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NSG 478 > Neuro day 2 > Flashcards

Neuro day 2 Flashcards

1
Q

Surgery: Burr Holes

A
  • Hole drilled in the skull
  • Used to assess presence of brain swelling, or removal of a hematoma or abscess, making a bone flap, shunting procedure or placement of a drain
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2
Q

Surgery: Decompressive craniectomy

A
  • For refractory brain swelling
  • Removal of part of skull so the brain can expand
  • Complications include, infection and potential for brain injury because the brain is largely unprotected
  • Bone flap is replaced once the brain swelling is resolved
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3
Q

Surgery:Craniotomy

A
  • Opening skull to access brain
  • Skull cut to crete a bone flap, bone flap temp removed to access brain
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4
Q

Surgery: Cranioplasty

A

Removal of cranial defect with autologous bone, plastic or metal plate

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5
Q

Supratentorial Craniotomy

A

Craniotomy above the tentorium
* Positioning post op:
* Avoid head rotation
* Pt on back or side, avoid surgical side down if there was a large lesion removed
* 1 Pillow
* HOB 30 degrees

Turn every 2 hours with skin care

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6
Q

Infratentorial craniotomy

A

Craniotomy by the Posterior fossa
* Pt positioning post op
* Pt kept flat on one side, off the back
* Small firm pillow used to keep neck neutral
* Turn body as an entire unit (Log roll), to avoid strain on incision
* Can elevate the bed slowly as tolerated

Turn every 2 hours with skin care

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7
Q

Transsphenoidal Craniotomy

A
  • Through the mouth and nasal sinuses to reach the nasal sinus
  • Used to resect tumors, usually at the base of the skull
  • Approach allows direct access to sella turcica
  • Minimal risk of trauma or hemorrhage
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8
Q

Surgery: Awake Craniotomy

A
  • Used for cortical mapping (Poking area of the brain and seeing if the patient is affected) used to determine language and sensorimotor function when resecting brain tissue/tumor
  • Pt is put to sleep while skull is opened and then woken up to map, after mapping the patient is put to sleep again
  • Area of the brain is stimulated with a probe and then assess patient response
  • Sensorimotor mapping
    • can see abnormal involuntary movements of face, arm and leg
    • Pt asked to report abnormal sensations such as numbness/ tingling
  • Language mapping: Pt is asked to count numbers, name objects ect. used to determine aphasia
  • Visual mapping: Patient reports any visual phenomena, field cut, abnormal vision
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9
Q

Surgery: Intraoperative MRI

A
  • Guides the brain resection in real time
  • Able to identify residual tumor after tumor resected to guide further surgery
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10
Q

Tentorium

A
  • An extension of the dura mater that separates the cerebellum from inferior cerebrum and occipital lobes
  • Essentially its the line between the cerebrum and cerebellum
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11
Q

Supratentorial and infratentorial surgery: Medications

A
  • Anticonvulsant (Phenytoin, Levetiracetam, fosphenytoin)
  • Corticosteroids (Dexamethasone), only if pt has a tumor
  • Diuretics: Mannitol, Furosemide (fluid retention)
  • Antibiotics, on call or to or
  • Benzo, anxiety
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12
Q

Supratentorial and infratentorial surgery: Nursing actions Preop

A
  • Neuro assessment for baseline to compare post op
  • Pt shower and wash hair before surgery
  • Hair shaved with electric clippers
  • Foley cath placed in the OR
  • Art line placed in OR
  • Establish communications alternatives prior to surgery (picture cars, writing board)
  • Reassurance and support: What to expect post op (Dressing, ICP monitor, swelling, bruising, intubated)
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13
Q

Supratentorial and infratentorial surgery Post op: Reducing cerebral edema

A
  • Mannitol
  • Dexamethasone IV, change to oral asap, taper dose 5-7 days, may need extended taper
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14
Q

Supratentorial and infratentorial surgery: Post op, Relieve pain and prevent seizures

A
  • Acetaminophen for temp and mild pain
  • Opiate for postop pain if needed
  • Anticonvulsant prophylactic following supratentorial craniotomy, Increased risk for seizure
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15
Q

Supratentorial and infratentorial surgery: Post op mgmt

A
  • Reduce cerebral edema
  • Relieve pain and prevent seizures
  • Monitor ICP
  • Monitor for infection
  • Neuro checks
  • Vital sings
  • Resp function
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16
Q

