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Nursing school level 4 > Final test 453 > Flashcards

Final test 453 Flashcards

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1
Q

patho of aneurysm

A

Dilation of arterial wall, thin wall blister
Rupture at Dome
Rupture During Activity

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2
Q

aneurysm results from

A

Developmental defects in Media and Elastica of Artery Wall

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3
Q

classification of arteries

A

saccular (berry), fusiform (giant), and mycotic

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4
Q

Saccular (Berry)

A

Most Common
85% Involve Circle of Willis
Leak—>WARNING “Worst headache of my life”

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5
Q

Fusiform (Giant)

A

Large - 3cm or more in diameter

Rarely Rupture

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6
Q

Mycotic

A

Arterial Wall Weakens
Usually on distal branch
rare

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7
Q

Clinical Presentation of aneurysm

A

close to aseptic meningitis - change in LOC, severe headache, fever, EKG changes

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8
Q

how would you diagnose aseptic meningitis

A

lumbar puncture (LP) but cannot do it if their ICP is elevated

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9
Q

what type of EKG changes would you see with an aneurysm

A

a tachy/brady arrhythmia

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10
Q

clinical grading of an aneurysm is most important

A

on day of OR and the higher the grade the worse the prognosis

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11
Q

Aneurysm PrecautionsNursing Care

A 
Patient Positioning
Seizures
Monitor S/S Increasing ICP
VS
Respiratory
Temperature
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12
Q

Treatment Options for aneurysm

A

Choice
Clipping – a surgery to clip the aneurysm to prevent bleeding
Coiling - when surgery is not an option

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13
Q

mortality rate with No Surgery with aneurysm

A

70% mortality

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14
Q

how much blood can be fatal during an aneurysm

A

30-50 cc of Blood

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15
Q

patients who get their aneurysm fixed are at risk for

A

Potential for Rebleed 7-10 days - Plts regenerate q 7-10 days
It takes 7-10 days for Fibrin to be removed

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16
Q

Vasospasm

A

Abnormal narrowing of the cerebral arteries. Constriction of the artery or branch in comparison to corresponding vessel on the other side of the aneurysm vessel.
Frequently occurs in the vessel adjacent to the ruptured aneurysm

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17
Q

Highest morbidity and mortality complication of aneurysm

A

vasospasm??

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18
Q

highest risk for vasospasm

A

3-14 day from the initial leak with Peak @ 5 days following initial rupture

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19
Q

what causes vasospasm

A

Etiology Unclear:
By-products of Blood-Breakdown
Release of serotonin, prostaglandin and histamine–spasmogenic substances
Increased influx of calcium into vasc smooth musc—altered cell contraction

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20
Q

Dx of vasospasm

A

Made using angiography Transcranial Doppler (TCDs) – higher rate of flow on the side with the aneurism

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21
Q

first signs of vasospasm

A

global or focal neuro defects

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22
Q

other signs of vasospasm

A

Worsening H/A, Seizures, Increase B/P

Onset of confusion

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23
Q

most common drug prescription for vasospasm

A

Nimodipine

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24
Q

nimodipine

A

Calcium Channel Blocker
Lipid sol. Readily crosses BBB
Prevents influx of Ca into smooth muscle

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25
Q

nimodipine may be _______ if hypotension is not controled

A

dose divided and given more frequently if can’t control for hypotension

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26
Q

triple H therapy with vasospasm

A

Hypervolemia
Arterial Hypertension
Hemodilution
Hemodynamic Monitoring!!!!!

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27
Q

what can be seen given to create hypervolemia in vasospasm

A

Crystalloids (Lactated Ringers, NS)

Colloids (Albumin)

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28
Q

goal for hypertension during vasospasm

A

SBP 160-200mmhg if clipped

SBP 120-150mmHg not clipped

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29
Q

Vasopressor Agents to create hypertension in vasospasm

A

Dopamine (Intropin)
Dobutamine (Dobutrex)
Neosynepherine

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30
Q

why hemodilution for vasospasm

A

Thought to decrease viscosity–>improved cerebral blood flow (CBF) but May reduce oxygen-carrying capacity with lowered Hct

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31
Q

Complications of “Triple H” for vasospasm

A 
Increased ICP
Hemorrhage into an area of infarction from the vasospasm
Increased ischemic edema
Rupture of and unclipped aneurysm
Pulmonary edema, CHF, MI
Dilutional Hyponatremia
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32
Q

Craniotomy nursing care

A 
Skin/Positioning (bone flap?)
Assess Neuro
Monitor CV/Renal
Alleviate H/A
Administer Meds
Head Dressings
Hemovac
Complications
O2 Treatments
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33
Q

