Altered LOC.

Question 1

Alert:

Answer 1

attends to environment, responds appropriately to commands and questions with minimal stimulation.

Question 2

Confused:

Answer 2

disoriented to surroundings, may have impaired judgment, may need cues to respond to commands.

Question 3

Lethargic:

Answer 3

drowsy, needs gentle verbal or touch stimulation to initiate response.

Question 4

Obtunded:

Answer 4

responds slowly to external stimulation, needs repeated stimulation to maintain attention and response to the environment.

Question 5

Stuporous:

Answer 5

responds only minimally with vigorous stimulation, may only mutter or moan as a verbal response.

Question 6

Comatose:

Answer 6

no observable response to any external stimulation.

Question 7

Persistent vegetative state:

Answer 7

after brain injury; no cognitive function; have sleep-wake cycles; no voluntary movement.

Question 8

Locked-in syndrome:

Answer 8

motor pathway destroyed; cognitive fx but no motor; communicates by eye movement.

Question 9

Structural causes of LOC:

Answer 9

trauma, vascular, infection, neoplasms.

Question 10

Metabolic causes of LOC:

Answer 10

hypoxic encephalopathy, toxins, body temp extremes, seizures; HHNK, DKA, hypoglycemia.

Question 11

Glasgow coma scale:

Answer 11

eye opening: spontaneous – 4, to speech – 3, to pain – 2 , none – 1.
verbal response: oriented – 5, confused – 4, inappropriate – 3, incomprehensible -2, none – 1.
motor response: obeys commands – 6, localizes to pain – 5, withdraws form pain – 4, flexion to pain -3, extension to pain – 2, none – 1.

Question 12

Interventions for LOC:

Answer 12

ABC’s: support ventilation; head of bed up 30 degrees; avoid aspiration; turn to remove secretions; assess lung sounds; pulse ox; ABG’s; improve tissue perfusion: improve CO, hydrate, and turn q2 hours to improve venous return, TOM, TEDS; orient: sight, hearing, avoid neglecting; assess ability to chew; minimize confusing arrangement; clocks and calendars; pictures of family/friends; turn off lights at night; be patient and consistent; slow speech; body temp management: may need antipyretics or warming/cooling blankets; prevent injury: pad side rails if seizure risk; call light in reach; elimination needs; mobility: ROM, ambulation; skin care; nutrition; elimination needs; skin integrity; self-care.

Question 13

Intracranial volume:

Answer 13

brain tissue - 80%, CSF - 10%, blood - 10%

Question 14

Monroe-Kellie Doctrine:

Answer 14

an increase of volume of one intracranial component must be compensated by decrease in one or more of the other components so total volume remains fixed. Normal ICP ranges from 0-15 mmHg.

Question 15

Causes of increased ICP:

Answer 15

head injury, CVA, inflammatory lesions, brain tumors, intracranial surgery, CO2.

Question 16

If a patient becomes acutely unconscious, manage it as…

Answer 16

an actual or potential elevation in ICP.

Question 17

Factors that increase brain matter:

Answer 17

cerebral edema, tumor, hemorrhage.

Question 18

Factors that increase cerebral blood flow:

Answer 18

hypoxemia, hypercapnia, anesthetic agents, histamines, acidosis, and some antihypertensives.

Question 19

Increase in CO2:

Answer 19

relaxes smooth muscle, dilates cerebral vessels, decreases vascular resistance, increasing cerebral blood flow.

Question 20

Factors that increase CSF:

Answer 20

CSF, hydrocephalus, obstruction of CSF drainage pathways, lesions.

Question 21

Causes of transient increase in ICP:

Answer 21

Valsalva, isometric muscle contractions, shivering, decerebration, coughing/sneezing, REM sleep, noxious stimuli.

Question 22

Increased ICP is a ___.

Answer 22

medical emergency!

Question 23

Immediate tx of increased ICP:

Answer 23

fluid restriction, osmotic and loop diuretics, corticosteroids, anti-seizure meds, stool softener.

Question 24

Decrease ICP by:

Answer 24

HOB up.

Question 25

With increased ICP, monitor:

Answer 25

draining of CSF, hypoventilation, fever, fluid and electrolytes.

Question 26

Mild hyperventilation…

Answer 26

reduces PaCO2 = increased cerebral vasoconstriction = reduced cerebral blood flow = increased venous return = reduced ICP.

Question 27

With increased ICP…

Answer 27

increased need for glucose.

Question 28

Fluid should be…

Answer 28

restricted to reduce cerebral edema.

Question 29

Care of patient with increased ICP:

Answer 29

avoid hypotension and hypoxia, HOB elevated at 30, avoid jugular venous outflow obstruction, prevent/avoid coughing/valsalva/hip flexion/high PEEP, prevent agitation, decrease stimuli, body positioning.
don’t cluster.

Question 30

Early stage of increased ICP:

Answer 30

change in LOC (confusion, lethargy, restlessness), pupillary dysfunction, decreased visual acuity, motor weakness, headache.

Question 31

Later stage of increased ICP:

Answer 31

decreased LOC, vomiting, hemiplegia/hemiparesis, posturing, vital sign changes (Cushing’s triad), papilledemia (long standing increase in ICP).

Question 32

Headaches:

Answer 32

90% vascular or muscle contraction, 10% from underlying intracranial, systemic, or psychological disorder.

Question 33

Four types of migraines:

Answer 33

classec, common, hemiplegic/opthalmoplegic, and basilar artery.

Question 34

Classic:

Answer 34

may begin with aura; few hours to a few days.

Question 35

S/S of classic migraine:

Answer 35

seeing stripes, spots, lines, scotomata, light and noise sensitivity.

Question 36

Before a classic migraine:

Answer 36

mood changes, fatigue, difficulty thinking, depression, sleepiness, hunger, thirst.

Question 37

Common:

Answer 37

lasts longer than classic, similar onset, light and noise sensitivity.

Question 38

Hemiplegic/opthalmoplegic:

Answer 38

rare, severe unilateral pain, extraocular muscle palsy, ptosis, hemiplegia.

Question 39

Basilar artery:

Answer 39

young females before periods, prodromal - vision loss, vertigo, ataxia, dysarthria, tinnitus, tingling of fingers and toes; severe occipital throbbing, vomiting.

Question 40

Muscle contraction headache:

Answer 40

dull, persistent; tender spots on head and neck “hatband.”

Question 41

Intracranial bleed headache:

Answer 41

neuro deficits, narcotics fail to relieve; bleed can be in subdural or subarachnoid.

Question 42

Cluster headache:

Answer 42

early adult, more in males, episodes cluster together; throbbing, unilateral pain; infraorbital from head to neck; flushing, tearing, stuffy nose; severe form of head pain.

Question 43

Cluster headache onset and tx:

Answer 43

at night, abrupt; tx: verapamil, lithium, NSAIDs; narcotic analgesic.

Question 44

Tension headache:

Answer 44

no family hx; often in adolescents; dull, bilateral, neck-shoulder; no prodromal; can last hours to days; tx with ASA or tylenol.

Question 45

Cerebral aneurysm:

Answer 45

Berry - most common type; occur at bifurcation in Circle of Willis; more adults than children, more females than males.

Question 46

Causes of subarachnoid hemorrhage from aneurysm:

Answer 46

congenital defect of vessel wall, head trauma, hypertension, hold age, infection, atherosclerosis.

Question 47

Symptoms of cerebral aneurysm:

Answer 47

sudden severe headache, NV, loss of consciousness, preceded by activity, nuchal rigidity, fever, restless - irritability - blurred vision - seizure.