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Med Surg2 > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Normal Intracranial Pressure 🧠

A

5 - 15 mmHg

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2
Q

Increased ICP in the 🧠 can cause

A

⬆️pressure on the 🩸vessels 🪢

causing ⬇️oxygen flow to the 🧠

🚨 Medical 🏥 Emergency 🚨

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3
Q

Early symptoms of ICP 🧠

A

Low levels of oxygen:
Restlessness 🤼‍♂️
Irritability
Agitation
Altered LOC
Headaches 🤯
Sudden 🤮 w/out nausea

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4
Q

Late symptoms of ⬆️ ICP

A

Nuchal rigidity
Fixed & dilated pupils 👀
Babinski reflex
Abnormal posturing
(Decerebrate- out)
(Decorticate- toward the core 🤌🏽)

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5
Q

Cushing’s Triad

A

-Systolic Hypertension (widened pulse pressure)
-Irregular breathing 🫁
-Bradycardia ⬇️🫀

🚨Sit up as high as you can 🚨

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6
Q

Nursing considerations for ICP 🧠

A

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

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7
Q

Medications 💊 for ICP

A

Diuretic:
IV mannitol to ⬇️ ICP
👀watch kidneys

Anti-seizure drugs:
To prevent seizures

Corticosteroids:
To ⬇️ inflammation
Monitor BS🩸& 🦠, 🧂levels

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8
Q

What are the 2 types of Stoke?

A

Ischemic Stroke🪨🛑

Hemorrhagic Stroke🩸

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9
Q

What is an Ischemic Stroke?

A

🩸 flow is cut off due to a blockage 🪨🛑, which leads to ischemia

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10
Q

What are the two types of blockages🛑in an Ischemic Stroke?

A

Thrombosis:
🩸clots that forms on the artery wall

Embolism:
🩸clot, air, or fat travels➡️w/in the body & gets suck, blocking 🩸flow

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11
Q

What is a Transient Ischemic Attacks (TIA)

A

A mini stroke

A warning ‼️ sign of an impending stroke

No cerebral infarction or ☠️ occurs in a TIA

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12
Q

What is a 🩸Hemorrhagic Stroke?

A

The collection of 🩸in the brain that leads to ischemia & ⬆️ ICP

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13
Q

What can a 🩸Hemorrhagic Stroke be caused by?

A

Ruptured artery
Aneurysm (weakening of vessel)
Uncontrolled HTN

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14
Q

Classic symptom of a Hemorrhagic stroke

A

Sudden severe headache 🤯

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15
Q

Modifiable risk factors for a Stroke

A

HTN 🚨
Atherosclerosis
Anticoagulation therapy
Uncontrolled DM 🍬
Obesity 🫃
Stress
Oral contraceptives
Smoking 🚬

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16
Q

Non-Modifiable risk factor for Stroke

A

Family 👨‍👩‍👧‍👧 Hx of Stroke
Older age 👵🏽
Male 👨🏼
Black 👴🏾
Hispanic 🇪🇸🇲🇽
Native American 🪶
Asian 🌏

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17
Q

Diagnostic for a stroke

A

CT (faster) 🩻
MRI later

Always identify the type of stroke BEFORE starting treatment

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18
Q

Treatments 💊 for Ischemic Stroke

A

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

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19
Q

Treatment for hemorrhagic stroke

A

Prevent & treat ⬆️ ICP

Seizure precautions 🚨

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20
Q

Be FAST (Stroke)

A

F- Facial droop
A- Arm Weakness
S- Speech difficulty
T- Time to call 911

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21
Q

Complications of a Right ➡️sided Stroke

A

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

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22
Q

Complications of Left⬅️ sided Stroke

A

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

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23
Q

What can cause ⬆️ ICP?

A

Swelling of 🧠 tissue
Bleeding 🩸
⬆️ CSF 💦
Tumor 🪨
Infection 🦠
Head injury 🏎️⛷️🧗‍♀️🚴🏼