Monitor for what complications after a craniotomy

A

Seizures
Hyponatremia
Dehydration
Be prepared for insertion on ICP or Ventriculostomy

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34
Q

brain tumors etiology

A

Based on Tumor growth, increased ICP and cerebral edema
Direct pressure on Brain Tissue
Fld. Accumulation, hemorrhage, or by-products

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35
Q

what to look for with brain tumors

A

Frontal — Behavior, Cognitive, Intellectual
Parietal — Think sensory
Temporal — Understand Speech
Occipital — Visual
4th Ventricle or Brain Stem — Sudden Death
Drop Mets—Onset of LE Weakness
headaches - worse at night
seizures - effects 50% of brain tumor pts

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36
Q

diagnostic studies for brain tumors

A 
H&P
CT
MRI
PET
Bone Scan
EEG
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37
Q

cranial surgery for brain tumor

A

Stereotactic surgery

Craniotomy

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38
Q

goals of craniotomy

A

Goals: Identify Tumor, remove or debulk mass, prevent or manage ICP issues.

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39
Q

Treatment Options for brain tumor

A

Seeding
High Concentrated Radiation Dose
Radiosurgery
Chemotherapy (limited due to BBB)

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40
Q

Monro-Kellie

A

The principle of homeostatic intracerebral volume regulation.

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41
Q

Autoregulation

A

Ability of the brain to regulate the diameter of the arterioles

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42
Q

Increased B/P or Decrease PaCO2

A

CONSTRICTION

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43
Q

Decreased B/P or Increased PaCO2

A

DILATION

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44
Q

Coupling

A

Cerebral Blood flow meets Metabolic Needs

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45
Q

Hyperemia

A

Cerebral Blood Flow > Needs i.e…. Edema

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46
Q

Subflow

A

Cerebral Blood Flow < Needs i.e….. Ischemia, infarction

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47
Q

Cranio-Cerebral Trauma

A

Vehicular Accidents (leading cause)
Falls
Violence

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48
Q

Leading cause of death ages 1-44

A

cerebral trauma

49
Q

response to uncontrolled ICP- Within seconds

A

Injured cells spill their contents into extracellular fluids and extracellular ions enter the cells
- all the neural activity stops

50
Q

response to uncontrolled ICP- Within minutes

A

Tissue begins to swell

Large changes in tissue sodium, potassium, calcium and water concentration.

51
Q

response to uncontrolled ICP- Within hours

A

BBB breaks down, blood flow fails, hemorrhage may occur

52
Q

response to uncontrolled ICP- Within days

A

Inflammatory cells infiltrate the lesion site

53
Q

response to uncontrolled ICP- Within weeks

A

debris carried of and digested by microphages

54
Q

response to uncontrolled ICP and macrophages

A

Macrophages release various cytokines
Induces microvascular injury, vasodilation & increased endothelial permeability
Promotes ion and H2O shifts, leading to vasogenic edema
Ultimately, cerebral ischemia and impaired autoregulation.

55
Q

Diffuse

A

concussion - generalized, wide spread

56
Q

focal

A

localized - contusion

57
Q

Post-Concussive Syndrome(PCS)

A

S/S emotionally labile, H/A, fatigue, sleep disturbances, changes in cognition.

58
Q

Diffuse Axonal Injury (DAI)

A

Not just a blow to the head
Result of brain moving back and forth.
Tissue slides over tissue

59
Q

Hematoma- epidural

A

Bleeding Between Skull and Dura
Arterial Bleed
SURGICAL EMERGENCY
85% Accompanying Skull Fracture

60
Q

subdural hematoma

A 
Bleeding Between the Dura and arachnoid layer
Causes immediate pressure to brain
******Venous Blood*****
Acute  Within 24 hours
Subacute  2-10 days
Chronic  2 weeks - months
61
Q

Basilar Skull Fracture- anterior

A

Fx Parasinuses, “Raccoon Eyes”, CNI, Rhinorrhea –Never stick NG tube in because they will likely have a crack in bone and the tube can go into their brain

62
Q

Basilar Skull Fracture- middle

A

Fx Temporal Bone, Middle ear, Otorrhea, Tinnitus, Deafness, N/V, Vertigo, Nystagmus

63
Q

Basilar Skull Fracture- posterior

A

Epidural Bleed—Proximity of Internal Carotid, “Battle Signs” - bruising behind the ears

