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Med surg 2 > CNS assessment > Flashcards

CNS assessment Flashcards

1
Q

Glasgow coma scale

A

Eye-none, to pain, to voice, spontaneous
Verbal-None, no words only sounds, words but not coherent, disoriented conversation, Normal conversation
Motor-None, decerebrate, decorticate, withdraws to pain, localized pain, normal
Add together. mild-13-15 mod-9-12 severe- 3-8 less than 8 is a problem

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2
Q 
aphasia/dysphasia 
dysarthria
Anisocoria
diplopia
dysphagia
papilledema
aptaxia
ataxia
hemiplegia
nystagmus
A

aphasia/dysphasia- cerebral cortex- cant understand language
dysarthria-mm of speech- cerebral of CN
Anisocoria-unequal pupils optic nerve
diplopia-seeing double II, IV, VI
dysphagia-IX, X brainstem
papilledema-optic disc swelling-II
apraxia-cerebral cortex- difficulty moving
ataxia-Cerebellum
hemiplegia-Motor cortex paralysis of one side
nystagmus-Cerebellum, brainstem, vestibular rapid pupil movement from side to side,

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3
Q

head injury

A

Scalp, skull, Brain

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4
Q 
Head injury 
Laceration
Skull fracture
Head trauma
Contusion 
Hemorrhage
Epidural hematoma
subdural hematoma
intracerebral hematoma
A

Laceration-cut with lots of blood
Skull fracture- Bone fx
Head trauma-Concussion or traumatic brain injury
Contusion/hemorrhage-bruising, bleeding in brain
Epidural hematoma- Tear in art in brain
subdural hematoma- broken blood vessles below duramater
intracerebral hematoma -bleeding in cerebrum

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5
Q

What are the manifestions of head injuries

A 
Altered LOC
Headache
Nausea vom
Seizures
Increases ICP 
possible hyperthermia if hypothal is damaged
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6
Q

Basilar skull fractures

A

Liner fraction involving base of skull tear in duramater-leakage of CSF
Rhinorrhea, otorrhea
battles sign- posturicular ecchymosis
racoon eyes-periorbital ecchymosis

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7
Q

tx for head injuries

A 
CT-most effective
Emergency tx
Surgery-Craniectomy, craniotomy
tx cerebral edema
manage ICP
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8
Q

Head emergency initial

A 
CAB if unresponsive, ABC if responsive
assume neck injury with head injury
stabilize cervical spine 
Apply 02 non-rebreather
Establish IV with 2 large bore cath 
Intubate if less than 8
control bleeding with sterile pressure dressing 
Remove patients clothing
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9
Q

Head emergency ongoing

A

Maintain normothermia using blankets
monitor vitals and Aand O GCS and pupil size and reactivity
If gag reflex is impaired expect intubation
assess rhinorrhea otorrhea snd scalp wounds
give fluids cautiously to prevent fluid overload and increasing ICP

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10
Q

What is the monroe kelly doctrine

A

If volume in 1 component goes up the volume in the other must go down to maintain ICP.

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11
Q

Numbers for stuff in the brain
what is normal pressure and when do we treat
how do we measure

A 
CSF-10 percent
Blood-12 percent
brain-75 percent 
5-15
tx at 20 
Pressure transducer
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12
Q

What is CPP how to calculate what is normal and what is MAP and how to calculate

A

CPP- cerebral perfusion pressure- it is how much blood is getting to the brain

PP=MAP-ICP
normal-60-100 less than 50 is ischemia and less than 30 is incompatible with life
Mean arterial pressure- amount of blood during one cardiac cycle
MAP=(DBPx2)+SBP/3
normal is 70-100

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13
Q

6 things Damaged brain tissue can cause

A

Hypercapnia, acidosis, impaired auto-regulation, Hypertn and cerebral vasodilation, brain hernia

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14
Q

Vasogenic edema

and three things that cause it

A

Leakage of lg molecules from capillaries intosurrounding extracellular space
Brain tumorrs, abcess, toxins

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15
Q

Cytotoxic edema and 3 things that cause it and one thing about it

A

Disruption in the integrity of the cell membrane causes fluids to shift into the the cells
Cerebral hypoxia, destructive lesions or trauma BBB intact

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15
Q

Cytotoxic edema and 3 things that cause it and one thing about it

A

Disruption in the integrity of the cell membrane causes fluids to shift into the the cells
Cerebral hypoxia, destructive lesions or trauma BBB intact

