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CCRN Study Deck > Neurologic 7% > Flashcards

Neurologic 7% Flashcards

1
Q

Raccoon Eyes

A

Indication of basal skull fracture involving anterior fossa
Dripping of fluid from nose or ear of patient with basal skull fracture highly suggestive of a cerebrospinal fluid (CSF) leak.

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2
Q

CSF Leakage

A

Leakage from the nose or ear canal indicates a tear in the dura.
Dural tears increase the risk of infection.
Nursing care: Provide a sterile field for the drainage, nasal packing could lead to increased intracranial pressure (ICP).

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3
Q

Recombinant Tissue Plasminogen Activator (rt-PA)

A

Fibrinolytic Agent
Must be initiated within 3 hours of onset of symptoms
Complications:
Intracranial bleeding
Seizure (suggestive of intracranial hemorrhage).

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4
Q

Therapeutic Hypothermia

A

Reduces the metabolic demand of the brain.
Most important intervention to prevent anoxic encephalopathy is the prompt restoration of cerebral oxygenation through basic life support and advanced cardiovascular life support.
This often includes hypothermia immediately afterwards.

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5
Q

Why keep a neurological patient’s head in neutral head position?

A

Keeping the head and neck in a neutral position allows optimal venous drainage through the jugular veins.

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6
Q

Cerebral Perfusion Pressure (CPP) = ?

A

CPP = mean arterial pressure (MAP) - ICP
Goal CPP of at least 60 mm Hg.
Ex. ICP is 40 mm Hg, MAP must be at least 100 mm Hg to keep CPP at least 60 mm Hg.

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7
Q

Increase in ICP

A

Positive Pressure Ventilation (increases intrathoracic pressure)
Hypoxia (leads to vasodilation

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8
Q

Which of the following should not be used to determine central response to pain?

  • Sternal Rub
  • Trapezius Squeeze
  • Nailbed Pressure
  • Supraorbital Pressure
A

Nailbed Pressure
Nailbed pressure is peripheral pain.
Can be used to determine whether the patient can feel and withdraw such as checking for paralysis

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9
Q

Neurologic Change Early Signs

A

Change in LOC is the best indicator for change in neurologic function.
Reflection of cerebral and reticular activating system functioning.
Pupil changes may be early but usually follow LOC
Changes in motor function usually are an indication of a focal lesion in one of the cerebral hemispheres.
Vital sign changes are a late sign of intracranial hypertension.

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10
Q

Neurologic Change Late Signs

A

Elevated blood pressure
Dysrhythmias (Bradycardia)
Posturing

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11
Q

Major Sources of Intracranial Hypertension after Craniocerebral Trauma

A

Cerebral Edema and Expanding Lesions (e.g. hematoma)

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12
Q

Computated Tomography (CT) Scan of Head

A

Performed initially following stroke-like symptoms to identify intracranial hemorrhage

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13
Q

Angiogram

A

Visualizes extracranial and intracranial vasculature
Would be performed if intracranial hemorrhage is identified on a CT scan
Definitively show the location and size of any aneurysmal dilation

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14
Q

Lumbar Puncture

A

Collection of cerebrospinal fluid (CSF) by lumbar puncture
Can identify if and what infective organisms are present
If organism is bacterium, CSF will be cloudy and the glucose level will be decreased.
Contraindicated in patient with clinical indications of intracranial hypertension because herniation may occur

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15
Q

Evoked Potentials

A

Evoked potential studies measure the electrical responses in brain waves in response to sensory stimuli and are not indicated.

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16
Q

Cerebrospinal Fluid (CSF)

A

Test positive for glucose

Glucose in the CSF is 60% of the glucose in the serum.

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17
Q

Compensation

A

Ability of the brain contents to be shifted to prevent intracranial hypertension when intracranial volume increases

  1. Cerebrospinal fluid (CSF) production decreases
  2. Reabsorption is increased
  3. CSF is shunted to the lumbar spine
  4. Central nervous system hypertension causes hypocapnia, alkalosis, and vasoconstriction which reduce the amount of blood in the cranium.
  5. Eventually part of the brain is shifted out of the cranium (i.e., herniation)
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18
Q

Autoregulation

A

Relates to the ability of the crebral vessels to change size to normalize blood flow.

