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CNUR 305 > Advanced Neurological Concepts > Flashcards

Advanced Neurological Concepts Flashcards

1
Q

What is a spinal cord injury? what is the morbidity and mortality?

A

Any injury to the neck or back that interrupts spinal cord functioning. Cervical is most common injury.
Usually males age 15-25
Life span decreased by 15-30 years
Mortality effect most by respiratory complications (pneumonia), renal (UTI) and Integumentary (Pressure ulcer)

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2
Q

What are the three types of acute spinal cord injuries?

A

Destruction (direct trauma)
Compression (by bone fragments, hematoma, or disk material)
Ischemia (Damage or impingement on the spinal arteries

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3
Q

What are the three results of neurological damage in the moment of spinal impact?

A

Cord compression, direct cor injury, disruption of cord blood supply

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4
Q

What is a secondary spinal injury? What are the causes?

A

Injury which occurs after the initial injury.

May be caused by swelling/inflammation, ischemia, moving of bony fragments.

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5
Q

What is a tetraplegia injury?

A

No movement in all 4 limbs

Will require manual ventilation

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6
Q

What is a paraplegia injury?

A

No movement in lower 2 limbs, Below C8

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7
Q

How is Neurological injury classified?

A

By the lowest segment of the spinal cord, where motor and sensory function on both sides of the body are normal

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8
Q

What is the dermatomes assessment?

A

Sensory assessment
Test the sensory points on each side of the body, with the sharp and dull ends of a paperclip
Have the patient’s eyes closed

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9
Q

High-Cervical Nerves (C1-C3) Most Severe

What is the movement functioning? ADLs? Complications?

A

Tetraplegia, spastic paralysis
Require complete assistance for ADLs
Respiratory- require mechanical ventilation, apnea is fatal
No bowel or bladder control
Need a wheelchair with special mouth control

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10
Q

Spinal cord injury:C6

Function and ADLs

A

Weak grasp
Has shoulder/bicep control to transfer ad push w/c
No bowel/bladder control
Requires some assistance, still has some degree of independence

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11
Q

C5 keeps _________ alive

A

Diaphragm

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12
Q

Thoracic T1-6 Injury

What is the movement functioning? ADLs?

A

Full use of upper extremities
Can transfer themselves in position changes
Can still do ADL’s with some modifications
Can Drive a vehicle with hand controls
No bowel/bladder control

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13
Q

Classifications of SCI: Amount of Cord injury, what is a complete transection?

A

No transmission of messages beyond the level of the injury

No sensation and no voluntary movement below the level of injury

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14
Q

Classifications of SCI: Amount of Cord injury, what is a Incomplete Transection?

A

Some messages are being transmitted
Interrupted messages may be motor, sensory or a combo of both
Variable degree of loss of function and sensation

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15
Q

What is Neurogenic Shock? What are the signs and symptoms?

A

Involves the SNS and results in autonomic instability
Hemodynamic syndrome that can occur in 30 minutes after injury and last up to 6 weeks
SCI and or above T6
Loss of sympathetic input from hypothalamus- decreased SNS vasoconstrictor tone
Parasympathetic is unopposed and takes over
-Massive vasodilation without compensation- venous pooling and decreased cardiac output
No sympathetic response and no compensation
Symptoms:
1. Hypotension-Rx, fluids and inotropes
2. Bradycardia- Rd, atropine, pacemaker
3. Peripheral Vasodilation- warm, flushed

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16
Q

What is spinal shock?

A 
The loss of motor and sensory after trauma
Occurs in 50% of patients with SCI
Temporary in Acute phase
Will resolve with gradual recovery of reflexes
Symptoms below the injury:
Reflexes depressed/absent
Loss of sensation
Flaccid Paralysis
Everything below is flaccid
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17
Q

What is Autonomic Dysreflexia? What are the signs and symptoms?

A

T6 or higher
What: Loss of normal compensatory mechanisms when sympathetic nervous system is stimulated
Triggers are visceral stimulation
Over distended bladder, bowels
Pain
Sensory stimulation
Vasoconstriction of vessels below SCI, BP rises, baroreceptors sense BP and parasympathetic activated, PNS attempts to lower BP and heart rate

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18
Q

What are the divisions of the peripheral nervous system?

A

Autonomic: Sympathetic and Parasympathetic
Somatic: Allows the voluntary movement of muscles within the body, Receives sensory input

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19
Q

What is the normal sympathetic response?

A

Fight or Flight
Turned on in response to a significant stressor
Release of epinephrine and norepinephrine
Increased BP, increased heart rate, vasoconstriction, diaphoresis, dilated pupils, goosbumps

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20
Q

What is the normal Para-sympathetic response?

