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NUR 212 > 2.9 Neurological, Sensory-Motor > Flashcards

2.9 Neurological, Sensory-Motor Flashcards

1
Q

Describe the following reflexes and their significance
REFLEXS CORNEAL
CN V & VII

A

When the cornea is touched there should be a brainstem reflex leading to blinking or bilateral eyes and tearing

Absence means something is affecting the nerves such as a tumor, brain stem CVA or brain death

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2
Q

Describe the following reflexes and their significance

OCULOCEPHALIC “DOLL’S EYES”

A

Positive reflex: when the head is turned the eyes should turn with opposite

Negative reflex: when the head is turned the eyes become fixed straight ahead

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3
Q

Describe the following reflexes and their significance

OCULOVESTIBULAR “COLD CALORICS”

A

When ice cold water is used to irrigate the EAR. The brainstem reflex should trigger the eyes to look toward the direction of the irrigated ear

Absence of the reflex indicate brain death

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4
Q

Describe the following reflexes and their significance
GAG
CN IX & X

A

There should be contraction of posterior pharynx muscles when stimulated

Absence can mean over sedation or brain death

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5
Q

Describe the following reflexes and their significance

BABINSKI

A

Planter response to movement of a hard object up the bottom of the food. Normal response is curling of all toes inward (negative Babinski)

Dorsiflexion or fanning of the toes indicates presence of Babinski (abnormal) and can indicate spinal cord or brain injury. (positive Babinski)

This is a primitive response in infants and can also occur with ETOH intoxication or seizure activity

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6
Q

Neuro assessment abnormal findings and their significance

RESPIRATORY CONSIDERATIONS

A

Damage to pons/medulla leads to inability to regulate breathing patterns based on oxygen and carbon dioxide. As a result, you have irregular patterns of breathing depending on the area of injury

Excessive yawning or sighing: first sign of deterioration
Cheyne-stokes: altered deep and rapid breathing with periods of apnea
Hyperventilation: 40 breaths/min or higher
Apneustic: long inhalation and long exhalation
Ataxic/Apneic: uncoordinated or irregular breathing, pt no longer responding to carbon dioxide

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7
Q

What is the Glasgow Coma Scale

A

Measure a person’s level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body
3 PARTS

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8
Q

Components of the Glasgow Coma Scale

EYE OPENING

A 
Eye Opening:
Spontaneously 4
To sound 3
To pain/pressure 2
No response 1
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9
Q

Components of the Glasgow Coma Scale

VERBAL RESPONSES

A 
Verbal responses:
Oriented 5
Confused 4
Single words 3
Incomprehensible sounds 2
No response 1
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10
Q

Components of the Glasgow Coma Scale

BEST MOTOR RESPONSE

A 
Best motor response:
Obeys commands 6
Localizes pain 5
Flexion-withdrawal 4
Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
No response (flaccid) 1
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11
Q

What does a GCS of 3 mean?

A

Could mean patient is dead
OR
Severe neurological injury

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12
Q

Describe the following head injury

BLUNT

A

No break in skin:
Acceleration (hit in head with bat)
Deceleration (fall)
Acceleration/decelerations (combination of two), Rotation, usually not good outcome, (brain rotating within skull, MVA, shaking baby)

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13
Q

Describe the following head injury

PENETRATING

A

Break in skin: gunshot, knives, metal object, rocks/objects of nature.
NI:
Never pull out object, secure and held in place
Control bleeding
High infection risk

Domestic: CPS, APS

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14
Q

Describe the following head injury

COUP-CONTRECOOUP

A

Acceleration and Deceleration head injury

ie: MVA with the head being forced forward and then back with anterior and posterior injury. Think “whiplash”

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15
Q

Pathophysiology and assessment finding of the following hematomas
EPIDURAL

A

Focal (localized) injury
Hematoma/Hemorrhage

Epidural:
Blood in space between the skull and dura mater, typically from an arterial bleed. Common with skull fractures

Findings:
Loss of consciousness then regain consciousness
ICP
Emergent surgical

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16
Q

Pathophysiology and assessment finding of the following hematomas
SUBDURAL

A

Focal (localized) injury
Hematoma/Hemorrhage

Subdural:
Blood in space between dura and arachnoid typically from a venous bleeding