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19
Q

Cranial Nerves V (trigeminal), VII (facial), IX (glossopharyngeal), X (vagus), and XII (hypoglossal)

A

Important for eating without the danger of aspiration.
Control gag and swallow response
Must be intact bilaterally to protect the patient’s airway.

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20
Q

Decerebrate Posturing

A

Abnormal extension

Arms extended and hyperpronated

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21
Q

Decorticate Posturing

A

Abnormal flexion

Arms flexed against the chest

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22
Q

Early Sign of Uncal Herniation

A

First sign is ipsilateral pupil dilation with a sluggish reaction as a result of pressure on cranial nerve III.
Motor weakness may occur but would be on the contralateral side.
Contusion can act as a mass lesion and cause a unilateral shift and uncal herniation.

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23
Q

A scalp laceration located over a depressed skull fracture requires what?

A

Immediate surgery because there is a direct route between the outside environment and the brain, increasing risk for infection.

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24
Q

Meningitis

A 
Classic clinical presentation includes:
Headache
Stiff neck
High fever
Kernig sign
Brudzinski sign
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25
Q

Decrease in ICP

A 
Low paCO2 (hyperventilation) (causes cerebral vasoconstriction and decrease in intracranial volume)
Cerebral dehydration with osmotic diuretics (mannitol) would decrease intracranial volume
Sedation decreases the oxygen requirements of the brain and may contribute to maintenance of normal ICP
Hypocapnia (low PaCO2) (Causes vasoconstriction which decreases intracranial volume and pressure)
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26
Q

Myasthenia Gravis

A

Disorder of voluntary muscles caused by a defect in nerve impulse transmission at the neuromuscular junction.
Causes muscle weakness and fatigability.
Autoimmune disorder with destruction of acetylcholine receptors causing interference of neuromuscular transmission leading to muscle weakness and fatigability

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27
Q

Cranial Nerve III

A

Ability of the pupil to constrict
As ICP increases, changes in pupil size and reactivity occur
Pupil on the side of the pressure will dilate and become sluggish in response to light and finally nonreactive to light
Controls the ciliary response and constriction of the pupil

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28
Q

Cranial Nerve II

A

Responsible for vision

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29
Q

Cranial Nerves III, IV, and VI

A

All involved in eye movement

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30
Q

Cardiac Condition Representing Greatest Risk for Ischemic Stroke

A

Atrial fibrillation
Most significant cardiac risk factor for ischemic stroke
Due to mural thrombi which develop in the atria and then embolize from the left atrium to the cerebrovascular system
Prevention of stroke is primary reason that patients with chronic afib are maintained on anticoagulants

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31
Q

Subdural Hematoma

A

S/S may not occur for weeks to months after trauma
Many patients cannot remember a precipitating trauma
May occur spontaneously, especially in elderly patients, alcoholics, and patients taking anticoagulants
Can be acute, subacute, or chronic

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32
Q

Major Complications of Subarachnoid Hemorrhage

A

Cerebral Vasospasm
Narrowing of the vessel lumen caused by actual constriction or inflammation
Occurs anytime from 3 days to 2 or 3 weeks after hemorrhage
Cerebral rebleeding
Peaks 24 to 48 hours after hemorrhage and again 7 to 10 days after the initial bleed
*Mortality rate is high with both complications

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33
Q

Subarachnoid Hemorrhage

A

Caused by vascular problem
Bleeding from an aneurysm, that blood irritates the meninges.
Clinical presentation not consistent with intracranial, epidural, or subdural bleeding because the blood is not in contact with the meninges in those situations

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34
Q

Monro-Kellie Hypothesis

A

Physiologic concept
If one of the three intracranial volumes goes up, one of the other two intracranial volumes will go down to prevent an increase in ICP.
About shifting of intracranial contents to prevent an increase in ICP