64
Q

Coma mnemonic

A 
AEIOU TIPPS
A – alcohol
E - epilepsy (heat stroke, hypothermia) 
I - insulin (diabetic emergency) 
O - overdose or oxygen deficiency 
U - uremia (toxins due to kidney failure) 
T - trauma (shock or head injury) 
I - infection 
P - psychosis 
P - poisoning 
S - stroke
65
Q

Glasgow Coma Scale

A

Three Essential Components
Eye Opening
Verbal Responsiveness
Motor Response

66
Q

Glasgow Coma Scale - numerical score

A

15 Normal
13-14 Mild Head Injury
9-12 Moderate Head Injury
8 or < Severe Head Injury

67
Q

Intracranial Pressure Monitoring

A

Monitor ICP levels to guide medical therapy and nursing care.
Effective diagnostic tool to measure the ICP and CPP

68
Q

Normal ICP

A

Normal Wave
ICP Under 20
Rises sharply, slopes to baseline

69
Q

CPP

A

Cerebral perfusion pressure - MAP – ICP

70
Q

PP < 60mmHg

A

ISCHEMIA

71
Q

CPP > 150mmHg

A

Hyperemia

72
Q

what do we need to remember to look out for with brain injury

A

Diabetes Insipidus (DI)

73
Q

respiratory rate comes from

A

the pons and medulla - see different resp. patterns when there is pressure on the pons or medulla – chart what you see in the moment

74
Q

blood pressure during a head injury

A

Usually stable during initial insult
Increasing ICP activates vasomotor center of the medulla—> Increased SBP
Compensation to maintain CPP

75
Q

pulse during head injury

A 
Bradycardia:
As B/P increases, Pulse decreases, way to increase Stroke Volume (body compensating)
Tachycardia:
with Hypotension consider Volume
Decompensatory stage, Brain Death
76
Q

tachy-brady rhythmia

A

body wants to do its normal thing but the vagus nerve says no slow down

77
Q

temp is regulated by the

A

hypothalamus

78
Q

you see hypothermia in what neuro issues

A

Spinal Shock, Metabolic coma, over dose (OD), Brain stem

79
Q

you see hyperthemia in what neuro issues

A

(100.5 or greater): Infection - ICP cath– with these tubes we can see more infections

80
Q

dilated pupils

A

compressed cranial nerve 3

81
Q

bilateral dilated fixed pupils

A

ominous sign

82
Q

pinpoint pupils

A

pons damage or drugs

83
Q

Increased Intracranial Pressure s/s

A

Most Sensitive Indicator - change in LOC!!! – red flag that something is happening
VS – increase systolic pressure and decreasing pulse
Pupils – late sign!!

84
Q

brain injuries and younger populations

A

young people can compensate a lot longer than older people – they don’t show many signs until late

85
Q

how to test for brain perfusion or brain death

A

Nuclear Blood Flow Test – injecting a radioactive isotope.

Harvard Criteria

86
Q

what to assess when thinking a pt has brain death

A

cephalic reflexes - oculovestibular – what’s happening with ear nerves – syringe of ice water and stick in the ear and patient should look at the ear the ice is going in and have nystagmus. Oculocephalic – if patients head is moving their eyes should move too in order to keep gaze (intact) – not intact = eyes staying midline.

87
Q

Nursing Care for Increased ICP

A

Positioning
Room - Have a good temp and calm quiet room Assessment
Respiratory Care
Activity/Family - can be there as long as the patient is tolerating it – watch their VS based on who is coming in the room

88
Q

drugs to control ICP/CPP

A

Mannitol – common – potent osmotic diuretic – causes a pull from tissue back to vascular bed. Remember this decreases BP and cerebral perfusion
Pentobarbital- coma inducing drug
Pain Meds/Sedation
Paralytics

89
Q

procedures to control ICP/CPP

A

Invasive Procedures – Ventriculostomy – drain CFS

Surgery – Hemicraniectomy (removal of bone flap)

90
Q

what area of the spine is hurt most often

A

C 5-6

91
Q

Mechanisms of Injury with spinal injury

A 
Acceleration/Deceleration
- Head-On MVA
Deformation	
- Whiplash
Axial Loading
- Jump off Building or Diving
Penetrating Wounds
- Knife, GSW, etc.
92
Q

symptoms of spinal shock

A 
Flaccid Paralysis *
- Lower Motor Neuron Lesion
Loss of Spinal Reflex
Loss of Sensory *
Loss of Ability to Perspire below level of injury 
Loss of Bowel and Bladder Function
(Neurogenic Shock)
93
Q

Neurogenic Shock symptoms

A

Unstable VS because sympathetic Nervous system lost
Profound hypotension
HR – bradycardic

94
Q

spinal shock duration

A

Immediate onset, few days - months, usually 1-6 weeks.

