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NURS 2514 > Chapter 7 Acute Neuro > Flashcards

Chapter 7 Acute Neuro Flashcards

1
Q

Structures of the Brain (2)

A
  • Cerebrum

- Cerebellum

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2
Q

What is cerebrum consist of?

A
  • Right and left hemisphere

- Divided into 4 lobes

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3
Q

What are the 4 lobes of cerebrum?

A
  • Occipital
  • Parietal
  • Temporal
  • Frontal
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4
Q

What is the function of cerebellum?

A

Coordinates voluntary movements and maintains posture

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5
Q

What is contralateral processing?

A
  • Left hemisphere receives inputs from the right side of the body and vice versa.
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6
Q

What is optic chiasm

A
  • crossing of optic nerves in the brain

- Forms an X

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7
Q

What are the structures of the Brain?

A
  • Brain Stem
  • Hypothalamus
  • Thalamus
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8
Q

What is the function of the brain stem?

A
  • Regulates cardiac and respiratory function
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9
Q

What is the function of Hypothalamus (3)

A
  • Controls body temp
  • CNS to endocrine
  • Smooth muscles, HR, bladder contractions etc
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10
Q

What is the function of Thalamus

A
  • Sorts information and passes it on the cerebral cortex where it can initiate and coordinate movements in response to the sensations
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11
Q

What are ventricles

A

Four cavities within the brain, filled with cerebrospinal fluid (CSF), that connects with one another and with the spinal canal.

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12
Q

What is Cerebrospinal Fluid (CSF)

A
  • Clear, colourless fluid that circulates within the subarachnoid space that surrounds the brain, brain steam and spinal cord.
  • Provides cushioning for the brain and the spinal cord; allows fluid shifts from cranial cavity to spinal cavity; and carries nutrients.
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13
Q

What is the other use of CSF?

A
  • CSF provides useful diagnostic info relating to certain nervous system disease.
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14
Q

Where is CSF Absorbed?

A

Arachnoid Villi

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15
Q

what are the 3 protective layers that surrounds the brain and spinal cord called? what are the 3?

A

Meninges

1) Dura Mater
2) Arachnoid
3) Pia mater

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16
Q

where is dura mater located

A

Outer most layer that is closest to the skull

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17
Q

where is Arachnoid located?

A

Middle layer, delicate impermeable membrane

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18
Q

Where is pia matter located?

A

Delicate and adhere to the surface of the brain and spinal cord.

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19
Q

where is CSF located?

A

CSF is found in the subarachnoid space ( between arachnoid and pia matter )

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20
Q

What is inter-cranial pressure

A

sum of all the pressure within the three components

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21
Q

what are the 3 components of inter-cranial pressure

A
  • Brain Tissue - 80%
  • Blood - 10%
  • Cerebrospinal Fluid - 10%
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22
Q

Why cant the total volume cannot change

A
  • The skull is a rigid and protective covering of the brain.
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23
Q

What is the “Monro-Kellie doctrine”

A

A change in 1 component requires a change in another.

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24
Q

Factors that influence ICP under normal circumstances are changes in (6) :

A

1) Blood pressure
2) Cardiac function
3) Intra-abdominal and intra thoracic pressure
4) Body position
5) Body temp
6) blood gases, particularly CO2 levels

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25
Q

Normal brain function depends on..

A
  • consistent supply of blood ( for oxygen & nutrients/ glucose)
  • Brain relies on healthy heart & lungs for perfusion
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26
Q

Disease that cause increase ICP (4)

A
  • Brain trauma
  • Brain Tumour
  • Brain Infections
  • Brain Hemorrhage
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27
Q

what is the normal ICP pressure

A

5-15 mmHg

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28
Q

What is the pressure of increased ICP

A

> 20 mmHg

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29
Q

What is the normal CPP

A

70 to 100 mmHg

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30
Q

what is the minimum CPP

A

50 - 60 mmHg necessary for adequate cerebral perfusion

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31
Q

CPP of <50mmHg is associated with?

A

cerebral ischemia

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32
Q

What is cerebral perfusion pressure (CPP) ?

A

net pressure gradient that drives oxygen delivery to cerebral tissue. Pressure needed to ensure adequate brain tissue perfusion.

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33
Q

Formula for CPP?

A

MAP - ICP = CPP

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34
Q

What are the 3 compensatory mechanisms?

A

1) CSF Volume
2) Autoregulation
3) Carbon dioxide (PaCO2), Oxygen (PaO2), pH

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35
Q

Explain compensatory with CSF volume

A

Displacement of CSF into the spinal subarachnoid space or the basal subarachnoid cistern and to lesser degree, by altering CSF production and absorption rates.

