Neurological 1- Exam 2 Flashcards
What is the most important indicator of the patient’s condition in patient’s with neurologic dysfunction?
LOC
Posturing with hands towards core of the body.
Decorticate
Posturing with hands away from the body.
Decerebrate
What can be assessed in patient’s with altered LOC?
-Verbal responses (A&O x4)
-Alertness
-Motor responses (posturing)
-Respiratory status
-Eye signs (equal, round, reactive to light)
-Reflexes (deep tendon)
Definition: unconsciousness, unarousable unresponsiveness
Coma
Definition: unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
Akinetic mutism
Definition: devoid of cognitive function but has sleep-wake cycles
Persistent vegetative state
Definition: inability to move or respond except for eye movements due to a lesion affecting the pons
Locked-in syndrome
Is altered LOC the disorder or the result of a pathology?
Result of a pathology (Ex: alcohol intoxication, kidney injury)
What are some common complications of patients with altered LOC?
-Respiratory distress or failure
-Pneumonia
-Aspiration
-Pressure ulcer
-Deep vein thrombosis
-Contractures
What intervention can ultimately promote the development of pressure ulcers?
SCD’s
What is an intervention that can aid in the development of pressure ulcers?
SCD’s
What is a contracture?
Permanent shortening of muscles
What should priority nursing interventions in patient’s with altered LOC focus on?
ABC’s- maintaining an airway
What are specific nursing interventions that can aid in maintaining an airway in patient’s with altered LOC?
-Frequent monitoring of respiratory status, including auscultation of lung sounds
-Positioning to prevent accumulation of secretions and prevent obstruction of upper airway- HOB elevated 30 degrees; lateral or semipro position
-Suctioning, oral hygiene, and CPT
What are some nursing interventions specifically for maintaining tissue integrity?
-Assess skin frequently, especially areas w/ high potential for b/d
-Frequent turning; use turning schedule- at least q2h
-Positioning in correct body alignment
-Passive ROM
-Clean eyes w/ cotton balls moistened w/ saline
-Use artificial tears as prescribed
-Measures to protect eyes
-Frequent, scrupulous oral care
What are some nursing interventions specifically used for maintaining fluid status?
-Assess fluid status by examining tissue turgor & mucosa, laboratory test data, & I&O
-Administer IVs, tube feedings, & fluids via feeding tube as required; monitor ordered rate of IV fluids carefully
What are some nursing interventions specifically used for maintaining body temperature?
-Adjust environment & cover pt. appropriately
-If temp is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, & allow fan to blow over pt. to increase cooling
-Monitor temp. frequently & use measures to prevent shivering
What does shivering do when a pt. has increased ICP?
Increases ICP further
What are some nursing interventions specifically used when promoting bowel & bladder function?
-Assess for urinary retention & urinary incontinence
-May require indwelling or intermittent catheterization
-Bladder training program
-Assess for abdominal distention, potential constipation, & bowel incontinence
-Monitor bowel movements
-Promote elimination w/ stool softeners, glycerin suppositories, or enemas as indicated
-Diarrhea may result from infection, medications, or hyperosmolar fluids
Why are stool softeners used in pt’s with increased ICP?
To reduce straining that can increase ICP further
What are some nursing interventions specifically used for sensory stimulation & communication?
-Talk to & touch pt. & encourage family to talk to & touch pt.
-Maintain normal day-night pattern of activity; orient the patient frequently
-When arousing from coma, a pt. may experience a period of agitation; minimize stimulation at this time
-Programs for sensory stimulation
-Allow family to visit & provide support
-Reinforce & provide consistent info to family (keep it simple)
-Referral to support groups & services for family
What is the Monro-Kellie hypothesis?
When there is an increase in any one of the components of the skull - brain tissue, blood, or CSF - this will cause a change in the others, since there is limited space in the skull
If 1 goes up, another has to go down.
What is the normal ICP?
10-20 mm Hg
What causes increased ICP?
Disease or injury
What are adverse effects of increased ICP?
-Ischemia
-Cell death
-(further) edema
If increased ICP causes brain tissues to shift through the dura, resulting in herniation, what will be impacted?
Respirations
Definition: Refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow
Autoregulation
Decreased CO2 results in ____(1)____, & increased CO2 results in ___(2)_____.
- Vasoconstriction
- Vasodilation
What is the formula for CPP (cerebral perfusion pressure)?
CPP= MAP-ICP
What is the formula for MAP?
MAP= D+1/3(S-D)
What is the normal CPP?
70-100
What does a CPP less than 50 indicate?
Decreased perfusion; permanent neurologic damage
What are some of the earliest manifestations of increased ICP?
*Changes in LOC
-Any change in condition: restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements
-Pupillary changes & impaired ocular movements
-Weakness in one extremity or one side
-Headache: constant, increasing in intensity, or aggravated by movement or straining
What are some late manifestations of increased ICP?
