Ch 61- Neurologic Dysfunction Flashcards
1
Q
define coma
A
unconsciousness, unarousable unresponsiveness
2
Q
akinetic mutism
A
unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
3
Q
persistent vegetative state
A
devoid of cognitive function but has sleep–wake cycles
4
Q
locked-in syndrome
A
inability to move or respond except for eye movements due to a lesion affecting the pons
5
Q
locked in syndrome is caused by a lesion affecting what brain structure?
A
pons
6
Q
what are the three causes of ALOC?
A
neurologic (head injury or stroke)
toxicologic (drug overdose or alcohol intoxication)
metabolic (hepatic or kidney; DKA)
7
Q
What are the steps of assessment in a patient with ALOC?
A
- LOC including alertness and verbal response
- motor response- posturing
- respiratory status- if abnormal, may be issue with brainstem aka medulla
- eye response- pupil size and response
- reflexes- DTR, gag, swallow, corneal, plantar
8
Q
what should the nurse do for a patient without a corneal reflex
A
place eye coverings/protection on patient
9
Q
what is the continuum for LOC?
A
awake,alert, oriented; confused; delirious; lethargic; somnolent; stuporous; unconscious
10
Q
define confused
A
inability to think as clearly or as quick as you normally would (not at their baseline)
11
Q
define delirious
A
(do not confuse dementia and delirium) acute confused state that begins with being disoriented; if not recognized and treated quickly can progress and patients can die
12
Q
lethargic
A
slow to respond, drowsy, little energy,
13
Q
somnolent
A
so drowsy, they only want to sleep, difficulty following commands, difficult to arouse,
14
Q
stuporous
A
unresponsive except by VIGOROUS stimulation; sternal rub, shake,
15
Q
unconscious
A
lack or ability to notice anything in environment
16
Q
what would a patient with decorticate positioning look like?
A
flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet.
17
Q
what would a patient with decerebrate positioning look like
A
involving extension and outward rotation of upper extremities and plantar flexion of the feet.
18
Q
what are some complications that can arise from ALOC?
A
respiratory distress or failure, pneumonia, aspiration, pressure injury, DVT, contractures
19
Q
what is the primary goal when caring for a patient ALOC
A
maintaining patent airway!
20
Q
an increase in what 3 parts of the skull can change the volume of each other
A
brain tissue (parenchyma), blood, CSF
21
Q
what is the Monro-Kellie hypothesis
A
because of limited space in the skull, an increase in any one of components of the skull (brain tissue (parenchyma), blood, cerebral spinal fluid (CSF) will cause a change in the volume of the others
22
Q
what is normal ICP?
A
10-20 mmHg
23
Q
what happens when ICP increases
A
decreased cerebral perfusion which causes ischemia, cell death, and (further) edema
24
Q
what is brain herniation and how is it treated?
A
brain tissues shift through dura
no treatment; pt will die!
25
what is the term for the brain's ability to to change the diameter of blood vessels to maintain relatively constant cerebral blood flow
autoregulation
26
what happens to the brain vasculature in response to decreased CO2?
vasoconstriction
27
what happens to brain vasculature in response to increased CO2
vasodilation
28
what are the criteria for BP and ICP levels for autoregulation mechanism to work?
SBP must be between 50-150 mmHg
and ICP must be less than 40
29
where is ICP usually measured
lateral ventricles
30
what is a serious complication associated with increased ICP that can result in death?
brain herniation
31
what is the normal Cerebral perfusion pressure (CPP)
70-100 mmHg
32
if a patients BP is 160/70 and their ICP is 15 what is their CPP?
85
33
what is the MAP of a patient with a BP 160/70?
100
34
how do you calculate MAP?
SBP + (2 x DBP) divided by 3
35
list the early manifestations of increased ICP?
1. changes in LOC
2. restlessness, confusion, increased drowsiness, lethargy, increased respiratory effort, purposeless movement
3. pupillary changes & impaired ocular movements
4. weakness in one extremity or one side
5. headache: constant, increasing in intensity, or aggravated by movement or straining
36
what is the first sign of increased ICP?
altered LOC
37
what are the late manifestations of increased ICP
1. Vital signs: increased SBP, widened PP, slowing HR, fluctuating pulse from rapid to slow, increased temp
2. projectile vomit
3. durther deterioration of LOC: stupor to coma
4. hemiplegia, decortication, decerebration, or flaccidity
5. Respiratory pattern alterations include Cheyne-Stokes breathing & arrest
6. loss of brainstem reflexes- gag, swallow, corneal, pupil
38
the nurses sees the patient experiencing cushings triad. is this a late or early sign of increased ICP and what are the components of cushing triad?
late sign
cushing triad= HYPERTENSION, BRADYPNEA, BRADYCARDIA
39
what happens to temperature, pulse, and blood pressure during late signs of increased ICP?