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36
Q

Explain compensatory with Autoregulation

A
  • Brain has an ability to regulate its own blood flow in response to its metabolic needs despite the systemic blood flow.
  • By dialating and constricting cerebral blood vessels, the brain can ensure constant blood flow.
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37
Q

what is the purpose of autoregulation

A
  • To ensure adequate CBF to meet metabolic needs of the brain tissue and to maintain cerebral perfusion pressure within normal limits
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38
Q

Autoregulation fails when?

A

When theres extreme hypertension and hypotension

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39
Q

Explain compensatory with carbon dioxide, oxygen, pH

A
  • increase in CO2 (decrease O2) relaxes the smooth muscles, dilates cerebral vessels, decrease cerebrovascular resistance, and increases CBF to bring more O2
  • decrease in CO2 ( increase O2) reverse this process and decreases CBF
  • if CO2 is not raised, anaerobic metabolic begins, resulting in an accumulation of lactic acid. As lactic increases and hydrogen ions accumulates, the cerebral environment becomes more acidic. With acidic environment further vasodilation occurs in continue to attempt to increase blood flow.
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40
Q

What are the 3 main components of skull that makes up our intracranial pressure?

A
  • Tissue - 80%
  • Blood - 10%
  • CSF - 10%
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41
Q

Summarize the 3 compensatory mechanisms to maintain cerebral blood flow

A

See notes..

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42
Q

What can increased ICP in brain tissue

A
  • Tumor
  • Abscess
  • Edema
  • Contusion ( Bruise )
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43
Q

What can increased ICP in Blood?

A
  • Inter-cranial hemorrhage

- Intracranial hematoma

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44
Q

What can increased ICP in CSF (2)

A
  • Hydrocephalus

- Meningites

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45
Q

Consequences of high ICP (9)

A
  • Cerebral Edema
  • Compression of brain vessels, tissue, ventricles
  • Decreased blood flow
  • Tissue hypoxia
  • Death of brain cells
  • Acidosis
  • Impaired Autoregulation
  • Brain stem compression
  • Brain herniation
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46
Q

Explain the cascade of events from insult to the brain to death

A

Insult to brain > Tissue edema> increase ICP< compression of blood vessels> low cerebral flow
> Low O2 with death of brain cells> edema around necrotic tissue> Increase ICP with compensation of brain stem and respiratory centre > accumulation of CO2> Vasodilation > increase ICP resulting from increase blood volume > death

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47
Q

What is brain herniation

A

Shifting of brain tissue from one space in the brain to another through various openings.

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48
Q

Is Brain herniation an emergency?

A

YES

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49
Q

Clinical Manifestations of Increased ICP (6)

A
  • Change in level of consciousness
  • Changes in vital signs
  • Ocular signs
  • Decrease in motor functions
  • Headache
  • Vomiting
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50
Q

What is the earliest sign on increase ICP?

A

Level of consciousness

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51
Q

Increase ICP Manifestation: Level of Consciousness (4)

A
  • Early sign of increased ICP
  • Related to decrease in cerebral flow
  • Affects brain stem –> specifically RAS
  • Can lead to coma if state unrelieved
52
Q

If level of consciousness is unrelieved then what can it lead to?

A

Can lead to coma state

53
Q

What does RAS control?

A

Controls conciousness

54
Q

What is the deepest state of unconsciousness?

A

comatose

55
Q

who regulates temperature?

A

Hypothalamus

56
Q

Who regulates HR and respiratory?

A

Brainstem

57
Q

what is the late sign of high ICP?

A

Vital signs

58
Q

Increase ICP Manifestation: Changes in Vital signs are caused by?

A

Increasing pressure on the thalamus, hypothalamus, pons, and medulla

59
Q

What are the 3 cushings triads?

A

1) Increase Blood pressure
2) Decrease HR
3) Irregular respiratory rate, periods of apnea –> Cheyne Stokes

60
Q

changing in vital signs means..

A

Close to reaching hernation

61
Q

cushings triad: Explain increase BP

A
  • increase in systolic pressure (widening pulse pressure)
  • Body tries to regulate due to decrease in blood flow which results in vasoconstriction in the whole body and causes increase in BP
62
Q

cushings triad: Decrease HR (bradycardia)

A
  • Baroreceptors (Aortic Arc) sense the increase in BP and initiates the PSN to kick in and decrease the HR due to body thinking that it already have good CO and BP. This results in decrease HR
63
Q

cushings triad: Irregular RR

A
  • As ICP worsens, the pressure on Brainstem increases and it leads to irregular respiratory pattern and periods of apnea.
  • Maybe present but often do not appear until ICP has been increased for some time or suddenly and markedly increases (ex. head trauma)
64
Q

Cushing’s Triad is…Med..

A

Medical emergency!!

65
Q

Cushing Triad an early or late sign?

