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Medsurg 2 > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Signs and symptoms of increasing ICP

A

changes in LOC and speech
Change in Vital signs: cushings triads
pupil changes, papilledema, dolls eyes
posturing: decebrate, decorticate, flaccid
decreased sensory/motor skills
Ha, Vomiting

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2
Q

what is cushings triads?

A

bradycardia
abnormal respirations
Increased SBP (widened pulse pressure)

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3
Q

risk factors of increased ICP

A

secondary brain injury
tumors
closed head injury
ruptured blood vessels
embolism
thrombosis
ischemia
hydrocephalus (children)

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4
Q

nursing interventions for ID and decrease ICP

A

neuro checks, GCS scale
semi fowlers (30-35 degrees)
change position slowly
main hydration (NS, maintance fluid, gives volume)
Strict I/Os
hypothermia

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5
Q

what are the 3 NOs with increased ICP

A

NO narcotics
NO sedatives
NO coughing (tessalon pearls given to suppress cough)

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6
Q

why do we induce hypothermia in a pt with an increased ICP

A

prevents swelling from increasing, protects brain integrity and brain compliance

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7
Q

Respiratory Nursing interventions for increased ICP

A

immobility, airway patency, suction, ventilation, PCO2 okay?

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8
Q

Nursing interventions to protect from injury?

A

assess if CSF is coming from nose and ears
prevent aspiration and eye damage (NS drops)
seizure precautions
quiet enviornment

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9
Q

Immobility Nursing interventions

A

ROM
skin breakdown
reposition (log roll)
assess motor response and pt movement

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10
Q

what causes increased ICP?
why do these things occur?

A

occurs with increase in size of intracranial contents (IC blood volume, CSF, brain tissue edema and dilated cerebral arteries)

occurs due to cerebral hemorrhage, cellular toxins, ischemic cells

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11
Q

what ABGs are present with increased IPC

A

increased in PaCo2 (hypercapnic) and acidosis

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12
Q

what diagnostic testing do we do for increased ICP

A

cat scan
MRI
PET
ICP monitoring
EEG

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13
Q

how do we tx increasing ICP

A

osmotic diuretic
Mannitol
Hypertonic solutions (2-3% NS)
Corticosteroids to decrease inflammation
anticonvulsants

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14
Q

what are complications of increased ICP

A

Herniation, SIADH, DI

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15
Q

why do we give hypertonic solutions to pts with increasing ICP

A

pulls fluid into intravascular spaces which decreases ICP

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16
Q

what is CPP
how do you calculate it?
what is the normal range for it?

A

Cerebral perfusion pressure
MAP- ICP = CPP
normal ranges: 60-80

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17
Q

what is the gold standard for monitoring ICP? why?

A

ventriculostomy system
allows to monitor ICP and drain fluid off

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18
Q

what does CPP represent?

A

net pressure gradient that drives o2 delivery to cerebral tissue, determines cerebral blood flow

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19
Q

what 2 thing does loss of cerebral regulation do and what do they lead to?

A

Increase in BP = increase cerebral blood volume = increase extravasation and edema = Increase ICP

or

decrease in BP = decrease in cerebral blood volume = increase hypoxia, hypercabia and acidosis = Increase ICP

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20
Q

what does the Parasympathetic nervous system control?

A

Rest and digest
-stimulates digestive tract to process/eliminate food waste

slow HR, decrease BP

controls erection

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21
Q

what does the sympathetic nervous system control? what does it increase? what does it decrease?

A

Fight or flight
increases: HR, heart contraction, energy stored in liver (sweaty palms), basic metabolic rate, muscle strength
and Opens aveoli for easier breathing

Decreases: function less important in emergency (digestive/urination)

controls semen release

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22
Q

what controls the autonomic nervous system? what controls the somatic nervous system?

A

autonomic: subconscious controls
Somatic: voluntary, muscle movement

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23
Q

what is part of the peripheral nervous system?

A

autonomic, somatic, parasympathetic and sympathetic

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24
Q

what part of the brain does depression shrink?

What does alzheimers do to the brain?

What is poor memory caused by?