Post op mgmt, cranial surgery: Neuro checks

A
  • Frequently, initially 15-60 min to detect increased ICP, edema, bleeding
  • Maintain cerebral perfusion (CPP: 60-70)
  • Monitor for hypoxia, hypercarbia
  • ETT until pt starts to awaken, has spontaneous respiration
  • Edema peaks 24-36 hours postop, monitor for decreased LOC
  • Proper positioning: based on type of surgery
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17
Q

Post op mgmt, cranial surgery: Monitor vitals

A
  • Document fluctuations and signs of increased ICP
  • HR, RR, SBP
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18
Q

Post op mgmt, cranial surgery: Resp function

A
  • Avoid hypoxia which cna increase cerebral ischemia
  • ABG, Rate and pattern
  • Risk of impaired gas exchange, atelectasis and pul function
  • Reposition every 2 hours to mobilize secretions and prevent stasis
  • Suction if needed, cautiously and short periods (Can increase ICP)
  • Humidity in O2 to thin secretions
  • Once alert, deep breathing, yawning , sighing, incentive spirometer, coughing , chest PT
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19
Q

Post op mgmt, cranial surgery: Monitor Temp

A
  • May be hypothermic initially after surgery, slowly rewarm avoid shivering (Increases ICP)
  • Assess for hyperthermia and treat fever (remove blankets, place ice packs, antipyretics)
  • Aseptic technique if handling intraventricular drainage device, central lines, art line
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20
Q

Post op mgmt, cranial surgery: Check surgical dressing

A
  • Surgeon always does the first dressing change
  • Check for bleeding or CSF drainage
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21
Q

Post op mgmt, cranial surgery: Sensory deprivation

A
  • Periorbital edema from surgery, blood drains into the orbits, swells eyes shut
  • Elevate HOB unless contraindicated
  • Apply cold compress
  • Announce when you enter the room to avoid startling the pt
  • Extubate Asap
  • Bulky head dressings can affect hearing, blocking hearing
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22
Q

Post op monitoring of complications, skull surgery: Increased ICP and bleeding

A
  • Hematoma, extradural, subdural, intracerebral
  • pt does not wake up
  • New post op neuro deficits (Dilated pupils, restless, confusion)
  • Return to OR for evacuation of clot
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23
Q

Post op monitoring of complications, skull surgery: Infection

A
  • CHeck surgical site for redness, drainage, tenderness, bulging, seperation, foul odor, pus
  • Aseptic technique with all lines, catheters, dressing changes per protocol
  • Reinforce dressing until surgeon assesses and or removes
  • Cultures if needed
  • Antibiotics
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24
Q

Post op monitoring of complications, skull surgery: CSF leak

A
  • Monitor for clear thin drainage from suboccipital incision (Infratentorial surgery is more common)
  • Pt cant cough blow nose or sneeze
  • Risk for meningitis
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25
Q

Post op monitoring of complications, skull surgery: Monitor for seizure activity

A

Prevention is best treatment and it is essential to avoid cerebral edema, hypoxia

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26
Q

Post op monitoring of complications, skull surgery: monitor fluids and lytes

A
  • Serum and urine electrolytes, BUN, creatinine, glucose
  • Daily weight strict I+O
  • Fluid restriction if possible
  • NPO then ice chips and advance as tolerated
  • Monitor for N+V, (Vomiting increases ICP)
  • Monitor for hyperglycemia, especially if on corticosteroids, fingersticks
  • Gastric ulcer prophylaxis: PPI or H2
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27
Q

Post op teaching and discharge planning post craniotomy

A
  • Meds: Especially anti seizure meds, if you suddenly stop taking them you can have a rebound seizure
  • Showering: Discression per surgeon, no baths or submerging in water generally especially in lakes or rivers
  • Protective helmet; if skull defect
  • Post hospital care depending on diagnosis and deficits: Home care vs rehab vs long term care
  • Case mgmt; social work hospice oncology referral, radiation referral
  • Pt/OT: weakness mobility self care deficits
  • Speach therapy
  • Cognitive therapy
  • Psych eval
28
Q

Complications of transsphenoidal surgery

A
  • Transient DI
  • CSF leakage
  • Post Op meningitis
  • Pneumocephalus
  • SIADH
  • Sinusitis
  • Visual changes (bilateral field cuts, diplopia due to closeness of optic chiasm)