- Temp= high/erratic
- SBP increases and DBP stays the same; causes widened pulse pressure\
- pulse is slow and bounding
40
what value is considered a widened pulse pressure?
> 100 pulse pressure
41
what intervention can be done by the physician to decrease ICP and CO2 levels
induce hyperventilation
42
what is a risk associated with inducing hyperventilation to reduce ICP
alkalosis
43
how do you calculate pulse pressure?
- a narrow pulse pressure is indicative of what type of problem? what about a widened pulse pressure
PP= SBP-DBP
- Narrow pulse pressure = < 25% of SBP and indicates cardiac problem
- wide pulse pressure = > 100 and indicative of neuro problem
44
what are the assessment steps of a patient with increased ICP?
- history of event leading up to illness
- evaluate LOC & mental status
- cranial nerves
- cerebellar function
- reflexes
- motor & sensory function
- GCS
- pupil checks
- vital signs
- ICP assessment
45
what is score range for glasgow coma scale?
3-15
46
How do you score eye opening response according to glasgow coma scale?
spontaneously- 4
to speech- 3
to pain- 2
none- 1
47
how do you score verbal response according to GCS?
oriented- 5
confused- 4
inappropriate- 3
incomprehensible- 2
none- 1
48
how do you score motor response according to GCS
obeys commands- 6
localizes to pain- 5
withdraws from pain- 4
flexion to pain-3
extension to pain- 2
none-1
49
what areas of the brain can the nurse expect a catheter to be placed for ICP monitoring?
ventricle, subarachnoid, intraprenchymal space, subdural space
50
what interventions can be used to decrease ICP?
- monitor ICP & cerebral oxygenation
- decrease cerebral edema
-maintain cerebral perfusion- with dobutamine, norepi, levophed
-control fever
- reduce CSF and intracranial blood volume
- maintain oxygenation & metabolic demands
51
How is cerebral edema decreased? what medications, fluid, etc. used?
1. Mannitol- osmotic diuretic to pull fluid from cell
2. 3% saline- hypertonic saline
3. fluid restrictions
4. directly drain CSF via catheter
52
how is temperature controlled in cases of increased ICP
cooling blankets, acetaminophen suppository,
53
is it safe to induce hypothermia to patients with neurological problems experiencing increased ICP?
controversial- however it can provide brain rest
54
3 major problems assoicated with increased ICP?
brain herniation, SIADH, DI
55
what is SIADH
syndrome of inappropriate antiduretic hormone
- causes body to hold onto fluid
- patient becomes volume overloaded and sodium is diluted
- treat with fluid restriction
56
what is diabetes insipidus
- decreased secretion of ADH
patient has excessive urine output, decreased urine osmolality, & serum hyperosmolarity
- treat with electrolyte replacement, synthetic vasopressin, & fluids
57
what are the goals for patients with increased ICP?
- Maintenance of patent airway
- Normalization of respirations
- Adequate cerebral tissue perfusion
- Respirations
- Fluid balance
- Absence of infection
- Absence of complications
58
what should be avoided in pts with increased ICP?
- vasalva maneuver & no enemas
- loud atmospheres & increased stimuli
* minimize stress
59
what should the nurse monitor in patients with increased ICP?
- respiratory status & lung sounds
- position head in neutral position w/ HOB raised 0-60 degrees to promote venous drainage
- no hip flexion, valsalva menuver, abdominal distension, or other stimuli that could increase ICP
- maintain calm quiet, atmosphere that is stress free
- monitor fluid status; I&O
- use strict aseptic technique when assessing ICP monitoring systems
60
what is a craniotomy
opening of the skull
61
what are the purposes of a craniotomy
remove tumor, relieve elevated ICP, evacuate a blood clot, control hemorrhage
62
craniectomy
excision of portion of skull
63
cranioplasty
repair of cranial defect using a plastic or metal plate
64
Burr Holes
circular openings for exploration or diagnosis to provide access to ventricles or for shunting procedures, aspirate a hematoma or abscess, or make a bone flap
65
what is a tentorium
imaginary line that is a dural fold separating the upper portion of cerebrum and cerebellum
- divided into supra & infratentorium
66
what are the three cranial surgical approaches
Supratentorial, infratentorial, transphenoidal
67
what is the medical management preoperative care for cranial surgery
- Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies
- Medications are usually given to reduce risk of seizures
- Corticosteroids, fluid restriction, hyperosmotic agent (mannitol), and diuretics may be used to reduce cerebral edema
- Antibiotics may be given to reduce potential infection
- Diazepam may be used to alleviate anxiety and for seziure prohylaxis
68
what is nursing management preoperative care for cranial surgery
- Obtain baseline neurologic assessment
-Assess patient and family understanding of and preparation for surgery
- Provide information, reassurance, and support
69
whata re the 4 aims of postoperative care from cranial surgery?