Findings:
Acute: s/s during time of injury or few days later
Pupil changes
HA
Resp changes
Chronic: s/s can be weeks to months
Fall is common
Mimic dementia
Slow changes to complete loss of consciousness
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17
Q

Pathophysiology and assessment finding of the following hematomas
INTRACEREBRAL

A

Focal (localized) injury
Hematoma/Hemorrhage

Intracerebral:
Blood deep in brain tissue, most common with contusions, penetrating trauma, depressed skull fractures

Findings:
HA
Vomiting
Seizures
Reduced level of consciousness
Hemiparesis
Surgical need
Drain placed
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18
Q

Identify the complication of a traumatic brain injury

HERNIATION

A

Herniation Syndrome:
Shifting of the brain tissue into another part of the brain due to blood or edema.
Shifting shears/tears the vasculature causing decreased brain perfusion and ultimately brainstem compression and herniation

Supratentorial (3 types):
Cingulate: highest up in brain, increased ICP
Central: compression of midbrain, rapid decline of level of consciousness or coma
Uncal/lateral: pressing brain centrally, CNIII trapped, pupil dilation, decreased level of consciousness, respiratory arrest

Infratentorial:
Upward or downward displacement through foramen magnum altering vital functioning. May have altered respirations, fixed pupils, posturing, eventually resp or cardiac arrest

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19
Q

Identify the complication of a traumatic brain injury

BRAIN DEATH

A 
Non reversable loss of brain function
Must maintain normothermia
Absent of all reflexes
No depressant drug/ETOH poisoning
Institutional policy may include EEG, brain flow study, apnea test
Notify Gift of Life
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20
Q

Identify the complication of a traumatic brain injury

SIADH

A

Posterior pituitary can alter release of ADH

SIADH: syndrome of inappropriate antidiuretic hormone)
TOO much ADH causing retention of water
Urine: low volume, very concentrated, high specific gravity
Serum: low serum osmolality

Treatment:
Restrict fluid
Slowly replace Na+

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21
Q

Identify the complication of a traumatic brain injury

DIABETES INSIPIDUS

A

Posterior pituitary can alter release of ADH

Diabetes Insipidus:
Insufficient ADH causing diuresis
Urine: increased urine output, low specific gravity
Serum: increased serum osmolality

Treatment:
Fluid replacement
Reduce Na+
Replace ADH with vasopressin

22
Q

Identify the complication of a traumatic brain injury

HYPERTHERMIA

A

Impaired function of the hypothalamus altered temperature regulations (as long as infection has been ruled out). Increased temperature means increased cerebral metabolic rate and increased ICP. Antipyretics will not help. Use of ice packs and cooling blankets.

23
Q

Identify conditions that predispose a patient to increased intracranial pressure (IICP)

A 
Hydrocephalus
Bleeding in the brain
Swelling of the brain
Aneurysms
Brain/head injury
High blood pressure
Stroke
Infections: meningitis, encephalitis
24
Q

