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Physical Health - NP602 > Assessment and nursing management of neurological compromise > Flashcards

Assessment and nursing management of neurological compromise Flashcards

1
Q

When the body is resting it uses what percentage? of oxygen and glucose?

A

20-25%

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2
Q

Interruption to blood blow causes irreversible damage within how much time?

A

3-8mins

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3
Q

What is autoregulation?

A

It is a way of maintaining brain blood flow despite changes in cerebral perfusion pressure. it is a major physiological regulatory process, whereby an increase in blood flow to an organ or tissue engenders vasoconstriction and a sustained increased vascular resistance.

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4
Q

What is cerebral perfusion pressure?

A

The pressure required to deliver adequate oxygen and glucose

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5
Q

How do we detect when autoregulation is lost?

A

When CPP (Cerebral perfusion pressure) is outside the range of 60-160mmhg.

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6
Q

What type of pressure test do we do to check if autoregulation is lost?

A

The CPP - Cerebral perfusion pressure

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7
Q

If autoregulation is lost what does the brain do to compensate?

A

The brain relies on mean arterial pressure (MAP) to maintain its blood supply. This will mean that if this patient sustains a brain injury and their blood pressure drops too low, there will not be enough pressure to drive the blood around the brain hence cause brain tissue hypoxia and furthermore death

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8
Q

Severely low levels of oxygen and glucose in the brain will cause what?

A

Brain tissue hypoxia and death

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9
Q

What are the main elements that generate intracranial pressure?

A

Brain tissue, blood volume and cerebrospinal fluid (CSF)

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10
Q

What happens when there is increased intracranial pressure?

A

A sudden increase in the pressure inside a person’s skull is a medical emergency. Left untreated, an increase in the intracranial pressure (ICP) may lead to brain injury, seizure, coma, stroke, or death.

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11
Q

If brain tissue increases what elements will counteract and decrease and why does this occur?

A

Intracranial blood and cerebrospinal fluid will decrease to maintain a normal intracranial pressure

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12
Q

If intracranial blood increases what elements will counteract and decrease and why does this occur?

A

Brain tissue and cerebrospinal fluid decrease to maintain normal intracranial pressure

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13
Q

If cerebrospinal fluid increases what elements will counteract and decrease and why does this occur?

A

Brain tissue and intracranial blood decrease to maintain a normal intracranial pressure

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14
Q

What is the Monro-Kellie doctrine?

A

The Monro-Kellie doctrine, or hypothesis, is that the sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two.

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15
Q

What is a brain herniation?

A

Brain herniation occurs when something inside the skull produces pressure that moves brain tissues. This is most often the result of brain swelling or bleeding from a head injury, stroke, or brain tumor.

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16
Q

What is cushings triad?

A

Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain.

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17
Q

What does cushings triad consist of?

A

Bradycardia, irregular respirations, and a widened pulse pressure. A widened pulse pressure occurs when there is a large difference between the systolic and the diastolic.

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18
Q

Increasing ICP (Intracranial pressure) results in what?

A

A lack of oxygen in brain tissue and a restriction of cerebral blood flow in the brain.

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19
Q

Increasing ICP (Intracranial pressure) is caused by what?

A

Head injurys, bleeding in the brain, tumors, infections, strokes, excess cerebrospinal fluid or swelling in the brain

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20
Q

Increasing ICP (Intracranial pressure) activates which reflex?

A

The cushing reflex

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21
Q

As ICP (intracranial pressure) increases it eventually becomes greater than - what other pressure?

A

The mean arterial pressure which typically must be greater that intracranial pressure in order for the brain to be adequately oxygenated.

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22
Q

What is brain ischemia?

A

a condition that occurs when there isn’t enough blood flow to the brain to meet metabolic demand. This leads to limited oxygen supply or cerebral hypoxia and leads to the death of brain tissue, cerebral infarction, or ischemic stroke.

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23
Q

When the brain is not receiving enough oxygen it activates which nervous system and does what?

