Final Exam Module 1 & 2 Flashcards
Status epilepticus is a medical emergency. It is continuous or rapidly occurring seizures. What does it cause?
brain damage, arrhythmias, hypoxemia, & acidosis
What is considered to be “impending status epilepticus?”
Seizure activity lasting longer than 5 minutes
What do we do for status epilepticus?
Initially, intravenous lorazepam/diazepam is administered to stop motor movements. This is followed by the administration of phenytoin.
May require endotracheal intubation for airway protection
Steps to Seizures
What do we do first?
Seizure Management Pearls
Protect the patient from injury.
Do not force anything into the patient’s mouth.
Turn the patient to the side to prevent aspiration and keep the airway clear.
Remove any objects that might injure the patient.
Suction oral secretions if possible without force.
Loosen any restrictive clothing the patient is wearing.
Do not restrain or try to stop the patient’s movement; guide movements if necessary.
Steps to Seizures
What medications?
IV push lorazepam or diazepam.
What do all anticonvulsants cause?
All anticonvulsants can cause drowsiness, ataxia (lack of coordination) and CNS depression (resp. depression)
Levetiracetam (Keppra): best choice for outpatient,
most popular, monitor CBC.
Phenytoin: causes gingival hyperplasia, bone marrow
suppression, rash, IV vesicant, monitor blood levels
and CBC (q3 months).
Carbamazepine: causes bone marrow suppression,
monitor blood levels and CBC.
Divalproex (Depakote): causes hepatotoxicity, bone
marrow suppression, monitor CBC, blood levels and
LFTs.
Steps to Seizures
What do we do once the seizure has stopped?
Reorient the pt.
Record the time the seizure began and ended.
Check blood glucose levels. Seizures can occur due to hypoglycemia.
Make sure airway is clear.
Ask if they have felt an aura before the seizure or have triggers.
How do we differentiate between bacterial
and viral meningitis? Which one is worse?
Meningitis is an acute infection and inflammation of meninges.
Differentiate by CSF analysis w/ lumbar puncture
Bacterial meningitis is an acute, life threatening emergency.
Good prognosis for viral meningitis.
What type of precautions is used for meningitis?
droplet
Clinical Presentation of Meningitis
-Headache like they have never felt before
-Nuchal rigidity, back of the neck is stiff
-Nausea/vomiting
-Photophobia: eye discomfort due to exposure to light
-Brudzinski Sign: flexion of the neck elicits flexion of hips and knees
-Kernig Sign: bilateral hamstring pain prevents straightening of the leg
What is the most important thing to monitor for meningitis?
level of consciousness
What do we do stat with bacterial meningitis?
Requires STAT LP followed by immediate IV antibiotics.
Do not give antibiotics before the LP, can skew the results.
What do we do for viral meningitis?
supportive care- antipyretics, hydration, and rest
What is the priority assessment post craniotomy?
-Monitor for and prevent increased ICP is the PRIORITY
Followed by:
-Observe dressing
-Prevent infection (handwashing)
-Monitor neurological status
-Monitor fluid and electrolytes
-Monitor for diabetes insipidus: during surgery the pituitary gland be affected
-Prevent complications of immobility: DVT prophylaxis, skin breakdown
What is the drug of choice for cerebral edema?
Dexamethasone (Decadron)
What is the difference between a primary spinal cord injury and a secondary injury?
Primary Injury: Initial disruption of cord.
Secondary injury: on-going damage from ischemia, inflammation, toxic metabolites, and edema.
What types of shock should you look out for w/ spinal cord injuries?
Neurogenic- damage to the nerves themselves
Hypovolemic- fluid loss
What is our priority with cervical spinal injuries?
Above C4 requires mechanical ventilation
C3, 4, & 5 keep the diaphragm alive.
All cervical injuries cause respiratory insufficiency meaning the pt will have
-Decreased cough
-Decreased vital capacity
-High risk of atelectasis and pneumonia
What do we see in spinal shock?