HIgh risk of complications due to puncture of dura mater

29
Q

Preop Transsphenoidal surgery:

A
  • Endocrine labs, ENT eval, imaging , fundoscopic exam and visual fields (Baseline) nasopharyngeal cultures, contraindication if sinus infection
  • Corticosteroids before and after surgery especially if pituitary is removed
  • ACTH no longer secreted, can develop adrenal insufficiency
  • Antibio can be given or not
30
Q

Preop Transsphenoidal surgery: Nursing actions

A
  • Teach, deep breathing and incentive spirometer
  • Teach: Need to avoid coughing, blowing nose, sucking through a straw or sneezing (All can increase ICP
31
Q

Post-op Transsphenoidal surgery:

A
  • Surgical approach disrupts the oral and nasal mucous membranes
  • Goal: Prevent infection and promote healing
  • Nasal packing: During initial post op period, its uncomfy and anxiety inducing
  • CSF leak: different methods available to close surgical defect and minimize a leak
    • Sella floor filled with gel foam pase, dura replaced, mucosal flaps placed over dura and fixed with surgical cellulose and fibrin glue
    • May have fat packing or tissue graft into sella to prevent CSF leak
  • Antibiotics until packing is removed
  • COrticosteroids for swelling
  • Analgesics, for pain
  • Foley cath; strict I+O
  • Monitor and treat DI or SIADH, super common after
32
Q

Transsphenoidal Surgery: Nursing actions

A
  • Vitals, hemodynamics and cardiac and vent
  • Visual acuity and visual fields assessed frequently, (Optic chiasm), if decreasing possible hematoma in sella
  • HOB raised to decrease pressure in brain and promote normal drainage (Avoid straining, use stool softeners), increases in ICP is bad, (Promote drainage and prevent leak)
  • I+O, daily weights
  • FE balance, monitor for DI
  • Advance diet as tolerated
  • Nasal packing, check for blood or CSF
    • Oral care, thirst dry mouth, mouth breathing
    • No teeth brushing until incision is removed
    • Warm saline mouth rinses
    • Cool mist humidifier
    • Lubricant to lips Clean around the nose with prescribed solution after packing is removed
33
Q

Transsphenoidal surgery, Discharge instructions

A
  • Humidifier
  • HOB 30 degrees 2wks
  • No nose blowing and avoid sneezing
  • Call for S+S infection or fever
34
Q

Syndrome of inappropriate Anti diuretic hormone (SIADH)

A
  • Water retention
  • Hyponatremias as a result of hypervolemia
  • Low serum osmolality
35
Q

SIADH mgmt

A
  • Fluid restriction
  • Replace lytes
  • Self limited
  • Conivaptan (caprisol), inhibits adh, want to avoid critical levels of this however
36
Q

Diabetes Insipidus (DI)

A
  • Excessive Urinary output
  • Elevated serum osmolality (High is dry)
  • Decreased urine osmolarity (So much fluid its dilute and clear)
  • Hypernatremia (Dehydration)
  • Low urine specific gravity
37
Q

DI mgmt

A
  • Replace fluids to compensate for UOP
  • Monitor K level (Can be low)
  • DDAVP (synthetic adh)
38
Q

3% hypertonic Saline

A
  • Hyperosmolar agent used for severe hyponatremia due to cerebral edema
  • Can cause irritation to vessel walls, give centrally if possible
  • Use largest peripheral vein with good flow, peripherally upper extremity if possible
  • 20-24 gauge to avoid trauma to vein
  • Monitor for redness, swelling , tenderness, extravasation
  • Monitor for pulmonary edema, neuro changes, strict I+O
  • Goal is to SLOWLY increase serum sodium by 5 mmol/L to acutely decrease brain swelling and reverse neuro symptoms
39
Q

DDAVP, Vasopressin

A
  • Used to reduce renal excretion of water in DI
  • Given IV, oral , nasal
  • Acts on distal tubule and collecting ducts in the kidney
  • Side Effects are hyponatremia (Seizure, confusion, HA) arrhythmias, fluid retention, rapid weight gain
40
Q

Conivaptan (vaprisol)

A
  • ADH inhibitor (Makes you pee)
  • Used to treat hyponatremia caused by SIADH (FVE)
  • Works at renal collecting ducts causing excretion of free water (Increased up, decreased urine osm)
  • Loading dose day 1 then continuous infusion for up to 4 days
  • Also used in CHF
  • Side effects; hypotension, thirst
41
Q