A

The sympathetic nervous system
This increases system blood pressure and an initial increase in heart rate.
The increase in BP signals the cartoid and aortic baroreceptors
Which activate the parasympathetic nervous system
Causing the heart rate to decrease

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24
Q

What are some indications of a worsening prognosis of increasing intracranial pressure?

A

Irregular respirations followed by periods where breathing ceases completely

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25
Q

What is apnea?

A

Apnea is the medical term used to describe slowed or stopped breathing

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26
Q

What are some symptoms a person with cushings triad may present with?

A

Headaches, vomiting, blurred vision, weakness, or changes in their behaviour or LOC

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27
Q

To assess and definitively diagnose cushings triad, what must be measured?

A

The ICP (intracranial pressure)

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28
Q

How is intracranial pressure measured?

A

Through a lumbar puncture (spinal tap) in which the cerebrospinal fluid is measures or through continuous monitoring by a catheter placed in the ventricle of the brain.

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29
Q

What assessments do we do to help determine the cause of ICP (increased cranial pressure)

A

A full history and physical exam

Imaging such as CTY scans or MRIs

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30
Q

Treatment for Cushings triad is focused on what?

A

Decreasing the intracranial pressure + reversing the cause of the increased cranial pressure.

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31
Q

What is Mannitol and what is it used for?

A

It is an osmotic diuretic medication (often provides through IV) and it is effective in lowering ICP (intracranial pressure) and increasing CPP (Cerebral perfusion pressure).

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32
Q

What medications can be used alongside Mannitol to increase CPP and decrease ICP?

A

Furosemide (Diuretic), steroids, and sedatives

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33
Q

What type of positioning and suggestments can be given to a patient to help lower ICP?

A

Hyperventilation, and laying with the head elevated (reverse trendelenburg position)

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34
Q

What are some procedures that may occur to lower ICP in a patient?

A

Drainage of extra cerebrospinal fluid. Rarely, a craniotomy, or removal of a small portion of the skull.

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35
Q

What would happen if cushings triad is left untreated?

A

Herniation can occur causing the brain tissue to shift to the opposite side of the brain or downwards towards the brainstem (uncal herniation)

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36
Q

uncal herniation can lead to what?

A

The loss of certain reflexes, loss of consciousness, and potentially death.

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37
Q

Cushings triad indicates what?

A

A severe lack of oxygen in the brain tissue

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38
Q

What are some signs and symptoms of neurological compromise and raised ICP relating to the cognitive system?

A

Poor memory, inability to sequence, change in comprehension, and confusion

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39
Q

What are some signs and symptoms of neurological compromise and raised ICP relating to pupil changes?

A 
The pupils will be:
Unequal
Sluggish
Oval 
Pinpoint
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40
Q

What are some signs and symptoms of neurological compromise and raised ICP relating to the behavioural system?

A

Disinhibition
Personality changes
Emotional

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41
Q

What are some signs and symptoms of neurological compromise and raised ICP relating to motor strength?

A 
Mild/mod/severe weakness
Hemiplegia (one sided arm/leg/face weakness)
Sensation changes 
Swallowing difficulties (dysphagia) 
Uncoordinated
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42
Q

What are some signs and symptoms of neurological compromise and raised ICP relating to speech?

A

Slurred (dysarthria)
Delayed
Word finding difficulty (Expressive/receptive dysphasia)
No speech (aphasia)

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43
Q

What are some signs and symptoms of neurological compromise and raised ICP relating to level of consciousness?

A

Drowsiness
Lethargy
Dizziness

44
Q

What are the early warning signs of increased cranial pressure?

A 
Confusion
Drowsiness
Headache
Forgetfulness
Limb weakness
Nausea
Photophobia
Diplopia
Oval pupils (from round)
Impaired extra-ocular movement
45
Q

What are some late early warning signs of raised ICP (intracranial pressure)?

A 
Projectile vomiting
Seizures
Fixed and dilated pupils
Loss of gag reflex
Abnormal flexion/extension of upper and lower limbs
Hypertension (widening pulse pressure) 
Bradycardia
Irregular respiratory pattern
46
Q

What are some neurological assessment tools?

