Exam 4 Flashcards
Normal Intracranial Pressure 🧠
5 - 15 mmHg
Increased ICP in the 🧠 can cause
⬆️pressure on the 🩸vessels 🪢
causing ⬇️oxygen flow to the 🧠
🚨 Medical 🏥 Emergency 🚨
Early symptoms of ICP 🧠
Low levels of oxygen:
Restlessness 🤼♂️
Irritability
Agitation
Altered LOC
Headaches 🤯
Sudden 🤮 w/out nausea
Late symptoms of ⬆️ ICP
Nuchal rigidity
Fixed & dilated pupils 👀
Babinski reflex
Abnormal posturing
(Decerebrate- out)
(Decorticate- toward the core 🤌🏽)
Cushing’s Triad
-Systolic Hypertension (widened pulse pressure)
-Irregular breathing 🫁
-Bradycardia ⬇️🫀
🚨Sit up as high as you can 🚨
Nursing considerations for ICP 🧠
Avoid ⬆️ ICP further
Head of the Bed 30 degrees or ➕
💩softeners to prevent straining
🚫endotracheal suction for >10 sec
Vitals- possible 🤒
Seizure 🫨precautions
Educate 📚to avoid:
Coughing
Sneezing
Blowing their nose 🤧
Bending over at hips
Medications 💊 for ICP
Diuretic:
IV mannitol to ⬇️ ICP
👀watch kidneys
Anti-seizure drugs:
To prevent seizures
Corticosteroids:
To ⬇️ inflammation
Monitor BS🩸& 🦠, 🧂levels
What are the 2 types of Stoke?
Ischemic Stroke🪨🛑
Hemorrhagic Stroke🩸
What is an Ischemic Stroke?
🩸 flow is cut off due to a blockage 🪨🛑, which leads to ischemia
What are the two types of blockages🛑in an Ischemic Stroke?
Thrombosis:
🩸clots that forms on the artery wall
Embolism:
🩸clot, air, or fat travels➡️w/in the body & gets suck, blocking 🩸flow
What is a Transient Ischemic Attacks (TIA)
A mini stroke
A warning ‼️ sign of an impending stroke
No cerebral infarction or ☠️ occurs in a TIA
What is a 🩸Hemorrhagic Stroke?
The collection of 🩸in the brain that leads to ischemia & ⬆️ ICP
What can a 🩸Hemorrhagic Stroke be caused by?
Ruptured artery
Aneurysm (weakening of vessel)
Uncontrolled HTN
Classic symptom of a Hemorrhagic stroke
Sudden severe headache 🤯
Modifiable risk factors for a Stroke
HTN 🚨
Atherosclerosis
Anticoagulation therapy
Uncontrolled DM 🍬
Obesity 🫃
Stress
Oral contraceptives
Smoking 🚬
Non-Modifiable risk factor for Stroke
Family 👨👩👧👧 Hx of Stroke
Older age 👵🏽
Male 👨🏼
Black 👴🏾
Hispanic 🇪🇸🇲🇽
Native American 🪶
Asian 🌏
Diagnostic for a stroke
CT (faster) 🩻
MRI later
Always identify the type of stroke BEFORE starting treatment
Treatments 💊 for Ischemic Stroke
Thrombolytic Therapy (TPA)
-ase meds 💊
(alteplase, reteplase, streptikinase)
Must be administered 3-4.5 🕒hours after onset of symptoms
🚨🚫TPA if 🩸disorder, arterial puncture w/in last week, previous hemorrhagic stroke, recent spinal surgery
Treatment for hemorrhagic stroke
Prevent & treat ⬆️ ICP
Seizure precautions 🚨
Be FAST (Stroke)
F- Facial droop
A- Arm Weakness
S- Speech difficulty
T- Time to call 911
Complications of a Right ➡️sided Stroke
Right = Reckless
Impulsive behavior
Rapid movements
Impaired judgment 🧑⚖️
Paralysis on the LEFT side of the body
Spatial-perceptual deficits (neglect of limb) 🦵🏻
Negative effects on the opposite side do not always occur
Complications of Left⬅️ sided Stroke
Left = Languages & Math
Aphasia, reading, or reasoning
Depression or anxiety
Receptive aphasia- unable to comprehend speech
Expressive aphasia- able to comprehend speech but unable to communicate back using speech
Paralysis on RIGHT side of body
Negative effects on the opposite side do not always occur
What can cause ⬆️ ICP?