A

depression shrinks hippocampus (important in learning/memory)

alzheimers = cerebral cortex atrophies, affects judgement/emotional control

Poor memory = shrunk hippocampus

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25
what is part of a neuro assessment?
mental status, motor function, reflexes, sensory/cerebellar function and cranial nerves
26
what lab assessments are part of the neuro assessment?
B12 hormone deficiency lumbar puncture: between L4 and L5 arachnoid space
27
what imaging is done in a neuro assessment?
xray, cerebral angiography, MR, CT, PET and MEG
28
what is the difference between EMG vs EEG
EMG: electromyography, identify nerve/muscle disorders and spinal cord disease EEG: electroencephalography: records electrical activity of cerebral hemispheres
29
what does the CNS conist of?
Forebrain cerebellum brain stem
30
what are the parts of the forebrain? what do they do?
frontal: consciousness, judgement, insight Temporal: speech recognition Parietal: movement, stimulus perception Occipital: vision
31
what does the cerebellum control?
movement/coordination
32
what does the brainstem control? what are the parts of it?
basic vital functions (breathing) 1. Mid brain 2. Pons 3. Medulla
33
describe decorticate posturing?
closed hands, legs and feet internally rotated inward arms adducted and flexed against chest
34
describe decerebrate posturing
head/neck arched, legs straight, and toes are pointed downward arms are straight, extended and hands are curled
35
what is part of the GCS scale? what does the score mean?
eye opening, motor response and verbal response higher the score, the better the patient
36
what are the scores of the NIHH stroke scale?
0= no stroke 1-4 = minor stroke 5-15 = moderate stroke 16-20 = moderat to severe stroke 21-42 = severe stroke
37
what categories does the NIHH stroke scale look at
LOC: (whats the month? how old are you?) do they follow commands (grips- open/close eyes) Best gaze Visual facial palsy motor arm motor leg limb ataxia sensory best language dysarthria extinction/inattention
38
how many categories are on the NIHH scale?
11
39
what occurs during a SCI?
ischemia to spinal cord
40
when does a majority of SCI happen?
16-30
41
what causes hyperflexion (SCI)? what occurs within the spinal cord?
force of car wreck whipping head forward/down anterior dislocation, ruptured longitudinal ligament
42
what is another name for an axial loading (SCI)? what is it caused by? what part of the spine is the injury to?
also known as vertical compression caused by jumping injury of cervical or lumbar spine
43
what medications do we give for SCI? what is an important nursing action we must do?
antiinflammatory and large doses of corticosteroids (500mg) cold fluids (make pt hypothermic) stabalize the spine, C collar, be careful when moving (log roll with 3 people) and place backboard to prevent further damage
44
what is spinal shock? when does it occur? how intense is it? when does it resolve? What is BCR?
temporary suppression of all reflex activity below level of injury occurs immediately after injury intensity/duration depends on level of injury once Bulbocavernous Reflex returns = spinal shock over BCR= osinki reflex, S2-s4 assessment (stimulate genitals and watch rectum retract)
45
what is neurogenic shock? what is the bodys response? when does neurogenic distributive shock occur?
temporary disruption of autonomic pathways below level of injury bodys response to sudden loss of sympathetic control (>50%) occurs in pt with a SCI above t6
46
describe a complete spinal cord lesion
total loss of motor, sensory, and reflex activity from below level of injury
47
what are the 3 types of incomplete spinal lesions?
anterior cord syndrome central cord syndrome Brown sequard syndrome
48
describe anterior cord syndrome
loss of motor function, pain and temperature but position, vibration and light touch remain intact
49
describe central cord syndrome
incomplete loss of motor function from waist up
50
describe Brown sequard syndrome
ipsilateral loss loss of motor function, vibration, position and deep touch sensation on same side of brain damage loss of pain, temperature and light touch on opposite side
51
what do we assess for Spinal cord lesions?
ABC indications of hemorrhage (abd or around fracture sites) LOC - GCS scale level of injury
52
describe tetraplegia
paralysis of all 4 limbs
53
describe quadriplegia
paralysis of all 4 limbs and body from neck down
54
describe quadriparesis
weakness of all 4 limbs
55
describe paraplegia
loss of motor/sensory function in lower half of body
56
describe paraparesis
