Care of Acute Neuro Patients Flashcards

Question

Reticular Activating system (RAS)

Answer 1

* Responsible for wakefulness/sleep wake cycle, attention, ability to focus, arousal, muscle tone * Located in hypothalamus and brainstem * Vascular supply from circle of willis * Receives input from spinal cord, sensory pathways, thalamus and cortex

Answer 2

* Stroke * Head Injury * Cerebral bleed * Tumor

Answer 3

* Drug overdose * Alc intox * Carbon monoxide

Answer 4

* Meningitis * Encephalitis * Brain abscess

Answer 5

* DKA * Hepatic or renal injury or failure * Hyponatremia * Hypoxia * Seizures * Heat stroke * Hypothermia

Answer 6

* Glascow coma scale (3-15) * Cranial nerves * Cerebellar function: Balance and coordination * Reflexes: Gag,pupils, DTR, Babinski * Motor function: Muscle strength * Sensory function: Ability to feel temp (warm and cold, sharp/light touch or vibration)

Answer 7

* Normal for adults: Stroke from heel to toes, the toes should crunch down * Abnormal: Stroke from heel to toes, the toes spread and go up

Answer 8

4.) Eyes open spontaneously 3.) Eyes open to commands 2.) Eyes open to pain 1.) No eye opening

Answer 9

1. None 2. Decerebrate posturing 3. Decorticate posturing 4. Withdrawal from pain 5. Purposeful movement to pain (Bats at your hand) 6. Obeys commands

Answer 10

1. None 2. Incomprehensible: Grunts or non words 3. Inappropriate: words are discernible 4. Confused: but able to answer questions 5. Orientated

Answer 11

* CMP: Electrolytes, glucose, calcium, liver function, kidney function, serum osmolality * CBC with diff: Noting abnormally high or low counts (Infection) * Coagulation studies (PT/INR/ PTT), (Can be hypoxia from anemia) * Ammonia level (hepatic encephalopathy) * Ketones (DKA) * Tox screen (Drugs) * ABG

Answer 12

Really good at telling us the fluid status

Answer 13

* **CT/MRI** * **No lumbar puncture in suspected increase in ICP, can cause brain herniation** * Perfusion CT: See vasculature * MR Spectroscopy: Can identify location of tumor stroke, epilepsy * EEG: detects abnormal brain waves * PET: Shows metabolic changes * SPECT: Shows a detailed 2d map of the brain * Cerebral angiogram: assess brain vasculature

Answer 14

* Pt intubated vs tracheostomy needed * Can the pt protect their own airway * Mechanical ventilation until determined | Done first

Answer 15

* BP, HR: Is it adequate to perfuse body and brain * Peripheral IV, ART line, Central line, Pulmonary art cath * IV fluids and meds | Done Second

Answer 16

* Determine neuro pathology * Treat the underlying cause * Prevent complications | Done third

Answer 17

* Space occupying lesion (Tumor, abscess, hematoma, contusion, subarachnoid hemorrhage * Generalized brain swelling (Liver failure (Hepatic encephalopathy) hypertensive encephalopathy) * Increased venous pressure (HF, obstruction of the superior mediastinal veins or jugular veins, venous thrombosis,) * Obstruction of CSF flow (Hydrocephalus, meningeal disease) * Increased production of CSF | Monro-kellie doctrine

Answer 18

Swelling of the brain resulting in an increase in volume of brain tissue

Answer 19

* Brain's ability to change the diameter of its blood vessels to maintain consistent CBF during alterations in systemic BP * Normally its in a state of equilibrium (CSF, Blood brain tissue) * Mechanism: Shift or displacement of CSF, increased absorption or decreased production of CSF, decreased cerebral blood volume * Occurs constantly based on changes in intrathoracic pressure (Coughing sneezing straining), posture, BP O2 and CO2 levels * **CAN BECOME IMPAIRED WITH PATHOLOGIC AND SUSTAINED INCREASED ICP**

Answer 20

* Essentially the skull vault is composed of 3 things, brain, blood and CSF, if one of those increase and the others don't decrease you're gonna have a hemorrhage * If one of these increase it causes a change in the volume of one or both components. * Loss of autoregulation;normal mechanisms exhausted; increased ICP and decreased cerebral blood flood -> Brain injury, ischemia and cell death

