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Complex Care > Acute Neuro Injuries > Flashcards

Acute Neuro Injuries Flashcards

1
Q

Where is CSF found?

A

ventricles, around the brain, spinal cord and subarachnoid space

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2
Q

What is the purpose of CSF

A

to cushion, absorb shock and provide nutrients

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3
Q

Middle cerebral

A

most common artery for stroke

feeds 2/3 of the frontal, parietal and temporal lobes

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4
Q

Basiliar

A

Stroke here can quickly be devastating

Can result in locked in syndrome so you can only move your eyes and it affects sleep/wake cycles

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5
Q

Assessment for anyone with brain injury

A
  1. establish a baseline
  2. Airway/respiratory function
  3. cerebral oxygenation and perfusion
  4. regain maximal cognitive motor and sensory function
  5. subtle changes are key (Glasgow coma scale)
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6
Q

Conscious exam

A

Orientation
Concentration
Affect/behavior (is their behavior normal for the situation?), memory and logic

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7
Q

Cognitive dysfunction can be seen in

A
  1. reasoning
  2. Expressive aphasia (can’t get the words out)
  3. REceptive aphasia (don’t understand what is said to them)
  4. Global aphasia (mix of both)
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8
Q

When a patient has a short memory how should you provide patient teaching?

A

repeat multiple time, provide a paper copy, teach caregiver

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9
Q

Transient ischemic stroke

A 
less than 24 hours
symptoms resolve - blood flow reestablished before damage 
no infarct on scan 
decreased blood supply
warning or potential stoke
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10
Q

Ischemic attack (stroke)

A

more than 24 hours
destruction of neural tissue
brain damage

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11
Q

Hemorrhagic stroke

A

leakage of blood or blood vessel into brain tissue

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12
Q

Can you have multiple TIAs without a stroke?

A

Yes

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13
Q

Ischemic stroke: thrombotic

A

injury to blood vessel wall –> formation of clot

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14
Q

Ischemic stroke: embolic

A

embolus occludes a cerebral artery –> embolus travels to circulation
Common cause is issues with the heart like a.fib

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15
Q

What is the difference between a thrombotic and embolic stroke?

A

The type of clot and where it came from

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16
Q

Where are the majority of aneurysms?

A

in the circle of willis

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17
Q

Intracerebral hemorrhage (ICH)

A

bleeding in the brain, usually basal ganglia, poor prognosis, HTN is common cause

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18
Q

Subarachnoid hemorrhage (SAH)

A

intracranial bleeding in the CSF filled space between arachnoid villa and Pia mater, aneurysm is the common cause

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19
Q

AVM (arteriovenous malformation)

A

abnormal dilated blood vessel with inappropriate capillary network, thin walls, tortuous and at risk for clot formation
Can interfere with perfusion to brain

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20
Q

Penumbra

A

area of hypoxia/ischemia or edema that can lead to damage

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21
Q

Clinical manifestations of a stroke

A
  1. weakness/paralysis
  2. numbness and tingling
  3. speech
  4. personality changes
  5. blurred. vision
  6. double vision
  7. motor function
  8. communication
  9. affect
  10. intellectual functioning
  11. spatial perception alterations
  12. elimination
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22
Q

What do you ask a patient before using contrast?

A

do you have any allergies to iodine, shellfish, or radioactive dyes?

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23
Q

What is important to ensure the patient has none for before an MRI?

A

NO METAL
no metal in the body or on the body
No jewelry, pacemakers, stents, or surgical implants

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24
Q

Diagnostics for stroke

A
  1. CT - most important
  2. MRI - more specific
  3. CTA - cerebral arteries
  4. MRA - vascular legions and blockages
  5. Intra-arterial digital subtraction angiography (DSA) - gold standard for aneurysms
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25
Q

Other tests for patient that have suffered a stroke

A
  1. cerebral blood flow angiogram
  2. ECG and 24 hour heat monitoring
  3. Chest x-ray
  4. Echocardiogram
  5. Coagulation studies
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26
Q

Alteplase

A

Recombinant tissue plasminogen activator
Protein that breaks up clots
Given within 3-3.4 hours after onset
Ischemic strokes only