Identify the signs and symptoms of IICP

A

Early s/s:
Decreased level of consciousness
HA
N/V

Late s/s:
Pupil changes
Posturing
Cushing’s Triad

25
Explain why a sudden rise in IICP is such a catastrophic situation
.
26
Describe type of intracranial monitoring | EPIDURAL PROBE
Probe is placed between skull and dura mater No drain Can monitor ICP numbers
27
Describe type of intracranial monitoring | SUBARACHNOID SCREW
Fiber optic catheter placement allows the sensor to record from inside the subdural space No drain Can monitor ICP numbers
28
Describe type of intracranial monitoring | INTRAVENTRICULAR CATHETER
IVC is used to connect the ventricles of the brain to an external ventricular drainage device (EVD) system. typically inserted into the right lateral ventricle as not to interfere with language
29
Describe purpose and priority nursing interventions for patient with a ventriculostomy
IVC is used to connect the ventricles of the brain to an external ventricular drainage device (EVD) system. typically inserted into the right lateral ventricle as not to interfere with language NI: Dependent drainage of CSF Closely monitor output Risk for infection, keep system sterile Must level transducer at the tragus of the ear (per physicians order) Monitor ICP and CPP (cerebral profusion pressure) readings
30
Describe nursing care and interventions that prevents IICP in the critically ill patient
``` Maintain dressings, drains, special precautions for bone flap removal Close monitoring of vitals and ICP Reduce infection risk (VAP, antibiotics) Frequent neuro checks HOB up min 30 degrees Low stimulation Seizure precautions Family teaching Pain control ```
31
Describe nursing implications and rationale for use of medication for head injury patient DIURETICS: MANNITOL FUROSEMIDE
Diuretics: in attempt to lower ICP Mannitol: hyperosmotic Furosemide: loop diuretic (enhances Mannitol) Nursing: Strict I/O Monitor for fluid overload Monitor for dehydration
32
``` Describe nursing implications and rationale for use of medication for head injury patient ANTICONVULSANTS: PHENYTOIN DIAZEPAM LEVETIRACETAM LORAZEPAM ```
Anticonvulsants: to reduce the likelihood of seizures Phenytoin: anticonvulsant Levetiracetam: anticonvulsant Diazepam: benzo, antianxiety, anticonvulsant, sedative/hypnotic, muscle relaxant Lorazepam: benzo, antianxiety, sedative/hypnotic, analgesic adjunct Nursing: Monitor for SI Rash Vitals: resp, BP
33
``` Describe nursing implications and rationale for use of medication for head injury patient B/P MEDS: LABETALOL HYDRALAZINE NOREPINEPHRINE ```
BP meds to maintain MAP (70-110 norm) within parameters Labetalol: beta blocker, antianginal, antihypertension Hydralazine: vasodilator, antihypertensive Norepinephrine: vasopressor, produces vasoconstriction Nursing: Monitor BP I/O Monitor for fluid overload
34
``` Describe nursing implications and rationale for use of medication for head injury patient SEDATIVE/HYPNOTICS: PROPOFOL MIDAZOLAM DEXMEDETOMIDINE ```
Sedative/hypnotics: to reduce stimulation, muscle contraction and overall cerebral O2 demand Propofol: anesthetic, short 1/2 life, may decrease BP, MUST be mechanically intubated Midazolam: benzo, antianxiety, anticonvulsant, sedative/hypnotic, CNS depression, amnesia Dexmedetomidine: sedative/hypnotic, ICU sedation, may decrease BP and HR Nursing: Monitor HR and BP SI
35
Describe nursing implications and rationale for use of medication for head injury patient STEROIDS
Steroids: to reduce cerebral edema **NOT indicated in TBI, only with tumors Dexamethasone: anti-inflammatory Nursing: Check blood sugar I/O Check edema
36
Describe nursing implications and rationale for use of medication for head injury patient HORMONES VASOPRESSIN
Hormones: for treatment of diabetes and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Vasopressin: replacement hormone, antidiuretic, vasopressor, reduce urine output and increase urine osmolality Nursing: I/O Monitor BP, HR
37
Describe nursing implications and rationale for use of medication for head injury patient GI MEDS: FAMOTIDINE PANTOPRAZOLE
GI prophylaxis: to reduce likelihood of ulcers due to the reduce gut motility and stress on the body Famotidine: antiulcer, histamine antagonist Pantoprazole: antiulcer, proton pump inhibitor Nursing: Monitor for blood in stool, emesis, gastric aspiration
38
Describe nursing implications and rationale for use of medication for head injury patient ANTIPSYCHOTIC: PHENOTHIAZINE CHLORPROMAZINE
Antipsychotic: with alternate use for hiccups or shivering. Alters dopamine in CSN Chlorpromazine: phenothiazines, antiemetic, antipsychotic Nursing: Monitor fluid intake Bowel function BP
39