A

Resting and Digesting
Opposite response to Fight or Flight
Increase in Acetylcholine
Peristalsis, decreased BP, decreased heart rate, vasodilation,constricted pupils

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21
Q

How is the stress response altered in those with a SCI?

A

SNS activates, BP rises
Baroreceptor sense increased BP
Parasympathetic system is activated but can only create a response down to the level of injury
Above SCI: There will be parasympathetic activation- Vasodilation, Bradycardia
Below SCI: Continue to see sympathetic activation- severe constriction of blood vessels which will cause the BP to continue to climb until AD is rectified

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22
Q

When a patient is experiencing autonomic dysreflexia, which action should the nurse complete first?
Notify physician, assess foley cath patency, place patient in trendelenburg, place patient in high fowlers

A

Place patient in trendelenburg, assess foley cath

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23
Q

Autonomic Dysreflexia Nursing Interventions

A

1st: Raise HOB to 90 degrees, remove or loosen any abdominal binders, ted hose, foley leg straps
2nd: Rule out each cause, start with most common (full bladder, bowel, impaired skin integrity
3rd: Monitoring, BP control

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24
Q

What is the collaborative care for SCI?

A
  1. Sustain Life
  2. Prevent further injury

ER: Trauma protocol, primary survey (ABCDE), Secondary Survey, Foley, NG

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25
Q

How can a C-spine be ‘cleared’?

A 
ONLY by a physician!!
ONLY can be cleared clinically (without xray) if the patient:
-is awake and orientated
-has no distracting injuries
-Has no drugs/ETOH in board
-Has no neck pain
-Is neurologically intact

Diagnostics:
Xray initially
MRI is the gold standard

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26
Q

What is the drug therapy for SCI?

A

High dose methylprednisone:(For inflammation) loading dose/infusion within 8 hours of injury
Inotropes: MAP 80-90
SYmptomatic Treatment: eg. Bradycardia, GI, stress, ulcers, hypoactivity, short term pantoloc

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27
Q

Ongoing drug therapy for SCI?

A 
Control or to prevent complicatoins
Vasopressors to maintain perfusio
Immobility:
Histamine H2 blockers to prevent stress ulcers. anticoags to prevent DVT
Stool softeners
Antispasmodics for muscle spasms
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28
Q

SCI Collaborative Care: external stabilization/immobilization

A

Initially bed rest, log rolling, hard collar

Align and stabilize the spine, decrease damaging motion, prevention of secondary injury, Traction (gardner-wells tongs, Halo vest)

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29
Q

SCI Collaborative Care: Surgical decompression and stabilization

A

Decompression of spinal cord/nerves
Cone/tissue is pushing against the cord
Realignment and stabilization of bone: spinal fusion, wiring or rods to hold vertebrae together

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30
Q

Nursing managment of immobolity

A

Log roll as a single uit, provide assistnace to keep alignment
care, traction, collars, plints, braces, assitive deices for ADLs
Flaccid paralysis: high top tennis shoes or splints to prevent contractures, frequent ROM
Spastic paralysis: prevent spasms by avoiding sudden movements or jarring of the bed, internal stimulus
Treat spasms by decreasing causes

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31
Q

Nursing managment of CVC

A

Assess VS with MAP of 85mmHg to perfuse the cord
DO
prevent/treat orthostatic hypotension
assess BP, abd binder, calf compressors, TED hose, symptomatic treatment
Minimize vagal stimulation
DVT prophylaxis

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32
Q

Nursing managment Respiratory

A

Assess resp status
above C4, total loss of resp function, mech ventilation
below C4, diaphragmatic breathing, phrenic nerve
DO airway management, suctioning, protect airway, physio

Complications:
secretion management, atelectasis, hypoventilation

33
Q

Nursing Management: GI

A

Assess hypomobility, paralytic ileus, constipation, distention
stress ulcers, malnourishment,
DO bowel care, bowel training and nutrition, swallow assess, high fiber and fluid intake

34
Q

Nursing Management GU

A

Assess incontinence, retention, UTI
DO regular and complete bladder drainage, indwelling catheter, intermittent catheterizations q3-4 hours
Flaccid bladder: automatic emptying of bladder, urine fills bladder and dribbles out
spastic bladder: reflex arc but no connection to brain, reflex fires at will

35
Q

Nursing Management: Integumentary

A

Assess skin breakdown

do position shifts, nutritional status, prevent surgical site infection

36
Q

Nursing Management: psychosocial

A

Assess patient and family, overwhelming sense of loss, working through grief
DO
working towards adjustment, maintaining hope, control over environment, decreased sympathy, firm kindness, continual support

37
Q

MAP = 2/3 ________+ 1/3____________

what is the normal range?