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27
Q

Stroke core measure/what needs to happen before discharge

A
  1. Venous thromboembolism
  2. discharge on antithrombotic therapy
  3. Anticoagulation therapy for a.fib/flutter
  4. Thrombolytic therapy
  5. Antithrombolytic therapy by end of hospital day 2
  6. Stroke education
  7. Assess for rehabilitation
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28
Q

Medication for stroke

A
  1. Antithrombotic (asirpin)
    2, Anticoagulants with a. fib (heparin/levenox)
  2. Cholesterol lowering agent (statin)
  3. Diabetic medication (insulin, metformin)
  4. Antihypertensive medication (metoprolol, lisinopril)
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29
Q

Surgical treatment/prevention of stroke

A
  1. Carotid endarterectomy
  2. Transluminal angioplasty
  3. Stenting
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30
Q

What is a carotid endarterectomy?

A

removes plaque from arteries

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31
Q

What is a transluminal angioplasty?

A

uses balloon to open up stenosed artery

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32
Q

What are modifiable risk factors to prevent a stroke?

A
  1. hypertension
  2. health diet: low fat, sugar and salt
  3. Weight control
  4. Regular exercise
  5. Smoking cessation
  6. Limit alcohol
  7. Know s/s of stroke
  8. Treat a.fib since it is a precursor to stroke
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33
Q

Watchman implant

A

inhibits blood to pool in this area so ischemic strokes can be prevented
Benefit: no long term anticoagulation medications

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34
Q

What does a SAH interfere with?

A

CSF reabsorption, hydrocephalus results and leads to vasospasms

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35
Q

What does a hemorrhagic stroke cause?

A

Increased ICP and changes in LOC

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36
Q

Does size, location and times of hemorrhage matter?

A

Yes they do.
Location- pons affects breathing
Size - the larger it is, the more damage and mortality
Time: if it spread quicker, increase in damage and mortality

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37
Q

SAH intervention

A

Medications: to decrease BP below 160
Interventional radiology: coiling
Surgical management: resection and emboli zing blood vessel
Minimize deficits, prevent rebleed, prevent vasospasms (nimodipine)
Hypervolemic, hypertensive, hemodiluation (tripe H therapy to prevent vasospasms)
Ventrculostomy

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38
Q

Nimodipine

A

Helps to prevent vasospasms
CCB
Check BP before giving the medication and hold if systolic is less than 90

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39
Q

What does the diet of a stroke patient look like?

A

Diet restriction and thicker liquids

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40
Q

Are stroke patients a fall risk?

A

Yes, they need to wear non-slip socks, bed alarm set, frequent checks, room near nurses station, ensure the call light is on the side they can see because they have visual deficits

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41
Q

Traumatic brain injury

A

Trauma to the skull, scalp, or brain

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42
Q

When do deaths occur after a TBI?

A
  1. immediately at the time of injury
  2. within 2 hours of the injury
  3. 3 weeks later
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43
Q

Primary/direct TBI

A
  1. laceration
  2. skull fracture
  3. concussion
  4. diffuse axonal injury
  5. focal lesions of laceration
  6. open penetrating/closed
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44
Q

Secondary TBI results from… and includes…

A

results from primary TBI and includes swelling, infection and hypoxic brain injury

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45
Q

Coup-contrecoup

A

coup - first impact

contrecoup - damage on opposite side when brain move back from primary impact

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46
Q

Epidural Arterial hematoma

A

neuro s/s appear quickly

47
Q

Subdural Venous hematoma

A

neuro s/s can be delayed

48
Q

Signs of a basilar skull fracture

A 
Battles sign (bruising behind ear) and raccoon eyes 
Worry about CSF leaks and antibiotics are given if CSF leak is suspected because there is a risk of meningitis
49
Q

Concussion

A

May have a brief loss of consciousness

HA, dizzy, concentration, sensitivities, amnesia of the event

50
Q

Post concussion syndrome

A 
weeks-months post concussion 
impact is often underestimated 
patient has memory/concentration concerns
Dull chronic headaches 
Poor school performance 
increase irritability
51
Q

What is a concern with a skull fracture?

A

CSF leaks

52
Q

TBI management

A 
Neuro checks for change in LOC
Monitor for increased ICP
Stroming 
Surgery:burr holes to remove blood 
Safety: high fall risk 
Risk for seizures
53
Q

What is storming

A

uncontrolled sympathetic response

S/S: high HR, high BP, sweating, high RR, dilation of the pupils, hyperthermia

54
Q

What is a major concern when a patient is storming?