A

Late sign

66
Q

Increase ICP Manifestation: Changes in Vital signs such as changes in temperature is caused by?

A

Associated pressure on the hypothalamus

67
Q

What does Cranial Nerve 3 do? (3)

A
  • Allow movement of the eyes and eyelids
  • Motor and sensory function
  • Pupil constrictions and response to light
68
Q

Is ocular sign an early or late sign?

A

Late sign

69
Q

Why is ocular affected?

A

Cranial nerve exits on top of the brainstem. It becomes compressed when someone has high ICP

70
Q

Compression of oculomotor nerve (Cranial 3) results in? (5)

A
  • Dilation of pupil ipsilateral (same side) to mass or lesion.
  • Sluggish
  • no response to light
  • Inability to move the eye upward
  • ptosis of eyelid
71
Q

Ocular signs can be

A

bilateral or unilateral

72
Q

ocular signs is the result of

A

shifting of the brain from the midline, a process that compresses the trunk of CN 3, paralyzing the pupil spincter.

73
Q

other cranial nerve that is affected

A

CN 2 - optic
CN 4 - trochlear
CN 6 - abducens

74
Q

Signs of other CN affected

A
  • Blurred vision
  • Diplopia
  • Changes in extraocular movement
75
Q

Increase ICP Manifestation: Decrease Motor Function (3)

A
  • Contralateral hemiparesis or hemiplegia
  • Decorticate Posturing
  • Decerebrate Posturing
76
Q

What is hemiparesis

A
  • Mild or partial weakness on one side or half the body
77
Q

Hemiplegia

A
  • Severe paralysis of one side of the body
78
Q

What decorticate posturing? Where is the damage

A
  • Damage occurred to the cerebral hemisphere. The thalamus and the midbrain. Less severe compared to decerebrate.
  • Flexor
79
Q

Decerebrate Posturing? Where is the damage

A
  • Result of brain stem damage which means pressure is compressing the brainstem and pushing down and reaching herniation
  • extensor
80
Q

Posturing indicates

A
  • can indicate that brain herniation is occurring or is about to occur (for both)
81
Q

Posturing (4)

A
  • Bad sign of brain injury
  • Can occur on its own
  • Can be elicited using painful stimuli
  • Happens from result of brain herniations or immolate herniation
82
Q

which one is “better” decorticate or decerebrate

A

Decorticate is better than decerebrate because decerebrate means they’re reaching herniation and will die.

83
Q

Increase ICP Manifestation: cause of Headache

A
  • Caused by compression of vessels and nerves in the brain
84
Q

Increase ICP Manifestation: Headache is described as?

A
  • Described as continuous
85
Q

ncrease ICP Manifestation: What aggrevates Headache

A

Aggravated by moving and straining ( increases more pressure in the brain)

86
Q

What is the non specific sign of increase ICP

A

Vomiting

87
Q

Increase ICP Manifestation: Vomiting

A
  • Usually occurs without nausea
  • Related to direct pressure on vomiting centre (medulla)
  • Projectile
88
Q

Explain how high ICP affects the brain cells

A
  • high ICP affects the brain cells through lower cerebral flow caused by compressions due to high ICP it can lead to tissue death/ cell death.
89
Q

Define brain herniation

A

Brain herniation is when tissues moves from one space in the brain to another through various openings.

90
Q

Describe Cushing’s Triad

A
  • Late symptoms of ICP
  • increase Systemic BP - due to decrease flow
  • Bradycardia - Baroreceptor sense increase in BP so decrease the HR
  • Irregular RR - Brain stem compressed leading to dysfunction in respiratory.
91
Q

Which cranial nerve is associated with high ICP? provide rationale

A
  • Cranial nerve number 3

- Cranial nerve 3 exits on top of the brain stem so it becomes compressed when someone has increase ICP.

92
Q

what is the cause traumatic Brain Injury

A
  • Fall
  • Motor Vehicle Accident
  • Struck by object
  • Sports
93
Q

What is one of the leading cause of death in Canada?

A
  • TBI
94
Q

Traumatic Brain Injury

A
  • Broad term to describe an injury caused by a force outside the brain
95
Q

TBI can be (3)

A
  • Open vs close
  • Diffuse vs Focal
  • Primary vs Secondary
96
Q

Laceration

A

a cut or skin wound. Non of the skin is missing

97
Q

Hematoma

A

A collection of blood

98
Q

Hemorrhage

A
  • profuse bleeding from a vessel

- Active bleeding not clotting

99
Q

Contusion

A

bruise to the brain tissue within a focal area

100
Q

Coup

A

damage occurring at the site of direct impact of the brain or skull

101
Q

Countercoup

A

Damage occurring on the opposite side away from the injury

102
Q

What is open head injury

A

object enters the brain through the skull ( bullet, knife, etc) damage is done through penetration of the brain tissue.

