:
- V-fib, bradycardia, cardiac arrest
- hepatitis
Interventions:
- Given IV
- Monitor BP & HR (report bradycardia)
- safety precautions ( if Ataxic or drowsy)
Dilantin (phenytoin)
Antiseizure/anticonvulsant/mood stabilizer
- slows transmission of impulses in the CNS
- prevents seizure
- reduces pain
Use: tonic-clonic, complex-partial, mixed seizures
Side effects:
-Drowsy/ ataxia (lose muscle control)
- fluctuating BP
- HF, urine retention
- Rash, hepatitis
- Aplastic anemia (body stops producing new blood cells)
- Agranulocytosis
- Increased BUN
Adverse reaction:
- Stevens-Johnson syndrome
Interventions:
- Monitor BP
- Avoid Alc. and excessive sunlight
-Report fever, jaundice, bruising/ bleeding
Tegretol (carbamazepine)
antiseizure/ antipsychotic
- PO/IV
used to decreases seizure activity
- simple, complex, absent seizures
Side effects:
- Lethargy/ dizziness
- Ataxia (lose muscle control)
- Thrombocytopenia
- N/V/H, weight gain
- Tumor, Alopecia
Interventions:
- Monitor Blood work
- Safety precaution (if drowsy)
depakote (valproic acid )
Antiseizure/ Anticonvulsant ( PO/IV)
- stabilise electrical activity in the brain and prevent seizures
- Decreases severity and incidence of seizures
Side effects:
- Somnolence (strong desire for sleep, or sleeping for unusually long periods)
- Dizzy, impaired coordination
- Abnorm. behavior
- Fatigue, infection
adverse reaction:
- hepatitis
- stevens-johnson syndrome
Interventions:
- Safety precaution (if drowsy)
- Ask when last seizure was
- Interacts w/ other drugs
- No Alc.
- DO NOT STOP TAKING
- May alter RBC, WBC, and liver function
Keppra (levetiracetam)
Antiseizure/ Sedative/ benzodiazepines (PO, IM, IV)
- Initial tx of epilepsy
- Also used before surgery and medical procedures to relieve anxiety
Side effects:
- Drowsy, rash
- N/V/D
- Resp. depression
- Hypotension
- Phlebitis
adverse reaction:
- ECG changes
- Tachycardia
- Apnea
- Cardiac arrest (IV, rapid)
Interventions:
- Safety precaution (if drowsy)
- Monitor for extravasation
- Monitor BP
Ativan (Lorazepam)
Antiseizure/ Sedative (IV)
- can treat anxiety, muscle spasms, MS, CIWA and seizures
Side effects:
- Hypotension
- Blurred vision
- Slurred speech
Adverse reaction: Resp. depression
Interventions:
- Assess IV site
- Monitor vitals
- May go into alc./drug withdrawal
Diazepam (Valium)
MS agent given subq
action: modifies immune responses responsible for MS by serving as a decoy to local antibodies
Side effects:
- n/v/d
- blurred vision
- tachycardia
-ecchymosis
adverse reactions:
- vaginal hemorrhage
- laryngospasms
Glatiramer acetate (Copaxone)
Short term confusional state w/ sudden onset (reversible/ transient)
- disturbance in consciousness that impairs awareness of environment
Management:
- Treat cause
- infection give antibiotics, agitation give antipsychotics
- drug interaction = change med
- Private room w/ minimal stimulus, reorientate, family objects in room, keep same nursing staff (impaired cognition)
- Nonpharm interventions to help sleep/ relax, plan activities to get uninterrupted sleep, nightlight (sleep disturbance; sundowner)
-Bed lowest position, allow pt to sit in chair, encourage visitors (potential injury)
Stimulate mind & maintain activity
- keep hydrated/ well nourished (hypovolemia risk)
Watch for electrolyte imbalance
Goals: Safety, comfort, decrease anxiety
Delirium
What are some causes of Delirium?
Helpful Hint: think “PINCHME”
- P: Pain
- I: Infection
- N: Nutrition
- C: Constipation/ urinary retention
- H: Hydration
- M: Meds
- E: Environmental triggers
What lab results would you see in a patient with delirium?
High BUN & Cr
What are factors that contribute to delirium?
Infections:
- meningitis, encephalitis, HIV, UTI
- Bacteremia, septicemia
Cardiovascular disease:
- Hypovolemia, CHF
Metabolic conditions:
- Fluid / electrolytes, DM
- Hepatic/renal/pulm, failure
Vascular incidents:
- Stroke, chronic subdural hematoma
Trauma:
- Head injury, burns, hip fracture
NCLEX QUESTION
The nurse is collecting data from a client, and the client’s spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?
