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Critical Care Nursing > Nervous System Alterations > Flashcards

Nervous System Alterations Flashcards

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1
Q
  • Cells of the nervous system

- Transmission of impulses

A
  • Cells of the nervous system
    • Neurons
    • Neuroglia
  • Transmission of impulses
    • Dendrites
    • Axon
    • Synaptic knob
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2
Q

Cerebral circulation

A
  • Receives 15% to 20% of cardiac output
  • Carotid arteries (anterior circulation)
  • Vertebral arteries (posterior circulation)
  • Cerebral veins empty into venous sinuses
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3
Q
  • Brain metabolism
  • Cerebral blood flow
  • Blood-brain barrier
A
  • Brain metabolism
    • Cerebral glucose < 70 mg/dL = confusion
    • Cerebral glucose < 20 mg/dL = damage
  • Cerebral blood flow
    • Autoregulation
      • Changes in pressure
      • Changes in CO2: Alters cerebral blood volume with change in blood vessel size
  • Blood-brain barrier
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4
Q

NEUROLOGICAL ASSESSMENT

A
  • History of illness/injury
  • Baseline assessment
  • Mental status
  • Full Outline of Unresponsiveness (FOUR): Eye response, motor response, breathing pattern, brainstem reflexes
  • Glasgow Coma Scale
    • Eye opening
    • Speech
    • Motor response
  • Language and comprehension
    • Expressive dysphasia
    • Receptive dysphasia
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5
Q

CRANIAL NERVE FUNCTION

A
  • All cranial nerves should be assessed for baseline data

- Pupillary response

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6
Q

MOTOR FUNCTION

Evaluate all motor function at baseline assessment

A
  • Movement (symmetry)
  • Strength (symmetry) (out of a 5-point scale, 5 best response)
  • Muscle tone
  • Posture
  • Coordination
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7
Q

What are the reflexes?

A
  • Deep tendon
  • Superficial
  • Pathological
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8
Q

Sensory Function (5)

A
  • Sharp
  • Dull
  • Hot
  • Cold
  • Position sense
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9
Q

RESPIRATORY ASSESSMENT

A
  • Respiratory pattern
  • Respiratory rate
  • Assessed differently with mechanically ventilated patients
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10
Q

ONGOING ASSESSMENTS

A
  • Assessments are compared to baseline
  • Completed hourly
  • Alert to increased intracranial pressure
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11
Q

INCREASED INTRACRANIAL PRESSURE

A
  • Associated with many neurological problems - Components of ICP: brain tissue, blood, CSF fluid
  • Monro-Kellie doctrine
    • Increase in any one component requires a reduction in one or both of other components to sustain normal ICP
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12
Q

ICP: Increased brain volume

- Common cause

A
  • Common cause: cerebral edema
    1) Cytotoxic
  • Intracellular swelling of neurons
  • Hypoxia/hypo-osmolality
    2 Vasogenic
  • Increased capillary permeability
  • Tumors/meningitis
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13
Q

ICP: Increased blood volume

- What can it cause?

A
  • Loss of autoregulation
  • Decreased oxygenation
  • Hypercapnia (excess carbon dioxide)
  • Increased metabolic demands
  • Obstruction of venous outflow
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14
Q

ICP: Increased cerebral spinal fluid

A
  • Hydrocephalus (enlarged head)
    • Blockage of normal flow
    • Obstruction of normal reabsorption
    • Excess production of CSF fluid
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15
Q

INTRACRANIAL PRESSURE MONITORING

  • Indications
  • Purpose
  • Transducer system
A
  • Indications
  • GCS score 3 to 8
  • Purpose
  • Assess response to therapy
  • Augment neurological assessment
  • Transducer system
  • Fluid-filled
  • Normal saline with no preservatives
  • No pressurized flush system
  • Microchip
  • Fiberoptic catheter
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16
Q

CEREBRAL OXYGENATION MONITORING

  • Jugular Oxygenation Saturation
  • Partial Pressure of Brain Tissue Oxygen
A

1) Jugular Oxygen Saturation
- Monitored via a fiberoptic catheter
* Internal jugular vein/jugular venous bulb
* Normal value 60%-70%: Does not ensure adequate perfusion
* Values < 50% indicate ischemia
2) Partial Pressure of Brain Tissue Oxygen
- Monitor probe placed in brain white matter
- Goal: PbtO2 greater than 20 mm Hg

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17
Q

INCREASED INTRACRANIAL PRESSURE DIAGNOSTIC TESTS

1) Blood/Urine
2) Radiographic/Other

A

1) Blood/Urine
- ABGs
- CBC
- Coagulation profile
- Electrolytes
- Serum osmolality
- Urinalysis and osmolality
2) Radiographic/Other
- Computed tomography (CT) of the head
- Magnetic resonance imaging (MRI)
- Cerebral blood flow with transcranial Doppler
- Evoked potentials
- EEG
- Angiography