A

2/3 diastolic + 1/3 systolic

65-100

38
Q

Intracranial pressure is exerted from the combined total volume of what 3 things? What is the range?

A

Brain tissue, CSF, Blood

0-15

39
Q

CPP=______ - _______? What is the range?

A

Cerebral Perfusion Pressure = MAP - ICP

70-100

40
Q

Scalp Laceration: Assessment and treatment

A

Assessment: mechanism of injury, if it gaps you would consider stitches, small unmoving lacerations can use skin glue
Treatment: very vascular, visualize, closure, Rx: tetanus, antibiotic ungt

41
Q

What are Skull fractures: Closed or Open?

A

A disruption/ break in the structure of the bone
Force> bone strength
Closed: skin intact
Open: scalp laceration

42
Q

Skull fracture: Linear skull fracture. What is it and what are the types??

A 
Linear means aligned. Fracture line in cranial bone, but the bone does not move. Most common type of skull fracture.
Types:
Hairline, vault of the skull
Basal, floor (base) of the skull
Diastatic: along a suture line
43
Q

Basal Skull Fracture Symptoms

A

Blood leaks from the fracture site:
Racoon eyes d/t pooling (bilateral periorbital ecchymosis
Battle’s Sign, postauricular ecchymosis. Bruising behind the ear

CSF Leakage from Meningeal Tear
Otorrhea and rhinorrhea

44
Q

Linear Skull Fracture: types according to # of fragments

A

Simple:
Occurs along 1 line splitting the bone in 2 pieces
Committed >2 fragments

45
Q

Depressed Skull Fracture

A

Bone fragments are comminuted
Fragments are displaced inward
increases ICP by decreased volume of the skull

46
Q

Brain Injury Severity: Mild

A

Initial GCS:13-15

Degree of Post Traumatic Amnesia:

47
Q

Brain Injury Severity: Moderate

A

Initial GCS: 9-12
Degree of Post Traumatic Amnesia: 1 to 7 days
Duration of Loss of consciousness: >30 minutes to

48
Q

Brain Injury Severity: Severe

A

Initial GCS: 3-8
Degree of Post Traumatic Amnesia: >7 days
Duration of Loss of consciousness: >24 hours

49
Q

What is the difference between retrograde amnesia and post-traumatic amnesia

A

Retrograde- memories shortly before the injury

Post-traumatic: confusion immediately following TBI, problems creating new memories

50
Q

TBI: concussion

A

Traumatically induced alteration in mental status, with out without a loss of consciousness
Memory loss, alteration of mental state, or personality, focal neurological deficits
Balance/motor problems, disorientation, LOC, loss of memory, blank look, vomiting

51
Q

What is post concussion syndrome?

A

One concussion puts you at risk for future events
Symptoms of concussion can last > 3 months after the injury, wide range of symptoms: physical, such as headache, cognitive, difficulty concentrating, emotional and behavioural irritability.

52
Q

What is chronic traumatic encephalopathy?

A

Memory loss, confusion, impaired judgment, reduced impulse control, aggression, explosive anger, depression, and progressive dementia

53
Q

What is a TBI primary injury?

A

Impact injury

Damage is done, fractures, skull fractures, lacerations

54
Q

What is a TBI Secondary injury?

A

Processes initiated by the trauma
Occurs hours-days following injury
40% of TBI patients deteriorate
Eg. Ischemia, cerebral edema

55
Q

What is a TBI: Coup-Countrecoup injury?

A

Force of the initial blow s great enough to cause:
Brain damage at the site of the initial impact between the skull and the brain
Brain to move in the opposite direction and hit the opposite side of the skull, causing damage to the other side
The side that received the initial blow it the coup
The opposite of the initial impact is the countrecoup

56
Q

Epidural Hematoma presentation and treatment

A

Caused by a focused blow to the head. Blood is pumped to the trauma and occupies the space. Must be caught and dealt with quickly.
Presents:
85-95% of patients have an overlying fracture of the skull
Majority located in the temporoparietal region where skull fractures cross the path of the middle meningeal artery
Class presentation of brief LOC–lucid and decreased LOC
Tx:surgical evacuation

57
Q

Subdural hematoma presentation and treatment

A

Injury is below the dura, typically venous (slower)
Most common type of traumatic intracranial lesion
deceleration injury fall/MVA without skull fracture
Presentation:
Acute: within 48 hours of injury
Sub-Acute: 2-14 days
Chronic: Weeks to months
Treatment: site and size dependant, surgical evacuation performed if necessary

58
Q

Subarachnoid Hemorrhage

A

Between arachnoid and pia mater
Usually a burst aneurism
Occurs in 25-40% of patients with a moderate.severe head injury
Up to 50% die or are left with impaired brain function

59
Q

INtraparenchymal (Bleeding within the brain):

Intracerebral hemorrhage and intraventricular hemorrhage

A

intracerebral: Parenchymal injuries from lacerations of contusions, large deep vessel injury, pushes/compresses adjacent brain tissue
Intraventricular: very severe TBI with a poor prognosis, very serious as the ventricles are ischemic

60
Q

What is a Diffuse Axonal Injury?