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24
Q

Ocular signs for ⬆️ ICP

A

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 ↔️

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25
Types of motor function
Localize- move toward pain (🙋🏽‍♀️) Withdraw- 👋🏼move away from pain Decorticate posturing (to core 🤌🏽) Decerbrate posturing (🫷🏽👳🏼‍♀️🫸🏽
26
Phenytoin
Given after TBI to prevent seizure activity. 🚫give with other 💊 IV tubing should be flushed before & after Phenytoin
27
Mannitol 🦭💊
-A hypertonic solution used to ⬇️ICP, also a diuretic. -Give undiltuted through filter to 🚫administering of particulates
28
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
29
What should be given in attempts to ⬇️ICP during Cushings Triad?
Hypertonic solution 💦 3% NS
30
What should you do if someone with a spinal injury has ⬆️ICP?
Cervical collar Lay flat ‼️Reverse Trendelenburg‼️
31
Nutritional Balance for ⬆️ICP
May have feeding tubes 👀 wound healing 🚫TPN 🩸due to ⬆️ risk of 🦠 May need to ⬆️glucose for injured brain
32
Normal Serum Osmolarity
280 - 295 (💦in the 🩸)
33
At what GCS should you intubate?
8
34
What is the gold standard monitoring for ICP?
Ventriculostomy Monitor # Use aseptic technique if accessing drain Might have orders to remove # of fluid 💦
35
What can be a 🚨 severe outcome of ⬆️ICP?
Shifting intracranial structures leading to 🚨Herniation = ☠️🏴‍☠️🪦
36
DAI (Diffuse Axonal Injury)
Nerve damage doesn’t come back TBI- twisting/rotating of 🧠- nerves damage
37
Epidural hematoma can lead to
Emergency 🚨 “Talk🗣️ & die ☠️syndrome” Pass out, wake up/talk, sudden death (Arterial bleeds🩸)
38
A subdural hematoma is
Venous Chronic 👵🏽👴🏼 due to atrophy and Acute (watch for 🩸)
39
With cranial surgeries🔪 or any surgery you should always know?
What kind of surgery For cares: Skin site 🩸At site 🦠 elevation
40
Aneurism 🩸
Out pouching of a blood vessel, that can burst and bleed You can coil or clip these
41
An hemorrhagic stroke has the chance
To re-bleed 🩸again
42
Anticipated treatments and orders for an Ischemic Stroke 🖤
CT scan, ASA💊, MRI (takes 30-60 min), Hapatin, Anticoags, BP 💊
43
What is Spinal Shock ⚡️
More deficits than the level of injury
44
What is Neurogenic Shock? 😱
Lack of communication w/ the PNS and SNS causing vasodilation ⭕️ T6 or ⬆️
45
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
46
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)
47
With head injuries try to avoid NG 👃🏽tubes, especially with
Facial or skull fractures 💀
48
Risk factors for CVA
🚬, obesity 🫃🏻, inactivity 🛋️, 🍾🍻, HLD 🐖, HTN, DM🍬, Afib, CAD, 🧑‍🧑‍🧒‍🧒Hx, previous TIA, 👵🏽👴🏼, gender, race 👩🏾👨🏽👦🏻👨🏿‍🦱
49
Vasospasm management for hemorrhagic 🩸 stroke
Nimodipine 💊 (Ca channel blocker) ⬇️vasospasms
50
Nursing management for strokes
Neuro assessments 🫀Tele 🫁 MSK- ROM Skin- Q2 turns GI- stress ulcers Urinary- 💛I/O Speech- picture board Sensory- 🔥/🧊 Coping- rehab
51
Manifestations of Neurogenic shock ⚡️
⬇️Hypotension ⬇️Bradycardia 🫀 Temp dysregulation Sx for up to 6wks
52
Manifestations of Spinal Shock
Deep tendon & sphincter reflexes loss of sensation & flaccid paralysis ⬇️level of injury Last days to weeks 📆
53
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 🩺
54
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)
55
Spinal cord injury L1-L5 Nursing cares
Paraplegia Paralysis ⬇️ waist Self catheterization 💛 =Prone to 🦠
56
Complete SCI
Total loss of sensory & motor ⬇️ level of injury
57
Incomplete SCI
Some loss of voluntary motor & sensation 5 syndromes: Brown-sequard Cauda equina Central cord Anterior cord Conus medullaris
58
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 💙
59
Cauda equina
Complete loss of sensation in Sattle area 🤠 🍑 Patchy sensation in lower extremities
60
Autonomic Dysreflexia Triggers
Spinal injury T6 or ⬆️ Triggered by sustained stimuli @T6 or ⬇️from: Restrictive 🥋🧦👖 Pressure areas 🍑🦶🏼 Full bladder 💛 Fecal impaction 💩
61
Autonomic Dysreflexia S&S
⭕️Vasodilation⬆️: Flushed face 🧔🏻 ⬆️ sweating ⬆️ BP HA 🤯 Distended neck veins ⬇️ HR 🕳️Vasoconstriction ⬇️ level: Pale Cool 😎 No sweating
62
Manifestations of Parkinson’s Disease
Chronic & progressive damage ⛏️ to nerves in 🧠 Tremor 👋🏼 Pill rolling 🤌🏽💊 bradykenesia (slow movement) Hunched, unstable gate🚶🏽 Hallucinations 😵‍💫 Dementia 🤔 Depression
63
Beginning symptoms of Parkinson’s
Tremor 👋🏼& Flat effect 😶
64
➡️Later signs of Parkinson’s
Speech 🗣️ Dysphagia BP changes Gait instability Weak chewing 🫢
65
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 🤌🏽
66
Lewy Bodies
Build up of protein in 🧠 Causes abnormal 🧠 fx and Parkinson’s
67
MS is more common
In women 💃🏻 20 - 40 yrs old Overweight 🤰🏻 Low vitamin D 🌤️ Smoking 🚬 (can cause relapse of MS)
68
Multiple Sclerosis is where
The myelin sheaths break down around nerve
69
Early manifestations of MS
Vision Changes 👀 ❤️💚 color distortion 🚨Blindness in one 👁️
70
Other manifestations of MS
Extremity weakness Balance coordination 🦵🏻 Numbness & tingling 📌 Lhermitte’s sign “MS hug” (Spasms to intercostal & abd nerves)
71
Rursing management of MS
Independence ⬇️Reduce triggers Manage fatigue 😴 (🚫exacerbation) 🚫🚬 Coping Manage stress Meds 💊: Dizziness Depression Pain Interferon B No cure‼️
72
Autonomic Dysreflexia is
Life threatening 🚨due to: Status epileptics MI Stroke Death☠️🏴‍☠️🪦

Med Surg2 (5 decks)

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