Exam 2 neuro blueprint Flashcards
what are the early signs of ICP monitoring?
Early signs:
Agitation
restless/ irritability
Change in LOC
Decreased mental status
Sudden vomiting w/o nausea
what are the late signs of ICP monitoring?
Late signs:
Seizures
Posturing (decorticate and decerebrate)
Cushing’s triad
what are the late deadly signs of ICP monitoring?
Late deadly signs:
Lungs: irregular respirations and Cheyne strokes respirations
Neck: nuchal rigidity (stiff neck)
Brain stem affected:
Eyes: pupils “fixed and dilated” unequal and 8mm (normal = 2-6 mm)
Foot: babinski reflex and toes fan out when stimulated = BAD
Seizures and coma
Abnormal posturing: decorticate and decerebrate
what is the glascow coma scale?
Behavior = eyes opening, verbal response, and motor response
Response = eyes (1-4 grade), verbal (1-5 grade), and motor (1-6 grade)
Eyes opening = 4 (open spontaneously), 3 (open to speech), 2 (open to pain), 1 (no eye opening)
Verbal response = 5 (oriented to time, person, place), 4 (confused), 3 (inappropriate words), 2 (incomprehensible sounds), 1 (no verbal response)
Motor response = 6 (obey commands), 5 (moves to localized pain), 4 (withdrawal from pain), 3 (abnormal flexion), 2 (abnormal extension), 1 (no motor response)
what are the ratings for the glascow coma scale?
13-15 mild
9-12 moderate
3-8 severe
Less than 8 = intubate
what is mannitol?
Is an osmotic diuretic. Elevated blood plasma osmolality, resulting in enhanced flow of H2O from tissues, including the brain and CSF, into interstitial fluid and plasma
Used to decrease ICP
Must be given IV
Systemic EDEMA may occur due to enhanced flow of fluid AWAY from the brain and INTO interstitial space.
Watch for signs of heart failure as a result.
what does ICPS for TBI stand for?
I - immobilize C spine, log roll pt
C - CO2 low; lower CO2 means lower ICP. CO2 dilates vessels and will increase ICP
P - positioning: 30-35 degrees (semi-fowlers), no flexing/bending, not cough, sneezing, etc.
S - suctioning: 10 secs or less, infrequent, hyperventilate pt
what is the management for TBIs?
A,B,C’s (VS w/ O2 stat), stabilize cervical spine (position pt w/ HOB 30-45 degrees), intubate (GCS <8) or if gag impaired or absent, control external bleed, and maintain normothermia
Prevent secondary injury: by treating cerebral edema and increased ICP
Concussion and contusion: monitor and manage ICP
Skull fx: if CSF leak, prophylactic ABX, and surgery (elevate depressed bones, remove fragments; craniotomy and cranioplasty.
Manage ICP monitoring system and ICP: manage N/V and minimize environmental stimulation
Manage eye problems: prevent corneal damage
Manage hyperthermia (goal 36-37 degrees C): cooling blanket, etc.
Manage CSF leak: rhinorrhea or otorrhea (notify HCP), teach client not to sneeze or blow nose and no NGT or NT suction (if basilar skull fx r/f meningitis)
Implement seizure precautions and prophylaxis: manage headache and prevent
VTE, skin breakdown
what is an open TBI?
Basilar skull fracture (visible of the external skull)
Key finding: clear of blood-tinged drainage from the eyes, ears, nose that is positive for glucose = CSF
what is a closed TBI?
Concussion (CM: brief LOC, headache, retrograde amnesia (memory loss of events immediately prior to injury)
Contusion (more emergent; described as: coup, countercoup, and together)
Coup
Countercoup
Together: coup-countercoup
affecting 1 area of the brain due to impact
coup
affecting the area opposite of coup
countercoup
typically affecting the frontal and occipital lobes
together; coup-countercoup
what is a CVA?
1 risk factor = HTN (over 140 SBP)
Types: ischemic & hemorrhagic strokes
what is “BE FAST”?
Be Fast = Balance (headache & dizzy), eyes (sudden loss of vision in one of both eyes), face (does the pts face look uneven?, arm (weak), speech (difficulty), and time (call 911).
what happens with a L brain stroke?
L brain = language & logic (dysphasia, reading/write problems, R hemiparesis, and R side neglect) L brain = R side affect and pt safety: consider which side is stonier, responsible for out verbal abilities.
what happens with a R brain stroke?
R brain = reckless & really creative (lack of impulse control, behavior changers, L hemiparesis, and L side neglect) R brain = L side affect and pt safety: strong side and behavior and impulse control, can be difficult for families to see
what is important to know about a CVA?
Last known well time determines the start of the CVA, arrival to ED = 0 M to treatment, CT scan must be done to determine treatment, ischemic or embolic = blocked vessels
what is the nursing management for a CVA?
Nursing management: neuro assessment Q1-2H (NIH stroke scale), VS including ICP, CPP Q1-2H and PRN, resp status, I&O, fluid balance, IV fluids, ECG and cardiac enzymes, serum electrolytes especially Na+, bladder and bowel function, and ability to communicate.
what are the interventions for a CVA?
Interventions: admin rt-PA as ordered, perform bedside swallow screen, support resp function, elevate HOB 30 degrees, place NG tube (implement aspiration precautions), bleeding precautions, positioning, mobility, ROM, manage client w/ unilateral neglect and visual field cut, obtain PT and OT evaluation early, aphasia interventions, provide skin care, early mobility, eye care, mouth care, prevent constipation, hemorrhage precautions (pre-op) if applicable (risk for rebelled), monitor for complications, and teaching (BP control, stroke diagnosis, activation of EMS, warning signs and symptoms, client specific and fam specific risks for CVA, smoking cessation, diet needs (high fiber and adequate fluid intake), meds for prevention of CVA, and “FAST”.
what is tPA?
tPA is the treatment of choice for CVA if started within 60M of arrival to care center
Weight based, dose 0.9 mg/kg - 10% bolus - 90% remainder/1H, IV injection
Blood clot formation — tPA injected IV — blood clots dissolve — restored blood flow
what is the exclusion criteria for tPA?
seizure w/ CVA, on anticoagulants, head trauma last 3 months, history of ICH, GI/GU w/in the last month, lumbar puncture last week, improved neuro symptoms (SBP > 185, DBP > 110 w/ 1-2 doses PRN labetalol, INR >1.7 elevated PTT and/or elevated platelets.
what is the RN scope of care for tPA?
obtain verbal consent prior to tPA admin if deemed appropriate for pt with ischemic CVA, take tPA tubing and pump (MRI compatible) to start to prevent delay, before starting tPA double check med, and confirm bolus and scheduled dose, tPA dosed by pharm.
what are the complications of a spinal cord injury?
Complications lead to emergency and life threatening problems
Neurogenic shock
what is neurogenic shock?
any factor that stimulates parasympathetic activity or inhibits sympathetic activity of vascular Smoot muscles can cause neurogenic shock, which results in widespread and massive vasodilation.
what are the causes and CM of neurogenic shock?
Causes: spinal cord injury above T5, spinal anesthesia, and vasomotor center depression (severe pain, drugs, hypoglycomia)
Symptoms: low systemic vascular resistance, excessive parasympathetic activity, and bradycardia
The 2 biggest problems that arise = hypotension and bradycardia
what is effected with a cervical injury (C1-C8)?
effects all 4 limbs and impaired breathing
what is effected with thoracic injury (T1-T12)?
effects lower limbs (Paraplegia) and legs, bladder, bowels
what is effected with a Lumbar injury (L1-L5)?
effects legs and bladder
