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Critical Care Nursing > Nervous System Alterations > Flashcards

Nervous System Alterations Flashcards

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
Traumatic Brain Injury Classifications | Secondary
- Consequence of initial trauma * Inflammatory response * Release of cytokines - Vasogenic edema
26
TRAUMATIC BRAIN INJURY MANAGEMENT | Nursing
- Neurological assessment * Glasgow Coma Scale - Airway assessment - ICP monitoring - Hemodynamic monitoring - Interventions to control elevated ICP - Evaluation of diagnostic tests
27
Traumatic Brain Injury Management | Medical/Surgical
- Same as increased intracranial pressure - Several surgical procedures * Craniotomy - Bone fragments - Evacuation hematoma - Foreign body removal 
28
ACUTE STROKE – HEMORRHAGIC
- 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
ACUTE STROKE NURSING MANAGEMENT
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
ACUTE STROKE NURSING MANAGEMENT | Neurological assessment
- Hemorrhagic (SAH) variations - Localized headache - Nuchal rigidity (impaired neck flexion) - Pain above and behind the eye - Photophobia - Restlessness/irritability - Worst headache
31
ACUTE STROKE NURSING MANAGEMENT | Neurological assessment
1) Hemorrhagic (SAH) variations - Localized headache - Nuchal rigidity (impaired neck flexion) - Pain above and behind the eye - Photophobia - Restlessness/irritability - Worst headache
32
ACUTE STROKE MEDICAL MANAGEMENT | Hemorrhagic Stroke
- Goal: MAP < 130 mm Hg - Glycemic management - Diagnostic exams * CT evaluation * Laboratory tests - Medications * IV antihypertensives * Manage ICP with Osmotic diuretics
33
Acute Stroke Medical Management | Ischemic Stroke
- Goal: BP < 220 mm Hg; diastolic < 120 mm Hg - Glycemic management - Diagnostic exams * CT evaluation * Laboratory tests - Medications * rT-PA
34
Seizures | Abnormal electrical discharge in the brain
- Partial - Simple partial - Complex partial - Generalized seizures
35
Status Epilepticus
- Seizures in close proximity to each other - Lasting longer than 30 minutes - Two or more without full recovery
36
STATUS EPILEPTICUS NURSING MANAGEMENT
- Maintain airway and ventilation - Neurological assessment - Characteristics of seizure activity - Cardiac monitoring - Hypoglycemic management - Safety precautions
37
STATUS EPILEPTICUS MEDICAL MANAGEMENT | -Medications
- Benzodiazepines - Anticonvulsants * Dilantin * Cerebyx - Phenobarbital
38
CNS INFECTIONS | -Bacterial Meningitis
- Neurological emergency - Infection of the pia and arachnoid layers - CSF - Transmission * Blood * CSF contamination during surgical procedures * Skull
39
CNS INFECTIONS Clinical manifestations
- Headache - Fever - Vomiting - Rash - Nuchal rigidity * Kernig’s sign * Brudzinski’s sign - Diagnostics * Lumbar puncture—CSF
40
MEDICAL/NURSING MANAGEMENT
- Antibiotics - Corticosteroids - Droplet precautions - Private room - Dim light - Monitor for increased ICP - Seizure precautions
41
SPINAL CORD INJURY (SCI)
- Motor vehicle crashes (MVCs) - Falls - Gunshot wounds - Sports injuries - Diving accidents
42
Spinal Cord Injury: Spinal Shock
Complete loss below level of injury - Motor - Sensory - Reflex activity
43
Spinal Cord Injury: Neurogenic Shock
- Disruption of autonomic pathways | - Temporary disruption of autonomic pathways below level of injury
44
SCI LESIONS Types
1) Complete 2) Incomplete - Anterior cord syndrome - Central cord syndrome - Brown-Séquard syndrome
45
SPINAL CORD INJURY ASSESSMENT
- 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
SPINAL CORD INJURY ASSESSMENT
- Neurological - Hemodynamic - Gastrointestinal tract - Autonomic dysfunction - Bowel or bladder dysfunction - Skin - Psychological
47
SPINAL CORD INJURY NURSING MANAGEMENT
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
AUTONOMIC DYSREFLEXIA
- 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
SPINAL CORD INJURY MEDICAL MANAGEMENT
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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