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AH 3 > Exam 3 - neuro trauma shock spinal > Flashcards

Exam 3 - neuro trauma shock spinal Flashcards

1
Q

Why is mannitol given

A

For ICP that has exceeded 15-20 mmHg for at least 10 min

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2
Q

How does mannitol work to decrease ICP?

A

(osmotic diuretic) draws fluid out of brain cells by increasing the osmolality of the blood

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3
Q

Repeated use of mannitol can lead to what

A

risk of seizure, risk of fluid and electrolyte imbalance, cautious in pts with renal disease (continual elevations in osmolality)

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4
Q

Nursing responsibilities for Mannitol

A

Monitor vitals, urinary output, CVP, pulmonary pressure, assess for dehydration, assess for muscle weakness, tingling, paresthesia, confusion, and excessive thirst, assess for pulmonary edema, monitor near and ICP, monitor renal function and electrolytes

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5
Q

When do you not admin Mannitol

A

Do not admin if crystals are present in solution and do not admin with blood products

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6
Q

How to admin mannitol

A

IV bolus or infusion with a inline filter and observe infusion site for infiltration

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7
Q

Assessment for a patient with ALOC

A

assess LOC (confusion, restlessness, lethargy, progressive disorientation time then place then person, mental processing first then pressure increases more primitive function is lost, pupils (sluggish response to light, fixed pupils), papilledema, abnormal motor responses (hemiparesis early then hemiplegia decorticate/decerebrate), vitals (increase in MAP and systolic, decrease pulse, hyperthermia, altered respirations, N/projectile V

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8
Q

Nursing care for ALOC

A

Airway maintenance = gag

Airway clearance = cough

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9
Q

Diagnostic labs for ALOC

A

Blood glucose, serum electrolytes, ABGs, liver function tests, toxicology

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10
Q

Decorticate posturing

A

upper arms are close to the sides the elbows, wrists, and fingers are flexed and the legs are extended with internal rotation and the feet are plantar flexed

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11
Q

Decerebrate posturing

A

neck is extended with jaw clenched, arms pronated extended and close to the sides legs are extended straight out and the feet are facing outward

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12
Q

Cheyenne-Stokes Respirations

A

alternating periods of deep and rapid breathing followed by periods of apnea

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13
Q

what part of the brain is damaged in Cheyne-stokes respirations

A

diencephalon

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14
Q

Neurogenic hyperventilation

A

may exceed 40 BPM the result of uninhibited stimulation of the respiratory centers

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15
Q

what part of the brain is damaged in neurogenic respirations

A

midbrain damage

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16
Q

Apneustic respirations

A

characterized by sighingon mid-inspiration or prolonged inhalation and exhalation; results from excessive stimulation of the respiratory centers

17
Q

what part of the brain is damaged in Apenustic respirations

A

Pons

18
Q

Ataxic/Apneic Respirations

A

(totally uncoordinated and irregular) probably as a result of the loss of responsiveness to CO2

19
Q

What part of the brain is damaged in ataxic/apenic respirations

A

medulla

20
Q

Doll eye movement

A

reflexvice movement of the eyes in the opposite direction of head rotation. Positive doll eye response is head turned to side but eyes still facing forward (brainstem function)

21
Q

Glasgow coma scale

A

Eyes open (4-1) best motor response (6-1) best verbal response (5-1)

22
Q

lowest possible GCS

A

3 = coma

23
Q

what does a GCS of 8 mean

A

pt is unresponsive and cannot protect airway so airway management is necessary

24
Q

manifestations of an acute stroke

A
  • Internal carotid artery: contralateral paralysis/deficits of the arm, leg, and face, aphasia (if dominant hemi is involved), apraxia, agnosia and unilateral neglect (if nondominant hemi is involved)
  • Middle cerebral artery: drowsiness, stupor, coma, contralateral hemiplegia/sensory deficits of the arm and face, global aphasia (if dominant hemi is involved)
  • Anterior cerebral artery: contralateral hemiplegia/sensory deficits of the toes, foot, and leg, loss of ability to make decisions or act voluntarily, urinary incontinence
  • Vertebral artery: pain in the face, nose, or eye, numbness/weakness of the face on involved side, problems with gait, dysphagia
25
Q

FAST (stroke)

A

Face - drop
Arm- weakness
Speech- slurred or none
Time- time of onset

26
Q

treatment of acute stroke

A

antithrombotic/anticoag, start CT scan to rule out bleed, if time of symptoms is less than 3 hours give tPA in ER to dissolve clot, stroke team will take patient for cerebral angiogram to attempt to remove clot, rehab

27
Q

nursing care of acute stroke

A
  • Holistic, individualized nursing care is essential in all settings and focus on promoting the achievement of maximum potential and quality of life. Family often faced with many changes the nurse should assess and identify the needs and provide info/referrals
  • Collaborating with interprofessional team to ensure adequate treatment of the underlying process while providing care that supports the physical and psychologic responses
28
Q

subarachnoid bleed cause and manifestations

A

ruptured intracranial aneurysm
Sudden, explosive headache and neck pain, N/V, a stiff neck and photophobia (due to meningeal irritation), cranial nerve defects, stroke syndrome, cerebral edema, DI, and hyponatremia (from the pituitary

29
Q

Treatment of subarachnoid bleed

A

Interventions using radiology, angiography, and a variety of procedures may be used to prevent aneurysm rupture or to stop the bleeding. Surgery is the treatment of choice to repair the bleeding artery. Calcium channel blockers are used to improve neuro deficits due to vasospasm following subarachnoid hemorrhage

30
Q

Nursing care for subarachnoid bleed

A

prevent rebleeding as well as meet the needs resulting from neuro deficits. priority is to treat ineffective cerebral tissue perfusion

31
Q

Subdural hematoma causes

A

Closed head injury, acceleration-deceleration injury, cerebral atrophy, chronic ETOH abuse, use of anicoags, contusion

32
Q

manifestations od subdural hematoma

A
  • Acute/Subacute: headache, drowsiness, agitation, slowed thinking, confusion *subacute may develop more slowly
  • Chronic: may not appear until weeks to months after injury. Confusion, slowed thinking, drowsiness
33
Q

Nursing care for subdural hematoma

A

Maintaining an effective airway and breathing pattern, continuous assessment, monitoring neuro function as well as other body systems. Monitor ICP and symptoms like vomiting/headache/lethargy/restlessness/purposeless movements/changes in mentation

34
Q

Epidural hematoma causes

A

skull fractures contusion

35
Q

Epidural hematoma manifestations

A

Momentary loss of consciousness followed by a lucid period (few hours – ½ days) then rapid deterioration in LOC (drowsiness to confusion to coma), seizures headache, hemiparesis, fixed pupil, rise in BP with decrease in pulse and respirations

36
Q

Treatment of epidural hematoma

A

Managing IICP, airway management, hyperventilation, fluid resuscitation, positioning, temperature regulation, medications, surgery Surgical evacuation of the clot = burr holes

37
Q

Nursing care of epidural hematoma

A

Maintaining airway and breathing, continuous assessment and monitoring of neuro function, monitor ICP,

38
Q

Treatment of epidural hematoma

A

Managing IICP, airway management, hyperventilation, fluid resuscitation, positioning, temperature regulation, medications, surgery Surgical evacuation of the clot = burr holes

AH 3 (1 decks)

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