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2.0 Adult Nursing Exam 3 > Neuro Assessment & Interventions part 2 > Flashcards

Neuro Assessment & Interventions part 2 Flashcards

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1
Q

What is a motor assessment generally?

A

When you assess movement, strength, and tone of the arm and legs.

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2
Q

What is the most important thing to look for when doing the motor function assessment?

A

The most important part is symmetry.

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3
Q

If the movements are asymmetrical, where are is the damage in the brain?

A

The damage will be on the opposite side of the brain that the deficit is of the limbs.

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4
Q

What does Decerebrate posture look like?

A

Arms are at the side and extended with the wrists pronated.

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5
Q

What does Decorticate posturing look like?

A

Arms are tucked into the core.

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6
Q

What does Decerebrate posture indicate?

A

Brain stem damage

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7
Q

What does Decorticate posture indicate?

A

Overstimulation or pain is causing muscles to contract

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8
Q

You see your patient with a tucked in posture to the core. The family is in the room. What do you as the nurse do?

A

Ask the family to step outside because the patient is being overstimulated.

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9
Q

What is the most important part of the neuro assessment?

A

LOC changes

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10
Q

T/F

A decrease in LOC is a disorder

A

False. LOC is a continuum from normal to coma. If this changes, it is a result of a pathology.

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11
Q

What are some pathologies that cause LOC changes?

A

Septic

UTI

dehydration

(just for an example - don’t memorize).

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12
Q

What are the characteristics of a coma?

A

Unconscious

Unresponsive

Inability to arouse

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13
Q

What are the characteristics of the Persistent Vegetative state?

A

No cognitive function but has sleep wake cycles still

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14
Q

Your walk in. You ask your patient a question but they cannot respond or move their body. The only thing moving is their eyes.

What condition could this be?

A

Locked-in Syndrome

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15
Q

What is the cause of Locked-in Syndrome?

A

A lesion affecting the pons of the brain

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16
Q

What medication can mimic Locked-in Syndrome?

A

Giving a paralytic without giving a sedative.

  • socs or rocs
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17
Q

You aren’t sure about the patient heart sounds. And you doubt what you are hearing. What can you do?

A

Move the patient around, tap with it on the monitor.

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18
Q

What to assess when feeling the pulse?

A

Rate, rhythm, and quality of the pulse

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19
Q

How do we assess tissue perfusion?

A

Cap refill and temperature

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20
Q

When checking temperature, what are we assessing for?

A

Hypothermia or Hyperthermia && also if we induced it or if it was caused by an underlying cause

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21
Q

CPP equaltion

A

MAP - ICP

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22
Q

What does increased ICP related to fluid result in?

A

Increases odds of brain herniation into the brain stem (brain drop) and death.

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23
Q

How does the brain Autoregulation when there is increased ICP?

A

Autoregulation: The brain is able to change the diameter of the vessels to maintain the blood flow

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24
Q

What does decreased CO2 cause?

A

Vasoconstriction

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25
Q

What does a high co2 cause?

A

Vasodilation

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26
Q

How can we manipulate the cerebral blood flow to the brain with the ventilator?

A

We can control the CO2 levels on ventilator by keeping it between 35-45 (normocapnia).

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27
Q

What orders can we use to decrease ICP?

A

Hypertonic fluids - 3% , mannitol

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28
Q

Why do people will increased ICP have headaches?

A

Complain of headache due to increased pressure in the skull

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29
Q

Why do the pupils change in size and reaction for increased ICP?

A

Pupils change because of compression of the 3rd Cranial nerve.

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30
Q

What type of motor loss do you expect to see in a patient with increased ICP?

A

Unilateral/asymmetrical

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31
Q

What changes in the respiratory pattern do you expect for increased ICP?

A

Slowed or changed breathing rate

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32
Q

What pulse pressure changes occur in increased ICP?

A

A rise in pule pressure

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33
Q

What temperature changes do you expect with someone with increased ICP?

A

Loss of temperature control so - shivering, hot, shivering, hot.

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34
Q

What blood pressure changes are going to occur with increased ICP?

A

Systolic pressure will rise + a widening pulse pressure (systolic - diastolic).

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35
Q

What behavior symptoms occur with increased ICP?

A

Restlessness and anxiety

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36
Q

Why might there be seizures with increased ICP?

A

Due to the vessels being compressed, the oxygen can’t get to the brain.

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37
Q

What posturing changes are you looking for with increased ICP?

A

Decerebrate

Decorticate

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38
Q

What happens to the eyes with increased ICP?