Swelling of 🧠 tissue
Bleeding 🩸
⬆️ CSF 💦
Tumor 🪨
Infection 🦠
Head injury 🏎️⛷️🧗♀️🚴🏼
Ocular signs for ⬆️ ICP
Compression of CN 3️⃣
-sluggish or no response to 🔦
-Fixes, unilateral, dilated pupil= 🚨
-blurred vision
-Diplopia = double vision
-Papilledema= swelling of 👁️nerve
-Extraocular movements= quick ↔️
Types of motor function
Localize- move toward pain (🙋🏽♀️)
Withdraw- 👋🏼move away from pain
Decorticate posturing (to core 🤌🏽)
Decerbrate posturing (🫷🏽👳🏼♀️🫸🏽
Phenytoin
Given after TBI to prevent seizure activity.
🚫give with other 💊
IV tubing should be flushed before & after Phenytoin
Mannitol 🦭💊
-A hypertonic solution used to ⬇️ICP, also a diuretic.
-Give undiltuted through filter to 🚫administering of particulates
Which ABG results would be desirable for a client with ⬆️ICP?
PO2 of 97
PCO2 of 35
Reasoning:
PO2 should be maintained close to 100 to promote cerebral oxygenation
PCO2 indicates a low normal level, preventing vasodilation that happens with hypercapnia
What should be given in attempts to ⬇️ICP during Cushings Triad?
Hypertonic solution 💦
3% NS
What should you do if someone with a spinal injury has ⬆️ICP?
Cervical collar
Lay flat
‼️Reverse Trendelenburg‼️
Nutritional Balance for ⬆️ICP
May have feeding tubes
👀 wound healing
🚫TPN 🩸due to ⬆️ risk of 🦠
May need to ⬆️glucose for injured brain
Normal Serum Osmolarity
280 - 295
(💦in the 🩸)
At what GCS should you intubate?
8
What is the gold standard monitoring for ICP?
Ventriculostomy
Monitor #
Use aseptic technique if accessing drain
Might have orders to remove # of fluid 💦
What can be a 🚨 severe outcome of ⬆️ICP?
Shifting intracranial structures leading to
🚨Herniation = ☠️🏴☠️🪦
DAI
(Diffuse Axonal Injury)
Nerve damage doesn’t come back
TBI- twisting/rotating of 🧠- nerves damage
Epidural hematoma can lead to
Emergency 🚨
“Talk🗣️ & die ☠️syndrome”
Pass out, wake up/talk, sudden death
(Arterial bleeds🩸)
A subdural hematoma is
Venous
Chronic 👵🏽👴🏼 due to atrophy and
Acute (watch for 🩸)
With cranial surgeries🔪 or any surgery you should always know?
What kind of surgery
For cares:
Skin site
🩸At site
🦠
elevation
Aneurism 🩸
Out pouching of a blood vessel, that can burst and bleed
You can coil or clip these
An hemorrhagic stroke has the chance
To re-bleed 🩸again
Anticipated treatments and orders for an Ischemic Stroke 🖤
CT scan, ASA💊, MRI (takes 30-60 min), Hapatin, Anticoags, BP 💊
What is Spinal Shock ⚡️
More deficits than the level of injury
What is Neurogenic Shock? 😱
Lack of communication w/ the PNS and SNS causing vasodilation ⭕️
T6 or ⬆️
A pt is monitored following a craniotomy to evacuate a subdural hematoma. Which finding 🚨the RN to an early indication of ⬆️ ICP?
Delayed responses and ⬆️ lethargy
For a pt who is suspected of having a stroke, what’s the most important piece of info the RN can obtain?