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35
Q

Abnormalities Possible With Subarachnoid Hemorrhage

A

Cardiac dysrhythmias (torsades de pointe, T-wave changes, and U-waves
Protein levels are low in any negative LP
Hyponatremia occurs either due to SIADH or cerebral salt wasting, without complete clarity of the cause.
No hyperkalemia

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36
Q

Broca Aphasia

A

Inability to express oneself
Motor or expressive aphasia
Caused by a problem in Broca area of the frontal lobe

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37
Q

Wernicke Aphasia

A

Inability to understand what is being communicated
Sensory or receptive aphasia
Caused by a problem in Wernicke area of the temporal lobe

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38
Q

Dysprosody

A

Lack of inflection during speech, Foreign Accent Syndrome

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39
Q

Dysphagia

A

Difficulty swallowing

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40
Q

Epidural Hematoma

A

Classically present with short period of unconsciousness followed by a lucid interval and then rapid deterioration
Usually caused by arterial bleeding

41
Q

Linear Fractures Link to Epidural Hematoma

A

Linear fractures of the temporal bone frequently disrupt the middle meningeal artery and cause epidural hematoma

42
Q

Intracerebral Hemorrhage

A

Usually associated with hypertension, aneurysm, or arteriovenous malformation

43
Q

Amyotrophic Lateral Sclerosis (ALS)

A

Chronic progressively debilitating disease
Causes degeneration of the upper and lower motor neurons and muscular atrophy
Not considered hereditary disorder
No demyelination
Not caused by trauma

44
Q

Transient ischemic attack (TIA)

A

Cerebral hypoperfusion
Reversibility within 24 hours
Stroke-like symptoms

45
Q

Contusion

A

Bruise on the brain

46
Q

Oculocephalic Reflex

A

Patient must be assessed for cervical spine injury prior to testing oculocephalic reflex
Doll’s eyes
Requires head to be turned side to side
Normal response is that the eyes move in the direction opposite the direction the head is turned.
Absence of doll’s eyes is when eyes stay midline or fall to the direction that the head is being turned toward.
Absence of doll’s eyes indicates brainstem injury.

47
Q

Guillain-Barre Syndrome (GBS)

A

Acquired acute inflammatory demyelinating axonal polyneuropathy.
Affects motor more than sensory nerves.
Frequently follows a viral or bacterial illness or influenza vaccination.
Patients with GBS are admitted to the critical care unit most often for acute respiratory failure.

48
Q

HOB for infratentorial craniotomy

A

0 degrees (flat)
Infratentorial means below the tentorium
Tentorium is a fold of the dura that separates the cerebrum from the cerebellum and the brainstem.
The head of the bed should be maintained at 0 to 20 degrees after infratentorial craniotomy to prevent pressure on the brainstem.

49
Q

Battle Sign

A

Basal skull fracture of the middle fossa.

Bruising of the mastoid.

50
Q

Basal Skull Fractures of the Posterior Fossa

A

Do not cause either raccoon eyes or Battle Sign

Do increase the risk of epidural hematoma and cranial nerve defects.

51
Q

Cushing Triad

A

Cushing Reflex
Late sign of increased intracranial pressure (ICP).
Increased systolic blood pressure with a decrease in diastolic blood pressure (widened pulse pressure) and bradycardia.

52
Q

Kernig Sign

A

Resistance to leg extension with the hip flexed.

Indicative of meningeal irritation

53
Q

Uncal herniation

A

Uncus, located at the tip end of the medial temporal lobe, protrudes over the tentorial edge as a result of increased intracranial pressure.
Side-to-side shift
Cranial nerve III is compressed by this displacement, causing dilation and nonreactivity of that pupil.
Eventually will cause pressure on the brainstem and respiratory cessation.

54
Q

Central herniation

A

Downward displacement that puts pressure on the reticular-activating system.
First sign is change in level of consciousness.
Eventually will cause pressure on the brainstem and respiratory cessation.