partial loss of motor/sensory function in lower extremties or both legs
57
what parts of the spinal cord would require ventilation if damaged?
C1-C3 = ventilation depended C4-C5 = may or may not need ventilation below C5= intact diaphragmatic breathing
58
what does paralysis of diaphragmatic or intercostal muscles do?
creates ineffective breathing patterns
59
what are parts of airway management?
assess resp function optimize pulmonary function by positioning
60
how do we stabalize the cardiovascular system of people with spinal cord lesions? why do we do this?
we maintain a MAP of 85-90 we do this to maintain spinal cord perfusion
61
what are other nursing interventions we do for spinal cord lesions?
DVT proph gastric decompression (keep stomach empty) skin care elimination
62
what is autonomic dysreflexia?
MEDICAL EMERGENCY occurs above t6, after resolution of spinal shock
63
what causes autonomic dysreflexia?
caused by intense, sympathetic response to stimuli such as a kinked urinary catheter or fecal impaction
64
what are s/sx of autonomic dysreflexia?
severe HTN Ha Bradycardia diaphoresis
65
how do we manage autonomic dysreflexia?
assess and remove cause bowel and bladder regimen (I/O's needed)
66
what do we do to stabalize spinal cord injury patients
halo vest surgical intervention (plates, rods, bone grafts) give medications: high dose corticosteroids Vasopressors/fluids PPI's IVF
67
what are the priority issues with acute spinal cord injuries?
resp distress/failure potential for cardiovascular instability (shock/autonomic dysreflexia) potential for secondary spinal cord injury decreased mobility/sensation
68
what conservative tx do we use for cervical neck pain? what surgical management do we do?
conservative tx: soft collars Surgical: anterior cervical diskectomy and fusion
69
what is gamma knife surgery?
type of radiation therapy used to tx tumors, vascular malformations and other abnormalities in the brain Is NOT an actual surgery due to not having an incision
70
describe a transient ischemic stroke (TIA)? what does it reduce?
mini stroke happens when cerebral artery is temporarily blocked, decreasing blood flow to brain reduces focal neurologic dysfunction due to interruption of cerebral blood flow
71
describe a thrombotic stroke
thrombus develops in arteries supplying blood to the brain which deprives the area of blood
72
describe an embolic stroke
when fatty plaque or blood clot forms somewhere else in the body, breaks loose and travels to the brain in blood stream
73
describe a hemorrhagic stroke
a blood vessel breaks and bleeds into the brain
74
describe a regular stroke (not a TIA)
complete artery blocked, area of brain cell death occurs Medical emergency needs immediate tx to prevent permanent disability
75
what are risk factors of having a stroke
DM obesity HLD HTN smoking not ETOH
76
what do we assess on a stroke pt
ABC cognitive changes motor changes sensory changes cranial nerves CV psychosocial labs and imaging
77
what imaging is required after a stroke
CT scan
78
what does the Left side of the brain control
controls movement critical thinking logic reasoning language science/math/writing and number skills
79
what does a L sided brain stroke cause?
R sided weakness, paralysis & sensory impairment problems with speech/understanding (aphasia) visual problems, cant see R visual field in each eye slow performance (caution) aware of deficits (depression/anxiety caused) impaired comprehension of math
80
what does the R side of the brain control
movement of L side art/music awareness imagination, intuition holistic thought spatial awareness
81
what does a R sided brain stroke cause?
paralysis/neglect of L side vision issues, facial weakness and problems swallowing denies/minimize problems rapid short attention span quickly, over curious behavior poor decision making impulsive safety problems impaired time concept and memory loss
82
nursing care for ischemic stroke what is the first line tx:
Assess ABC FIRST first line tx: thrombolytic therapy
83
describe thrombolytic therapy
-admin of a bolus of alteplase over 1 min followed by an infusion over 60 min dissolves clot and restores blood flow
84
when should alteplase be administered? what should they administer after?
within 3-4.5 hrs of onset of sx after the pt must be placed on PO antiplatelt therapy (ASA 325 mg) within 24-48hrs
85
how should we manage bp after a stroke
must be decreased gradually over a next few days
86
what nursing care do we provide for a hemorhhagic stroke
- most pt managed by relieving ICP (ventricular drain placement or craniotomy) -CPP between 60-80
87
Cardiovascular care for hemorrhagic stroke? why do we do this?