A 
AVPU 
Alert - awake and talking
V - responds to voice
P - responds to pain
U - unresponsive

GCS (Glasgow coma scale)

  • Arousal (eye opening)
  • Awareness (Verbal response)
  • Activity (Motor response)
Nervous system assessment - cranial nerves/spinal nerves 
Coordination and balance
Gait
MMSE
Speech and language
47
Q

What things we might observe under “airway” when considering a neuro patient (rapid assessment)

A

Under threat airway - related to reduced LOC (raised ICP, drug induced, metabolic acidosis, and seizures) or related to snoring (‘neuro snore’)

Obstructed airway - Due to obstruction of the tongue or spinal nerve damage (C3-5 phrenic nerve)

48
Q

What is metabolic acidosis?

A

Metabolic acidosis develops when too much acid is produced in the body. It can also occur when the kidneys cannot remove enough acid from the body.

49
Q

What are some ‘airway’ nursing interventions for a neuro patient?

A

Positioning: Maintain head and neck alignment for airway patency and avoid rise in ICP (chin tilt/jaw thrust) + consider the potential of a spinal cord injury

Clear secretions: Ensure patient can clear own secretions + consider suctioning + be aware of increased ICP with valsalva manoeuvres

Airway adjuncts (airway management): Nasopharangeal, oropharangeal, caution in base of skull fractures and facial trauma

50
Q

What is the valsalva manoeuvre?

A

The Valsalva maneuver is a breathing method that may slow your heart when it’s beating too fast. To do it, you breathe out strongly through your mouth while holding your nose tightly closed. This creates a forceful strain that can trigger your heart to react and go back into normal rhythm.

51
Q

What is a Nasopharangeal airway?

A

a nasopharyngeal airway, also known as an NPA, nasal trumpet (because of its flared end), or nose hose, is a type of airway adjunct, a tube that is designed to be inserted into the nasal passageway to secure an open airway.

52
Q

What is an oropharangeal airway?

A

An oropharyngeal airway (oral airway, OPA) is an airway adjunct used to maintain or open the airway by stopping the tongue from covering the epiglottis.

53
Q

What things we might observe under “breathing” when considering a neuro patient (rapid assessment)

A

Respiratory rate, depth, and rhythm: irregular breathing rates and patterns indicating neurological dysfunction

Breath sounds: adventitious sounds (listening via auscultation)

Percussion: Listening for Dullness or hypereasonance

54
Q

Crackles or reduced air entry on auscultation could indicate what?

A

Aspiration or alveolar collapse.

55
Q

What are some nursing interventions for ‘breathing’ when considering a neuro patient.

A

Supplemental oxygen: administer O2 as prescribed to reverse hypoxaemia and help prevent cerebral hypoxia.

Positioning: ensure patient is repositioned regularly to prevent atelectasis + maximise air entry for effective gas exchange - but avoid elevating head too much as this can cause a rise in ICP and be cautious with spinal cord injurys and hemiplegia to avoid second inury

Clear secretions: Ensure oral secretions are cleared to minimise aspiration risk and maintain regular oral hygiene to prevent microbial growth transfer from mouth to lungs

Assess and report changes in respiratory pattern

56
Q

What is cerebral hypoxia?

A

Cerebral hypoxia refers to a condition in which there is a decrease of oxygen supply to the brain even though there is adequate blood flow

57
Q

Can CO2 increase or decrease ICP?

A

CO2 is a potent vasodilator and will contribute to rising ICP, further reducing blood flow

58
Q

What is hemiplegia?

A

paralysis of one side of the body.

59
Q

What things we might observe under “circulation” when considering a neuro patient (rapid assessment)

A

General appearance: we would observe skin colour, temp (core, peripheral, cap refil), and oedema

Renal Function: we would check for fluid and electrolyte imbalance, any increase in urine output, and decrease in urine output.

