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Neuro Rehab 2 > Neuro ICU > Flashcards

Neuro ICU Flashcards

1
Q

what are 9 challenges of acute neuro PT management

A

level of acuity/medical instability
level of arousal
cog changes
behaviors
language and communication
visual disturbances
multiple medical monitoring devices
precautions and comorbidities
physical environment

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2
Q

what are common cognitive changes that are challenges in acute neuro pt management

A

unable to process auditory info
irrational thoughts
confusion
hallucinating
memory problems/amnesia

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3
Q

what is the focus of care in a neuro ICU

A

preserving life
protecting neural tissue
prevent secondary consequences of prolonged immobility (ie pressure ulcers, DVT, pneumonia)

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4
Q

how is a neuro step down unit different from neuro ICU (4)

A

more medically stable
less medical monitoring
higher nursing ratio
focus shifts to recovery, dc planning

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5
Q

focus of care in neuro step down unit

A

shift to recovery, dc planning

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6
Q

nursing ratio in neuro ICU vs neuro step down unit

A

in ICU - 1:1
step down - 1:6 nurse to pt

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7
Q

what is ICP

A

intracranial pressure
pressure exerted by CSF w/i ventricles

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8
Q

what is CPP

A

cerebral perfusion pressure

measure of how much O2 is getting to brain tissue

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9
Q

how is CPP calculated

A

MAP - ICP

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10
Q

relationship of CPP to ICP

A

CPP dec w inc of ICP

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11
Q

what is the normal range for ICP

A

0-15mmHg

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12
Q

how is the structure of the skull a factor in CPP’s inverse relationship to ICP

A

skull is tightly fused
- not forgiving or able to easily adapt if change in ICP d/t edema, swelling, inc in BP, extracellular fluid

so if ICP inc, limited space that will cause CPP to dec

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13
Q

what MD orders might be placed if they are monitoring ICP levels

A

HOB > 30deg
activity
acceptable ICP ranges for interventions

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14
Q

why is it important to check MD orders for ICP monitoring

A

no strict guidelines for what activity is acceptable w different ranges of ICP
- up to MD

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15
Q

what are examples of ICP monitors

A

ICP bolt
intraventricular catheter
epidural sensor

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16
Q

what is a consideration for PT when using a ICP monitor

A

keep transducer at level of external auditory meatus always for accurate reading

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17
Q

what is a specific benefit to intraventricular catheters over other ICP monitors

A

get readings right from ventricle
also drain CSF if acute inc

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18
Q

what type of patient is an intraventricular catheter appropriate for

A

high ICP or at risk of spike
- can drain CSF quickly

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19
Q

what is a contraindication for PT with regard to ICP

A

if active CSF drainage present
- external ventricular drain must be clamped for mobility

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20
Q

what is a general guidance for ICP level during exercise

A

<25mmHg
- not standard or fixed precaution
- coordinate w team

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21
Q

what is the normal CPP range

A

70-100mmHg

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22
Q

what value should CPP be above at all times and why? what are the PT implications?

A

40mmHg
- if less than 40, ischemia and infarction can occur w/i minutes (no longer adequate O2 delivery to brain structures)

if <40 during treatment, go to nurse and defer treatment

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23
Q

what is the risk of elevated ICP and why

A

brain and/or brainstem herniation (often fatal)

closed pressure system and only place to go is down into foramen magnum

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24
Q

what are 8 signs of inc ICP

A

change in LOC - lethargy, coma
pupils dilated or fixed
blurred or double vision
paresis/ms weakness
HA
sz (EEG feedback, tonic clonic)
n/v
HTN, bradycardia, RR change

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25
Q

what are 3 s/sx of infection

A

nuchal rigidity
- resistance in moving head, flexing neck

inc body temp (diaphoresis)

other neuro changes

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26
Q

why is infection a common complication

A

wound from accident
indwelling devices

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27
Q

how does the ICP waveform correspond to the cardiac and respiratory cycles

A

corresponds w cardiac
between respiratory waves

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28
Q

what are 6 techniques for medical management of inc ICP

A
  1. anti-HTN meds
  2. osmotic diuretic
  3. mechanical vent to maximize O2 delivery
  4. ventriculostomy to drain CSF
  5. craniectomy
  6. sedation
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29
Q

why is mechanical ventilation used to manage inc ICP

A

short term set to hyperventilate
- lower CO2 levels (CO2 dilates cerebral blood vessels and inc ICP) and induce alkalosis
-> constrict vessels -> dec ICP

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30
Q

why are anti-HTN meds and osmotic diuretics prescribed for inc ICP

A

dec pressure in system

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31
Q

why is sedation or pharmacological coma used to manage inc ICP

A

dec level of agitation and metabolic demands on system

32
Q

what are 2 things we have control over for medically managing inc ICP

A

positioning: HOB >30deg
dec environmental stim/limit agitation

33
Q

why do you want to dec environmental stim when there is inc ICP and what is the challenge with doing this in a neuro ICU setting

A

dec sensory inputs -> calmer and dec agitation -> dec metabolic demands and blood flow -> dec ICP

hard to dec environmental stim in ICU w all the machines and people

34
Q

what does the literature say about mild to mod hypothermia in managing inc ICP

A

lowers metabolic demands and overall calms system down

not well supported in literature
- studies in acute SCI, less in TBIs

35
Q

what is a common secondary complication that pts are on prophylactics for in a neuro ICU