Answer 21

70-100 is ideal Above 60 is ok Below 50 is bad

Answer 22

Below 50 mmHg

Answer 23

MAP-ICP Indicates the pressure which blood has to flow against in the skull which limits perfusion to the brain

Answer 24

* Increase in SBP (widening Pulse pressure) * Decrease in HR * Decrease in RR

Answer 25

* Nervous system response to acute elevation in ICP * Autoregulation becomes ineffective * Changes in mental status occur * Vital signs change as well (Cushing's triad)

Answer 26

Cerebral ischemia, infarction, brain death

Answer 27

* Difference between the systolic and diastolic bp * Not the same thing as MAP

Answer 28

* Mean arterial pressure * Average art pressure in one cardiac cycle, varying due to CO and SVR * (2DBP+SBP)/3

Answer 29

* **Life threatening** event which an area of the brain exits the skull vault through one of the rigid intracranial barriers * Classified based on structure it exits through * Path of least resistance, with a build up of pressure in the skull the brain has to go somewhere * CT of the brain showing a midline shift indicates **URGENT** intervention | monro kellie

Answer 30

* HA, Vomiting * Changes in LOC (restless agitation, confusion, increased sleepiness), high highs low lows * **Cushing triad**

Answer 31

* Dilated, fixed unilateral pupils (**Blown pupil**) or fixed bilateral unequal pupils * Decorticate or decereberate posturing * Oculomotor paresis (EOM) * Homonymous hemianopia- visual field cut * Hemiparesis * Loss of reflexes: Oculocephalic, oculovestibular, corneal

Answer 32

* Identify increased ICP early, prevent dmg * Relieve increased ICP * Decrease Cerebral edema * Lower volume of CSF * Decrease Cerebral blood flow * Maintain cerebral perfusion

Answer 33

* Oral intubation, avoid nasotracheal intubation * Correct blood pressure, maintain CPP to 60-70 * Place ICP Monitoring device and ART line

Answer 34

* Increases coughing, gagging, which increases intrathoracic pressure which in turn increases ICP

Answer 35

* Gold standard * Connected to drainage bag for excessive **CSF drainage** * Complications: Infection, hemorrhage during placement, difficult to place with small ventricles, ventricular collapse, occluded cath

Answer 36

* Thin cable with electronic or fiber optic transducer at tip placed directly on the brain parenchyma through a burr hole on the skull * Lower risk of infection, hemorrhage and easier to place * Cons: **Cannot** drain csf, can lose accuracy over time and mechanical failure due to complex design

Answer 37

* Bolt with fluid coupled system, hollow screw placed through skull, dura punctured and CSF communicates with the fluid column and transducer * Lower risk of infection and hemorrhage * Cons: Can clog with debris, unreliable, and less accurate

Answer 38

Optical transducer that rest against the dura, often inaccurate, limited use

Answer 39

When no reliable neuro exam can be performed due to sedation, anesthesia, low GCS (<9)

Answer 40

3-8 Comatose

Answer 41

1. Zeroed to atmospheric pressure at the level of the tragus (Level of the foramen of monro) and leveled with a 0 mark on the drainage bag 2. Drain set at a specific height above tragus for drainage (15cm H20); So when ICP exceeds that amount it will drain off 3. Always level transducer for position changes (T+P) 4. Ensure all connections are secure and no leakage of fluids (Infection risk as its connected directly to the brain)

Answer 42

* Maintain an ICP goal of <20 mmHg * Remove CSF via a ventriculostomy * Elevate HOB 30 degrees to enhance cerebral venous drainage and keep head and neck midline, avoid neck rotation and flexion * Sedation (Control agitation pain and excessive muscular activity, which all increase ICP) * Hypervent (Decreases PaCO2, goal is 26-30 only really used in emergency * Hydration: Maintain **Euvolemic** state (**Isotonic fluids only .9%)** * restrict oral free water * No .45% NS or DSW because they contain more water * Keep osmolality 295-305 (High and dry) * Mannitol to decrease cerebral edema and ICP (Osmotic diuretic) * Keep CPP **greater than 60 (Use vasopressors not fluids)** * Antihypertensives only in cases of severe HTN (180/95) and only if they are able to maintain their CPP * Corticosteroids: Used for edema for **Tumor or infection only** * Minimize suctioning (Increases ICP) * Avoid valsalva maneuver (Stool softeners) * Treat the fever (increases metabolism, which increases ICP) maintain **normothermia** * Anticonvulsants