103
Q

Closed

A
  • Blow to the head which result in the brain moving and shaking within the skull
  • Brain bounce against side of the the skull and causes more damage (ex. coupcontrecoup damage)
104
Q

Diffuse vs Focal (4) each

A

Diffuse

  • Widespread area of damage
  • Difficult to view with diagnostics
  • Results from acceleration/ deceleration ( shifting and rotating)
  • Example: Diffuse axonal injury, hypoxia, meningitis, concussions

Focal

  • localized to one area
  • Easier to visualize with diagnostics (CT scan)
  • Results from blunt and penetrating trauma
  • Examples: Lacerations, skull fractures, contusions, hematomas
105
Q

What is primary Injury (2)

A
  • Occurs during the initial insult

- Related to the injury at the time of trauma –> for example, contusion, damage to blood vessels, axonal shearing

106
Q

what is secondary injury (4)

A
  • Indirect result of injury
  • Hours to days after the initial injury
  • Most facilities are due to secondary injury
  • Complications such as cerebral edema, cerebral hypoxia, ischemia, increased intracranial pressure.
107
Q

explain the cascade of events for secondary starting from injury to edema

A
  • Cerebral edema > Increase ICP > decrease blood flow> tissue hypoxia > increase co2 and Decrease pH > increase flow of blood > increase ICP > hypoxia and cell death > cell death leads to cytotoxic chemicals released which damages more.
108
Q

What is basilar skull fractures

A
  • Fractures that occurs on the base of the skull

- Risk of CSF leak into sinuses close to the injury

109
Q

Basilar Skull Fractures manifestations (4)

A
  • Bilateral Periorbital Ecchymosis (Raccoon eyes)
  • Postauricular Ecchymosis (Battle sign)
  • CSF rhinorrhea
  • CSF otorrhea
110
Q

Leak of CSF is risk for

A

meningitis

111
Q

Basilar Skull Fractures complication (5)

A
  • Meningitis
  • intracranial infections
  • hematoma
  • brain tissue damage
  • hemorrhage
112
Q

What is TBI complications

A

Hematomas

113
Q

What is hematomas

A

collections of blood between meninges

114
Q

Types of Hematoma (4)

A

1) Epidural Hematoma
2) Subdural Hematoma
3) Intraparenchymal hematoma
4) Subarachnoid hematoma

115
Q

What is risk factors of hematoma? (4)

A
  • Older age
  • alcohol
  • anticoagulants
  • antiplatelets
116
Q

What is subdural hematoma? (3)

A
  • found between dura mater and arachnoid layer of the brain
  • It is venous in origin, the hematoma is much slower to develop into a mass large enough to produce symptoms
  • caused by traumatic Brain Injuries
117
Q

3 types of subdural hematoma

A

1) Acute
2) Subacute
3) Chronic

118
Q

explain acute hematoma

A
  • manifestations occurs within 48hours of the injury

- Immediate deterioration

119
Q

What is subacute hematoma

A
  • 2-14 days of injury
  • ## alterations in mental status as hematoma develops; progression depends on site and location
120
Q

Chronic hematoma(3)

A
  • weeks to months to develop
  • more common in older adults (50’s to 60’s)
  • Non-specific, non-localizing progression; progressive alteration in LOC.
121
Q

Is bacterial meningitis medical emergency

A

yes

122
Q

what is bacterial meningitis

A

acute inflammation of the meninges (pia mater, arachnoid mater, and dura mater)

123
Q

bacterial meningitis occurs to who? (3)

A
  • infants
  • older adults
  • high risk population
124
Q

when is bacterial meningitis more prevelent? why?

A
  • winter or spring

- because its secondary to viral respiratory diseases

125
Q

what virus causes bacterial meningitis

A

1) pneumococcus meningitis
2) meningococcal meningitis

  • H. Influenza used to be common cause but vaccine decreased meningitis r/t this organism
126
Q

bacterial meningitis: massive inflammatory response leads to? explain

A
  • cerebral edema
  • The inflammatory response to the infection of the meninges and CSF may increase CSF production, while exudate accumulation leads to blockage of the arachnoid villi causing obstruction of CSF absorption. The resulting hydrocephalus may cause an increase in ICP. The purulent secretions that are produced spread quickly to other areas of the brain through the CSF. If this process extends into the brain parenchyma or if concurrent encephalitis is present, cerebral edema and increase ICP become more of a problem.
127
Q

Why must patient be observed closely if they have bacterial meningitis

A
  • Observe closely for manifestations of increase ICP which is thought to be result of swelling around the dura, and increased CSF volume.

NURS 2514 (11 decks)

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