A

Papilledema due to the optic nerve being swollen

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39
Q

What medications can be used during seizure precautions?

A

Keppra

Ativan

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40
Q

What LOC changes occur with increased ICP?

A

Decreased LOC

  • use GCS to evaluate this
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41
Q

What heart rate do you expect with a patient with late signs of increased ICP?

A

They go from being tachycardic to being bradycardic because the autoregulation isn’t working anymore at this point

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42
Q

What breathing rate do you expect as a late sign of increased ICP?

A

Apnea due to trying regulate the Co2 levels

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43
Q

What major cluster of signs do we see in late increased ICP?

A

Cushings Triad

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44
Q

What is Cushings Triad?

A

Increased systolic blood pressure + widening pulse

Late onset of Bradycardia

Decrease respiratory rate/bradyapnea

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45
Q

What changes can be seen in regular and late increased ICP?

A

Posture changes

Pupil changes

Seizures

Papilledema

46
Q

Symptoms of papilledema of the eye

A

Fleeting disturbances in vision

Headache

Vomiting

47
Q

What causes cushing traid?

A

Increase in sympathetic outflow to the heart in order to try to compensate and increase arterial blood pressure and widening pulse

48
Q

When will we see Cushing Triad?

A

Seen in terminal stages of acute head injury

49
Q

How often do we do neuro checks?

A

Do neuro checks every hour or q15 if there are orders

50
Q

T/F

Increase ICP is done so evenly in the skull

A

False. ICP is not evenly distributed

51
Q

Why do we need to make sure our neuro assessments are thorough?

A

Because you have to know the “last known well” if something goes wrong.

52
Q

Why should you pay attention to speech?

A

Some patients have slur but if you hear an acute slur, that is indicative of neuro issues.

53
Q

Why do we need to check trends when evaluating vital signs for cushings traid?

A

Sometimes patients brady down at night

54
Q

How far does the ICP monitor measure?

A

It measures only the local area

55
Q

What side is the ICP monitor inserted in the head?

A

Opposite side of the injury because it takes a backwards photo

56
Q

What does Pbt02 stand for?

A

Brain tissue oxygenation mmhg

57
Q

What is the pbto2 of normal brain tissue?

A

Greater than 20 mmHG

58
Q

What will the pbtO2 be if the brain is hypoxic?

A

Less than 20

59
Q

What is the pbto2 if you have severe ischemia?

A

Less than 10

60
Q

What is the normal for CPP?

A

70 - 100

61
Q

What happens if your CPP is less than 50?

A

Permanent neurological damage

62
Q

Normal range for PbtO2?

A

20 - 40 mmhg

63
Q

Are CPP and CBF the same thing?

A

NO

64
Q

What makes CBF different than CPP?

A

CBF tells us how much blood the vessels in the blood have received.

CPP is the amount of blood sent.

65
Q

What two measurements do we need to be in agreement for brain death (when patient/family asks)?

A

CPP and CBF need to be in agreement

66
Q

What can we do to decrease ICP?

A

Reduce CSF

Preserve cerebral metabolic functioning

Avoid increased ICP more

67
Q

How can we reduce the volume of CSF?

A

Ventriculostomy/EVD

VP shunt

68
Q

When placing a VP shunt, where does the CSF fluid go?

A

Fluid is shunted to the abdomen

69
Q

What is a Ventriculostomy?

A

Tube that goes into the ventricles of the brain to monitor ICP and drain out cerebral spinal fluid.

70
Q

How can we control the amount of CSF drained with a Ventriculolstomy?

A

Adjust the height of the fluid collection device

71
Q

What fluids can we use to decrease fluid volume for increased ICP?

A

Use diuretics and hypertonic fluids

72
Q

Where does the ICP monitor need to be aligned to?

A

The trachus or foramen of Monro

73
Q

How do we make sure the cerebral metabolic function is adequate?

A

Focus on oxygenation and perfusion of the brain

Glucose levels

Watch ICP/CPP

74
Q

What interventions can increase ICP that we want to avoid?

A

PRN suctioning

Turning or bathing

75
Q

What positioning increases ICP?

A

Head flexion/extension or being off midline. Keep legs straight as well

  • roll up a towel for their head
76
Q

What maneuver increases ICP?

A

Valsalva’s Maneuver

  • coughing, baring down
77
Q

Your ICP drain hasn’t had any output. What do you as the nurse do?

A

Check for kinks and make sure the patient isn’t laying on it

78
Q

Can we change the dressing site of a ICP drain?

