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Med Surg 2 > acute Intracranial Problems > Flashcards

acute Intracranial Problems Flashcards

1
Q

3 types of non compressible contents in skull

A

Brain tissue
CSF
Blood

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2
Q

Monro-kellie doctrine

A

The sum of volumes of brain, CSF and intracranial blood is constant

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3
Q

Normal ICP
Increased ICP definition
Risk for what with increased ICP

A

Normal: 5-15
Increased icp: >20 mmHg for >5mins
Risk for herniation with increased ICP

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4
Q

Primary vs secondary injury

A

Primary:
Blunt force

Secondary:
Swelling
Ischemia
Hypoxia
(Things that are caused by primary)

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5
Q

Causes of increased ICP

A

Increased brain volume

Increased CSF

Increased cerebral blood volume

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6
Q

What causes increased brain volume

A

Edema
Hypo osmolality
Increased capillary permeability

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7
Q

What causes increased CSF

A

Hydrocephalus
Excess production of CSF

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8
Q

What causes increased cerebral blood volume

A

Ineffective ventilation

Hypoxia

Hypercapnia (vasodilation) too much CO2

Hypocapnia (vasoconstriction too little CO2

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9
Q

Normal CO2 range

A

35-45

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10
Q

Early signs of increased ICP

A

Restlessness, agitation, change in behavior (sign of change in LOC)

HA (worst HA in your life)
Visual disturbances
N/V
Vitals change
Seizures

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11
Q

Late sign of increased ICP

A

Significant change in LOC

Fixed, dilated or unequal pupils

(Cushings triad):
1.HTN w/ widening pulse pressure (systolic and diastolic get further
2. Brady cardia
3. Irregular breathing patterns (cheyne-stokes or agonal breathing)

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12
Q

Clinical manifestations of increased ICP

A

Change in LOC (due to impared cerebral blood flow 🔽 O2)
-subtle symptoms (difficult to around, flat effect(their normal then no response), disoriented)
-severe coma:no response to pain, non pupil, gag or cough reflexes

Ocular signs:
Sluggish, non-reactive, difference in size
(ipsilateral dilation is a late sign): same side as injury

Motor:
🔽 in function
Hemiparesis or hemiplegia
Decorticate posturing
Decerebrate posturing

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13
Q

Decerebrate vs decorticate

A

Decerebrate (away from core)
Damage to upper brain stem

Decorticate (to the core)
Damage to one or both corticospinal tracts

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14
Q

Glasgow coma scale
Eyes
Best motor response
Best verbal response

A

Eyes:
4 spontaneous
3 to verbal command
2 to pain
1 no response

Best motor response
6 obey
5 localizes pain
4 flexion-withdrawl
3 decorticate
2 decerebrate
1 no response

Best verbal response
5 oriented and converses
4 disoriented and converses
3 inappropriate words
2 incomprehensible sounds
1 no response

Score 3-15

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15
Q

Increased ICP complications

A

Inadequate cerebral perfusion:
CPP <60 (cerebral perfusion pressure
50=ischemia and neuro damage
30=ischemia uncompatible w/life

Cerbral herniation:
Through open skull fracture
Downward
Laterally

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16
Q

increased ICP diagnostic test

A

CT: asap, check for bleed (no contrast)
MRI: tissue changes and ischemia
ABG: CO2 or hypoventilation
EEG: check for seizures
Cerebral angiography: blockages in brain
ICP measurement devices: measure pressures
Transcranial doppler: like a CT

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17
Q

ICP labs

A

BMP: Na (may increase)
Coags

Test if you have SIADH or DI:
Urine specific gravity
Serum osmolality

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18
Q

Management of ICP`
-figure out what
-nutirition
-meds for what
-support what
-normal valures

A

Figure out cause: infection, trauma

Nutrition: tube feed or parenteral

Med for ulcer prevention

Support VS:
Meds to control BP (want MAP 50-70)
Control temp
Ventilation:
-PO2 >80
-CO2 35-45
CO2 >45 (causes cerebral vessel to dilate increasing ICP)
CO2 <35 (vasoconstriction trouble getting O2 to tissue)

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19
Q

ICP meds and fluids
-control metaboic demands with what meds

A

ALL fluids in NS NO D5W!!!

Mannitol
Hypertonic saline (doesnt cross BBB & drawls fluid out)
Corticosteroids : with abscesses or tumors

Control metabolic demands:
-sedatives
-pain meds
-antipyretics
-seziure meds: pentobarbital coma if increased ICP refractory to other TX: must be on ventilator and in ICU
- 🔽 enviornmental stimuli

20
Q

Mannitol
What it does
Dose
Se
Pt must have

A

🔽 brain water content
Dose: 0.5-1g/kg over 15 mins

Se: HOTN, dehydration, electrolyte disturbances

Pt must have adequate intravascular volume prior to infusion:
UOP, BP, HR, quality of pulse, skin turger.

