Exam 3 Neuro: Care of Critically Ill Patients with Neurologic Problems (15 questions) Flashcards
1
Q
Transient Ischemic Attack (TIA)
A
- “Warning sign”
- Transient focal neurologic dysfunction
TIA: minutes to < 24 hours - Brief interruption in cerebral blood flow
2
Q
Stroke types
A
- Thrombotic
Gradual onset
Ischemic - Embolic
Sudden onset
Ischemic - Hemorrhagic
Sudden onset
3
Q
Stroke (brain attack)
A
- Change in normal blood supply to brain
Supplies glucose and oxygen
Removal of metabolic waste
4
Q
Stroke risk factors
A
- Smoking
- Substance abuse
- Obesity
- Sedentary lifestyle
- Oral contraceptive use
- Heavy alcohol use
- Use of phenylpropanolamine (PPA)
No longer produced in US
5
Q
Stroke Symptoms/assessment
A
- NIH Stroke Scale Score 0-40 - Cognitive changes - Visual changes - Facial palsy - Motor changes - Sensory changes - Cranial nerve assessment - CV assessment
6
Q
Right Hemisphere stroke symptoms
A
- Disorientation
- Loss of depth perception
- Unilateral body neglect syndrome
- Denial of illness
- impulsiveness
7
Q
Left Hemisphere stroke symptoms
A
- Aphasia, alexia, dyslexia
- Acalculia
- Right visual field deficit
- Anxiety, anger, frustration
- Intellectual impairment
8
Q
Stroke protocol (general)
A
- Goal of ED door to treatment:
< 60 minutes - Neuro exam q 15 min for first 2 hours
9
Q
Thrombolytic protocol
A
- IV (systemic) thrombolytic therapy
- Recombinant tissue plasminogen activator (rtPA) or Retavase
- Eligibility criteria Last seen normal (LSN) less than 3 hours Can extend to 4.5 hours Age < 80 years No anticoagulant use, INR < or = 1.7 NIH scale < or = 25 NO history of both stroke AND diabetes Priority of care
10
Q
Stroke medication
A
- Thrombolytics
- Anticoagulants
ASA, clopidogrel - Lorazepam, other antiepileptics
- Calcium channel blockers
- Stool softeners
- Analgesics (for pain)
- Antianxiety drugs
11
Q
Stroke nursing interventions
A
- Neuro assessments Post thrombolytic NIH guidelines - Monitor ICP - Safety (unilateral neglect) - Emotional support - Education - Bed at least 30 degrees
12
Q
Brain tumor nonsurgical management
A
- Radiation therapy
- Chemotherapy
Orally, IV, intra-arterially or intrathecally
Direct drug delivery post-surgically - Stereotactic radiosurgery
Gamma knife, CyperKnife
13
Q
Brain tumor craniotomy
A
- Surgical removal of a section of bone (bone flap) from the skull for the purpose of operating on the underlying tissues, usually the brain
14
Q
Brain tumor medication
A
- Analgesics
- Dexamethasone
- Phenytoin
- Pantoprazole (protonix)
15
Q
Craniotomy post-op care
A
- Fluid balance: Observe for DI/SIADH
- Incision
Assess site
Observe presence or absence of bone flap
Observe for CSF leak - Monitor ICP/Decrease ICP
Ventriculostomy - Avoid activities that increase ICP
Stool softeners to avoid valsalva
Antiemetics for N/V
Antipyretics/cooling blanket for fever - DVT prophylaxis
- Stress ulcers: Cushing Stress Ulcer
- Pneumonia:
High risk aspiration altered LOC - Proper positioning:
Avoid body position that increase ICP - Eye care
Washed, gloved hands
16
Q
Transsphenoidal hypophysectomy (TPH) nursing interventions
A
- HOB increase to 35-40°
- Hourly UOP
- Monitor electrolytes
- Avoid any straining
Antiemetics
Do NOT blow your nose - Monitor for visual disturbances
17
Q
Transsphenoidal hypophysectomy (TPH) complications
A
- Air embolism
- CSF leak
meningitis - Diabetes Insipidus
- Visual disturbances
18
Q
Subarachnoid Hemorrhage (SAH) from cerebral aneurysm
A
- Bleeding in the space between the brain and the tissue covering the brain.
- Damage to microvessels in the subarachnoid space
19
Q
SAH pre-op nursing care
A
- BP control (want it low), keep low To prevent rebleeding - Bedrest - Dark, quiet environment - Stool softeners, no straining - No restraints, keep calm - HOB ↑ 35- 45° degrees at all times - DVT precautions - Educate family to keep calm environment
20
Q
SAH Post-operative management
A
- Complications can lead to death
Cerebral vasospasm
Treatment: - HHH after clipping - Hypertensive Increase BP and CO with vasoactive drugs - Hypervolemic Volume expanders - Hemodilution Fluid
21
Q
SAH Complications
A
- Hyponatremia Isotonic fluids (N.S.)