Answer 43

* Hypothermia (Controversial, don't want them to shiver) * Pentobarbital coma: Decreases metabolic command * Decompressive craniectomy: Cut a chunk of skull off so the brain can expand

Answer 44

* Remove blood clot * Resect tumor * Divert CSF if hydrocephalus * Treat metabolic disorder

Answer 45

* Vent support * Seizure prevention * F/E maintenence * Nutrition * Skin care * Pain and anxiety * Oral cvare * Monitor for infection

Answer 46

* Should have 3 peaks * P1-P3

Answer 47

* Percussion wave due to art pulsation * It represents SBP * Should be the tallest wave

Answer 48

* Represents brain compliance, tidal wave * If P2 is greater than P1 there is increased intracranial volume and pressure, decreased brain compliance **Impending herniation**

Answer 49

* Dicrotic wave * Aortic valve closure

Answer 50

* Plateau waves * Transient, recurring elevations in ICP * Lasting 5-10 min * Ranges 40-100 mmHg * **Indicates changes in volume, early cerebral perfusion compromise** * **Decreased brain compliance, impending herniation** | Very bad

Answer 51

* Last 30 sec-2 min * Unclear value in clinical practice * Normal

Answer 52

* Small rhythmic oscillations * 4-8 per min * Appear related to rhythmic variations in art BP and resp

Answer 53

* Oxy sat in jugular venous bulb or vial cath in brain * Can identify changes in cerebral oxygenation * Desaturations can reflex early cerebral ischemia before increase in ICP occurs * Can improve outcomes * Reflects overall brain perfusion no specific injured area

Answer 54

Monitors oxy and temp

Answer 55

* Direct impact * Sudden or rapid acceleration and decelerations * Penetrating injury * blast injury

Answer 56

* Consequence of direct contact to the head or brain during initial injury * External: Contusion, lacerations, external hematomas, skull fractures * Intracranial: Subdural hematoma, concussion, diffuse axonal injury

Answer 57

* Evolves over hours and days after initial injury due to lack of glucose and oxygen deliver to the cells * Intracranial: Hemorrhage, cerebral edema, intracranial hypertension, hyperemia, seizures, vasospasm * Systemic: hypotension, hyperthermia, hypoxia, hypercarbia, infection, electrolyte imbalances, anemia

Answer 58

* Cerebral edema: cerebral hypoxia and ischemia, cerebral metabolic impairment, cerebral vasospasm, increased intracerebral pressure * Cell death * Increased glutamate * Mitochondrial dysfunction, impairment of glucose metabolism * Blood brain barrier dmg * Excitotoxicity * Complement activation and inflammation and ROS generation

Answer 59

* Causes persistent localized pain * Can produce hemorrhage from nose, pharynx or ears * Battle sign, racoon eyes * Basal skull fracture: suspected when csf escapes from the ears and nose * Risk for meningitis due to open dura * Csf is clear, very watery * Test for **beta 2 transferrin**, collect in a small tube

Answer 60

Close observation

Answer 61

Surgery to elevate the skull and debridement

Answer 62

* Head accelerates then rapidly decelerates or collides with another object * Causes brain tissue dmg but no open dura

Answer 63

Object penetrates the skull, entering the brain through the dura and dmgs the brain tissue

Answer 64

* Temp loss of neuro function without apparent structural dmg to the brain * Mgmt: Observation and prevent secondary injury * Monitor for changes in LOC worsening HA dizziness, seizure, abnormal pupil response, vomiting irritability, slurred speech, numbness or weakness in arms or legs * Repeat concussions lead to chronic traumatic encephalopathy

Answer 65

Terrible, involves the shearing of nerve fibers as the brain rotates in the skull

