Exam 4 Flashcards
Signs and symptoms of increasing ICP
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
what is cushings triads?
bradycardia
abnormal respirations
Increased SBP (widened pulse pressure)
risk factors of increased ICP
secondary brain injury
tumors
closed head injury
ruptured blood vessels
embolism
thrombosis
ischemia
hydrocephalus (children)
nursing interventions for ID and decrease ICP
neuro checks, GCS scale
semi fowlers (30-35 degrees)
change position slowly
main hydration (NS, maintance fluid, gives volume)
Strict I/Os
hypothermia
what are the 3 NOs with increased ICP
NO narcotics
NO sedatives
NO coughing (tessalon pearls given to suppress cough)
why do we induce hypothermia in a pt with an increased ICP
prevents swelling from increasing, protects brain integrity and brain compliance
Respiratory Nursing interventions for increased ICP
immobility, airway patency, suction, ventilation, PCO2 okay?
Nursing interventions to protect from injury?
assess if CSF is coming from nose and ears
prevent aspiration and eye damage (NS drops)
seizure precautions
quiet enviornment
Immobility Nursing interventions
ROM
skin breakdown
reposition (log roll)
assess motor response and pt movement
what causes increased ICP?
why do these things occur?
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
what ABGs are present with increased IPC
increased in PaCo2 (hypercapnic) and acidosis
what diagnostic testing do we do for increased ICP
cat scan
MRI
PET
ICP monitoring
EEG
how do we tx increasing ICP
osmotic diuretic
Mannitol
Hypertonic solutions (2-3% NS)
Corticosteroids to decrease inflammation
anticonvulsants
what are complications of increased ICP
Herniation, SIADH, DI
why do we give hypertonic solutions to pts with increasing ICP
pulls fluid into intravascular spaces which decreases ICP
what is CPP
how do you calculate it?
what is the normal range for it?
Cerebral perfusion pressure
MAP- ICP = CPP
normal ranges: 60-80
what is the gold standard for monitoring ICP? why?
ventriculostomy system
allows to monitor ICP and drain fluid off
what does CPP represent?
net pressure gradient that drives o2 delivery to cerebral tissue, determines cerebral blood flow
what 2 thing does loss of cerebral regulation do and what do they lead to?
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
what does the Parasympathetic nervous system control?
Rest and digest
-stimulates digestive tract to process/eliminate food waste
slow HR, decrease BP
controls erection
what does the sympathetic nervous system control? what does it increase? what does it decrease?
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
what controls the autonomic nervous system? what controls the somatic nervous system?
autonomic: subconscious controls
Somatic: voluntary, muscle movement
what is part of the peripheral nervous system?
autonomic, somatic, parasympathetic and sympathetic
what part of the brain does depression shrink?
What does alzheimers do to the brain?
What is poor memory caused by?
depression shrinks hippocampus (important in learning/memory)
alzheimers = cerebral cortex atrophies, affects judgement/emotional control
Poor memory = shrunk hippocampus
what is part of a neuro assessment?
mental status, motor function, reflexes, sensory/cerebellar function and cranial nerves
what lab assessments are part of the neuro assessment?
B12
hormone deficiency
lumbar puncture: between L4 and L5 arachnoid space
what imaging is done in a neuro assessment?
xray, cerebral angiography, MR, CT, PET and MEG
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
what does the CNS conist of?
Forebrain
cerebellum
brain stem
what are the parts of the forebrain?
what do they do?
frontal: consciousness, judgement, insight
Temporal: speech recognition
Parietal: movement, stimulus perception
Occipital: vision
what does the cerebellum control?
movement/coordination
what does the brainstem control? what are the parts of it?
basic vital functions (breathing)
1. Mid brain
2. Pons
3. Medulla
describe decorticate posturing?
closed hands, legs and feet internally rotated inward
arms adducted and flexed against chest
describe decerebrate posturing
head/neck arched, legs straight, and toes are pointed downward
arms are straight, extended and hands are curled
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
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
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
how many categories are on the NIHH scale?
11
what occurs during a SCI?
ischemia to spinal cord
when does a majority of SCI happen?