- Rebleeding
Sudden onset HA, N&V,
Increased BP
Respiratory changes - Hydrocephalus
Ventriculostomy – temporary measure
Shunt – permanent measure - Seizures
Prophylactic anticonvulsant medication
22
Q
ICP normal value
A
Normal level: 5 – 15 mm Hg
23
Q
Increased ICP
A
- Typically treat ICP > 20 mm Hg that is sustained for 5 minutes
- An ICP level of 10-20, means the brain is borderline – it’s compensating
24
Q
CPP – cerebral perfusion pressure calculation
A
- CPP = MAP – ICP
- Normal/Target 70 – 95 mmHg
- CPP < 60 = hypoperfusion of brain
- CPP < 40 = brain ischemia
25
Q
ICP monitors
A
- Ventriculostomy
- Camino Monitors: Fiberoptic technology
26
Q
Care for Ventriculostomy
A
- Open Vs Closed
- Open: stopcock at zero point is open to drainage. When pressure in brain exceeds level of drip chamber, CSF will drain out.
- Closed: Monitoring only – no drainage
27
Q
ICP wave forms significance
A
Can be indicator of neuro change before numbers change
28
Q
ICP nursing interventions
A
- Monitor serum electrolytes
- Monitor serum Dilantin/Phenobarbitol levels
- CVP monitoring: Avoid volume depletion
- Diuretics
- Keep systolic BP 140 –160
- Hyperventilation
- Antiseizure meds: Phenytoin, Phenobarbitol
- Antipyretics/cooling blanket
- Pt positioning: Maintain HOB 30-45 degrees
- Head in neutral plane
- Avoid activities that increase ICP
29
Q
Increased ICP: Herniation
A
- Shifting of tissue from one compartment in the brain to another
Uncal herniation most common (Supratentorial herniation)
Lateral displacement uncus over edge tentorium - Leads to coma, loss of reflexes, posturing, loss brain stem function, and death.
30
Q
Care for Camino Monitors: Fiberoptic technology
A
- No transducer or anything to level
- Heavy cable – secure to patient
- ICP and CPP at least hourly
- Record waveform every 8 hours
31
Q
Mild traumatic brain injury
A
- Grade 1
- Altered or LOC <30 min with normal CT &/or MRI
- GCS 13-15
- PTA < 24 hrs
32
Q
Moderate traumatic brain injury
A
- Grade 2
- LOC < 6 hrs
with abnormal CT &/or MRI - GCS 9-12
- PTA < 7 days
33
Q
Severe traumatic brain injury
A
- Grade 3
- LOC > 6 hrs with abnormal CT &/or MRI
- GCS <9
- PTA > 7 days
34
Q
Skull fracture signs
A
- Raccoon eyes (Frontal or orbital fracture)
- Battle sign (Basilar Skull Fracture)
35
Q
Epidural hematoma pathophysiology
A
- Associated with skull fracture
- Damage to dura, veins and arteries
- 80% caused by: Arterial bleeding
Middle meningeal artery
Small percentage: venous bleeding
36
Q
Epidural hematoma symptoms
A
- *Immediate LOC, followed by lucidity, then rapid deterioration
- *Dilated, fixed pupil on the same side of injury
37
Q
Subdural Hematoma pathophysiology
A
- Small bridging veins torn between the dura and the skull, bleeding into the subdural space
38
Q
Subdural Hematoma symptoms
A
- Venous
- *Neuro altered from time impact (drowsy, confused)
- Progressive deterioration
Acute: first 48 hours
Subacute: 2 days to 2 weeks
Chronic: 2 weeks to several months
39
Q
Diffuse axonal injury (DAI) pathophysiology
A
-extensive lesions in white matter tracts occur over a widespread area
40
Q
-Mild DAI:
A
coma 6-24hrs, follows commands by 24hrs
41
Q
Moderate DAI:
A
coma lasting > 24hrs, no brainstem signs
42
Q
Severe DAI:
A
coma prolonged & associated w/ prominent brainstem signs
43
Q
Concussion
A
- A sudden transient mechanical head injury with disruption of neural activity
- Considered benign and resolves spontaneously
- May or may not lose consciousness
44
Q
Post Concussive Syndrome
A
- Symptoms 2 weeks to 2 months after concussion CM:
- N & V, drowsiness
- Persistent HA
- Lethargy
- Personality and behavior changes
- Shortened attention span
- Decreased short term memory
- Changes in intellectual ability
45
Q
Epidural/Subdural Bleed: Management Goals
A
- Surgical intervention
Craniotomy
Decompression: Evacuate clot, control bleeding
- Decrease ICP CSF drain (post op edema expected to peak 48-72 hours after surgery)
- CPP 70 or above
- Euthermia
- Analgesics & Sedatives
- Sodium level 145 or greater
- HCT level (The more it is diluted the better it flows)
- PaCO2 level