Heart rate: We would check for tachycardia, brachycardia, rhythm (regular/irregular), and quality (weak/bounding)

Blood pressure: We would check for hypertension, normotension and hypotension

60
Q

Why may Dullness or hypereasonance occur during percussion for a patient with a neuro issue?

A

this may occur when fluid replaces air filled sacs or there is over-inflation over the lung field (this would be considered in a patient with impaired LOC or swallow)

61
Q

If a neuro patient was flushed what might this indicate?

A

That they have an infection.

62
Q

If a neuro patient was cyanotic what might this indicate?

A

That this patient has hypoxia

63
Q

If a neuro patient had a raised core temp what might this indicate?

A

Infection and raised metabolic activity or damage to the hypothalamus in head injury

64
Q

If a neuro patient has oedema what might this indicate?

A

Pulmonary and cardiac dysfunction

65
Q

If a neuro patient has a fluid and electrolyte imbalance what might this indicate?

A

neurological damage as this can cause disruption of NA+/K+ pump or disruption in hormone release leading to alterations in normal blood chemistry.

66
Q

If a neuro patient has increased urine output what might this indicate?

A

Diabetes insipidus (DI): a rare condition where you pee a lot and often feel thirsty. It is caused by problems with a chemical called vasopressin (AVP), which is also known as antidiuretic hormone (ADH). AVP is produced by the hypothalamus and stored in the pituitary gland until needed

67
Q

If a neuro patient has a decrease in urine output, what might this indicate?

A

Secretion of inappropriate anti-diuretic hormone (SIADH)*

68
Q

If a neuro patient was tachycardic what may this indicate?

A

That they have an infection - this would be an inflammatory response

69
Q

If a neuro patient was bradycardic what may this indicate?

A

That they have raising ICP

70
Q

If a patient has had a brain injury what will this do to the rhythm of their heart?

A

It will alter the electrical activity and cardiac conductivity of the heart changing the rhythm

71
Q

What will lowering cardiac output do to the quality of the heart rhythm?

A

This will make it weak and thready

72
Q

If a neuro patient has a bounding heart rhythm what may this indicate?

A

Infection to compensate for hypotension.

73
Q

Increase in systolic blood pressure, a decrease in heart rate, and abnormal respirations can indicate what?

A

High ICP, and potentially death

74
Q

If a neuro patient had hypertension what could this indicate?

A

Rising systolic blood pressure in raised ICP
Widening pulse pressure
and a potential spinal cord injury (causing autonomic dysreflexia)

75
Q

What is autonomic dysreflexia?

A

an abnormal, overreaction of the involuntary (autonomic) nervous system to stimulation. This reaction may include: Change in heart rate. Excessive sweating. High blood pressure

76
Q

If a neuro patient had hypotension what could this indicate?

A

Infection causing vasodilation and ‘leaky’ vessels

and for spinal cord patients this could mean impaired ANS control

77
Q

What are 6 circulation based nursing interventions for a neuro patient?

A
  1. Administer prescribed medication to maintain BP within set parameters (preventing further hypertension + rise in ICP and also to maximise cerebral perfusion pressure and o2 delivery)
  2. Maintain accurate fluid balance and report urine increase/decrease to guide intervention (preventing dehydration in excessive output or cerebral oedema in reduced output)
  3. Remove excess bedding and implement cooling techniques (to reduce elevated core temp and reduce metabolic demand)
  4. Ensure TED stockings are applied to prevent DVT due to immobility.
  5. Record and report changes in HR and bp to help identify secondary cerebral ischaemia
  6. Regular position changes to promote tissue perfusion
78
Q

What things we might observe under “disability” when considering a neuro patient (rapid assessment)

A

Level of consciousness (spontaneous eye movements/requiring stimulus?/any confusion/ability to follow verbal commands)

Motor strength (any weakness, coordination problems, hemiplegia, and paraesthesia)

Pupils and extra-ocular movement (unequal, sluggish, irregular shape, irregular movement)

Pain (neuropathic pain, photophobia, headache, and assess analgesia requirements)

Speech (aphasia, dysarthria)

79
Q

What is paraesthesia?