A

Shear, twisting, forces causing wide spread axonal damage
Can be mild to severe
Outcome is unpredictable
90% remain in a vegetative state

61
Q

What are signs and symptoms of neurological deterioration?

A 
Any change in neuro status
new onset seizure activity
CSF leakage
Pupillary changes
vital signs- rising body temp, increased systolic pressure, bradycardia, chance in resp pattern
posturing- decorticate or decerebrate
62
Q

Eyes change on same side as injury and limbs change on opposite. T or F?

A

true

63
Q

Early ICP, LOC, sensory, motor and other

A

Altered of decreased LOC, personality changes, confusion, restlessness, irritable
Visual disturbances, subtle changes in speech
decreased voluntary movement, contralateral hemiplegia (opposite side weakness), pronator drift (close eyes, hold limbs out and they will drop)

64
Q

Late ICP, LOC, sensory, motor and other

A

Further decreased LOC, reduced responsiveness, impaired speech to aphasia, flexion -extension posturing, decreased or absent reflexes, pupillary changes, decreased reactivity, projectile vomiting with no nausea, cushing’s triad

65
Q

What is Cushing’s Triad?

A

Cushing’s triad is a clinical triad variably defined as having: Irregular respirations (caused by impaired brainstem function) Bradycardia. Systolic hypertension (Widening Pulse Pressure)

66
Q

Cranial surgery: What is a Burr hole?

A

Opening into the cranium made with a drill, used to remove localized blood and fluid beneath the dura

67
Q

Cranial surgery: What is a craniotomy?

A

Opening into the cranium with the removal of a bone flap, and opening the dura to remove a lesion, repair a damaged area, drain blood, or release increased ICP

68
Q

Cranial surgery: What is a Craniectomy?

A

Excision into the cranium to cut away a bone flap.

69
Q

Cranial surgery: What is a Cranioplasty?

A

Repair of a cranial defect resulting from trauma, malformation or previous surgical procedure, artificial material used to replace damaged or lost bone.

70
Q

Nursing Management of patient’s with a TBI, Assessments and Goals?

A

Airway, neuro assessment, vital signs and parameters, temp, cushings, MAP
Complications: diabetes insipidus, SIADH, Seizure

Goal: Normal Parameters
ICP, SBP-MAP, Oxygenation, temperature, fluid balance,

71
Q

Monitoring for complications: ADH

A

Peeing less, ADH is antidiuretic hormone released by the pituitary, promotes water absorption

-DIabetes Insipidus: decreased ADH, Which equal excessive urine production
TX: Synthetic ADH, fluid replacment

Syndrome of Inappropriate ADH
increased ADH
high ADH equals low urine productions
TX: fluid restriction

72
Q

Nursing Management of Severe TBI: Maintain ICP at

A

Draining CSF decreases ICP
Administering sedation prevents ICP increases
Administering Mannitol is effective to decrease ICP
THe diuretic effect of mannitol can cause increased sodium and serum osmolarity levels and should be monitored at regular intervals
Elevate the head of the bed to 30 degrees and position patient in a neutral position
Removing or loosening rigid collars may decrease ICP

73
Q

Nursing Management of Severe TBI: Maintaining CPP between 50-70 mm Hg, optimizes cerebral perfusion

A 
Continuous ICP monitoring
Administering catecholamine (norepinephrine).
74
Q

Nursing Management of Severe TBI: Preventing DVT

A

Pharmacological treatment may be safe for DVT prophylaxis

Applying mechanical prophylaxis on admission may assist to prevent DVT eg. Tinz BID

75
Q

Nursing Management of Severe TBI: Adequate Nutrition

A

Initiating adequate nutrition within 72 hours of injury

Providing continuous intragastric feeding may improve tolerance

76
Q

Nursing Management of Severe TBI:Glycemic Control

A

Insulin therapy, given IV drip, for elevated serum glucose can improve outcomes
subcutaneous insulin admin has been shown to be unsafe and less effective than IV admin in critically ill patients

77
Q

Nursing Management of Severe TBI: Seizures

A

Administering antiepileptic drugs

78
Q

Brain Death- what is it define as?

A

Neurological determination of death, irreversible condition, no cortical or brainstem activity
Absent brainstem reflexes: corneal response, oculocephalic reflex, oculovestibular reflex
Absent Respiratory effort: apnea test

CNUR 305 (7 decks)

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