16-30
what causes hyperflexion (SCI)? what occurs within the spinal cord?
force of car wreck whipping head forward/down
anterior dislocation, ruptured longitudinal ligament
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
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
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)
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
describe a complete spinal cord lesion
total loss of motor, sensory, and reflex activity from below level of injury
what are the 3 types of incomplete spinal lesions?
anterior cord syndrome
central cord syndrome
Brown sequard syndrome
describe anterior cord syndrome
loss of motor function, pain and temperature
but position, vibration and light touch remain intact
describe central cord syndrome
incomplete loss of motor function from waist up
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
what do we assess for Spinal cord lesions?
ABC
indications of hemorrhage (abd or around fracture sites)
LOC - GCS scale
level of injury
describe tetraplegia
paralysis of all 4 limbs
describe quadriplegia
paralysis of all 4 limbs and body from neck down
describe quadriparesis
weakness of all 4 limbs
describe paraplegia
loss of motor/sensory function in lower half of body
describe paraparesis
partial loss of motor/sensory function in lower extremties or both legs
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
what does paralysis of diaphragmatic or intercostal muscles do?
creates ineffective breathing patterns
what are parts of airway management?
assess resp function
optimize pulmonary function by positioning
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
what are other nursing interventions we do for spinal cord lesions?
DVT proph
gastric decompression (keep stomach empty)
skin care
elimination
what is autonomic dysreflexia?
MEDICAL EMERGENCY
occurs above t6, after resolution of spinal shock
what causes autonomic dysreflexia?
caused by intense, sympathetic response to stimuli such as a kinked urinary catheter or fecal impaction
what are s/sx of autonomic dysreflexia?
severe HTN
Ha
Bradycardia
diaphoresis
how do we manage autonomic dysreflexia?
assess and remove cause
bowel and bladder regimen (I/O’s needed)
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
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
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
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
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
describe a thrombotic stroke
thrombus develops in arteries supplying blood to the brain which deprives the area of blood
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
describe a hemorrhagic stroke
a blood vessel breaks and bleeds into the brain
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
what are risk factors of having a stroke
DM
obesity
HLD
HTN
smoking
not ETOH
what do we assess on a stroke pt
ABC
cognitive changes
motor changes
sensory changes
cranial nerves
CV
psychosocial
labs and imaging
what imaging is required after a stroke
CT scan
what does the Left side of the brain control
controls movement
critical thinking
logic
reasoning language
science/math/writing and number skills
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
what does the R side of the brain control
movement of L side
art/music awareness
imagination, intuition
holistic thought
spatial awareness
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
nursing care for ischemic stroke
what is the first line tx:
Assess ABC FIRST
first line tx: thrombolytic therapy
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
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
how should we manage bp after a stroke
must be decreased gradually over a next few days
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
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
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
what kind of medications do some hemorrhagic stroke patients need
anti-seizure meds prophylactically to precent spontaneous epileptiform
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
what bp medications do we give to people who are candidates for fibrinolysis ? (POST-Treatment)
post tx: sodium nitroprusside
OR Narcidipine/labetolol (combined)
what bp medications do we give to people who are NOT candidates for fibrinolysis
SBP >220 and DBP > 140
sodium nitroprusside
besides blood pressure drugs for stroke what other drugs do we give?
neuroprotective drugs (Antioxidants)
anticoags
lorazepam (antiepileptic)
stool softeners
analgesics for pain
antianxiety
what surgeries do we do for stroke?
carotid artery angioplasty with stenting
endarterectomy
extra-intracranial bypass
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
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
what are nursing interventions for unilateral neglect?
eye patching
feedback training
neck muscle vibration
mirror therapy
prism adaptation and
visual exploration training
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
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
what is multiple sclerosis
chronic disease charcaterized by demyelination and axonal nerve damage = disrupted nerve impulses and inflammation/scarring of CNS
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
describe Secondary progressive MS (SPMS)
similar to RRMS at first but then immune attacks become constant = steady progression of disability
describe Primary progressive MS (PPMS)
one constant attack on myelin
describe progressive relapsing MS (PRMS)
one constant attack on myelin with bouts super imposed = faster disability
what is charcots triad?
consists with sx of MS
-Dysarthria
-intentional tremors
-nystagmus
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)
genetic and environmental factors of MS
genetic: female, encodes HLA DR2
enviornment: infections, vit D deficiency
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
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
what kind of care do we not want to give to an MS patient?
DO not give cluster care, will fatigue patient
how often do we observe neuro deficits in new stroke patients
q15x4
q30x2
qhr
what are a late sign of change in Stroke?
pupils
what sign indicates pt is worsening (stroke)?
mod changes