A

Tingling or prickling, “pins-and-needles” sensation; usually temporary, often occurs in the arms, hands, legs or feet.

80
Q

What may irregular movement of the pupils be attributed to for a neuro patient?

A

Indicative of increases in ICP

But also consider medications as they can affect reactions to light

81
Q

What is neuropathic pain?

A

Neuropathic pain is often described as a shooting or burning pain. Caused by damage to the nervous system

82
Q

What is photophobia?

A

Photophobia is eye discomfort in bright light.

83
Q

What is nuchal rigidity?

A

Nuchal rigidity simply refers to neck stiffness. Tightness and inability to move the neck muscles

84
Q

What are analgesics?

A

Analgesics are medications that relieve pain by either reducing inflammation or changing the way the brain perceives pain

85
Q

What is aphasia?

A

Inability to comprehend or articulate speech in specific areas of the brain

86
Q

What is broca’s (non-fluent) aphasia?

A

Moderate-severe impairment of speech, in-tact comprehension

87
Q

What is wernickes (fluent) aphasia?

A

Mild impairment of speech, poor comprehension and inappropriate use of words

88
Q

What is global aphasia?

A

Poor articulation of speech and poor comprehension

89
Q

What is dysarthria and what is it caused by?

A

Slurred speech - caused by damage to the central nervous system or peripheral nervous system in motor-speech system (left cerebral hemi affected more than right)

90
Q

What are some environment interventions for a neuro patient?

A
  1. Maintain a low stimulus environment to avoid rise in ICP (dim lights and minimal noise)
  2. Record and report NZEWS to identify deterioration
  3. Ensure safe environment around the patient bed space to prevent falls and avoid injury (for example placing a more disoriented patient closer to nurses station)
91
Q

What are some diagnostic tests we could do for a neuro patient?

A

CT (Computerised tomography)
MRI (magnetic resonance imaging)
Carotid ultrasound/Doppler (measures cerebral blood flow)
EEG (Electroencephalograms - calculates electrical activity in brain)
Cerebral angiography (identifys responsible blood vessel)
Lumbar puncture for CSF analysis

92
Q

Why may older people be harder to assess?

A

Harder due to factors such as: comorbidities and polypharmacy

93
Q

Why may symptoms in older people take longer to present? (neurological symptoms)

A

Because the brain atrophies with age

94
Q

What is the basic role of an Antiemetic for neurological compromise? ?

A

to provide nausea relief

95
Q

What is the basic role of an antipyretic for neurological compromise? ?

A

to reduce metabolic activity

96
Q

What is the basic role of a Diuretic for neurological compromise? ?

A

To control fluid balance

97
Q

What is the basic role of a corticosteroid for neurological compromise? ?

A

To reduce cerebral oedema

98
Q

What is the basic role of an Antiepileptic for neurological compromise? ?

A

To control neurotransmitters

99
Q

What is the basic role of a thrombolytic for neurological compromise? ?

A

Fast dissolution of blood clots

100
Q

What is the basic role of an antiplatelet for neurological compromise?

A

Prevents platelets from sticking together and clumping

101
Q

What is the basic role of an analgesic for neurological compromise? ?

A

To reduce the SNS activity and reduce ICP

102
Q

What is the basic role of skeletal muscle relaxants for neurological compromise? ?

A

To ease contractures

103
Q

What is the basic role of an anti-parkinson for neurological compromise? ?

A

To increase dopamine/reduce acetylcholine activity to improve motor coordination

104
Q

What is the basic role of a faecal softener for neurological compromise? ?

A

To prevent straining and increase ICP

105
Q

What is the basic role of antibiotics for neurological compromise?

A

To reduce systemic inflammation and cerebral oedema

106
Q

What is the basic role of antiarrhythmics for neurological compromise?

A

They improve cardiac output and cerebral perfusion

107
Q

What is the basic role of antihypertensives for neurological compromise?

A

They prevent secondary cerebral ischaemia through raised ICP

Physical Health - NP602 (3 decks)

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