Neuro Assessment & Interventions part 2 Flashcards
What is a motor assessment generally?
When you assess movement, strength, and tone of the arm and legs.
What is the most important thing to look for when doing the motor function assessment?
The most important part is symmetry.
If the movements are asymmetrical, where are is the damage in the brain?
The damage will be on the opposite side of the brain that the deficit is of the limbs.
What does Decerebrate posture look like?
Arms are at the side and extended with the wrists pronated.
What does Decorticate posturing look like?
Arms are tucked into the core.
What does Decerebrate posture indicate?
Brain stem damage
What does Decorticate posture indicate?
Overstimulation or pain is causing muscles to contract
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?
Ask the family to step outside because the patient is being overstimulated.
What is the most important part of the neuro assessment?
LOC changes
T/F
A decrease in LOC is a disorder
False. LOC is a continuum from normal to coma. If this changes, it is a result of a pathology.
What are some pathologies that cause LOC changes?
Septic
UTI
dehydration
(just for an example - don’t memorize).
What are the characteristics of a coma?
Unconscious
Unresponsive
Inability to arouse
What are the characteristics of the Persistent Vegetative state?
No cognitive function but has sleep wake cycles still
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?
Locked-in Syndrome
What is the cause of Locked-in Syndrome?
A lesion affecting the pons of the brain
What medication can mimic Locked-in Syndrome?
Giving a paralytic without giving a sedative.
- socs or rocs
You aren’t sure about the patient heart sounds. And you doubt what you are hearing. What can you do?
Move the patient around, tap with it on the monitor.
What to assess when feeling the pulse?
Rate, rhythm, and quality of the pulse
How do we assess tissue perfusion?
Cap refill and temperature
When checking temperature, what are we assessing for?
Hypothermia or Hyperthermia && also if we induced it or if it was caused by an underlying cause
CPP equaltion
MAP - ICP
What does increased ICP related to fluid result in?
Increases odds of brain herniation into the brain stem (brain drop) and death.
How does the brain Autoregulation when there is increased ICP?
Autoregulation: The brain is able to change the diameter of the vessels to maintain the blood flow
What does decreased CO2 cause?
Vasoconstriction
What does a high co2 cause?
Vasodilation
How can we manipulate the cerebral blood flow to the brain with the ventilator?
We can control the CO2 levels on ventilator by keeping it between 35-45 (normocapnia).
What orders can we use to decrease ICP?
Hypertonic fluids - 3% , mannitol
Why do people will increased ICP have headaches?
Complain of headache due to increased pressure in the skull
Why do the pupils change in size and reaction for increased ICP?
Pupils change because of compression of the 3rd Cranial nerve.
What type of motor loss do you expect to see in a patient with increased ICP?
Unilateral/asymmetrical
What changes in the respiratory pattern do you expect for increased ICP?
Slowed or changed breathing rate
What pulse pressure changes occur in increased ICP?
A rise in pule pressure
What temperature changes do you expect with someone with increased ICP?
Loss of temperature control so - shivering, hot, shivering, hot.
What blood pressure changes are going to occur with increased ICP?
Systolic pressure will rise + a widening pulse pressure (systolic - diastolic).
What behavior symptoms occur with increased ICP?
Restlessness and anxiety
Why might there be seizures with increased ICP?
Due to the vessels being compressed, the oxygen can’t get to the brain.
What posturing changes are you looking for with increased ICP?
Decerebrate
Decorticate
What happens to the eyes with increased ICP?
Papilledema due to the optic nerve being swollen
What medications can be used during seizure precautions?
Keppra
Ativan
What LOC changes occur with increased ICP?
Decreased LOC
- use GCS to evaluate this
What heart rate do you expect with a patient with late signs of increased ICP?
They go from being tachycardic to being bradycardic because the autoregulation isn’t working anymore at this point
What breathing rate do you expect as a late sign of increased ICP?
Apnea due to trying regulate the Co2 levels
What major cluster of signs do we see in late increased ICP?
Cushings Triad
What is Cushings Triad?
Increased systolic blood pressure + widening pulse
Late onset of Bradycardia
Decrease respiratory rate/bradyapnea
What changes can be seen in regular and late increased ICP?
Posture changes
Pupil changes
Seizures
Papilledema
Symptoms of papilledema of the eye
Fleeting disturbances in vision
Headache
Vomiting
What causes cushing traid?
Increase in sympathetic outflow to the heart in order to try to compensate and increase arterial blood pressure and widening pulse
When will we see Cushing Triad?
Seen in terminal stages of acute head injury
How often do we do neuro checks?
Do neuro checks every hour or q15 if there are orders
T/F
Increase ICP is done so evenly in the skull
False. ICP is not evenly distributed
Why do we need to make sure our neuro assessments are thorough?
Because you have to know the “last known well” if something goes wrong.
Why should you pay attention to speech?
Some patients have slur but if you hear an acute slur, that is indicative of neuro issues.
Why do we need to check trends when evaluating vital signs for cushings traid?
Sometimes patients brady down at night
How far does the ICP monitor measure?
It measures only the local area
What side is the ICP monitor inserted in the head?
Opposite side of the injury because it takes a backwards photo
What does Pbt02 stand for?
Brain tissue oxygenation mmhg
What is the pbto2 of normal brain tissue?