55
Q

Intracranial Pressure (ICP) Waveforms

A waves

A

A waves: (Plateau waves)
Spontaneous, rapid increases in pressure between 50 and 200 mm Hg that last 5 min or more.
Waves cause cerebral ischemia and are most clinically significant.
Immediate intervention necessary to prevent further brain injury and herniation.
A waves are AWFUL

56
Q

Intracranial Pressure (ICP) Waveforms

A waves

A

A waves: (Plateau waves)
Spontaneous, rapid increases in pressure between 50 and 200 mm Hg that last 5 min or more.
Waves cause cerebral ischemia and are most clinically significant.
Immediate intervention necessary to prevent further brain injury and herniation.
A waves are AWFUL

57
Q

Intracranial Pressure (ICP) Waveforms

B waves

A

B waves are BAD
Look for and prevent causes of intracranial hypertension.
Elevation of ICP to 20 to 50 mm Hg occurring every 30 seconds to 2 min.

58
Q

Intracranial Pressure (ICP) Waveforms

C waves

A

C waves are COOL.

Elevation of ICP to 20 to 25 mm Hg every 4 to 8 min

59
Q

Rule of Truama

A

Everything moves until it stops.

60
Q

Rule of Trauma

A

Everything moves until it stops.

61
Q

Vasospasm

A

Significant cause of morbidity in patients with subarachnoid hemorrhage

62
Q

Vasospasm

A

Significant cause of morbidity in patients with subarachnoid hemorrhage

63
Q

Intracranial Pressure (ICP) Monitoring Systems Management

A

Continuous flush preferred to avoid small volume increases in ICP.
Heparin not added due to causing intracranial hemorrhage.
Cerebrospinal fluid does not clot.
Preservative-free saline only for priming tubing due to potential for meningeal irritation from preservatives.
Transducer leveled to the foramen of Monro. (External reference point is tragus of the ear).

64
Q

Pentobarbital-Induced Coma

A

Ideally have ICP line inserted.
Monitor changes in ICP and calculation of cerebral perfusion pressure (CPP) as well as brain tissue oxygen monitor.
LOC cannot be assessed for patients in coma.
Pupil changes best assessment to detect neurologic changes in the earliest stage for this patient.

65
Q

Pronator (Ulnar) Drift

A

Indicates unilateral weakness

Patient holds out arms in front and one arm drifts slightly downward.

66
Q

Hemiparalysis

A

Prevents patient from even raising limbs when testing muscle weakness.

67
Q

Hemianesthesia /Agnosia

A

Test for sensory findings in stroke patients

68
Q

NIH Stroke Scale (NIHSS)

A

Questions should be asked in order.
Answers should come from the patient rather than the family.
What the patient can actually do should be recorded.
Assessment should be objective.

69
Q

Effect of intracranial volume increase on intracranial pressure (ICP)

A

With no brain pathology, a small initial increase in intracranial volume has no effect.
Brain is normally compliant.
Injured brain is noncompliant.
increase in volume result in increased pressure.
Small increase in volume results in profound increase in ICP and resultant herniation.

70
Q

Cytotoxic Cerebral Edema

A

Caused by hypo-osmolality or hypoxia with resultant failure of the sodium-potassium pump.
Cellular - have cellular cause
Cardiac arrest is global brain problem which would affect all cells.

71
Q

Vasogenic Cerebral Edema

A

Increase in extracellular fluid caused by a breakdown of the blood-brain barrier with the resultant increase in vascular permeability.
Begins locally and becomes more generalized.
Common causes are trauma (including surgical trauma), tumors, hemorrhage, and abscesses.
Craniotomy for a brain tumor
Traumatic brain injury
Brain abscess secondary to sinus infection

72
Q

Passive Range of Motion

A

Slight resistance expected when flexing and extending the limb.

73
Q

Transphenoidal Hypophysectomy

A

Common for CSF leak from the nose to occur approximately 48 hours following procedure.