A

seizures

36
Q

what is the danger of having a sz on top of a brain injury

A

sz on top of already damaged neural structures can amplify damage

37
Q

what is the immediate action for someone having a sz

A

lie them on their side
remove tight clothing
remove sharp objects
place soft flat object under head

if something was in person’s mouth, try to remove to prevent aspiration

call for nurse and/or MD

38
Q

what are lab values to monitor acutely

A

CBC (WBC, Hgb, Hct, Plt)
ESR
Chem-7
coagulation profiles
- PT/PTT/INR

39
Q

why is ESR monitored

A

indirect measure of inflammation

40
Q

what are the 2 most important lab values to look at when treating a pt in a neuro ICU

A

ESR
coag profile

41
Q

what information does a clotting profile give you (3)

A

determine ability to initiate clotting sequence

dx clotting disorders

monitor effects of coag therapy

42
Q

what does it mean if someone is a “therapeutic level” when it comes to coagulation

A

blood has been sufficiently anticoagulated

43
Q

what is the therapeutic range for INR

A

2-3

44
Q

PT implications of INR > 3.5

A

risk for bleeding
modify activity

45
Q

PT implications of INR >5

A

may need bed rest

*no activity** - mobilization or bronchopulm hygiene
- can cause bleeding and bleeding into joints (hemarthrosis)

46
Q

PT implications of INR < 2

A

risk for developing blood clot

PROM
compression boots donned for longer periods
monitor skin for s/sx of DVT (redness, pain, swelling)

47
Q

what might be the team’s medical management if the pt’s INR > 5

A

vit K injections or change of anti-coag med rx to get INR into therapeutic range

48
Q

what are the activity guidelines based on INR >/= 4

A

no resistive exercise
only light exercise
- RPE </= 11
- close supervision if fall risk

49
Q

what are the activity guidelines based on INR > 5

A

exercise contraindicated
assess safety
prevent falls

50
Q

what are 3 common precautions in the neuro ICU

A

craniectomy/bone flap
spine precautions
aspiration precautions

51
Q

what are craniectomy/bone flap precautions

A

helmet when OOB
no pressure/contact on site

52
Q

what are spine precautions

A

vary but typically no bending, lifting >10lb, twisting

logrolling to roll, get in/out of bed

may require c-collar, TLSO, jewett brace

53
Q

what is the purpose of spine precautions

A

keep spine straight

54
Q

why are craniectomy precautions a thing

A

soft/gelatinous brain tissue is exposed w/o skull protection

55
Q

what are aspiration precautions

A

check status of swallowing prior to giving any PO’s

keep HOB elevated at all times

56
Q

what are the 2 main pt goals when in the neuro ICU

A

preserve life and viability of neural structures

prevent secondary complications (ie ROM)

57
Q

why is it important to be vigilant when working in a neuro ICU

A

modify POC based on emerging conditions

prepare for events such as:
PE
sz
inc in ICP
respiratory distress
acute change in neuro status
paroxysmal sympathetic hyperactivity (“storming”)

58
Q

what are secondary complications to prevent/limit

A

contractures
pneumonia
ms length
pressure ulcers

59
Q

what is storming

A

sudden onset of tachycardia, tachypnea at rest d/t autonomic dysfunction and triggered by a random stimuli (not always noxious - ie could be d/t to PT)

can be dangerous if prolonged

60
Q

why should you check w the nurse always before entering a room

A

can be acute change since last documented

61
Q

what are 2 PT goals acutely in the neuro ICU

A

promote safety w functional activities

prioritize and select exam procedures that align w goals

62
Q

what does it mean to prioritize/select exam procedures that align w goals for PT in acute neuro ICU setting

A

more important to examine gross functional mobility first
- might not be able to address impairments all at once

63
Q

what are components to consider with early mobility

A

close monitoring
MD orders
IP team coordination
environmental set-up

64
Q

what are the benefits to early mobility

A

dec LOS
inc home dc rate
dec cost
dec nosocomial infections
dec secondary complications

65
Q

what is the common progression with early mobility

A

PROM -> AAROM -> AROM -> rolling -> sit EOB -> bed to chair transfers -> standing -> amb

66
Q

considerations of skilled vs non-skilled therapy in hospital

A

think about if what we are doing is skilled or if we could train others (ie family, nurses) to do
- ex: positioning

67
Q

why is there such a heavy focus on preserving neural tissue acutely

A

more neural tissue saved and viable (limited ischemic core), more potential for neuroplasticity in rehab later

68
Q

what is the biggest risk with early mobility

A

dislodging line or tube

69
Q

what are the 4 main secondary consequences that we try to prevent and how

A
  1. contractures (d/t adaptive ms shortening, joint immobility)
    - use of positioning, splints
  2. pressure ulcers (d/t sedation won’t be moving spontaneously)
    - have to be repositioned q2hr
  3. DVT
    - prophylaxis
  4. pneumonia
    - pulmonary hygiene
70
Q

why does brainstem herniation from inc ICP lead to death

A

won’t be able to breath or have neurocentral functions

71
Q

what is the implication of a dec CPP

A

not enough bloodflow, oxygenation, metabolism to brain tissue

72
Q

what might cause ICP to spike when the pt is already in the neuro ICU

A

bronchopulm hygiene and suctioning
positioning
pain

73
Q

what are cons of intra-ventricular catheters

A

invasive
sacrifices some brain tissue

74
Q

once ICP >25 what is the risk

A

death

75
Q

what is an equivalent of CPP hitting 40

A

SpO2 <88

Neuro Rehab 2 (48 decks)

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