Exam 2 neuro blueprint

Question 1

what are the early signs of ICP monitoring?

Answer 1

Early signs:
Agitation
restless/ irritability
Change in LOC
Decreased mental status
Sudden vomiting w/o nausea

Question 2

what are the late signs of ICP monitoring?

Answer 2

Late signs:
Seizures
Posturing (decorticate and decerebrate)
Cushing’s triad

Question 3

what are the late deadly signs of ICP monitoring?

Answer 3

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

Question 4

what is the glascow coma scale?

Answer 4

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)

Question 5

what are the ratings for the glascow coma scale?

Answer 5

13-15 mild
9-12 moderate
3-8 severe
Less than 8 = intubate

Question 6

what is mannitol?

Answer 6

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.

Question 7

what does ICPS for TBI stand for?

Answer 7

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

Question 8

what is the management for TBIs?

Answer 8

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

Question 9

what is an open TBI?

Answer 9

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

Question 10

what is a closed TBI?

Answer 10

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

Question 11

affecting 1 area of the brain due to impact

Answer 11

coup

Question 12

affecting the area opposite of coup

Answer 12

countercoup

Question 13

typically affecting the frontal and occipital lobes

Answer 13

together; coup-countercoup

Question 14

what is a CVA?

Answer 14

1 risk factor = HTN (over 140 SBP)

Types: ischemic & hemorrhagic strokes

Question 15

what is “BE FAST”?

Answer 15

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).

Question 16

what happens with a L brain stroke?

Answer 16

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.

Question 17

what happens with a R brain stroke?

Answer 17

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

Question 18

what is important to know about a CVA?

Answer 18

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

Question 19

what is the nursing management for a CVA?

Answer 19

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.

Question 20

what are the interventions for a CVA?

Answer 20

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”.

Question 21

what is tPA?

Answer 21

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

Question 22

what is the exclusion criteria for tPA?

Answer 22

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.

Question 23

what is the RN scope of care for tPA?

Answer 23

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.

Question 24

what are the complications of a spinal cord injury?

Answer 24

Complications lead to emergency and life threatening problems

Neurogenic shock

Question 25

what is neurogenic shock?

Answer 25

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.

Question 26

what are the causes and CM of neurogenic shock?

Answer 26

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

Question 27

what is effected with a cervical injury (C1-C8)?

Answer 27

effects all 4 limbs and impaired breathing

Question 28

what is effected with thoracic injury (T1-T12)?

Answer 28

effects lower limbs (Paraplegia) and legs, bladder, bowels

Question 29

what is effected with a Lumbar injury (L1-L5)?

Answer 29

effects legs and bladder