A. Dementia
B. Schizophrenia
C. Seizure disorder
D. Obsessive-compulsive disorder
A. Dementia
NCLEX QUESTION
Which of these clinical observations should the UAP report to the LPN for a client with a brain tumor who is taking dexamethasone?
(Select all that apply)
A. Weight gain of 3 lbs since yesterday
B. Tremors and diaphoretic skin
C. Blood pressure change from 150/90 to 120/78
D. Complaints of a sore throat
E. Moist cough
A. Weight gain of 3 lbs since yesterday
D. Complaints of a sore throat
E. Moist cough
NCLEX QUESTION
A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition?
A. Memory loss occurring as part of the natural consequence of aging.
B. Difficulty coping with physical and psychological change.
C. Severe cognitive impairment that occurs rapidly.
D. Loss of cognitive abilities, impairing ability to perform activities of daily living.
D. Loss of cognitive abilities, impairing ability to perform activities of daily living.
NCLEX QUESTION
WHEN CARING FOR A PATIENT AFTER A HEAD INJURY, THE NURSE WOULD BE MOST CONCERNED WITH ASSESSMENT FINDINGS WHICH INCLUDE RESPIRATORY CHANGES ALONG WITH WHAT OTHER FINDINGS?
A. HYPERTENSION AND TACHYCARDIA
B. HYPOTENSION AND TACHYCARDIA
C. HYPOTENSION AND BRADYCARDIA
D. HYPERTENSION AND BRADYCARDIA
D. HYPERTENSION AND BRADYCARDIA
What are example of Mild neurocognitive Disorder?
Missing appointments
Forgetting when to take meds
Overwhelmed by activities
Loss of directions
Fixes:
- calendars
- Med holder
- Clocks, Planners
- Maps, GPS, time management (be home before dark)
Impaired ability to remember, think, or make decisions that interferes with doing everyday activities
- Not a part of normal aging
- Not a disease, but a clinical symptom
nursing interventions:
- Allow pt to perform what they can (impaired ADLs)
- Remove distraction from table, high protein foods (inadequate nutrition)
- Keep awake during the day (sleep disturbances)
- Safe environment (potential injury)
- establish toilet schedule, or urinary intervention (urinary incontinence safety)
- Agitation may mean pain, hunger, stress, fear, or toileting
Dementia
What are some nursing interventions for dementia?
Cognitive function:
- Diff. staying on task, diff. with decision making, carrying out plans & activities
- impairment to long & short term memory
-Inability to understand or use words
- Unable to perform usual activities
(Ex:driving)
-saying/doing inappropriate things, personality changes, insensitivity
Allow pt to perform what they can, establish toilet schedule (impaired ADLs)
Remove distraction from table, high protein foods ( inadequate nutrition)
Keep awake during the day (sleep disturbances)
Safe environment ( potential injury)
What are 3 different types of dementia?
Alzheimer’s Disease (most common)
Vascular dementia
Lewy Body Dementia
What are some dx associated with dementia?
TBI, subdural hematoma
Brain tumor
Neurosyphilis
AIDS
What medications would you give to a patient with Alz/dementia to slow down progression?
Donepezil (Aricept) - mild to severe
Memantine (Namenda) - mod to severe, used later
antidepressants & antipsychotics
HELPFUL FACT: Most meds act to increase the amount of acetylcholine in the brain
When are medications for Alz/dementia most effective?
Early to middle stage of Alzheimer’s disease
Treats symptoms of Alzheimer’s disease, seizures, and Afib (PO)
- Mild to severe
Helps improve your attention, memory and ability to complete your daily tasks
Contradictions: Does Not prevent/ slow neurodegeneration by AD
Side effects:
- N/V/D
- Dyspepsia
Adverse:
- Bradycardia
Nursing considerations:
- Notify HCP if HR < 60bpm
Donepezil (Aricept)
Treats dementia associated w/ Alzheimer’s disease (PO)
- Type of glutamate (amino acid that acts as a neurotransmitter in your brain) receptor
- Mod to Severe AD
Contradictions: Show improved behavior
& cognition bu decline in ADLs
Side effects:
- Headache
- Restlessness
- Insomnia
Adverse:
- Increased motor activity, agitation
Interventions:
- Monitor Ph of urine
Namenda (memantine)