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16
Q

interstital edema and three things that cause it

A

Build up of fluid in the brains ventricles-Hydrocephalus

too much CSF, obstruction of flow or reabsorption issue

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17
Q

Manifestations of ICP 10

A

Change in level of consciousness-Number one maybe irritability or sleepy
Change in vitals- Cushings and change in temp
Ocular- unilat pupils, slow, not reactive to light, can’t move eye up, eyelip pitosis, papolledema,
decrease in motor function-Posturing and hemiparesis or plagia
vomiting without nausea
HS that is constant
stiff neck cant bend down
Positive babinsky
seizure
coma

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18
Q

Pupil 3

A

1 dilated- CN111 8mm
Bilat dilated and fixed BAD sign
Pinpoint- pons damage or drugs

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19
Q

Decorticate

A

flexed arms, wrists, fingers with adduction in upper ext
extension internal rotation and plantar flex in lower
problem with cervical spine or cerebral hemisphere

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20
Q

decerebrate

A

all four extremities with rigid extension. Adduction in upper arms over pronation in arms, flexed hands, plantar flexed feet

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21
Q

Ventriculostomy

A

Gold standard for measuring ICP. Cath insertion into lateral vent, and connected to external transducer
you can measure pressure, remove a sample of CSF or give drugs

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22
Q

Diagnostic for IICP

A 
CT-Number one! MRI PET
EEG
cerebral angiography, ICP and brain tissue oxygen measurement
Dopler and ekoked potentail studies. 
subarachnoid screw 
NO LUMBAR PUNCTURE
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23
Q 
Breathing with IICP 
Cheyne stokes
Central neurogenic hypervent
Apneutic
CLuster
Ataxic
A

Cheyne stokes-BL hem metabolic dysfunction- cycles of hypervent and apnea
Central neurogenic hypervent-Regular rapid breathing lower mid and uper pons
Apneutic-mid brain lower pons prolonged inspirations with pause with expirratory pause
CLuster-medulla/pons cluster breaths with irregular pause
Ataxic -Reticular- irregular- deep mixed with shallow/pauses/slow

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24
Q

Mannitol 7 things

A

Mannitol- IV no PO
Plasma extension and osmotic
measure Is and OS need cath for accuracy in unconscious
can cause metabolic acidosis, hypok
BBW bronchospasms
CI in renal or increased osmolality
can cause edema/heart fail because of fluid overload

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25
Q

Drugs for IICP 10

A 
Mannitol
Hypertonic saline
Corticosteroids
H2 receptor antag to prevent bleeds and ulcers
Antiseizure meds 
Antipyretics
Sedatives, analgesics, barbituates 
stool softeners
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26
Q

Name some things that increase ICP 5

A

Fever, agitation, shivering, pain, seizures

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27
Q

Why are we worried about airway with IICP

A

Secretions may cause tongue to slip to back of throat

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28
Q

what do we look at for mental status

A

general appearance and behavior, cognition-AandO, memory, judgement, problem solve, mood and affect

29
Q

YOU NEED TO DO CRANIAL NERVES

A
30
Q

how to assess Motor 5

A

Strength, tone, coordination, symmetry, balance

31
Q

How to assess sensory

A

Touch, pain, temp, vibration, position, cortical-graphesthesia and stereognosis

32
Q

How to test reflexes 5

A

Babinski-toes up or down you brush up on foot and across
brudinski-pull head up and knees go up
kernigs0 cant straighten leg when hip is flexed to 90
clonus
dolls eye

33
Q

most common risk for a stroke 4 more to know

A

HTN

Alcohol, apnea, metabolic syndrome, BCP

34
Q

Heart conditions to cause a stroke

A

A fib, valve, congenital defects, History of TIA

35
Q

Ischemic stroke def and 2 kinds

A

Clot stops blood flow to brain
Thrombotic-Injury and formation of blood clot causes narrowing of blood vessle most common from HTN and DM and athero
Embolic- Embolism travels from some place else and occludes art=Infaraction and edema usually from A FIB

36
Q

Hemmorrhagic stroke

A

Bleeding and swelling from bleeding usually from aneurysm HTN and age

37
Q

Intracerebral hemorrhage

A

Bleeding into brain from rupture of a vessle
Suddent onset, Poor prog,
htn most common cause, usually during activity,