Time 🕦at which strike symptoms first appeared
(Last normal)
With head injuries try to avoid NG 👃🏽tubes, especially with
Facial or skull fractures 💀
Risk factors for CVA
🚬, obesity 🫃🏻, inactivity 🛋️, 🍾🍻,
HLD 🐖, HTN, DM🍬, Afib, CAD, 🧑🧑🧒🧒Hx, previous TIA, 👵🏽👴🏼, gender, race 👩🏾👨🏽👦🏻👨🏿🦱
Vasospasm management for hemorrhagic 🩸 stroke
Nimodipine 💊
(Ca channel blocker)
⬇️vasospasms
Nursing management for strokes
Neuro assessments
🫀Tele
🫁
MSK- ROM
Skin- Q2 turns
GI- stress ulcers
Urinary- 💛I/O
Speech- picture board
Sensory- 🔥/🧊
Coping- rehab
Manifestations of Neurogenic shock ⚡️
⬇️Hypotension
⬇️Bradycardia 🫀
Temp dysregulation
Sx for up to 6wks
Manifestations of Spinal Shock
Deep tendon & sphincter reflexes
loss of sensation & flaccid paralysis ⬇️level of injury
Last days to weeks 📆
Spinal cord injury C1-C7 Nursing cares
👀🫁 respiratory status:
Weakened intercostal muscles
Pneumonia 💦
Atelectasis
Incentive spirometer 💨
Chest physiotherapy
Tetraplegia
C4=Paralysis ⬇️ neck
C6= Paralysis ⬇️ shoulders
Temp, vitals 🩺
Spinal cord injury T1-T12 Nursing cares
Paralysis ⬇️ injury:
Some 🫁 issues
GI & bladder issues
Some movement of shoulders
Neurogenic bowel & bladder:
Bowel program 🚽
Sit up
Dig stim ☝🏽
GU- clamp foley 💛
Intermittent cath
T6⬇️= Tetraplegia (paralysis below chest)
Spinal cord injury L1-L5 Nursing cares
Paraplegia
Paralysis ⬇️ waist
Self catheterization 💛
=Prone to 🦠
Complete SCI
Total loss of sensory & motor ⬇️ level of injury
Incomplete SCI
Some loss of voluntary motor & sensation
5 syndromes:
Brown-sequard
Cauda equina
Central cord
Anterior cord
Conus medullaris
Brown-Sequard 🤎
Damage to 1/2 spinal cord
penetrating injury
Conta-lateral loss of pain and temp on opposite side of injury 💜
Loss on voluntary motor control on same side of injury 💙
Cauda equina
Complete loss of sensation in Sattle area 🤠 🍑
Patchy sensation in lower extremities
Autonomic Dysreflexia Triggers
Spinal injury T6 or ⬆️
Triggered by sustained stimuli @T6 or ⬇️from:
Restrictive 🥋🧦👖
Pressure areas 🍑🦶🏼
Full bladder 💛
Fecal impaction 💩
Autonomic Dysreflexia S&S
⭕️Vasodilation⬆️:
Flushed face 🧔🏻
⬆️ sweating
⬆️ BP
HA 🤯
Distended neck veins
⬇️ HR
🕳️Vasoconstriction ⬇️ level:
Pale
Cool 😎
No sweating
Manifestations of Parkinson’s Disease
Chronic & progressive damage ⛏️ to nerves in 🧠
Tremor 👋🏼
Pill rolling 🤌🏽💊
bradykenesia (slow movement)
Hunched, unstable gate🚶🏽
Hallucinations 😵💫
Dementia 🤔
Depression
Beginning symptoms of Parkinson’s
Tremor 👋🏼& Flat effect 😶
➡️Later signs of Parkinson’s
Speech 🗣️
Dysphagia
BP changes
Gait instability
Weak chewing 🫢
Nursing management for Parkinson’s
Small frequent meals 🍌
Schedule enough time for meals 🕦
Aspiration precaution 👄
Fall precautions
Good sleep
Promote 🏋🏽♀️- ⬇️ muscle rigity & 💩complications
Communication- no board 👋🏼(stand in front of person to read lips)
Promote independence 🤌🏽
Lewy Bodies
Build up of protein in 🧠
Causes abnormal 🧠 fx and Parkinson’s
MS is more common
In women 💃🏻
20 - 40 yrs old
Overweight 🤰🏻
Low vitamin D 🌤️
Smoking 🚬 (can cause relapse of MS)
Multiple Sclerosis is where
The myelin sheaths break down around nerve
Early manifestations of MS
Vision Changes 👀
❤️💚 color distortion
🚨Blindness in one 👁️
Other manifestations of MS
Extremity weakness
Balance coordination 🦵🏻
Numbness & tingling 📌
Lhermitte’s sign “MS hug”
(Spasms to intercostal & abd nerves)
Rursing management of MS
Independence
⬇️Reduce triggers
Manage fatigue 😴 (🚫exacerbation)
🚫🚬
Coping
Manage stress
Meds 💊:
Dizziness
Depression
Pain
Interferon B
No cure‼️
Autonomic Dysreflexia is
Life threatening 🚨due to:
Status epileptics
MI
Stroke
Death☠️🏴☠️🪦
