Acute Intracranial Flashcards
Bacterial Meningitis
manifestations
a) head
b) skin
c) other
d) what are positive for?
a) Headache,Fever, inc ICP,LOC
b) petechiae,red macular rash
c) nuchal rigidity(neck stiffness)
photophobia
SIADH(too much ADH=hyponatremia)
d) Kerning sign(kenn)
Brudzinski sihn(neck)
Meningitis DX
a) Analyze CSF bacterial or viral?
b) Lumber puncture pre-ope
c) lumber post-ope
a) bacterial=cludy, viral=clear
b) Consent
lateral recumbent, “cannonball” position
Make sure patient has not received heparin lovenox, w/in 24hrs.
c) Send specimen to lab
Supine 4-6 hours
Monitor puncture site
Increase fluid intake
Meningitis
Collaborative Care
a) what isolation? then what?
b) Minimize exposure to what?
c) Monitor for?
a) DROPLET ISOLATION
Private room
Report to Public Health department
b) exposure to bright light
c) increased ICP
HOB 30*
A nurse is assessing for the presence of Brudzinski’s sign in a patient who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique?SATA
A. Place patient in supine position
B. Flex patient’s hip and knee
C. Place hands behind the patient’s neck
D. Bend patient’s head toward chest
E. Straighten the patient’s flexed leg at the knee
A,C,D
What does a positive Kernig sign, Brudzinski sign, photophobia, and nuchal rigidity mean?
Infection
Increased intracranial pressure
Meningeal irritation
Cranial nerve dysfunction
Meningeal irritation
a) Thrombolytics, Inclusion
b) Thrombolytics, Exclusion
Ishemic cause PE, DVT
b) ischemic stroke
neuro defict present
non-contrast CT
(negative for hemorrhage)
Initiated within 3-4.5hr
c) >3-4.5 hr passed since onset
CT POSITIVE for hemorrhage
INR/PT/aPTT prolonged
major surgery within 14 days
previous stroke/head injury/GI bleed w/in 3M
recent active internal bleeding w/in 22days
Hemorrhagic Stroke
a) characteristics?
b) causes?
a) more serious
all sudden,get worse very quick
b) HTN
ruptures cerebral anerusym
cocaine use
trauma,a fib
Aneurysm and AVM
assessment
a) s/s?
b) BP must less than?
a) worst headache of my life
dec LOC
nuchal rigidity
photophobia
positive kerning or brudzinskin sign
b) 160
Brain tumer
S/S
Headache common worse at night
Seizure with metastases
N/V
Memory altered, mood/personality changes
Hydrocephalus
Increased ICP, cerebral edema
Brain tumer
a) surgery post-ope
b) VP shunt
a) monitor for ICP
b) make sure to monitor for infection
-inc ICP, dec LOC. restlessness, headache, blurred vision.vomiting
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure?
Place client in jacket restraint
Wrap client hands in soft “mitten” restraints
Tuck client arms and hands under the drawsheet
Apply a wrist restraint to each arm
Wrap client hands in soft “mitten” restraints
The earliest signs of increased ICP the nurse should assess for include?
Cushing triad
Unexpected vomiting
Decreasing level of consciousness
Dilated pupil with sluggish response to light
Decreasing level of consciousness
Exam
Change in respiratory status
a) cycle of hyperventilation and apnea(periods of shallow breathing alternate with periods of deeper, rapid breathing)
b) Sustained, regular, rapid deep breathing(even during states of sleep, low PaCO2)
c) prolonged inspiration
d) clusters of breath followed by irregular pauses(apneic episodes)
e) completely irregular with irregular pauses and increasing periods of apnea
a) Cheyne-stokes
b) Central neurogenic hyperventilation
c) Apneustic
d) cluster
e) ataxic
Exam
Glasgow Coma Scale
a) Possible score from?
b) critically ill patient is less than?
a) 3-15
b) 9
A patient with an intracranial problem does not open his eyes, has no verbal response except moaning and muttering stimulated, and flexes/withdraws his arm in response to painful stimuli. The nurse records the patient’s GCS score as
6
7
9
11
7
Monro-Kellie hypothesis
a) what is 3 elements?
b) loss of autoregulation occurs with?
a) 80% is the brain tissue
10% is the cerebrospinal fluid
10% is the intravascular blood
b) injury to the brain which cause hypotension and hypoxia
→ cerebral ischemia and impaired cerebral autoregulation
Chemical autoregulation
a) Vasoconstriction occurs when?
b) Cause ICP inc or dec?
c) we don’t want dec too much PaCO2 why?
a) body becomes alkalotic(PaCO2 <35)
b) dec
c) leads too much vasoconstriction and brain tissue death
hemical autoregulation
a) Vasodilation occurs when?
b) Cause ICP inc or dec?
a) becomes acidotic or hypoxic
b) Inc
An unconscious patient with increased ICP in on ventilation support. The nurse notifies the health care provider when arterial blood gas measurements reveal a
a. pH 7.43
b. SaO2 of 92%
c. PaO2 of 50
d. PaCO2 of 30
c
Cerebral Perfusion Pressure
a) How CCP calculated
b) Normal CPP is?
c) High ICP means?
d) CCP 50?
e) CPP less than 30?
a) MAP-ICP=CPP
b) 60-100 mmHg
the higher number is better blood flow
c) compressed arterioles in the brain= Low oxygen, low glucose= Ischemia
d) Ischemia
e) Incompatible with life!!!!
BP 150/80 ICP 25
What is the CCP?
Early S/S of Increased ICP
Changes in Level of Consciousness
Vomiting-usually not preceded by nausea
Vital signs:no change until late
dec motor function
decorticate and decerebrate posture
s/s inc ICP posture
a) DeCORticate
b) DEcErEbratE
a) flextion
b) extend/more serious
Late Sign
Cushing Triad
Cushing triad involves
Inc SBP
Widened pulse pressure
Bradycardia with full bounding pulse
Irregular respiratory pattern
The nurse recognizes the presence of Cushing triad in the patient with
Increased pulse, irregular respiration, increased BP
Decreased pulse, irregular respiration, increased pulse pressure
Increased pulse, decreased respiration, increased pulse pressure
Decreased pulse, increased respiration, decreased SBP
Decreased pulse, irregular respiration, increased pulse pressure
to Decrease ICP
a) position?
b) how to prebent Hypoxia
Maintain PaO2 and PaCO2 how much?
c) drug?
a) HOB 30*
Maintain head/neck in neutral alignment
b) Maintain PaO2 > 100 & sat > 95%
Maintain PaCO2 35-45
c) Mannitol
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion r/t cerebral tissue swelling. What nursing intervention will be included in the plan of care?
Keep HOB elevated to 30 degrees
Position patient with knees and hips flexed
Suction patient frequently to improve oxygenation
Cluster nursing interventions to provide uninterrupted rest periods
Keep HOB elevated to 30 degrees
SIADH
a) s/s
b) osmolality
c) serum osmolality
a) very small, very concentrated urine
JVD,crackles, tachycardia, HTN
b) greater than 1.030
c) less than 285
hyponatremia
Diabetes insipidus
a) s/s
b) osmolality
c) serum osmolality
a) super pee out,super thirsty
b) less than 1.005
c) grater than 295