Due to acute spinal injury
Loss of motor, sensory and reflex activity at the level of injury and below:
-Flaccid paralysis
-Flaccid bladder
-Paralytic ileus- gut is going to slow down or stop
-Loss of sensation
-Decreased or absent reflexes
Can last days to months. Spasticity may emerge after spinal shock resolves.
Who has the highest risk of developing neurogenic shock?
High risk w/ injury above T6
What sets neurogenic shock apart from spinal shock?
hemodynamic phenomenon
What are the three critical features of neurogenic shock?
Hypotension
Bradycardia
Poikilothermia
All other shocks have hypotension and TACHYcardia
What is the cause of autonomic hyperreflexia?
distended bladder and fecal impaction
We need to dis-impact them or drain their bladder or their BP will continue to go through the roof.
What are the priority symptoms of autonomic hyperreflexia?
Severe, life-threatening hypertensive crisis.
Other sx include: HA, blurred vision, diaphoresis, & flushing
What is the nursing care for autonomic hyperreflexia?
-Elevate HOB to help reduce BP (PRIORITY)
-Monitor BP
-Remove noxious stimuli
-If BP remains elevated administer BP medication
-Close neuro assessment
Immediate Post- Spinal Cord Injury
-Immobilize injury w/ backboard & neck brace
-Prioritize ABCs
-Comprehensive neuro assessment (touch, pain, muscle strength)
-Methylprednisolone (Solu-Medrol) can help w/ inflammation
-Maintain MAP between 80-90 (may require dopamine)
-NG tube for ileus
-Stress ulcer prophylaxis with a PPI
-DVT prophylaxis (SCDs & Lovenox)
What is the formula to calculate MAP?
(SBP + 2DBP) / 3
What is a Transient Ischemic Attack (TIA)?
“Mini-stroke”
Reversible cerebral ischemia. Usually precedes thrombotic stroke: “Warning sign”. Commonly caused by carotid stenosis.
What is the ABCD assessment tool for stroke risk?
Age of at least 60 years
BP of at least 140/90 (either SBP, DBP, or combination)
Clinical TIA features
Duration of symptoms
What is the medication management for TIA?
Antiplatelets drugs such as aspirin or Plavix
What are other management techniques for TIA?
ABCS of stroke management
-Blood pressure management
-Controlling diabetes, if necessary
-Lifestyle changes: smoking cessation, encouraging physical activity, dietary management
What are the two types stroke?
Ischemic (occlusive) and Hemorrhagic (bleeding)
What are the two types of ischemic strokes? What is the main cause of each type?
-Thrombotic –> Atherosclerosis
-Embolic –> A-Fib
What are the 4 types of hemorrhagic strokes? What is the main cause if each type?
-Intracerebral hemorrhage –> severe or sustained HTN
-Subarachnoid hemorrhage –> ruptured aneurysm or AVM rupture
-Aneurysm
-Arteriovenous malformation (AVM) –> congenital abnormality
What is FAST?
Facial dropping, arm pain, slurred speech, & time=brain
Interventions for cerebral aneurysms
clipping and coiling
Thunder clap headache
Subarachnoid hemorrhage
What are the hallmark signs/sx of a stroke?
-Sudden weakness
-Difficulty talking
-Difficulty understanding
-Severe headache with no known cause
What is the first priority for stroke patient?
Ensure pt is transported to a stroke center.
Complete focused/rapid assessment. Remember that there is always a risk that LOC will change.
Broca’s aphasia vs Wernicke’s aphasia
difficulty talking vs difficulty understanding
Emergent Care Stroke
-Assess ABCs
-Provide oxygen (this is an ischemic issue)
-2 Large bore IVs
-Take blood samples and blood glucose
-Perform NIH Stroke Scale
-Order a non-contrast CT- must be read within 45 minutes
-Obtain 12-lead to look for A-fib
-Do not delay CT to get ECG
Within 45 minutes of the patient’s arrival, the specialist must decide, based on the CT scan, if a hemorrhage is present.
Take these actions if a hemorrhage is present:
-Note that the patient is not a candidate for fibrinolytics.
-Arrange for a consultation with a neurologist/neurosurgeon.
-Consider transfer, if available.