Monitor BP frequently maintain with a Goal SBP of 140 and needs to stay in between 13-150 to avoid overcorrection of reverse coagulopathy
88
what if patient takes anticoagulants when hemorrhagic stroke occurs? what do we do to avoid over correction?
we must give reversal agents and plasma products to reverse coagulopathy -over correction avoided by providing Cardiovascular nursing care
89
what kind of medications do some hemorrhagic stroke patients need
anti-seizure meds prophylactically to precent spontaneous epileptiform
90
what bp medications do we give to people who are candidates for fibrinolysis (PRE-Treatmentr?)
pre tx: labetolol IVP (10-20mg) OR Nicardepine and Enalapril
91
what bp medications do we give to people who are candidates for fibrinolysis ? (POST-Treatment)
post tx: sodium nitroprusside OR Narcidipine/labetolol (combined)
92
what bp medications do we give to people who are NOT candidates for fibrinolysis
SBP >220 and DBP > 140 sodium nitroprusside
93
besides blood pressure drugs for stroke what other drugs do we give?
neuroprotective drugs (Antioxidants) anticoags lorazepam (antiepileptic) stool softeners analgesics for pain antianxiety
94
what surgeries do we do for stroke?
carotid artery angioplasty with stenting endarterectomy extra-intracranial bypass
95
what is unilateral neglect? where does the injury occur in most cases?
attention disorder that arises as result of injury to the cerebral cortex most cases - the R parietal cortex is injured and L side of the body/space is ignored
96
features of unilateral neglect what behaviors do they display?
pt fail to report, respond or orient to meaningful stimuli on affected side heterogenous - sx are different in each eprson pts behave as if the space opposite of lesion doesnt exist anymore displays behaviors such as eating food on only one side of their plate and shaving only half of their face
97
what are nursing interventions for unilateral neglect?
eye patching feedback training neck muscle vibration mirror therapy prism adaptation and visual exploration training
98
priority collaborative problems for a patient with a stroke may be
inadequate perfusion to the brain decreased mobility and ability to perform ADLs aphasia/ dysarthria sensory perception deficits
99
what does BE FAST stand for? what are other symptoms of stroke
B-alance (loss of balance, unexplained falls) E- yes (blurred vision, trouble seeing) F-acial drooping A-rm or leg weakness, S-lurred speech T-ime to call 911 paralysis, numbness sudden/severe ha, dizziness paralysis/numbness of one side of body confusion
100
what is multiple sclerosis
chronic disease charcaterized by demyelination and axonal nerve damage = disrupted nerve impulses and inflammation/scarring of CNS
101
what is the most common type of MS- describe it
Regressive remittent MS (RRMS) bouts of autoimmune attacks happening over months/yrs apart = increase in disability level each attacks = increased irreversible w/no increase in disability in between bouts
102
describe Secondary progressive MS (SPMS)
similar to RRMS at first but then immune attacks become constant = steady progression of disability
103
describe Primary progressive MS (PPMS)
one constant attack on myelin
104
describe progressive relapsing MS (PRMS)
one constant attack on myelin with bouts super imposed = faster disability
105
what is charcots triad?
consists with sx of MS -Dysarthria -intentional tremors -nystagmus
106
what are s/sx of MS
charcots triad visual disturbances (blurry, diplopia) muscle weakness/splasticity ataxia, tremors, paralysis balance and coordination issues cognitive changes (memory) trouble eating, talking and swallowing (part of dysarthria)
107
genetic and environmental factors of MS
genetic: female, encodes HLA DR2 enviornment: infections, vit D deficiency
108
what diagnostic procedures do we do for MS?
MRI of brain/spinal cord (white matter = plaque) CSF (increased antibodies, proteins and immune cells) evoked potential test to asses nerve signal transmission
109
what kind of medications do we give for sx management of MS
NO CURE corticosteroids (decrease inflammation) IVIG cyclophosphamide (cell cycle inhibitor) plasmapheresis immunosupressants (decrease cytokines, increase T cell function)w
110
what kind of care do we not want to give to an MS patient?
DO not give cluster care, will fatigue patient
111
how often do we observe neuro deficits in new stroke patients
q15x4 q30x2 qhr
112
what are a late sign of change in Stroke?
pupils
113
what sign indicates pt is worsening (stroke)?
mod changes

Medsurg 2 (8 decks)

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