Answer 66

* Hematoma in the brain * Epidural: above the dura * Subdural: Below the dura * Intracerebral: Within brain * S+S depend on how slow or quick the hematoma expands and compresses tissue

Answer 67

Can be fatal, due to the brain having no time to compensate Typically do worse

Answer 68

Generally do better than a fast bleed due to there being time for the brain being able to compensate

Answer 69

* Between the skull and the dura * Aften due to laceration of meningeal artery from skull fracture * Hemorrhage causes rapid pressure on the brain * Medical emergency: Surgery to make a burr hole or craniotomy to decrease ICP, remove clot, control bleeding, placement of a drain to prevent accumulation of blood

Answer 70

* Brief loss of consciousness, but then awake * Lucid, conversant but then increased restlessness, agitation, confusion, signs of herniation

Answer 71

* Collection of blood between the dura and brain * Often venous in origin * Acute or chronic depending on size of vessel and amount of bleeding

Answer 72

* Usually due to a fall * S+S: Change in LOC, Pupil changes, hemiparesis * Increased BP, Decreased HR/RR, comatose indicates a rapidly expanding hematoma * Treatment needs emergent craniotomy to remove the clot

Answer 73

* Brain has time to compensate * Hematoma develops slowly, weeks to months * Brain atrophied so there is more room to expand * Blood changes characteristics in 2-4 days, becoming thicker and darker * Brain adapts to this and you can see fluctuating neuro, personality changes, mental deterioration, focal seizures * Mgmt: Surgical evacuation of the clot (Burr holes or craniotomy)

Answer 74

* Bleeding into the parenchyma of the brain * Usually due to force exerted over small area of head (Missiles, bullets, stabbing) * S+S: INsidious, headache, neuro changes * Treatment: Supportive care, ICP control, careful fluid mgmt, lyte monitoring , antihypertensives * Surgery: Craniotomy, craniectomy to remove clot and control hemorrhage * Site may not be accessible or lack of clearly defined margin prevents removal of clot

Answer 75

* Due to severe head injury * From widespread shearing and rotational forces that produces dmg through the brain * Damage is diffuse across the entire brain * Poor prognosis: recovery depends on severity of injury * No awake, lucid period; patient is coma immediately with posturing (Decor/decerb) and global cerebral edema * Can have prolonged coma

Answer 76

* MRI/CT * Assume cervical spine injury until ruled out * Transported on a board with head and neck aligned in neutral position * Cervical collar * C-spine Xrays

Answer 77

* Preserve brain homeostasis and prevent secondary injury * Cerebral edema after TBI peaks 48-72 hours after injury

Answer 78

* Cerebral edema * Hypotension * Respiratory depression * Hypoexmia * F/lyte imbalance

Answer 79

* Stabilize ABC * Maintain CPP * ICP mgmt * Control hemorrhage * Maintain optimal ABG * Fluid and electrolyte balance * Maintain proper positioning to promote venous drainage * Seizure prophylaxis * Manage pain and anxiety and agitation * NG tube: prevent regurg/aspiration

Answer 80

* When did injury occur, what caused it, direction and force of the blow * Loss of consciousness at time of injury and for how long, was the pt arousable

Answer 81

* Done at least every hour * GCS to determine LOC * Assess motor function compare all extremities and L/R on command, speech and noxious stim * Pupils- Bilateral, sluggish, brisk to light, equal size or unequal * Behavior-Emotional lability, aggressive, uninhibited * Document thoroughly * Notify provider of changes immediately

Answer 82

Pupils unequal

Answer 83

* Cushing triad: Bradycardia, systolic hypertension, widening pulse pressure, resp depression

Answer 84

Bradycardia, Hypotension, tachypnea

Answer 85

* Maintain a temp under 100.4/38c (Increased temp increased metabolic demand on the brain * Fever may indicate brain stem dmg * Don't want them to shiver either as that can increase ICP