Describe nursing implications and rationale for use of medication for head injury patient NEUROMUSCULAR BLOCKING AGENT: VECURONIUM
Neuromuscular blocking agent: to provide paralysis in the event of uncontrolled seizures or need for induced hypothermia Vecuronium: IV fusion Nursing: Monitor HR, BP Peripheral nerve stimulator may be used to determine level of blockade induced. Determines level of paralyze of patient Four impulse are delivered to sites of ulnar, facial or tibial nerves: 0:4 too much paralytic 2-3:4 adequate paralysis 4:4 paralysis is insufficient
40
Identify priority assessments for barbiturate coma and neuromuscular blocking agents in pt with IICP
.
41
Describe the med/surg management of patients with cerebral aneurysm
Out pouching of cerebral artery, most common location is the circle of Willis If identified before rupture surgical interventions include clipping or coiling Prevent and treat of ruptured aneurysm: Vasospasm: use of Ca+ channel blocker Rebleeding: treat IICP
42
Describe the post op nursing care of a craniotomy patient
Cranial cavity is surgically opened, tumor/blood clot is excised via the bone flap removal and ultimate replacement of the bone Post op:
43
Identify nutritional modifications that are indicated for patients with head injuries
``` Patients may have swallow inability Tube feedings might be necessary Can increase metabolism Increase potassium intake Reduce carbs (too many carbs can cause CO2 buildup) NO nasal tubes, ONLY oral tubes ```
44
Describe post op care of the carotid endarterectomy patient
Surgical intervention to remove atherosclerotic plaque to prevent ischemic stroke (at the carotid artery bifurcation) Vitals: every hour HR: cardiac monitor Resp: monitor airway Pulse ox: O2 Dressing: to neck JP drain: check Cranial nerves: may have abnormality after surgery HOB: 30 degrees, support head with any movement
45
Describe pre and post op care for patient with corneal transplants
Lamellar: superficial replacement of cornea * *Penetrating: full thickness cornea is removed and replaced by donor - very fine sutures remain in place for 1 year (cornea is avascular and slow healing) - low risk of corneal rejection d/t avascular nature NC: Pain meds Position on unaffected side with HOB 30 degrees Administer steroid drops to reduce inflammation Assess eye patch/dressing for drainage Teach pt to avoid; coughing, sneezing, vomiting, straining Sudden sharp pain in eye may indicate hemorrhage Vision can take up to 12 mo to return
46
Describe pre and post op care of patients with enucleation
Removal of eye d/t malignancy, infection, glaucoma, intractable pain/trauma Outpatient Round implant placed to maintain shape Pressure dressing 24+ hours Pt can be up after surgery ``` NC: Observe for signs of hemorrhage Teach pt about s/s of infection and admin of drops Provide psychological support Irrigation of socket may be required ``` Long term eye prothesis is placed within 1-2 mo
47
Describe the effects a head injury has on reproductive health
Patient can experience: Sexual dysfunction Changes in hormone levels Infertility
48
What is the Cushing's Triad?
Increased ICP Increased BP Decreased HR Irregular respirations
49
Progression of IICP (cascade)
``` Cranial insult/injury= Tissue edema= Increase of ICP= Compression of blood vessels= Decreased cerebral blood flow= Decreased O2 with death of brain cells= Edema around ischemic tissue= Increased ICP with compression of brainstem/respiratory centers= Increase CO2 accumulation= Vasodilation= Increased ICP as result of increased blood volume= Death ```
50
8 (...ate) Interventions for ICP and TBI
1. Elevate - HOB min 30 degrees - avoid hip and neck flexion - The silence: reduce stimulation, provide block care 2. Oxygenate - deliver O2 is appropriate - blood transfusion: monitor Hgb for anemia (acidosis is NOT good = vasodilation = cerebral edema - limit suctioning: coughing/vomiting can increase ICP 3. Intubate - GCS of <8, notify provider - protect airway - optimal ventilation in critical patients 4. Hyperventilate - normal pCO2 is 35-45 mmHg - pCO2 = a potent vasodilator - hypercapnia (high pCO2) causes: vasodilation = cerebral edema = increased ICP - hypocapnia (low pCO2) causes: vasoconstriction = increase pH = decreased ICP = ischemia (lack of O2) 5. Medicate - BP med to maintain MAP within parameters - anticonvulsants - GI prophylaxis - antipsychotic - diuretics - hormones - steroids 6. Sedate - sedatives/hypnotics to reduce stimulation, muscle contraction and overall cerebral O2 demand - sedation does NOT remove their pain 7. Refrigerate - hyperthermia - hypothermia - goal normothermia 8. Evacuate - surgical intervention - ventriculostomy - nursing care post op

NUR 212 (22 decks)

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