38
Q

Subarachnoid hemmorhage

A

Intracranial bleeding into cerebrospinal fluid

rupture of aneurysm, trauma, drugs, fall,

39
Q

Cerebral aneurysm

A

Vasospasms, in cirle of willis, silet killer, loss of conscousness or not survivors often have significant complications

40
Q

R manifestations of a stroke 7

A

Paralysis of L side, L side neglect, spatial perception neglect, Minimize problems, Impulsive, impaired judgment, Impaired time concepts,

41
Q

L side manifestations of a stroke 9

A

Paralysis of R side, R side neglect, impaired speech and language, slow cautious movements, aware of def, depression, impaired comprehension, aphagias,

42
Q

S/s of motor effected by stroke

A

Apraxia, akensia, hypo/hyper reflexia, mobility, swallowing, gag, self-care, elemination issuesm, flaccidicy and spasticity

43
Q

Affect after stroke

A

Exaggerated emotional response depression frustration

44
Q

Tx for stroke 4

A

ABC, neuro checks, TX of edema, Prevent further injury,

45
Q

Ischemic stroke tx

A

Tpa-breakdown clot, 3-4 hours after onset, cant for hem!

46
Q

What is the surgery for Strokes

A

Carotis endarterectomy stent for occluded caroted art

47
Q

What is FAST

A

Face-Smile one side droops?
Arms raise arms on side droops?
Speech-Simple sentence
Time-any symptoms call 911

48
Q

Sx of stroke

A

Tinnitus, vertigo, HA, Dark blurred vison, Diploplia, ptosis, dysartheria, dysphagia, ataxia, uni/bilat weakness or numbness

49
Q

c4, c6, t6, L1

A

c4-Tetra and paralysis of respiratory, C6-tetra with pa in hands and arms, T6 para below chest, L1-Para below waist

50
Q

ASIA impairment scale for SCI

A

A-complete no S or M
B-incomplete-S nut no motor
C incomplete-M preserved- MM greater than 3 more than 1/2
D-Incomplete0 M presereved mm greater than 3 in 1/2
E-Normal

51
Q 
incomplete injuries
Anterior cord syndrome
Brown-
conus
cauda
A

Anterior cord syndrome-Damage to anterior spinal cord from compression r/t flextion-motor paralysis, loss of pain and temp sensation below (B)LOI
Brown-Damage to 1/2 of spinal cord commonly cervical-Contralateral (opposite side) - loss of pain/temp sensation BLOI
Ipsilateral (same side) – loss of voluntary motor function
conus-Damage to lowest part of spinal cord-motor weakness and altered sensation, burning sensation in UEs (LEs not as affected)
cauda-Damage to cauda equina-nerve bundle rootmotor function in LEs mb preserved, flaccid, or weak – more mid-moderate backpain
Decrease/loss of sensation in peri area  impotence, areflexic B/B

52
Q

Manifestations in spinal shock

A
  • Occurs shortly after injury (30-60 mins)
  • Loss of DTRs, sphincter reflexes
  • Loss of sensation, thermoregulation
  • Flaccid paralysis BLOI
  • Lasts days-weeks
  • Often masks postinjury neuro function
53
Q

Neurogenic shock manifestations

A

Occurs in injury ABOVE T6. SNS not working right to control vasomotor tone in the blood vessels  vasodilation  decreased resistance  HpTN  venous blood pooling  less filling of the ventricles  bradycardia and hypothermia (warm extremities, cold inside)  decreased CO + tissure perfusion  death

SX:	HpTN
	Bradycardia
	Hypothermia d/t blood pooling (warm outside, cold inside) 
	Decreased preload/filling
54
Q

Discuss the acute care treatment plan of a spinal cord injury (SCI) patient. Acute

A

Maintain patent airway/adequate ventilation (prehospital)
Prevent further damage via immobilization (prehospital)
Maintain perfusion via fluid replacement, control bleeding (monitor other trauma)
Keep pt warm (can’t regulate temp)
Indwelling catheter to prevent bladder distension
Only real tx = surgery (decompress, help reduce secondary injury, fuse bones) – 24 hours!