Answer 86

* Know elevated ICP mgmt * Proper position of head and body

Answer 87

* Drug level monitoring, need to maintain a therapeutic range * Side effects

Answer 88

* Airway: Maintain the airway, is the patient able to protect their own airway, if no they getting tubed * Oxygen sat and pulse ox * ABG: hypoxemia, hypercarbia, brain sensitive to hypoxia and deficits can worsen if hypoxic * Lungs sounds: Present? clear or adventitious? * Resp pattern: Regular irregular (Unless vented) cheyne stokes * RR: Low normal or high? * Cough reflex intact or absent: guard against aspiration, check cuff on ett or trach * CBC: Anemia HH plt function, WBC * Chest X-ray: Atelectasis, contusion, pneumothorax, neurogenic pulmonary edema * Sputum cultures * Minimize suctioning if increased ICP as it can increase ICP: If needed make it should * Monitor for ARDS, pneumonia , fluid overload * Good oral hygiene to help prevent against vent associated pneumonia * PEEP, use cautiously can increase intrathoracic pressure increasing ICP

Answer 89

* Assess vitals: HR+BP * Monitor for and treat arrhythmias: Determine the underlying cause * BP mgmt * IV fluids vs vasopressors, vasopressors are better * Manipulate CO to maintain adequate CPP * Maintain good MAP * Maintain CPP (60-70) * Monitor for venous thromboembolism (DVT and PE) * 12 lead ECG: Ischemia/ infarction

Answer 90

* Want to maintain normal levels * Strict I+O * Daily weight * Serum and urine electrolytes * Glucose level * Serum osmolality * Urine specific gravity and ketone * Monitor skin turgor and mucous membranes

Answer 91

* Hyponatremia * Effects of osmotic diuretic * Diabetes insipidus (DI) * SIADH * Hyperglycemic hyperosmolar syndrome

Answer 92

* Correct hyponatremia: Fluid restriction **3% hypertonic** saline **Do not correct rapidly** increase by 4-6 mEq/L over 24 hours * Correct Hypokalemia * Insulin for hyperglycemia * If giving mannitol, monitor for pulmonary edema and HF (Fluid staying in vasculature rather than excreted), want to see increased urine output

Answer 93

* Monitor and prevent ileus * Bowel sounds and abd distension * Nutrition early: improves outcomes and prevents ileus * Enteral feeds: NG, NJ PEG * Needs an active bowel to be used (Bowel sounds and no ileus) * HOB up to prevent aspiration * High cal high protein * TPN: not usually prefered * Constipation mgmt: From bed rest, NPO, fluid restrictions, pain meds * Bowel incontinence * Altered LOC * SKin care * GI bleeding prophylaxis (Basically everyone needs this) * PPI * Monitor for bleeding (Change in stool color, decreased H+H, gastric aspirate)

Answer 94

* Diuretics * Strict I+O * Mannitol * Monitor fluids and lytes * Incontinence * Skin care * Foley cath, condom cath * Monitor for infection

Answer 95

* Assess ROM, development of deformities or spasticity * Passive ROM * PT/OT * Splints: Hands feet and ankles * Proper positioning of patient with increased ICP * HOB 30 degrees * Minimal elevation of legs * Head and neck aligned neutrally

Answer 96

* Assess skin integrity and oral mucosa q8 hrs or more frequently * Assess under trach collar or ties or et tube * Turn and position Q2 hrs * OOB to chair 3x daily if able * Early ambulation if able * Skin care per institution policy * Allevyn * Speciality bed * Frequent oral care * Minimizes infection risk * Monitor for breakdown of lips from ET tube * Lubricant for lips

Answer 97

* initial brain injury * Emerging from coma * Increasing ICP * Fever * Hypoxia * Pain/discomfort * Full bladder * Restraints

Answer 98

* Ensure oxygenation is adequate, bladder not distended, dressings, cast, splints not constricting flow * Padded side rails * Wrap hands so they cannot pull out tubes and to prevent self injury, avoid restraints * Speciality bed, bed is at floor level * Reduce stimuli * Adequate lighting * re-Orientate pt * Avoid opiates to control restlessness/agitation * minimize disruption in sleep wake cycle, cluster nursing care , lights on, shade open, dark in evening * Limit waking pt if able * Keep sheets dry if incontinent