A

fluid loss because they are sweating so much

55
Q

Brain tumors

A

occupy space in the brain

56
Q

Brain tumors can…

A

infiltrate and destroy brain tissue
be encapsulated and displace tissue
just present with a HA
compress tissue and vessels –> ischemia, edema, IICP, focal deficits

57
Q

Gliomas

A

grow rapidly, infiltrates, difficult to remove completely, malignant

58
Q

Meningiomas

A

slow growing, usually benign

59
Q

Pituitary adenoma

A

affect endocrine function and vision

60
Q

Neuromas

A

from cranial nerves, CN VIII

61
Q

Primary sites for metastatic tumors are

A

lungs, breasts and colon

62
Q

Brain tumor clinical manifestations

A

seizure, weakness, personality changes, speech. paralysis

63
Q

Brain tumor diagnostics

A

CT/MRI and biopsy

64
Q

Brain tumor management

A

Surgery if possibly
Ventricular shunt if hydrocephalus
Radiation/chemo
New treatments

65
Q

Nursing care for brain tumor

A

Behavior management
Language deficits
Supporting family
Seizures

66
Q

Craniotomy

A

Remove part of the skull to remove tumor, hematoma, relieve ICP or bleed, clip aneurysm and then replace it

67
Q

Pre-op interventions for craniotomy

A

Baseline neuro exam

Vital signs

68
Q

Post-op craniotomy

A

Neuro exam
Vital signs every 30 for 4 hours and then every hour
Pain
N/V - do not want patient to puke because it increase ICP
Maintain cerebral perfusion and normal ICP
Prevent and minimize complications

69
Q

Post craniotomy your patient is vomiting and has LOC changes, what do you do?

A

Get them a CT immediately

70
Q

Hemicraniotomy

A

Portion of skull removed and remains off
Allows for swelling
Only thin skin protecting the brain so place sign above bed says no bone flap, helmet when up!

71
Q

Ongoing assessments for craniotomy patients

A

Neuro and VS - every 30 minutes for 4 hours, then every hour.
Report any deficits and monitor for pain, N/V and change in LOC

72
Q

Pituitary tumors clinical manifestations

A

Vision changes, HA, endocrine disorders like ACTH, GH

73
Q

Where are most pituitary tumors?

A

Most are in the anterior lobe which provides ADH and is close to the eyes

74
Q

Treatment of pituitary tumor

A

Surgical removal: transphenoidal - through the nose

75
Q

Post-op transphenoidal removal

A
  1. AVOID sneezing, straws, anything inserted into nose
  2. Evaluate clear fluid leakage in case it is CSF
  3. Evaluate SIADH or DI
  4. vision changes every 8 hours to check for a bleed
  5. Neuro/vitals every 4 hours
  6. monitor I/Os and encourage drink to thirst
76
Q

Is nasal drainage normal after transphenoidal removal?

A

Yes, you just have to make sure that it is not CSF and to only dab it, no blowing

77
Q

How do you evaluate for CSF?

A

halo on pillow or sample collection

78
Q

What is the number 1 symptom of a CSF leak?

A

headache

79
Q

How do you evaluate SIADH/DI?

A

urine specific gravity is done with each void and a daily serum Na and osmolarity
Close to 1.000 is DI
Close to 1.030 is SIADH

80
Q

What do you do if they go into DI?

A

send a serum Na and osmolarity and a urine Na and osmolarity

81
Q

What is increased ICP a complication of?

A

stroke, TBI, tumor

82
Q

CSF

A

hydrostatic forced measured in the brain’s CSF compartment
Normal: 5-15
More than 20 –> treatment

83
Q

Cerebral blood flow

A

blood passing through the brain tissue in 1 minute

84
Q

Cerebral perfusion pressure

A

pressure needed to ensure blood flow to the brain and is affected by BP
Normal: 60-70, want above 60
Below 30 is incompatible with life

85
Q

What does the brain need to function?

A

Glucose and oxygen - it can’t store these so it needs to have constant flow of this

86
Q

What can the body do to keep ICP and cerebral blood flow constant to the brain?