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18
Q

INCREASED INTRACRANIAL PRESSURE NURSING MANAGEMENT

  • Positioning
  • Suctioning
  • Assessment
A
  • Positioning
  • HOB elevation 30 degrees
  • Neutral head position
  • Turn side to side
  • Watch for return to baseline CPP
  • Suctioning
  • Only when necessary
  • Preoxygenate
  • Limit suction to 10 seconds
  • Assessment
  • Neurological exam
  • Vital signs
  • Cushing’s triad
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19
Q

INCREASED INTRACRANIAL PRESSURE MEDICAL MANAGEMENT

  • Adequate Oxygenation
  • Adequate hematocrit
  • Carbon Dioxide Management
A

Carbon Dioxide Management  PaCO2 35-45 mm Hg

 Avoid hyperventilation

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20
Q

INCREASED INTRACRANIAL PRESSURE MEDICAL MANAGEMENT

  • Adequate Oxygenation
  • Adequate hematocrit
  • Carbon Dioxide Management
A
  • Adequate Oxygenation
  • Goal: PaO2 > 80 mm Hg
  • Airway vigilance
  • Mechanical ventilation
  • Positive end-expiratory pressure (PEEP) – use with caution
  • Adequate hematocrit
  • Carbon Dioxide Management
  • PaCO2 35-45 mm Hg
  • Avoid hyperventilation
21
Q

INCREASED INTRACRANIAL PRESSURE MEDICAL MANAGEMENT

1) Diuretics
2) Fluid Administration

A

1) Diuretics
- Osmotic diuretics
* Reduce brain tissue volume
- Mannitol
- Hypertonic saline
- Loop diuretics
* Reduce brain tissue volume
* Decrease CSF formation

2) Fluid Administration
- Optimized fluid administration with isotonic solutions
- Strict intake/output
- Goal: serum osmolality less than 320 mOsm/L
- Colloids or blood products to restore volume

22
Q

INCREASED INTRACRANIAL PRESSURE MEDICAL MANAGEMENT

Blood Pressure

A
  • Goal: MAP 70-90 mm Hg
  • CPP: at least 70 mm Hg
  • Avoid hypertension: Increases cerebral blood volume
  • Nicardipine
  • Avoid hypotension
  • Ischemia
  • Vasopressors
23
Q

INCREASED INTRACRANIAL PRESSURE MEDICAL MANAGEMENT

- Metabolic Demands

A
  • Temperature control
  • Induced hypothermia
  • Goal: 34 – 35 C
  • Sedation
  • Benzodiazepines
  • Propofol
  • Analgesia
  • Seizure prophylaxis
  • Neuromuscular blockade
24
Q

TRAUMATIC BRAIN INJURY CLASSIFICATIONS

Primary

A
  • Direct injury to brain from impact
  • Coup injury
  • Contrecoup injury
  • Types
  • Concussion
  • Contusion
  • Penetrating injuries
  • Diffuse axonal injuries
  • Hematomas
  • Complications
  • Intracranial bleeding
25
Q

Traumatic Brain Injury Classifications

Secondary

A
  • Consequence of initial trauma
  • Inflammatory response
  • Release of cytokines
  • Vasogenic edema
26
Q

TRAUMATIC BRAIN INJURY MANAGEMENT

Nursing

A
  • Neurological assessment
  • Glasgow Coma Scale
  • Airway assessment
  • ICP monitoring
  • Hemodynamic monitoring
  • Interventions to control elevated ICP
  • Evaluation of diagnostic tests
27
Q

Traumatic Brain Injury Management

Medical/Surgical

A
  • Same as increased intracranial pressure
  • Several surgical procedures
  • Craniotomy
  • Bone fragments
  • Evacuation hematoma
  • Foreign body removal
    
28
Q

ACUTE STROKE – HEMORRHAGIC

A
  • Intraparenchymal hemorrhage
  • Bleeding into the brain
    • Uncontrolled hypertension
  • Ruptured cerebral aneurysm
  • Dilated cerebral artery that ruptures
  • Bleeding into subarachnoid space (SAH)
  • Arteriovenous malformation
  • Congenital abnormality forming an abnormal communication between arterial and venous systems in the brain
29
Q

ACUTE STROKE NURSING MANAGEMENT

A

1) Prevention
- Public education regarding signs/symptoms
2) Assessment
- History
- Time of onset of symptoms
- Neurological exam
* Mental status, cranial nerve function, motor strength, sensory function, neglect, coordination
3) NIH Stroke Scale
4) Airway, breathing, circulation

30
Q

ACUTE STROKE NURSING MANAGEMENT

Neurological assessment

A
  • Hemorrhagic (SAH) variations
  • Localized headache
  • Nuchal rigidity (impaired neck flexion)
  • Pain above and behind the eye
  • Photophobia
  • Restlessness/irritability
  • Worst headache
31
Q