Greater than 20 mmHG
What will the pbtO2 be if the brain is hypoxic?
Less than 20
What is the pbto2 if you have severe ischemia?
Less than 10
What is the normal for CPP?
70 - 100
What happens if your CPP is less than 50?
Permanent neurological damage
Normal range for PbtO2?
20 - 40 mmhg
Are CPP and CBF the same thing?
NO
What makes CBF different than CPP?
CBF tells us how much blood the vessels in the blood have received.
CPP is the amount of blood sent.
What two measurements do we need to be in agreement for brain death (when patient/family asks)?
CPP and CBF need to be in agreement
What can we do to decrease ICP?
Reduce CSF
Preserve cerebral metabolic functioning
Avoid increased ICP more
How can we reduce the volume of CSF?
Ventriculostomy/EVD
VP shunt
When placing a VP shunt, where does the CSF fluid go?
Fluid is shunted to the abdomen
What is a Ventriculostomy?
Tube that goes into the ventricles of the brain to monitor ICP and drain out cerebral spinal fluid.
How can we control the amount of CSF drained with a Ventriculolstomy?
Adjust the height of the fluid collection device
What fluids can we use to decrease fluid volume for increased ICP?
Use diuretics and hypertonic fluids
Where does the ICP monitor need to be aligned to?
The trachus or foramen of Monro
How do we make sure the cerebral metabolic function is adequate?
Focus on oxygenation and perfusion of the brain
Glucose levels
Watch ICP/CPP
What interventions can increase ICP that we want to avoid?
PRN suctioning
Turning or bathing
What positioning increases ICP?
Head flexion/extension or being off midline. Keep legs straight as well
- roll up a towel for their head
What maneuver increases ICP?
Valsalva’s Maneuver
- coughing, baring down
Your ICP drain hasn’t had any output. What do you as the nurse do?
Check for kinks and make sure the patient isn’t laying on it
Can we change the dressing site of a ICP drain?
No
Where is level 0 at?
The ear canal
What does a nurse need to check on the Ventriculostomy/EVD? (4)
Correct pressure settings
Make sure tubing is open so it can drain
Monitor the drainage
Monitor the dressing site
What can the nurse place on the door for a patient with EVD?
Sign that says not to move the patient
What is the difference between a lumbar puncture and a lumbar drain?
The puncture is used for testing. The drain is when it is hooked up to drain set up. They are not the same thing.
What is the leveling point of a Lumbar Drain?
There isn’t one! Trick question. It just uses gravity.
How will you know how much to drain with a lumbar drainage system?
There should be orders for a specific goal. Once you reach the goal, make sure to just go in and turn the valve off.
Your ICP rises. What does this mean for your CPP?
CPP falls.
- inverse relationship
If the ICP is increased, and this decreases your CPP, what will we manipulate to bring the CPP back up?
MAP - with medications
How can you make sure you have adequate vascular volume?
CVP readings
Urine output
Blood pressure
MAP
What do we use to manipulate the MAP?
Vasopressors
Fluids
CSF drains
Why will we sedate a patient with increased ICP?
List some meds
We sedate them because it decreases the workload and allows the brain to rest.
Fentanyl, Propafol, Opiods, Barbituates
What osmotic/hypertonic fluids will we use to maintain the CPP?
Mannitol, 3%
You are using a hypertonic agent to help drive CPP. What do you need to watch for?
Serum sodium levels q6hrs
What types of meds do we use to to increase the CPP?
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)
How does keeping a patient midline help increase CPP?
Being in the midline position decreases your ICP which will in return increase CPP.
What drainage system can be used to increase CPP?
Ventriculostomy/EVD since it decreases the ICP by pulling of spinal fluid and therefore increasing the CPP due to inverse relationship.
What system do we use as a temperature guide?
Licox catheter system
What is the normla brain tissue oxygenation pbto2?
20-40 mmhg
Associations of decrease brain pbtO2
Hypoxia
Increased ICP
Increased temp
Decreased CPP/MAP
How can we increase the pbto2 if it is low?
Drain the CSF
Increase CPP/MAP
Decrease temp (arctic sun wrap, bubble wrap).
Barbiturates
If a patient is intubated, why do we avoid high PIP and PEEP?
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
What pulse ox do we want for managing ICP?
above 94 %
Why will we have patients on anticonvulsant therapy?
Increase ICP causes seizures
Why do we want patients to be in Normothermia?
Decrease shivering and use of oxygen
Vasopressors we use for neuro?
Dopamine
Norepinephrine
Neosynephrine
Vasopressin
What dosage of dopamine do we use?
Could use high or low dose actually.
Why would we use a low renal dose of dopamine?
The vasodilation that occurs can help pull the fluid off with increased ICP - while still having a slight drive.
What rate will Neo or levo be at?
Lower rate
What rate will vasopressin be?
Not something we titrate
Do we have patient hyperventilate to manipulate the Co2?
Its seldom used. We just want to keep the Co2 within normal. No less than 32
What is the danger of low Co2?
Vasoconstriction which reduces perfusion
What should the HOB be at?
30 degrees to avoid restriction venous return
Why do we do early gut feeds for ICP?
To provide the hyper-metabolic needs of the brain
What ph level will lead to vasodilation?
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