A

No

79
Q

Where is level 0 at?

A

The ear canal

80
Q

What does a nurse need to check on the Ventriculostomy/EVD? (4)

A

Correct pressure settings

Make sure tubing is open so it can drain

Monitor the drainage

Monitor the dressing site

81
Q

What can the nurse place on the door for a patient with EVD?

A

Sign that says not to move the patient

82
Q

What is the difference between a lumbar puncture and a lumbar drain?

A

The puncture is used for testing. The drain is when it is hooked up to drain set up. They are not the same thing.

83
Q

What is the leveling point of a Lumbar Drain?

A

There isn’t one! Trick question. It just uses gravity.

84
Q

How will you know how much to drain with a lumbar drainage system?

A

There should be orders for a specific goal. Once you reach the goal, make sure to just go in and turn the valve off.

85
Q

Your ICP rises. What does this mean for your CPP?

A

CPP falls.

  • inverse relationship
86
Q

If the ICP is increased, and this decreases your CPP, what will we manipulate to bring the CPP back up?

A

MAP - with medications

87
Q

How can you make sure you have adequate vascular volume?

A

CVP readings

Urine output

Blood pressure

MAP

88
Q

What do we use to manipulate the MAP?

A

Vasopressors

Fluids

CSF drains

89
Q

Why will we sedate a patient with increased ICP?

List some meds

A

We sedate them because it decreases the workload and allows the brain to rest.

Fentanyl, Propafol, Opiods, Barbituates

90
Q

What osmotic/hypertonic fluids will we use to maintain the CPP?

A

Mannitol, 3%

91
Q

You are using a hypertonic agent to help drive CPP. What do you need to watch for?

A

Serum sodium levels q6hrs

92
Q

What types of meds do we use to to increase the CPP?

A

Paralytic - to keep patient still

Pressors - to drive the MAP

Sedatives - to allow healing and workload

Fluids - to take off fluid to decrease ICP (which inadvertently increase CPP)

93
Q

How does keeping a patient midline help increase CPP?

A

Being in the midline position decreases your ICP which will in return increase CPP.

94
Q

What drainage system can be used to increase CPP?

A

Ventriculostomy/EVD since it decreases the ICP by pulling of spinal fluid and therefore increasing the CPP due to inverse relationship.

95
Q

What system do we use as a temperature guide?

A

Licox catheter system

96
Q

What is the normla brain tissue oxygenation pbto2?

A

20-40 mmhg

97
Q

Associations of decrease brain pbtO2

A

Hypoxia

Increased ICP

Increased temp

Decreased CPP/MAP

98
Q

How can we increase the pbto2 if it is low?

A

Drain the CSF

Increase CPP/MAP

Decrease temp (arctic sun wrap, bubble wrap).

Barbiturates

99
Q

If a patient is intubated, why do we avoid high PIP and PEEP?

A

We don’t want them be dependent on vent and we don’t want the vent to interfere with cardiac output.

  • 5 to 8 hopefully peep
100
Q

What pulse ox do we want for managing ICP?

A

above 94 %

101
Q

Why will we have patients on anticonvulsant therapy?

A

Increase ICP causes seizures

102
Q

Why do we want patients to be in Normothermia?

A

Decrease shivering and use of oxygen

103
Q

Vasopressors we use for neuro?

A

Dopamine

Norepinephrine

Neosynephrine

Vasopressin

104
Q

What dosage of dopamine do we use?

A

Could use high or low dose actually.

105
Q

Why would we use a low renal dose of dopamine?

A

The vasodilation that occurs can help pull the fluid off with increased ICP - while still having a slight drive.

106
Q

What rate will Neo or levo be at?

A

Lower rate

107
Q

What rate will vasopressin be?

A

Not something we titrate

108
Q

Do we have patient hyperventilate to manipulate the Co2?

A

Its seldom used. We just want to keep the Co2 within normal. No less than 32

109
Q

What is the danger of low Co2?

A

Vasoconstriction which reduces perfusion

110
Q

What should the HOB be at?

A

30 degrees to avoid restriction venous return

111
Q

Why do we do early gut feeds for ICP?

A

To provide the hyper-metabolic needs of the brain

112
Q

What ph level will lead to vasodilation?

A

Low ph or acidosis means lots of Co2. Lots of co2 leads to vasodilatoin — which can cause hypoxia.

  • check abg
  • tbh i dont understand this

2.0 Adult Nursing Exam 3 (8 decks)

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