ACUTE STROKE NURSING MANAGEMENT

Neurological assessment

A

1) Hemorrhagic (SAH) variations
- Localized headache
- Nuchal rigidity (impaired neck flexion)
- Pain above and behind the eye
- Photophobia
- Restlessness/irritability
- Worst headache

32
Q

ACUTE STROKE MEDICAL MANAGEMENT

Hemorrhagic Stroke

A
  • Goal: MAP < 130 mm Hg
  • Glycemic management
  • Diagnostic exams
    • CT evaluation
    • Laboratory tests
  • Medications
  • IV antihypertensives
  • Manage ICP with Osmotic diuretics
33
Q

Acute Stroke Medical Management

Ischemic Stroke

A
  • Goal: BP < 220 mm Hg; diastolic < 120 mm Hg
  • Glycemic management
  • Diagnostic exams
  • CT evaluation
  • Laboratory tests
  • Medications
  • rT-PA
34
Q

Seizures

Abnormal electrical discharge in the brain

A
  • Partial
  • Simple partial
  • Complex partial
  • Generalized seizures
35
Q

Status Epilepticus

A
  • Seizures in close proximity to each other
  • Lasting longer than 30 minutes
  • Two or more without full recovery
36
Q

STATUS EPILEPTICUS NURSING MANAGEMENT

A
  • Maintain airway and ventilation
  • Neurological assessment
  • Characteristics of seizure activity
  • Cardiac monitoring
  • Hypoglycemic management
  • Safety precautions
37
Q

STATUS EPILEPTICUS MEDICAL MANAGEMENT

-Medications

A
  • Benzodiazepines
  • Anticonvulsants
  • Dilantin
  • Cerebyx
  • Phenobarbital
38
Q

CNS INFECTIONS

-Bacterial Meningitis

A
  • Neurological emergency
  • Infection of the pia and arachnoid layers
  • CSF
  • Transmission
  • Blood
  • CSF contamination during surgical procedures
  • Skull
39
Q

CNS INFECTIONS Clinical manifestations

A
  • Headache
  • Fever
  • Vomiting
  • Rash
  • Nuchal rigidity
  • Kernig’s sign
  • Brudzinski’s sign
  • Diagnostics
  • Lumbar puncture—CSF
40
Q

MEDICAL/NURSING MANAGEMENT

A
  • Antibiotics
  • Corticosteroids
  • Droplet precautions
  • Private room
  • Dim light
  • Monitor for increased ICP
  • Seizure precautions
41
Q

SPINAL CORD INJURY (SCI)

A
  • Motor vehicle crashes (MVCs)
  • Falls
  • Gunshot wounds
  • Sports injuries
  • Diving accidents
42
Q

Spinal Cord Injury: Spinal Shock

A

Complete loss below level of injury

  • Motor
  • Sensory
  • Reflex activity
43
Q

Spinal Cord Injury: Neurogenic Shock

A
  • Disruption of autonomic pathways

- Temporary disruption of autonomic pathways below level of injury

44
Q

SCI LESIONS Types

A

1) Complete
2) Incomplete
- Anterior cord syndrome
- Central cord syndrome
- Brown-Séquard syndrome

45
Q

SPINAL CORD INJURY ASSESSMENT

A
  • Airway and ventilation
  • Paralysis of diaphragm and intercostal muscles will
    result in ineffective breathing patterns
  • C1 to C3: ventilator dependent
  • C4 to C5: may or may not need ventilator
  • Below C5: have intact diaphragmatic breathing
46
Q

SPINAL CORD INJURY ASSESSMENT

A
  • Neurological
  • Hemodynamic
  • Gastrointestinal tract
  • Autonomic dysfunction
  • Bowel or bladder dysfunction
  • Skin
  • Psychological
47
Q

SPINAL CORD INJURY NURSING MANAGEMENT

A

1) Airway management
- Assessment of respiratory function
- Optimize pulmonary function with Positioning
2) Cardiovascular stability
- Maintain spinal cord perfusion: MAP 85 to 90 mm Hg
3) DVT prophylaxis
4) Gastric decompression
5) Skin care
6) Elimination

48
Q

AUTONOMIC DYSREFLEXIA

A
  • Occurs T6 or above after resolution of spinal shock
  • Intense sympathetic response to stimuli
  • Kinked urinary catheter
  • Fecal impaction
  • Severe hypertension, headache, and bradycardia
  • Assess and remove the cause
49
Q

SPINAL CORD INJURY MEDICAL MANAGEMENT

A

1) Spinal cord stabilization
- Halo vest
- Surgical intervention (plates, rods, bone grafts)
2) Medication
- Glucocorticoids – high dose
- Vasopressors/fluids
- Proton pump inhibitors
- IV fluids

Critical Care Nursing (15 decks)

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