- Detecting and reducing cerebral edema
- Relieving pain
-Preventing _seizures
- Monitoring ICP and neurologic status
*pt may be intubated and have arterial and venous lines
70
What should you assess in patients undergoing cranial surgery
- respiratory function/ABGS
- VS and LOC: signs of icnreasing ICP
- assess dressing and siogns of bleeding or CSF leakage
- potential seziures; document if occurs
- signs and symptoms of complications
- fluid status and labs
71
complications of cranial surgery
- Increased ICP
- Bleeding and hypovolemic shock
- Fluid and electrolyte disturbances
-Infection
- CSF leak
- Seizures
72
goals for pts undergoing cranial surgery
- Improved tissue perfusion
- Adequate thermoregulation
- Normal ventilation and gas exchange
- Ability to cope with sensory deprivation
- Adaptation to changes in body image
- Absence of complications
73
#1 intervention for pt under going cranial surgery
maintain cerebral perfusion
- Monitor respiratory status; even slight hypoxia or hypercapnia can affect cerebral perfusion
- Assess VS and neurologic status every 15 minutes to every hour
- Strategies to reduce cerebral edema; cerebral edema peaks 24 to 36 hours after surgery
- Strategies to control factors that increase ICP
- Avoid extreme head rotation
- HOB may be flat or elevated 30 degrees according to needs related to the surgery and surgeon preference
74
when does cerebral edema peak after cranial surgery
24-48 hours after surgery
75
how to regulate pt temp after cranial surgery?
- Cover patient appropriately
- Treat high temperature elevations aggressively; apply ice bags, use hypothermia blanket, administer prescribed acetaminophen
76
how to imporve gas exchange in post-op pt from cranial surgery?
- Turn and reposition every 2 hours
- Encourage deep breathing and incentive spirometry
-Suction or encourage coughing cautiously as needed (suctioning and coughing increases ICP)
- Humidification of oxygen may help loosen secretions
77
which medication CANNOT be taken after cranial surgery? why?
ibuprofen & other NSAIDS
- they have an antiplatelet effect
78
why is sensory deprivation important after cranial surgery
Periorbital edema may impair vision, announce presence to avoid startling the patient; cool compresses over eyes and elevation of HOB may be used to reduce edema if not contraindicated
79
how can self image be enhanced after cranial surgery
Encourage verbalization
Encourage social interaction and social support
Attention to grooming
Cover head with turban and, later, a wig
80
what other interventions can be done post-op in regards to fluid regulation and infection control?
- I & O, weight, blood glucose, serum and urine electrolyte levels, and osmolality and urine specific gravity
- Assess incision for signs of hematoma or infection
- Assess for potential CSF leak
- Instruct patient to avoid coughing, sneezing, or nose blowing, which may increase the risk of CSF leakage
- Use strict aseptic technique
- Patient education for self-care
81
what is delirium
- confused state, begins with disorientation and can progress to changes in LOC, irreversible brain damage, and sometimes death
- 80% of patients in ICUs are affected. The presence of delirium triples in-hospital mortality rates.
82
chornic, long term changes in confusion and LOC is likely to be?
dementia
83
what are the risk factors for delirium?
include age, existing dementia, prior coma, recent emergency surgery/trauma, taking benzos, having blood transfusions.
84
how can delirium be prevented?
- Provide therapeutic activities for cognitive impairment
- Reorient patient as needed
- Ensure early mobilization
- Control pain
- Minimize the use of psychoactive drugs
- Prevent sleep deprivation
-Enhance communication methods (particularly eyeglasses and hearing aids)
- Maintain O2 level and fluid/electrolyte balance
-Prevent surgical complications
85
what is dementia
- Cognitive, functional, and behavioral changes eventually destroy the ability to function
- Symptoms are usually subtle in onset and often progress slowly until they are obvious and devastating.
