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Nursing Semester 3 > Beth - Week 2 - Exam 1 > Flashcards

Beth - Week 2 - Exam 1 Flashcards

1
Q

what is important to consider for a pupil assessment?

A

“did the patient receive any meds that would alter pupils?”

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2
Q

what do pinpoint pupils indicate?

A

PONS damage or drugs

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3
Q

what do midpoint pupils (progressive dilation) indicate?

A

Intracranial Pressure

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4
Q

what do dilated (ipsilateral) pupils indicate?

A

Hematoma or CN 3 damage

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5
Q

what do bilateral dilated pupils indicate?

A

large hematoma/herniation (ominous sign)

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6
Q

T/F: new research proves MD and RN cannot accurately assess pupil size.

A

TRUTH

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7
Q

what is a pupillometer?

A

a handheld pupillary meaurement device to accurately assess changes in pupil size and reaction by taking 30 pics per second to obtain correct data.

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8
Q

what is the glasgow coma scale?

A

an objective tool to measure LOC and Id the severity of neurological injury for a pt with altered alertness.

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9
Q

what are the glasgow coma scores?

A

scored from 3-15

  • 3 being the worst
  • 15 being the best
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10
Q

what 3 characteristics are the GCS based on?

A
  • eye
  • motor
  • verbal
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11
Q

what is the scoring for eye opening?

A

4 - spontaneous
3 - to speech
2 - to pain
1 - none

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12
Q

what is the scoring for motor response?

A 
6 - obeys
5 - localizes
4 - withdraws
3 - abnormal flexion (reflex to pain)
2 - abnormal extension (reflex to pain) 
1 - none
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13
Q

what is the scoring for verbal response?

A 
5 - oriented conversation 
4 - confused conversation
3 - inappropriate words
2 - incomprehensible sounds
1 - none
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14
Q

what should we be aware of when it comes to GCS?

A

be aware of sensory losses and deficits

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15
Q

how do you elicit a pain response?

A

always start with the least noxious irritation or pressure

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16
Q

what are the classifications of painful stimuli?

A
  • central - response from brain

* peripheral - reflex response via the spine

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17
Q

what are acceptable pain stimuli?

A
  • pressure to the supraorbital area (finger to eyebrow - central)
  • trapezius pinch (shoulder - central)
  • sternal rub (central)
  • nail bed pressure (peripheral)
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18
Q

what is deemed as unacceptable pain stimulus?

A

pinching nipples or inner legs

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19
Q

what are the 3 causes of unconscious patients?

A

brain disorder, metabolic disorder, and functional/psychiatric

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20
Q

what are the two brain disorders?

A

supra tentorial

infra tentorial

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21
Q

what are the 6 causes of metabolic disorder?

A 
electrolyte imbalance
hypercalcemia
acidosis
uremia
liver disease
ETOH or drugs
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22
Q

what are two examples of functional/psychiatric?

A

fainting and hysteria

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23
Q

pathophys of CSF: what produces CSF?

A

the ventricles produce it

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24
Q

pathophys of CSF: what absorbs CSF?

A

the arachnoid villi absorbs it, leaving 150 cc in the brain and spinal cord

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25
Q

T/F: CSF goes down spine and circulates through 4 ventricles and body produces appropriate amt of CSF everyday.

A

TRUE

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26
Q

what does normal CSF look like?

A

clear, colorless, minimal WBC, no RBC, 60-150 mmH20 pressure.

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27
Q

what does abnormal CSF look like?

A

↑ protein, ↓ glucose, cloudy, blood (subarchnoid hemorrhage) weird color, odor

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28
Q

what are the causes of increased/abnormal CSF?

A
  • blood from trauma
  • hemorrhagic stroke
  • ruptured aneurysm
  • tumor
  • obstruction
  • infection
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29
Q

what are the causes of elevated CSF?

A
  • enlarged ventricles

- blood/tumor/organism enters spinal space

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30
Q

what are the 3 components of the munro-kellie theory?

A
  • brain tissue
  • intracranial blood volume
  • CSF
  • *all 3 maintain ICP**
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31
Q

what is the normal ICP pressure?

A

5 - 15 mmHg

- 60 - 150 mmH20 to maintain normalcy

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32
Q

what is the cerebral volume/contents?

A
  • CSF 10%
  • Intravascular blood 12%
  • Brain tissue 78%
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33
Q

T/F: Cough ↑ ICP for an instant; more pressure → ↓ blood flow → unconscious

A

TRUE

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34
Q

T/F edema → shunt away blood (↓ O20 and ↓ CSF

A

T

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35
Q

what factors influence ICP?

A
  • arterial pressure
  • venous pressure
  • intra-abdominal and intra-thoracic pressure (coughing)
  • posture (gravity)
  • temperature
  • blood gases (particularly CO2 levels)
36
Q

what are the 3 types of compensation/auto regulation?

A
  • CSF regulation
  • cerebral blood flow auto regulation
  • metabolic auto regulation
  • *they all work together**
37
Q

CSF regulation: what is compensation?