55
Q

Discuss the acute care treatment plan of a spinal cord injury (SCI) patient.
NExt

A 
Prevent DVTs (measure calf)
		Prevent skin breakdown (immobile and lack of sensation)
		Maintain adequate nutrition/fluid needs (this is usually increased – need lots nutrients to heal) 
		Treat pain (neuropathic)
56
Q

Discuss the acute care treatment plan of a spinal cord injury (SCI) patient. Long term

A

PT/OT to manage/prevent contractures
SP for swallow assess
Bladder/bowel training – self cath, retraining, prevent retention/infx
Recognize and manage autonomic hyperreflexia
Psychological support
Pt teaching – rehab goals, expectations of improvement

57
Q

Long term Complications of SCI

A 
Grief and depression – loss of control, mb function, SI 
	R/T immobility: 
		Pneumonia 
		UTIs
		Pressure ulcers	
		Sepsis 
		DVTs
		Mechanical ventilation probs, infx
58
Q

manifestations of autonomic hyperdysflexia

A

Injury @ T6 or higher. Exaggerated response from the SNS which is running unopposed by the PNS

Some irritating stimulus below T6 - usually bladder distension, bowel impaction, restrictive clothing, skin breakdown … SNS overreacts but can’t do much bc signals aren’t getting to the brain correctly. Signals ARE getting to SNS/PNS but they’re not working together, so … 

SNS turns on  vasoconstriction  severe HTN, HA, bradycardia, diaphoresis (ALOI), piloerection (BLOI)  baroreceptors can get signal to the brain and are like OMG HELP!  decreases HR in response to HTN but can’t dilate peripheral vessel BLOI
59
Q

Tx for Autonomic hyperreflexia

A

Sit pt upright or elevate HOB 45
Identify the cause and help – insert cath or look for kink, resolve impaction, remove clothing
Notify HCP
Monitor and manage BP (vasodilators) if sx continue
If left untx’d  M.I., stroke, status epilepticus

60
Q

Parkinsons disease patho

A

Chronic, progressive neurodegenerative D/O characterized by a gradual onset of sx r/t depletion of dopamine (affects movement, memory, focus) 
- slow movements - bradykinesia
- increased muscle tone – rigidity
- tremor @ rest, gait changes
Exact cause unknown – mb r/t environment, family hx, exposure to toxins, drugs, mb post-neuro problem (hydrocephalus, stroke, NG d/o’s, hypo-PTH, tumor, trauma
- abnormal clumps of Lewy Bodies
Men > women

61
Q

Manifestations of parkinsons

A 
Tremors (1st sign) -pill rolling 
		Rigidity 
		Akinesia (brady)			
		Postural instability (shuffling gait) 
	Depression, anxiety, apathy, fatigue, pain, urinary retention, constipation, ED, ST memory loss, cogwheel rigidity, lewy body clumps, retropulsion, fenestration, arms flexed, hypokineticdysartharia, loss of smell.
62
Q

Management for Parkinsons

A

Deep brain stimulation and ablation
exercise , transplantation of fetal neural tissue
anticohlenergics

63
Q

Complications for park 4

A

Halucinations, Immobility issues, orthostatic hypotn, dementia

64
Q

ASL

A

Death is usually from respiratory dysfunction

65
Q

ALS

what is it nursing interventions 7

A 
Loss of motor neurons 
mod-intense endurance exercises for trunk and limbs
facilitate communications 
decrease aspiration risk
Detect respiratory dysfunction
decrease pain
Risk for fall
divert
66
Q

What is huntingtons disease

A

Progressive, degenerative brain d/o – genetic
Onset usually 30-50 yo
Deficiency in ACH + GABA  excess DP

67
Q

Manifestations for Huntingtons

A
  • excessive and involuntary movements (chorea0
    - chewing, swallowing, gait severely impacted
    - severe depression, high r/f suicide
68
Q

** Coup-contrecoup injury

A

ccurs when brain moves inside skull d/t high energy or high impact injury mechanisms.
Coup/primary = direct impact of brain on skull
Contrecoup/secondary = second area of damage on opposite side from injury (more severe)

69
Q

Most common skull fracture location = basilar

A
  • damage to structures that protect the brain @ base of skull  leakage of CSF
    • only break in very severe trauma
    • NO NGT if this is happening
70
Q

Head injury manifestations

A

SX = rhinorrhea (CSF leak from nose), otorrhea (CSF leaks from ear), Battle’s Sign (ecchymosis @ cheek bones), Raccoon Eyes (ecchymosis around eyes)
High r/f meningitis

Clinical Manis:

- Altered LOC 
- HA
- N/V - Seizure activity - IICP - Hyperthermia if hypothalamus damaged

Med surg 2 (18 decks)

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