95
Q

spinal shock resolution

A

Return of minimal reflex , spasm activity

96
Q

spinal shock Treatment

A

Vasopressors, Poikilothermia

97
Q

what do we give for inflammation during spinal shock

A

Methylprednisolone- - Swelling above the injury is what we are worried about – this helps to decrease swelling/inflammatory response

98
Q

Methylprednisolone side effects

A

compromise the immune system (infection), cortisol issues, glucose goes up

99
Q

Immobilization during spinal injury

A

Halo Traction – maintains head in neutral position
Pin Care
- important to think about positioning with these contraptions

100
Q

surgical indication in spinal surgery

A 
If patient is experiencing any of these the patient should go into the OR unless excessive swelling is occurring:
Cord compression
Progressive neuro deficit
Compound fx of the vertebrae
Bone Fragment in the spinal canal
Inability to Reduce sublux with Tx
101
Q

type of procedures for spinal injury

A

Decompression with Fusion

Internal Fixation, Wiring, Plates, Rods

102
Q

Spinal Cord Syndromes - Central Cord

A

Highest % of Incomplete Lesions
Bladder Dysfunction
Varying degrees of sensory loss below the level of injury

103
Q

Spinal Cord Syndromes - Central Cord recovery

A

Return of Lower extremities, bladder function, Upper extremities, Fingers last

104
Q

Anterior Spinal Cord Syndrome

A

Immediate Complete Motor Paralysis
Hyperesthesia and Hypoalgesia
Preservation of Touch, Motion, Position
Assoc. with Flexion Injuries

105
Q

Hyperesthesia

A

(senses a lot of pain)

106
Q

Hypoalgesia

A

(not sensing pain)

107
Q

Anterior Spinal Cord Syndrome recovery

A

NO Ambulation or Hand Function, NO Bladder or Bowel, + Sensory

108
Q

Brown-Sequard Syndrome

A

incomplete cord- usually from penetrating

109
Q

Brown-Sequard Syndrome s/s

A

Loss of Sensory on ones side and Loss of Movement on the opposite side
Positioning VERY Important
Ambulation likely
Hand function usually returns
Bowel and Bladder Function usually not affected

110
Q

Brown-Sequard Syndrome is usually from

A

Open Wounds i.e. GSW, Knife

111
Q

Posterior Cord Syndrome

A 
Least Frequent and Least Known
Preservation of Anterior Cord (Motor)
Loss of Sensation 
Ambulation usually preserved
Hand Function minimally impaired
Bowel and Bladder usually unimpaired
112
Q

Autonomic Dysreflexia

A

Uninhibited SNS response to Noxious Stimuli
T 6 and above
More common in 1st year post injury, but can occur any time
MEDICAL EMERGENCY

113
Q

S/S of Autonomic Dysreflexia

A 
Elevated B/P (20 mmHg above baseline)
Bradycardia, Bronchospasm
H/A (may be severe and pounding)
Flushing &amp; Diaphoresis (above level of level of injury), Anxiety, Apprehension
Chills without fever, Nasal Congestion
Visual Changes (blurred, tunnel)
114
Q

respiratory Nursing Assessment and Management of SCI

A

Establish pulmonary baseline so you know if there is any change

  • Rate & Depth
  • Pulmonary Toileting, Quad Coughing- taking your fist and putting it right under the diaphragm and push in and up each time they cough
  • Breathing Pattern
  • Mechanical Ventilation, Temporary or Permanent
  • Observe for fatigue
115
Q

CV Nursing Assessment and Management of SCI

A

Observe for loss of SNS Control
Monitor Extremities for Circulatory Stasis
S.S Autonomic Dysreflexia

116
Q

GI/GU Nursing Assessment and Management of SCI

A

Early Bowel and Bladder Program
Monitor VS, Temperature Elevation
Monitor Daily Labs, WBC, Albumin
Anorexia, Nausea, Vomiting

117
Q

skin/MSK Nursing Assessment and Management of SCI

A

Identify Level of function
Inspect Skin and Turn Q 2 or as needed
Contractures and Spasticity (Upper Motor)
Determine Caloric Intake, Dietary Consult
Monitor Labs, Calcium and Alk Phos

118
Q

psychosocial/emotional Nursing Assessment and Management of SCI

A 
Assess and Determine Support System
Encourage Independance
Address Sexuality Issues
Assess Environment (Cultural)
Assess Coping Mechanisms
Continuity of Care
Spiritual
Age Specific

Nursing school level 4 (6 decks)

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