Answer 99

Due to hypothalamic dmg cerebral irritation hemorrhage infection

Answer 100

* Check temp every 2-4 hours (Continuous thermometer) * Identify cause of fever * Treat with acetaminophen and cooling devices * Maintain normothermia * Do not cause shivering: Increases ICP and metabolic demand * Culture blood urine and sputum * Antibiotics as prescribed

Answer 101

* Can occur immediately (within 24 hours) early (1-7 days ) or late (7+ days) * Causes increased ICP and decreased oxygenation * Admin anticonvulsant prophylaxis * Can be weaned off once past acute phase unless had a seizure

Answer 102

Increased pressure creates downward pressure of the brain stem, resulting in cessation of blood flow to the brain, causing irreversible anoxia and brain death

Answer 103

* Due to decreased secretion of ADH, from pituitary * Makes you pee a ton, decreasing urine osmolality and serum hyperosmolarity * Urine is clear * Mgmt: IV fluids, electrolytes, Vasopressin DDAVP | Dehydration is major concern

Answer 104

* Excessive ADH secreted * Stops you from peeing, volume excess * Serum Na is dilute as a result of the volume excess * Treated with fluid restriction with no free water and in severe cases 3% saline

Answer 105

* The person is dead when the brain is dead * Zero possibility of recovery * Needs to be verified by 1-2 physicians * Pt needs to be * Removed from sedation, neuromuscular blocking agents CNS depressants * Normal body temp (36 degrees) * SBP over 100 (Can use vasopressors) * No sevre lyte, acid base or endocrine disturbances

Answer 106

* Coma * Absence of brain stem reflexes * Apnea

Answer 107

Complete loss of consciousness

Answer 108

1. Pupillary reflex: Pupils are fixed, mid size or dilated **not** reactive to light 2. Corneal reflex: Drop of saline in the eye, person should blink if not its absent 3. Oculovestibular reflex: Irrigate each ear canal with ice water, absent if the eyes do not move to irrigated ear within 1 min 4. Gag Reflex 5. Cough reflex: Person coughs when suctioning 6. Occulocphalix reflex: Hold eyes open, turning head side to side, normally the eyes turn in opposite side the head is turning

Answer 109

* Removal from vent with no spontaneous breaths * Preoxy 100% for 10 min, vent 10 bpm Peep is 5 cmH20 if SPO2 >95 do abg, disconnect from vent continue with O2 100% 6l through ETT * Monitor for rep movements for 8-10 min , if none do an ABG at 8 min * If no respirations and PCO2 is >60 mmHg apnea test is positive

Answer 110

* Cerebral angiography-gold standard; confirms absence of blood flow to brain * CT angio or MR angio-shows cessation of cerebral blood flow * EEG—will show no brain activity * Somatosensory evoked potentials (SSEPs): no somatosensory evoked potentials in response to bilateral median nerve stimulation and no brain stem evoked potentials in response to auditory stimuli, can confirm EEG findings * Transcranial doppler ultrasound—can assess pulsations of middle cerebral arteries, vertebral and basilar arteries

Answer 111

* Need to maintain adequate tissue perfusion for potential organ donation * If family declines organ donation, cardiopulmonary support is withdrawn * Anticipatory grieving of the family help the family understand * Organ donation, needs brain death confirmation in order to proceed * Need to collab with a lot of other professions in this

Answer 112

* Provide proper suctioning of the endotracheal/tracheostomy tube to remove secretions from the airway. This also helps to prevent blockage of endotracheal or tracheostomy tubes. * Clean all the body parts, especially the face, back, and perineal area. * Provide dressing to open wounds (if any) and cover them with gauze pieces. * Every patient goes through a different situation despite having the same diagnosis. Nurses should manage the patients accordingly. * Visualization of patient treatment and prognosis, as well as counseling daily, may slowly help family members cope with the patient's degrading health status. * Change the patient's position every 2 hours to prevent bedsores. * Check the intravenous cannula sites for redness and swelling. * **Make sure that the "Do not attempt resuscitation order" (DNR) is in place** * Provide emotional and psychological support to the family and relatives of the patient, as they may deny seeing their loved ones in the end stage. * Find out and inform the organ donation center as soon as a patient is declared brain dead. * Respect the patient's cultural and religious backgrounds. * Record and report all the procedures that are done for the patient throughout the hospital stay.