A

↓ CSF production or ↑ CSF absorption

- this is good

38
Q

CSF regulation: what is decompensation?

A

due to an increase volume (lesion or edema)

- this is bad

39
Q

what is cerebral blood flow auto regulation?

A

automatic alteration in diameter of cerebral blood vessels to maintain constant blood flow to brain and the amt of blood required to provide oxygen and glucose to the brain (cerebral perfusion pressure CPP)

40
Q 
A PATIENT WITH INCREASED INTRACRANIAL PRESSURE
IS PLACED ON A VENTILATOR TO MAINTAIN PAO2 AT
100MMHG AND PACO2 AT 35 MMHG. THE
RATIONALE FOR THIS THERAPY IS TO:
A. INCREASE CEREBRAL BLOOD FLOW
B. CONSTRICT CEREBRAL BLOOD VESSELS
C. REMOVE FLUID FROM CEREBRAL TISSUES
D. DECREASE SYSTEMIC BLOOD PRESSURE
A

A: BECAUSE BRAIN IS GREEDY TO GIVE BRAIN ENOUGH O2 TO NOT DAMAGE BRAIN CELLS

41
Q

To reduce ↑ ICP, what should be done if the patient is hypoventilating?

A

there would be ↑ CO2 → ↑ potential edema so the RN needs to hyperventilate the pt to normalize acidosis and lower CO2

42
Q

To reduce ↑ ICP, what should be done if the patient is hyperventilating?

A

RN needs to hypoventilate the patient to normalize alkalosis and raise CO2

43
Q

what do irregular respirations indicate? (cheyne stokes)

A

pressure on brain stem

44
Q

a. INCREASE CEREBRAL BLOOD FLOW WITH A CO2 OF 35
a. IF THE (PACO2 WAS 25-34) CAUSES TO MUCH
VASOCONSTRICTION RESULTING IN( CBF)
b. CONSTRICT CEREBRAL BLOOD VESSELS
b. ARTERIAL VASOCONSTRICTION LOWERS CEREBRAL
BLOOD FLOW (CBF)
c. REMOVE FLUID FROM CEREBRAL TISSUES
c. NO WAY TO REMOVE FLUID BUT WE INCREASE O2
DELIVERY
d. DECREASE SYSTEMIC BLOOD PRESSURE
d. NO. CORRECTED HYPOXIA WOULD IMPROVE SBP

45
Q

TEST: what are the nursing considerations in regards to corneal abrasions?

A
  • NS/artificial tears
  • lubricants
  • eye shields
  • comatose, not blinking, washing face, etc*
46
Q

what are the nursing considerations in regards to stress ulcers?

A
  • d/t steroids
  • hyperacidity of gastric secretions (PPIs)
  • ↓ production of gastric mucous
  • NPO, feeding tube if no basal skull fracture
  • give antacids, H2 blockers, PPIs*
47
Q

what is the formula for CPP?

A

CPP = MAP - ICP

48
Q

what is the formula for MAP?

A

DBP x2 + SBP divided by 3

49
Q

what is a characteristic of MAP?

A
  • when a patient has ICP, BP has to be adequate enough to overcome edema in the brain.
  • swollen brain opposes MAP
50
Q

what is normal/compensation for cerebral blood flow auto regulation?

A
  • ↑ BP (↑ MAP) causes cerebral vessels to vasoconstrict

- ↓ BP (↓ MAP) causes cerebral vessels to vasodilate to maintain CPP Goal

51
Q

what is CPP (cerebral perfusion pressure) goal?

A

70 - 90 mmHg - lewis says 60-100

52
Q

what is the MAP norm?

A

70 - 90 mmHg

53
Q

what is abnormal/decompensation for cerebral blood flow?

A
  • MAP is 50 mmHg or > 150 mmHg

- prolonged ↑ ICP → ↓ cerebral blood flow → poor perfusion/ischemia-herniation

54
Q

CPP < 50 = ____
CPP > 100 = ____
CPP < 40 + _____

A

ischemia; ↑ ICP; will die

55
Q

for metabolic auto regulation, cerebral blood vessel tone is affected by ?

A

CO2, O2, and hydrogen ion concentration

56
Q

what is “normal”/compensation for metabolic auto regulation ?

A

the balance of acid/base and oxygenation is r/t VASOCONSTRICTION or VASODILATION of cerebral vessels to ↓ or ↑ blood supply to brain and rid the brain of waste products as needed

57
Q

what is decompensation for metabolic auto reg?

A

HYPOXIA and ACIDOSIS (↑ CO2) triggers VASODILATION

  • blood supply ↑ trying to wash away the waste product of CO2 but a compromised brain can’t handle the ↑ blood supply causing ↑ ICP and build up of lactic acid occurs
  • ALKALOSIS causes VASOCONSTRICTION
58
Q

Alkalosis causes ______ and acidosis causes _____

A

vasoconstriction and vasodilation

59
Q

what is normal ICP

A

5 - 15 mmHg OR 60 - 150 mmH20

60
Q

what is goal CPP

A

70 - 90 mmHg

61
Q

what is normal MAP?