Seizure:

A

Abrupt uncontrolled burst of electrical activity in the brain
* Many neurons firing at the same time, faster than normal
* Can cause involuntary movements, sensations, emotions and behaviors
* May have loss of awareness due to abnormally firing neurons

42
Q

Epilepsy

A
  • Chronic recurrent abnormal brain activity
  • Has multiple different causes and types of seizures
  • Diagnosed when person has 2 or more unprovoked seizures separated by at least 24 hours
43
Q

Provoked seizures

A
  • Caused by a specific precipitating factor
  • Fever, CNS infections, TBI, fluctuations in blood glucose or lytes
44
Q

Risk factors for seizures

A
  • Genetic predisposition–absence seizures common in children, tend to occur in families; SCN1A gene mutation (affects sodium ion channels)
  • Acute febrile state–usually children under 2 years (systemic infection)
  • TBI—early or late onset
  • Cerebral edema—especially if acute, risk decreases once edema resolved
  • Abrupt cessation of anti-epileptic drugs (AEDs)—seizure threshold is low and have rebound seizures; AEDs MUST be tapered
  • Infection—intracranial infection with increased ICP (meningitis, encephalitis)
  • Metabolic disorder—hypoglycemia, hyponatremia
  • Toxins—pesticides, carbon monoxide poisoning, lead poisoning
  • Stroke—within first 24 hours due to increased ICP
  • Heart disease—common cause of new onset seizures in older adults
  • Brain Tumor– due to increased bulk of tumor and increased volume in cranial vault. If associated with temporal lobe, increased risk.
  • Hypoxia—decreased O2 to brain can lead to seizures
  • Acute substance withdrawal or alcoholism
  • Fluid and Electrolyte imbalances—abnormal level of nutrients for neuronal function, hypervolemic state (decreased sodium)
45
Q

Triggers for seizures

A
  • Excessive fatigue, sleep deprivation
  • Increased physical activity and dehydration
  • Stress
  • Hormonal changes/ menstrual cycle
  • Hyperventilation
  • Acute alcohol ingestion or withdrawal
  • Excessive caffeine intake
  • Flashing lights
  • Substances: coke and other drugs
46
Q

Generalized Seizures:

A
  • Involves both hemispheres
  • May begin with an aura, Smell visual, hearing, emotion
  • Types
    • Tonic Clonic
    • Tonic
    • Clonic
    • Myoclonic
    • Atonic
    • Absence
47
Q

Generalized Seizures: Tonic-Clonic

A

Also called gran mal
* Starts with muscle stiffening (Tonic phase), pt may cry out and loss of consciousness, Then clonic movements begin (Jerking of extremities)
* Breathing can stop during tonic phase and be irregular during clonic phase
* Can become cyanotic, bite tongue or cheek, or become incontinent
* Postictal phase: confused then sleepy

48
Q

Generalized Seizures: Tonic

A
  • Only involves tensing
  • Sudden loss of consciousness, increased muscle tone, generally in back arms and legs
  • Can have arrythmias, apnea, vomiting, incontinence salivation
  • Can last 30 seconds ish

Turn them to their side so they dont aspirate

49
Q

Generalized Seizures: Clonic

A
  • Only the clonic phase
  • Last several min (Longer than tonic)
  • Muscles contract then relax, repeated jerks or twitches of muscles on both sides of body
50
Q

Generalized Seizures:Myoclonic

A
  • Brief jerking or stiffening of the extremities, symmetrical or asymmetrical
  • Only last a few seconds
51
Q

Generalized Seizures: Atonic

A
  • Loss of muscle tone for a few seconds
  • Pts will drop to floor
  • Confusion for a period of time after
52
Q

Generalized Seizures:Absence

A
  • Pt looks like they’re staring off into space. with or without slight twitching of muscles
  • Typically children
  • Momentary lapse in consciousness
53
Q

Partial seizures: Focal seizures

A
  • Only involve one hemisphere and one are of the brain
  • Types
    • Complex Partial/focal
    • Simple partial/focal
    • Secondary generalized
54
Q

Partial seizures: Complex partial/focal

A
  • Dazed or confused
  • Unable to respond to questions or directions for several min (Black out)
  • May have automatisms (Lip smacking, picking at clothes without their awareness)
  • Amnesia prior and after seizure
55
Q