A

Alter CSF amounts and cerebral vasoconstriction/dilation

87
Q

In order to maintain good CBF you need a MAP of..

A

70-150

88
Q

How do you assess ICP?

A
  1. Changes in LOC (most sensitive)
  2. Pupil exam/brainstem exam - late sign (fixed unilateral pupil size and shape - EMERGENCY)
  3. Motoring functioning (hemiparesis, hemiplegia, posturing)
  4. HA
  5. Vomiting
  6. Change in VS (cushings triad) - late
89
Q

What is cushings triad

A

HTN, widening pulse pressure, bradycardia, irregular respirations

90
Q

Herniation

A

happens with increase ICP, and is fatal when unrelieved

Will cause increased neuro deficits if untreated

91
Q

Diagnostics/monitoring ICP

A
  1. Intraventricular monitors - “ventriculostomy” is the gold standard
  2. Sensors that go in the brain in either the intraparenchymal, subarachnoid, or epidural space
92
Q

Factors that influence ICP

A
  1. Arterial/venous pressure
  2. Blood gasses (CO2)
  3. Intra-abdominal and intrathoracic pressure
  4. posture
  5. temperature
93
Q

Relationship between ICP and CPP

A

as ICP increases, CCP decreases

94
Q

Progression of a brain injury related to ICP

A

Cerebral edema and ICP peak in 2-3 days

Decrease of 1-2 weeks

95
Q

Blood pressure and ICP

A

Blood pressure needs to be within a good range to have adequate CCP
If it is too high it can cause too high of ICP
If it is too low it can cause too low of ICP

96
Q

How can you increase BP?

A

give fluids
colloids
vasoactive
osmotic diuretics (pull fluid from brain and encourage elimination)

97
Q

When do you treat HTN?

A

when CPP is above 120

98
Q

When do you treat ICP?

A

if it is above 20

99
Q

Blood gases and ICP

A
  1. Arteries dilate: increased CO2 –> decreased resistance –> increase CBF
  2. Arteries constrict: decreased CO2 –> increased resistance –> decreased CBF
100
Q

Positioning and ICP

A

Optimal HOB 30-45 degrees
Neck alignment is important
Caution any knee catching/elevating
Suction less than 10 seconds, 2 passes

101
Q

Temperature and ICP

A

Increased temperature –> increase ICP

102
Q

What can you do to reduce the temp of the patient? And how do you measure the temp of a patient?

A

Goal: normal body temp
Acetaminophen and mechanical cooling - beware of shivering because increase ICP
Measure internally such as rectal or bladder

103
Q

Medications to decrease ICP:

A
  1. osmotic diuretics - draws water from tissue into circulation (mannitol)
  2. Hypertonic 3% saline - increases osmolarity to decrease cerebral water
104
Q

What are considerations for mannitol and 3% saline?

A

Sodium, glucose, K, Mag levels

Serum osmolarity

105
Q

Pain management with ICP

A

morphine, propofol

106
Q

Medication for swelling with ICP

A

Decaron

Need to have a PPI or H2 blocker with it for GI bleeding

107
Q

Barbituates for ICP

A

Phenobarbital decreases cerebral metabolism

108
Q

Antiseizure meds can be given with ICP if..

A

seizure activity occurs

109
Q

Monroe Kelly hypothesis and ICP

A

If something in the brain is increase such as a tumor or edema, then something else must decrease like CSF or venous to compensate for that.

110
Q

Why are progressive changes in pt. presentation for increase ICP important?

A

Because it can lead to herniation if ICP is not treated and this can cause increased neuro deficits and death

111
Q

Rehab challenges for neuro injury

A

Quick initially and then it hits a plateau with ups and downs
Challenging for patients and their families (patients may have new behaviors and personalities depending on the location of their injury

112
Q

Epidermal hematoma vs subdural hematoma

A

Epidural: more severe and deadly because of arterial nature. Patient presents with loss of consciousness, then a period of lucidity, then rapid decline. Symptoms onset rapidly
Subdural: slower to present because of venous nature

113
Q

How is CBF regulated?

A

BP, CPP, MAP, CO2

114
Q

Is ischemia more likely with increased CBF or decreased CBF?

A

It can happen with both but is more likely to happen with decreased CBF

Complex Care (22 decks)

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