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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
Q

what is part of a neuro assessment?

A

mental status, motor function, reflexes, sensory/cerebellar function and cranial nerves

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26
Q

what lab assessments are part of the neuro assessment?

A

B12
hormone deficiency
lumbar puncture: between L4 and L5 arachnoid space

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27
Q

what imaging is done in a neuro assessment?

A

xray, cerebral angiography, MR, CT, PET and MEG

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28
Q

what is the difference between EMG vs EEG

A

EMG: electromyography, identify nerve/muscle disorders and spinal cord disease

EEG: electroencephalography: records electrical activity of cerebral hemispheres

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29
Q

what does the CNS conist of?

A

Forebrain
cerebellum
brain stem

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30
Q

what are the parts of the forebrain?
what do they do?

A

frontal: consciousness, judgement, insight
Temporal: speech recognition
Parietal: movement, stimulus perception
Occipital: vision

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31
Q

what does the cerebellum control?

A

movement/coordination

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32
Q

what does the brainstem control? what are the parts of it?

A

basic vital functions (breathing)
1. Mid brain
2. Pons
3. Medulla

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33
Q

describe decorticate posturing?

A

closed hands, legs and feet internally rotated inward
arms adducted and flexed against chest

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34
Q

describe decerebrate posturing

A

head/neck arched, legs straight, and toes are pointed downward
arms are straight, extended and hands are curled

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35
Q

what is part of the GCS scale?
what does the score mean?

A

eye opening, motor response and verbal response

higher the score, the better the patient

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36
Q

what are the scores of the NIHH stroke scale?

A

0= no stroke
1-4 = minor stroke
5-15 = moderate stroke
16-20 = moderat to severe stroke
21-42 = severe stroke

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37
Q

what categories does the NIHH stroke scale look at

A

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

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38
Q

how many categories are on the NIHH scale?

A

11

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39
Q

what occurs during a SCI?

A

ischemia to spinal cord

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40
Q

when does a majority of SCI happen?

A

16-30

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41
Q

what causes hyperflexion (SCI)? what occurs within the spinal cord?

A

force of car wreck whipping head forward/down

anterior dislocation, ruptured longitudinal ligament

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42
Q

what is another name for an axial loading (SCI)? what is it caused by? what part of the spine is the injury to?

A

also known as vertical compression

caused by jumping

injury of cervical or lumbar spine

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43
Q

what medications do we give for SCI? what is an important nursing action we must do?

A

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

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44
Q

what is spinal shock?
when does it occur?
how intense is it? when does it resolve?

What is BCR?

A

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)

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45
Q

what is neurogenic shock?
what is the bodys response?
when does neurogenic distributive shock occur?

A

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

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46
Q

describe a complete spinal cord lesion

A

total loss of motor, sensory, and reflex activity from below level of injury

47
Q

what are the 3 types of incomplete spinal lesions?

A

anterior cord syndrome
central cord syndrome
Brown sequard syndrome

48
Q

describe anterior cord syndrome

A

loss of motor function, pain and temperature
but position, vibration and light touch remain intact

49
Q

describe central cord syndrome

A

incomplete loss of motor function from waist up

50
Q

describe Brown sequard syndrome

A

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
Q

what do we assess for Spinal cord lesions?

A

ABC
indications of hemorrhage (abd or around fracture sites)
LOC - GCS scale
level of injury

52
Q

describe tetraplegia

A

paralysis of all 4 limbs

53
Q

describe quadriplegia

A

paralysis of all 4 limbs and body from neck down

54
Q

describe quadriparesis

A

weakness of all 4 limbs

55
Q

describe paraplegia

A

loss of motor/sensory function in lower half of body

56
Q

describe paraparesis

A

partial loss of motor/sensory function in lower extremties or both legs

57
Q

what parts of the spinal cord would require ventilation if damaged?

A

C1-C3 = ventilation depended
C4-C5 = may or may not need ventilation
below C5= intact diaphragmatic breathing

58
Q

what does paralysis of diaphragmatic or intercostal muscles do?

A

creates ineffective breathing patterns

59
Q

what are parts of airway management?

A

assess resp function
optimize pulmonary function by positioning

60
Q

how do we stabalize the cardiovascular system of people with spinal cord lesions?
why do we do this?

A

we maintain a MAP of 85-90
we do this to maintain spinal cord perfusion

61
Q

what are other nursing interventions we do for spinal cord lesions?

A

DVT proph
gastric decompression (keep stomach empty)
skin care
elimination

62
Q

what is autonomic dysreflexia?

A

MEDICAL EMERGENCY
occurs above t6, after resolution of spinal shock

63
Q

what causes autonomic dysreflexia?

A

caused by intense, sympathetic response to stimuli such as a kinked urinary catheter or fecal impaction

64
Q

what are s/sx of autonomic dysreflexia?

A

severe HTN
Ha
Bradycardia
diaphoresis

65
Q

how do we manage autonomic dysreflexia?

A

assess and remove cause
bowel and bladder regimen (I/O’s needed)

66
Q

what do we do to stabalize spinal cord injury patients

A

halo vest
surgical intervention (plates, rods, bone grafts)
give medications: high dose corticosteroids
Vasopressors/fluids
PPI’s
IVF

67
Q

what are the priority issues with acute spinal cord injuries?

A

resp distress/failure
potential for cardiovascular instability (shock/autonomic dysreflexia)
potential for secondary spinal cord injury
decreased mobility/sensation

68
Q

what conservative tx do we use for cervical neck pain? what surgical management do we do?

A

conservative tx: soft collars
Surgical: anterior cervical diskectomy and fusion

69
Q

what is gamma knife surgery?