Partial seizures: Simple partial/focal

A
  • Can cause twitching or change in sensation, strange taste or smell, deja vu, flushing, HR increased, unilateral extremity movements, pain sensation
  • Consciousness maintained
56
Q

Partial seizures: Secondary generalized

A
  • Begins in one part of the brain and spreads to both sides
  • Starts as focal but becomes generalized
57
Q

Test: seizures

A
  • Tox screen: Alc and other drugs
  • CMP, CBC with diff, colag studies, cultures if fever, lead levels
  • Screen for CNS infection (HIV infection, Meningitis, encephalitis)
  • Consider referral for genetic counseling if child
  • CT, MRI, PET determine potential cause of seizure
  • EEG records the electrical activity and can identify origin of seizure
58
Q

Seizure assessment

A
  • Detailed medical history:
  • Symptoms and duration of seizures
  • Past illnesses fevers other symptoms
  • Family history of seizures
  • Determine if provoked or unprovoked
  • Prior seizures or is this the first
  • Neuro consult
59
Q

Anti-epileptic drugs

A
  • Goal is to control seizure activity
  • Monotherapy is usually good, if not effective change to another drug
  • Do not abruptly discontinue
  • Pt should take at same time each day
  • Monitor for therapeutic levels of drugs
  • Monitor for side effects
  • Be aware of adverse effects and interactions with foods and other meds
  • Routine dental and oral care, some can cause gingival hyperplasia
  • Can develop tolerance, which can increase incidence of seizures, will need more frequent blood levels check with increase in dose
60
Q

Vagus nerve stim

A
  • Helps to manage partial seizures refractory to meds and refractory depression
  • Implanted in left chest wall and an electrode placed on the left vagus nerve
  • Programmed to give intermittent electrical impulses to the vagus nerve which then send signals to the brainstem then on to your brain
  • with the onset of a seizure a person can hold a magnet over the implanted device which will increase electrical charge, aborting the seizure
  • Does not cure seizures but can decrease the amount
  • Avoid MRI, microwaves, shortwave radios
  • Not sure how they work but hypothesis
    • Increasing blood flow to key brain areas
    • Raising levels of neurotransmitters important to control seizures
    • Changes EEG patterns during seizures
61
Q

Seizure mgmt: Surgical mgmt

A
  • Used in partial or generalized seizures
  • AED discontinued and EEG is done to determine area of seizure
  • Conventional surgery: Take the area out that is causing the seizure if its not a vital area
    • Wada test, neuropsych testing, Awake craniotomy
  • Partial corpus callosotomy: Cuts the corpus callosum preventing electrical signal between left and right brain, decreasing frequency and severity of seizures
  • Complications are going to be neuro deficits, infection and lack of success
62
Q

Wada test

A

Intracarotid amobarbital administered to see if language or memory will be affected, used in surgical mgmt of seizure

63
Q

Status epilepticus

A

More than one, in a 30 min time frame or one lasting longer than 5 min
* Complications: Hypoxia, inability of brain to return to normal function
* Acute condition and requires immediate attention to prevent perm loss of brain function or death
* Causes: Substance withdrawal, sudden withdrawal from AED, head injury, cerebral edema, infection, metabolic abnormalities
* Nursing: Maintain/ protect airway, provide O2 , establish IV access, ECG monitoring, pulse ox, ABG
* Administer diazepam or Lorazepam IV followed by Phenytoin or fosphenytoin

64
Q

Nursing care during a seizure

A
  • Maintain patient privacy and protect pt from injury (Pillow under head)
  • Position pt to provide patent airway (sidelaying)
  • Suction oral secretions
  • Turn pt to side to decrease risk of aspiration
  • Loosen restrictive clothing
  • Do not restrain the pt
  • Do not attempt to open the jaw or insert an oral airway
  • do not use a padded tongue blade
  • DOCUMENT: onset, duration, associated findings (LOC, apnea, Cyanosis , motor activity, incontinence) prior during and after the seizure (like a code)
65
Q

Nursing care after seizure: Postictal

A
  • Maintain patient in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions
  • Check vital signs
  • Assess for injuries
  • Perform neurological checks
  • Allow patient to rest
  • Reorient and calm the patient who may be agitated or confused
  • Determine if the patient experienced an aura
  • Try to determine a possible trigger

After Postictal
* Obtain a medical alert bracelet
* Med instructions
* State driving laws

NSG 478 (23 decks)

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