74
Q

Cerebellum

A

Controls balance and coordination
Presence of lesion results in difficulties with …
Coordinating movement
Equilibrium
Muscle tone
Proprioception
Ex. Nystagmus, ataxia, unsteady gait, and problems with rapid, alternating movements

75
Q

Pituitary Gland

A

Endocrine gland that controls release of hormones within the body

76
Q

Brainstem

A

Contains cardiac and respiratory centers, temperature, and other basic drives
Respiratory centers primarily in the pons with influence from the medulla

77
Q

Frontal Lobe

A

Controls voluntary motor function and behavior

78
Q

Cerebrum

A

Responsible for upper level functions such as integration of thought and control of voluntary functions

79
Q

Hypothalamus

A

Regulates body temperature, food and water intake, sleep, and endocrine function.

80
Q

Electromyelogram

A

Detects muscle disease

81
Q

Cisternogram

A

Shows CSF flow

82
Q

ICP A Wave Interventions

A 
Mannitol
Decreases cerebral edema
Hyperventilation therapy
Causes cerebral vessel constriction and decrease in blood volume in the head
Drainage of CSF via IVC
Reduces the volume of CSF in the head
83
Q

Intraventricular Catheter (IVC)

A

Closed system

84
Q

Fever in Neurologic Conditions

A

Each increase in temperature of 1 C, the cerebral oxygen consumption increases 7%.
Increase in body temperature has significant adverse effect on cerebral oxygenation.
Fever would cause a shift in the oxyhemoglobin dissociation curve to the right, which impairs pickup but facilitate drop-off of oxygen at the tissue level.

85
Q

To Maintain Autoregulation, CPP Must Be Maintained Above What Level?

A

50 mm Hg
Autoregulation is the ability of the cerebral vessels to change their size to normalize blood flow.
MAP of 60 mm Hg is required to perfuse vital organs. Normal ICP is around 10 mm Hg. CPP would be 50 mm Hg.

86
Q

Hyperventilation Therapy Reserved for Indications of Acute Herniation, Why?

A

Resultant vasoconstriction decreases intracranial volume and pressure but causes cerebral ischemia.
Hyperventilation causes respiratory alkalosis which causes vasoconstriction, decreasing intracranial volume and pressure.
Vasoconstriction potentially causes cerebral ischemia.

87
Q

Status Epilepticus Management

A
  1. Benzodiazepine (Lorazepam first choice. Diazepam may be used if lorazepam not available)
    Crosses the blood-brain barrier quickly.
  2. Phenytoin or Fosphenytoin
    Used following Lorazepam
  3. Phenobarbital
    Used after benzodiazepine or phenytoin has failed.
88
Q

Multiple Sclerosis (MS)

A

Progressive demylination of nerve fibers in the central nervous system (CNS)
Demyelinating disorder of white matter of the brain and spinal cord (CNS).
May have genetic aspect but not considered hereditary.

89
Q

Concussion

A

Associated with focal neurologic deficit or alteration in level of consciousness that clears within 6 to 12 hours or less.
Retrograde or antegrade amnesia is common.

90
Q

Med Management of Intracranial Hypertension

A

Diuretic (osmotic diuretic mannitol)

91
Q

Mannitol

A

Osmotic diuretic
Administer through an in-line filter due to likely presence of unseen crystals
May crystallize out of solution if exposed to low temperatures
If crystals present, warm solution
Use filter needle when drawing up from a vial

92
Q

Babinski Reflex

A

Indication of upper motor neuron lesion
Located in the central nervous system (brain or spinal cord)
Great toe moves upward and other toes fan out when bottom of foot is stroked.

93
Q

Cranial Nerve V

A

Trigeminal

Motor fibers innervate the muscles of mastication

94
Q

Cranial Nerve VII

A

Facial

Motor fibers innervate all muscles of the face

95
Q

Cranial Nerve IX

A

Glossopharyngeal

Works with X in swallowing and the gag reflex

96
Q

Cranial Nerve X

A

Vagus

Works with IX in swallowing and the gag reflex

97
Q

Cranial Nerve XII

A

Hypoglossal

Innervates muscles of the tongue

98
Q

HOB Elevation Goal

A

HOB at 30 degrees
Helps facilitate venous drainage via the jugular veins from the cerebrum.
HOB elevations of 45 degrees or greater may increase intra-abdominal pressure and increase intracranial pressure or decrease blood pressure.

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