A

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
Q

describe a transient ischemic stroke (TIA)?
what does it reduce?

A

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
Q

describe a thrombotic stroke

A

thrombus develops in arteries supplying blood to the brain which deprives the area of blood

72
Q

describe an embolic stroke

A

when fatty plaque or blood clot forms somewhere else in the body, breaks loose and travels to the brain in blood stream

73
Q

describe a hemorrhagic stroke

A

a blood vessel breaks and bleeds into the brain

74
Q

describe a regular stroke (not a TIA)

A

complete artery blocked, area of brain cell death occurs
Medical emergency
needs immediate tx to prevent permanent disability

75
Q

what are risk factors of having a stroke

A

DM
obesity
HLD
HTN
smoking

not ETOH

76
Q

what do we assess on a stroke pt

A

ABC
cognitive changes
motor changes
sensory changes
cranial nerves
CV
psychosocial
labs and imaging

77
Q

what imaging is required after a stroke

A

CT scan

78
Q

what does the Left side of the brain control

A

controls movement
critical thinking
logic
reasoning language
science/math/writing and number skills

79
Q

what does a L sided brain stroke cause?

A

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
Q

what does the R side of the brain control

A

movement of L side
art/music awareness
imagination, intuition
holistic thought
spatial awareness

81
Q

what does a R sided brain stroke cause?

A

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
Q

nursing care for ischemic stroke
what is the first line tx:

A

Assess ABC FIRST
first line tx: thrombolytic therapy

83
Q

describe thrombolytic therapy

A

-admin of a bolus of alteplase over 1 min followed by an infusion over 60 min
dissolves clot and restores blood flow

84
Q

when should alteplase be administered? what should they administer after?

A

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
Q

how should we manage bp after a stroke

A

must be decreased gradually over a next few days

86
Q

what nursing care do we provide for a hemorhhagic stroke

A
  • most pt managed by relieving ICP (ventricular drain placement or craniotomy)
    -CPP between 60-80
87
Q

Cardiovascular care for hemorrhagic stroke?
why do we do this?

A

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
Q

what if patient takes anticoagulants when hemorrhagic stroke occurs?
what do we do to avoid over correction?

A

we must give reversal agents and plasma products to reverse coagulopathy
-over correction avoided by providing Cardiovascular nursing care

89
Q

what kind of medications do some hemorrhagic stroke patients need

A

anti-seizure meds prophylactically to precent spontaneous epileptiform

90
Q

what bp medications do we give to people who are candidates for fibrinolysis (PRE-Treatmentr?)

A

pre tx:
labetolol IVP (10-20mg)
OR Nicardepine

and Enalapril

91
Q

what bp medications do we give to people who are candidates for fibrinolysis ? (POST-Treatment)

A

post tx: sodium nitroprusside
OR Narcidipine/labetolol (combined)

92
Q

what bp medications do we give to people who are NOT candidates for fibrinolysis

A

SBP >220 and DBP > 140
sodium nitroprusside

93
Q

besides blood pressure drugs for stroke what other drugs do we give?

A

neuroprotective drugs (Antioxidants)
anticoags
lorazepam (antiepileptic)
stool softeners
analgesics for pain
antianxiety

94
Q

what surgeries do we do for stroke?

A

carotid artery angioplasty with stenting
endarterectomy
extra-intracranial bypass

95
Q

what is unilateral neglect?
where does the injury occur in most cases?

A

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
Q

features of unilateral neglect
what behaviors do they display?

A

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
Q

what are nursing interventions for unilateral neglect?

A

eye patching
feedback training
neck muscle vibration
mirror therapy
prism adaptation and
visual exploration training

98
Q

priority collaborative problems for a patient with a stroke may be

A

inadequate perfusion to the brain

decreased mobility and ability to perform ADLs

aphasia/ dysarthria

sensory perception deficits

99
Q

what does BE FAST stand for?
what are other symptoms of stroke

A

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
Q

what is multiple sclerosis

A

chronic disease charcaterized by demyelination and axonal nerve damage = disrupted nerve impulses and inflammation/scarring of CNS

101
Q

what is the most common type of MS- describe it

A

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
Q

describe Secondary progressive MS (SPMS)

A

similar to RRMS at first but then immune attacks become constant = steady progression of disability

103
Q

describe Primary progressive MS (PPMS)

A

one constant attack on myelin

104
Q

describe progressive relapsing MS (PRMS)

A

one constant attack on myelin with bouts super imposed = faster disability

105
Q

what is charcots triad?

A

consists with sx of MS
-Dysarthria
-intentional tremors
-nystagmus

106
Q

what are s/sx of MS

A

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
Q

genetic and environmental factors of MS

A

genetic: female, encodes HLA DR2

enviornment: infections, vit D deficiency

108
Q

what diagnostic procedures do we do for MS?

A

MRI of brain/spinal cord (white matter = plaque)
CSF (increased antibodies, proteins and immune cells)
evoked potential test to asses nerve signal transmission

109
Q

what kind of medications do we give for sx management of MS

A

NO CURE

corticosteroids (decrease inflammation)
IVIG
cyclophosphamide (cell cycle inhibitor)
plasmapheresis
immunosupressants (decrease cytokines, increase T cell function)w

110
Q

what kind of care do we not want to give to an MS patient?

A

DO not give cluster care, will fatigue patient

111
Q

how often do we observe neuro deficits in new stroke patients

A

q15x4
q30x2
qhr

112
Q

what are a late sign of change in Stroke?

A

pupils

113
Q

what sign indicates pt is worsening (stroke)?

A

mod changes

Medsurg 2 (7 decks)

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