Neuro Flashcards
What are key elements of a neuro assessment?
History
motor and reflexes
mental status
memory
language
sensory function
cranial nerves
what 3 things are involved in GCS scale?
Eyes
Motor/movement
Verbal response
What is the normal ICP?
5-10 mmHg
What parameters indicate increased ICP?
if pressure is 20 mm Hg or greater
What can ICP lead to?
Herniation
What is herniation? When does it happen?
shifting of brain tissue from an area of high pressure to one of lower pressure
“brain tries to exit towards brain stem”
WHEN ICP IS SUSTAINED AT GREATER THAN 20 FOR 5 MINUTES OR LONGER
what is the normal range for cerebral perfusion pressure?
60-100 mmHg
How do you calculate cerebral perfusion pressure?
MAP - ICP
How do you calculate MAP?
SBP + 2(DBP) / 3
what are 3 causes of ICP?
Increased brain and blood volume
and cerebrospinal fluid
What is increased brain volume?
cerebral edema, increase in water content in brain tissue
What are the indications for ICP monitoring?
GCS of 3-8
What is the purpose of ICP monitoring?
assess response to therapy
augment neurological assessment
How to use the transducer system?
flush pressure tubing with sterile NS without preservatives
never use pressurized fluid
What is a ventriculostomy?
ventricle catheter system that connects to a drainage bag to drain CSF or blood
what is cerebral oxygenation monitoring?
fiberoptic catheter placed thru internal jugular vein to monitor oxygen saturation
what is the normal range for cerebral oxygenation?
60%-70%
What are the early signs of ICP?
Headache
N/V
Confusion (mental status change)
Visual changes (blurred/double vision)
Cheyne stokes respiration
What are the late signs of ICP?
Cushing’s triad
pupils fixed and dilated
posturing (decorticate/decerebrate)
coma
what does cushing’s triad mean and what are the signs?
PRIMARY signs that indicate increased ICP
widening pulse pressure
bradycardia
irregular breathing pattern
Nursing management of ICP
ELEVATE HOB 30 degrees
prevent hyperextension, flexion, or rotation of head
limit suctioning to 10-15 seconds HYPEROXYGENATE
prevent stress and emotions
prevent Valsalva maneuver
prevent constipation
prevent sudden arousal from sleep
keep lights low
antiseizure meds
treat fevers
What is the medical management of ICP?
oxygenation
CO2 management
diuretics
BP management
reduce metabolic demands
fluids (3% solution)
How do you reduce metabolic demands?
control temperature
sedation
prevent seizures
What medications are used to treat ICP?
Mannitol
diuretics
BP medications
seizure medications
What does Mannitol do?
pulls water from brain interstitium
What are the 3 types of hematomas?
epidural
subdural
intracerebral
Mild symptoms of TBI
loss of consciousness for seconds
headache
confusion
dizziness
blurred vision
ringing in ears
N/V
tiredness
sensitivity to light or sound
Moderate/severe symptoms of TBI
loss of consciousness for minutes to hours
persistent headache
seizures
loss of vision
difficulty understanding/communicating
balance/coordination challenges
Priorities for TBI
Airway patency
Control any bleeding
GCS monitoring
ICP monitoring
Level of consciousness
What can cause a spinal cord injury?
hyperflexion
hyperextension
excessive rotation
penetrating trauma
Clinical manifestations of neurogenic shock
profound bradycardia with hypotension
warm, dry and flushed skin
hypothermia
SCI involves the loss of…
Motor function
sensory function
Reflexes
Control of elimination
What is it called when there is an injury in cervical region of spine?
Quadriplegia
What is it called when there is an injury in thoracic region of spine?
Paraplegia
Nursing priorities for SCI
Ventilation/airway
Tissue perfusion
I&O
Neuro status
Mobility
Sensation
Bowl/bladder function
GI function
Skin integrity
sexual function
What is autonomic dysreflexia?
Life threatening condition where body overreacts to a noxious stimulus leading to dangerously high BP
signal from brain can’t get to site
Causes of autonomic dysreflexia
bladder distension
kinked catheter
bowl impaction
pressure injury
Expected findings for autonomic dysreflexia
Severe HTN
bradycardia
flushing
Sudden severe headache
pallor
blurred vision
restlessness
nausea
goosebumps
Nursing interventions for autonomic dysreflexia
Elevate HOB
loosen tight clothing
identify and remove trigger
administer BP meds
What is stuporous?
does not obey commands
difficult to arouse
Normal pupil size
1.5-6 mm
What is autoregulation?
brains ability to maintain consistent cerebral blood flow despite changes in systemic blood pressure or ICP
What is important to remember when a patient with suspected ICP is getting a CT?
do not use contrast
What some ICP diagnostic tests?
Imaging
ABGs
Coagulation profile
Urinalysis
serum osmolality
electrolytes
EEG