A

70 - 90 mmHg

62
Q

what is normal PaCO2?

A

35 - 45 mmHg or 30 mmHg

63
Q

what is normal PaO2?

A

80 - 100 mmHg

64
Q

what is normal pH?

A

7.35 - 7. 45

65
Q

TEST: what are the early signs of ↑ ICP?

A
  • EARLIEST: changes in LOC can be first (restlessness, agitation then lethargy = ↓ LOC)
  • Decrease in GCS (was orientated, now confused, agitated then lethargic)
  • change in speech
  • sluggish or unequal pupils; ptosis
  • motor/sensory (early to late)
66
Q

what are the two main late s/sx of IICP?

A
  • changes in GCS (posturing-decerebrate or decorticate; reacts only to pain/stupor/coma)
  • change in VS (abnormal respirations - rate, depth, pattern; cushing’s triad)
67
Q

EXAM: is cushing’s triad?

A
  • ↑ SBP with a widening pulse pressure (SBP-DBP)
  • ↓ HR - profound bradycardia; bounding pulse
  • altered irregular respirations
68
Q

what are the 8 other late s/sx of IICP?

A
  • headache
  • fixed/dilated pupils (CN 2/3)
  • loss of corneal reflex
  • loss of gag
  • hyperthermia (fever 103/104)
  • projectile vomiting
  • motor sensory (early to late; hemiplegia)
  • cardiac changes
69
Q

what are the 5 ways of treating elevated ICP?

A
  • CSF drainage
  • Medications
  • hypothermia
  • surgical intervention
  • hyperventilation
70
Q

what are the characteristics of CSF drainage treatment?

A

must have a ventricular drain placed

71
Q

what are the characteristics of med treatment?

A
  • mannitol
  • sedation
  • paralytics
72
Q

what are the characteristic of surgical treatment?

A
  • craniotomy

- craniectomy

73
Q

what are the characteristics of hyperventilation?

A
  • ONLY as a last resort

- can cause more damage

74
Q

what are the legal issues in organ donation (6)

A
  • < 70 for tissue (other special criteria)
  • < 65 for organs
  • no malignancy (except primary brain tumor)
  • no infectious disease
  • no high risk HIV
  • no long term hypotension
75
Q

EXAM: what are the 11 characteristics to determine someone is brain dead?

A
  • fixed/dilated pupils
  • absent corneals, gag, cough reflexes
  • no spont. movement
  • no response to pain
  • occasional spinal reflexes are intact
  • issues that complicate the assessment
  • must be normothermic
  • no CNS depressants (sedation, paralytic, pain)
  • no oculovestibular
  • absent oculocephalic
  • diagnositcs
76
Q

EXAM: what is brain death and who confirms it?

A

the irreversible cessation of all functions of the entire brain, including the brain stem
- need 2 physicians to confirm

77
Q

for the brain dead assessment, how is the lack of oculovestibular reflex assessed?

A

by “doll’s eye”

78
Q

how is the lack of oculocephalic reflex assessed?

A

ice caloric (ice in ear)

79
Q

what does dolls eye examine mean?

A
  • positive/normal: eyes move in the direction opposite to that of the head movement
  • negative: eyes move in the direction of the head movement; signifies severe brain damage or brain death
80
Q

what 4 diagnostics are used to confirm brain death?

A
  • EEG: absence of brain ; flat line; isoelectric x 30 min; cerebral silents
  • Transcranial doppler (TCD): no cerebral blood flow; some people don’t have windows → can’t see
  • Brain stem evoked potential: no waveform noted
  • cerebral angiogram: no cerebral flow (real way)
81
Q

what are the 3 cardinal signs of brain death?

A
  • coma
  • absence of brainstem reflexes
  • apnea (off ventilator for 7 minutes)
82
Q

what is the nursing role in organ donation?

A

since 98, RNs have to be trained as “designed requestor” before permitted to talk with families

  • check for documentation that authorizes a gift
  • donor team # and hospital policy
  • organ and/or tissue (skin, heart valves, tendon, bone, corneas, cartilage, middle ear, ligaments, veins)
  • tissue donation doesn’t require brain dead status
83
Q

why do you need a neuro exam on an unconscious patient?

A

because they are unconscious you must watch for reflexes, pupillary changes, and sign of cushing’s triad

84
Q

what are the priorities of the RN with an unconscious pt?

A

frequent assessment, prevention of skin breakdown, and other risk factors of a immobile patient

85
Q

EXAM: name the cardinal s/sx of a new neuro change in the unconscious patient?

A
  • sluggish pupils
  • loss of cough and gag
  • loss of reflexes (response to stimuli)
  • s/sx of cushing’s triad (↑ BP, ↓ HR, widening pulse pressure)

Nursing Semester 3 (29 decks)

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