21
Q

Mannitol nursing implications
Assess and labs
Use what to infuse

A

Serum osmo 2 hrs after dose
BUN & creatinine
Neuro assessment Q1

Must use a filter to infuse (crystalizes)
Assess med prior to infusion for these crystals

22
Q

Hypertonic saline
What it does (decreases what, increases what, prevents what)
Goal
How to administer and where
Assess what

A

🔽 cerebral water content
Increases MAP & CPP
Prevents hypernatremia

Goal:
Serum Na 145-155
Serum osmo <320

Administer as continuous infusion or single bolus dose
Must administer via central line
Assess lungs and CXR (risk of pulmonary edema)

23
Q

Nursing management
ABC
Neuro
Fluid and electrolytes
Seizure precautions

A

ABC:
Pt awake enough to protect airway
Must have adequate BP (MAP) for perfusion

Neuro:
GCS
Pupil
Motor
Reflexes: corneal reflex, cough and gag

Fluid & electrolyte: SIADH and DI

Seizure precaution

24
Q

Nursing actions to manage ICP

A

HOB 30 degrees (venous drainage)
Head midline with body (C-collar check fit)
Pre-oxygenate prior to suctionng
Space nursing activities out
Avoid excess stimulation

25
Q

TBI
Traumatic brain injury
Predictors of poor outcomes

A

GCS <8
Older
Associated hematoma
Posturing
Hypoxemia
Hypercapnia

26
Q

TBI patho
-what it is
-words to classify it
-skull fx types
-risk of

A

Damage to scalp, skull meninges and brain
Open or closed
Acceleration-deceleration (coup contracoup)

Skull fractuir:
-Linear fx: assess CSF leak, halo test, raccoon eyes, battle signs
-depressed fx: injury to skull and possible dura
If dura torn: brain exposed to environment
Risk for seizure

27
Q

TBI
Concussion
Contusion

A

Concussion:
Mechanical force to skill
May lose consciousness
Memory problems
Long term effects later with repeated blows to head

Contusion:
Coup and contracoup injury
Bleeding and bruising of brian

28
Q

TBI
Penetrating injury
Scalp laceration

A

Penetrating injury:
Low or high velocity force

Scalp laceration:
Clean, debride, assess for Fx
Bleeding
Avulsion (tendon or ligament come off bone)

29
Q

Hematomas:
Epidural
Subdural
Intracerebral

A

Epidural:
Blood between skull and dura
(associated wit artery, blood accumulates fast)

Subdural:
blood accumulates below dura and above arachnoid covering of brain
(Venous bleeds slower)

Intercerebral:
Hematoma within the brain tissue

30
Q

Diffuse axonal injury

A

Acceleration-deceleration mechanism
Shearing of axons
Cerebral edema: injury to cells/neurons
Pt remains unconscious
Lasting effects and requires pt/ot

31
Q

Secondary brain injury

A

Related to initial trauma:
Increased capaillary permeability
Increased cerebral edema
🔽 perfusion
Hypoxia
Infection

32
Q

Surgical interventions for ICP

A

Craniectomy: remove bone flap on affected side
Evacuate hematoma
May leave bone off and allow brain to swell

Cranioplasty: replace bone later

33
Q

Post of care for ICP

A

Assess ICP, VS, CSF leak

mechanical ventilation if needed

If EVD (external ventricular drain) monitor output

34
Q

Nursing management: head injury

A

assessment like ICP

Assess:
ABC
Neuro status Q1
GCS

35
Q

Brain tumors types
Primary
Secondary
Benign
Malignant

A

Primary lesion:
originates in brain

Secondary:
Metastasis: outside of brain comes to brain

Benign: slower growing

Malignant: faster more dangerous

36
Q

Brain tumor CM

A

HA
N/V
Seixures
Cognitive changes
Weakness
Aphasia (slurred speech)

37
Q

Brain tumor diagnostic studies

A

CT

MRI

EEG

History

38
Q

Brain tumor tx
Sx
Procedures
Other kinds
How it is adminsitered

A

Sx:
Craniotomy

Burr hole: drill holes to release pressure

Shunt: drain into ventricles of the brain allow us to move CSF elsewhere

Radiation
chemo
-meds that cross BBB
-Ommaya reservoir:intrathcal admin:
*Can administrate chemo and abx into csf

39
Q

Meningitis
What it is
Types and their types

A

Inflammation of meningeal tissue

Bacterial: more deadly:
-streptococcus pneuoniae
-neisseria meningitis

Viral:
-HIV, HSV
-abx given until confirmed then supportive, manage s/s

40
Q

Bacterial meningitis and viral miningitis CM
Similar ones

A

Fever
Iritability
Severe HA
Nuchal rigidity
Photophobia

41
Q

Bacterial meningitis CM seperate

A

Tachycardia
N/V
Seizures
Signs of elevated ICP
Decreased LOC
Petechial rash

(Viral could have but theyll be milder)

42
Q

Meningitis nuchal rigidity test

A

Brudzinski’s neck sign:
Flex neck causes flex in hip&knee

Kernigs sign:
Hip flexed and plain when straightening leg out

43
Q

Meningitis diagnostic test
1st then 2nd
Do what before ABX
What is expected in bacterial sample vs viral

A

1st: CT (see if it is safe to get it0
2nd: CSF via lumbar puncture only after CT scan
(Prevent herniation if too much fluid off too fast)

Culture before abx:

Bacterial: sample csf:
low glucose, high protein, WBCs (cloudy CSF) and culture will grow

Viral: sample csf:
Normal glucose, High protein, negative culture, less wbcs

44
Q

Bacterial meningitis tx
Meds
Monitor
Isolation

A

Meds:
-ABX IV
-Corticosteroids (drexomethazone)
-Manage fever (because ⬆️ BMR = ⬆️ O2 demand)
Anticonvulsants (prevent seizures)

Monitor:
F&E
Neuro status
Safety precautions: (pad rails, O2, suction, fall precautions)

Isolation:
Droplet

45
Q

Viral meningitis tx

A

No isolation
Start abx until dx confirmed, then DC

Antiviral: herpes or influenza the cause

Anticonvulsants

Usually just let it run its course

46
Q

Bacterial meningitis prevention

A

Vaccination

Handwashing

Abx for contacts if your not vaccinated

47
Q

Viral meingitis prevention

A

Reduce direct contact

Handwashing

Enteroviruses spread in stools too

Med Surg 2 (5 decks)

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