- Dementia in older adults is typically caused by some degree of neurodegeneration
- The most common type of dementia is Alzheimer's disease.
- Other dementias include degenerative, vascular, neoplastic, demyelinating, infectious, inflammatory, toxic, metabolic, and psychiatric disorders.
86
true or false: alzheimers can only be diagnosed via autopsy
TRUE
87
what is pseudobulbar effect?
- Involves inappropriate or exaggerated emotional expression, usually episodes of laughing or crying associated with brain injury
- “Pseudobulbar” refers to damage that occurs in the corticobulbar tracts in the brain. The emotional outbursts can cause embarrassment, anxiety, and depression, and often impair quality of life.
- Condition can coexist with mood disorders, such as depression, although crying in these patients should not be considered indicative of depression.
-Effective management with dextromethorphan hydrobromide and quinidine sulfate in patients with ALS, MS, stroke, TBI, and dementia.
88
what are seizures
Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons
89
Whata re the 4 classifications of seizures
- Focal: originates in one hemisphere (partial seizures)
- Generalized: occur and engage bilaterally
-Unknown: epilepsy spasms
- “Provoked” related to acute, reversible condition
90
patients is said to have epilepsy when?
if have more than one provoked seizure
91
what are the specific causes of seizures?
- Cerebrovascular Disease
- Hypoxemia
- Fever (Childhood)
- Head Injury
- Hypertension
- Nervous System Infections
- Metabolic and Toxic conditions
- Brain Tumor
- Drug And Alcohol Withdrawal
- Allergies
92
what is the plan of care for pt experiencing a seizure?
Observation and documentation of patient signs and symptoms before, during, and after seizure
93
What needs to be nearby in case of seizure?
what seizure precautions should be in place?
oxygen tubing, oxygen, and suction
- 2-3 side rails up and padded
- bed in lowest position
- patient in side lying position (immediate postseize)
- patient needs to be wearing loose clothing
94
what is status epilecticus
- Defined as a seizure lasting 5 minutes or longer or serial seizures occurring without full recovery of consciousness between attacks.
- Considered a medical emergency.
- Status epilepticus produces cumulative effects.
- Vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations.
-May produce venous congestion and hypoxia of the brain.
-Repeated episodes of cerebral anoxia and edema may lead to irreversible and fatal brain damage
95
Nursing interventions for status epilepticus
- draw labs: venous draw; serum electrolytes, serum glucose, phenytoin levels
- pts taking dilantin need phenytoin levels drawn
- if phenytoin levels low- can give more dilantin
- ensure working IV
- EEG
- VS
- neuro checks
- possible glucose if glucose levels are LOW
- if initial treatment ineffective; general anesthesia w/ short acting barbiturate to stop seizure activity
- pt will need to be intubated and sent to ICU (code blue will be called if this step is necessary)
Postictal period- time immediately after seizure and there is an INCREASED RISK OF CEREBRAL EDEMA
- Ictal period- during the seizure
96
what is the ictal period of a seizure
during the seizure
97
what does post ictal mean
after the seziure
98
what is a headache
- Also known as cephalalgia
- One of the most common physical complaints
Secondary headache is a symptom with an organic cause such as a brain tumor or aneurysm
Headache may cause significant discomfort for the person and can interfere with activities and lifestyle
99
what is primary vs secondary headache
- Primary headache has no known organic cause and includes migraine, tension headache, and cluster headache
-Secondary headache is a symptom with an organic cause such as a brain tumor or aneurysm
100
how should the nurse assess a headache
A detailed description of the headache is obtained
Include medication history and use
The types of headaches manifest differently in different persons and symptoms in one individual may also change over time
Although most headaches do not indicate serious disease, persistent headaches require investigation
Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes
Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam
101
how can the nurse manage headache pain?
Provide individualized care and treatment
Prophylactic medications may be used for recurrent migraines
Migraines and cluster headaches require abortive medications instituted as soon as possible with onset
Provide medications as prescribed
Provide comfort measures
Quiet, dark room
massage
Local heat for tension
102
what is a common med used to treat headaches
Imitrex
103
what should the nurse educate the patient on regarding headaches
Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention
Medication instruction and treatment regimen
stress reduction techniques
Nonpharmacologic therapies such as massage, cold compress, relaxation therapy,
Follow-up care
Encouragement of healthy lifestyle and health promotion activities