-Respiratory & vasomotor changes
-VS: ^ systolic BP, widening of PP, slowing of HR; pulse may fluctuate rapidly from tachycardia to bradycardia; temp. increase
-Projectile vomiting w/ no warning
-Further deterioration of LOC; stupor or coma
-Hemiplegia (1 side weak), decortication, decerebration, or flaccidity
-Respiratory pattern alterations including Cheyne-Stokes breathing & arrest
-Loss of brainstem reflexes: pupil, gag, corneal, & swallowing
Assessment of a pt. w/ ICP?
-Obtain hx of events leading to illness
-Evaluate mental status, LOC
-Assessment of selected cranial nerves
-Assess cerebellar function, reflexes, motor & sensory function
-GCS, pupil checks
-Frequent VS (watch for trends)
-Assessment of intracranial pressure
What is the lowest score a pt. can receive on the GCS?
3
What is the highest (best) score a pt. can receive on the GCS?
15
What is an example of an invasive ICP monitoring?
Intraventricular catheter
Other than a brainstem herniation, what are 2 other potential medical dx caused with ICP?
-Diabetes insipidus
-SIADH
What should planning & goals of a pt. w/ increased ICP focus on?
ABC’s
A- Maintenance of patent airway
B- Normalization of respirations
C- Adequate cerebral tissue perfusion
-Fluid balance
-Absence of infection
-Absence of complications
What is a craniotomy?
Opening of the skull
What is a craniotomy used for?
Removal of tumor, relieve ^ ICP, evacuate a blood clot, control hemorrhage
What is a craniectomy?
Excision of a portion of the skull
What is a cranioplasty?
Repair of cranial defect using a plastic or metal plate
What are Burr holes?
Circular openings for exploration or dx to provide access to ventricles or for shunting procedures, aspirate a hematoma or abscess, or make a bone flap.
What is the hyper osmotic agent used in increased ICP?
Mannitol
Why are corticosteroids used in the preoperative care of increased ICP?
To decrease inflammation
Why are anti seizure medications used in the preoperative care of increased ICP?
Decreases the risk of seizures; much ^ risk w/ ICP
Why is diazepam used in the preoperative care of increased ICP?
To alleviate anxiety
Why are antibiotics used in the preoperative care of increased ICP?
To reduce/prevention of potential infection
Name some medications that can be used in the preoperative care of increased ICP.
-Antianxiety: diazepam
-Antibiotics
-Corticosteroids
-Mannitol
-Diuretics
-Antiseizure meds
What are some preoperative diagnostic procedures used in increased ICP?
-CT scan
-MRI
-Angiography
-Trancranial Doppler flow studies
Who is responsible for giving the pt. & family details about the procedure when a pt. has increased ICP?
The surgeon
What is postoperative care aimed at?
-Detecting & reducing cerebral edema
-Relieving pain
-Preventing seizures
-Monitoring ICP & neurologic status
What kind of assessments should the nurse perform after an intracranial surgery?
-Frequent monitoring of respiratory function, including ABG’s
-Monitor VS & LOC frequently; note any potential signs of ^ ICP & notify provider
-Assess dressing & for evidence of bleeding or CSF drainage & infection
-Monitor for potential seizures; if seizures occur, carefully record & report to provider
-Monitor for S/S of complications (infection, etc)
-Monitor fluid status & laboratory data
What are potential problems after intracranial surgery?
-Increased ICP
-Bleeding & hypovolemic shock
-Fluid & electrolyte disturbances
-Infection
-CSF leak
-Seizures
When does cerebral edema peak after intracranial surgery?
24-36 hours
How often should VS & neurologic status be monitored after intracranial surgery?
q15 minutes
What are some strategies to control factors that increase ICP after intracranial surgery?
-No shivering
-Posture
-Bowel regimen
What level should the HOB be elevated to after a pt. has had intracranial surgery?
30 degrees
How can gas exchange be improved after intracranial surgery?
-Turn & reposition q2h
-Encourage deep breathing & incentive spirometry
-Suction or encourage coughing cautiously as needed (^ ICP)
-Humidification of oxygen may help loosen secretions
What can periorbital edema impair? And how can it be avoided?
Vision
Elevation of HOB used to reduce edema
What activities should a pt. that has undergone intracranial surgery avoid?
Coughing, sneezing, nose blowing- may increase risk of CSF leakage
What are focal seizures?
Originates in one hemispher
Type of seizure that originates in one hemisphere.
Focal
Type of seizure that occur & engage bilaterally.
Generalized
Type of seizure: epilepsy spasms.
Unknown
Type of seizure related to acute conditions such as electrolyte imbalances; reversible condition.
“Provoked”
What are specific causes of seizures?
-Cerebrovascular disease
-Hypoxemia
-Fever (childhood)
-Head injury
-HTN
-CNS infections (meningitis)
-Metabolic & toxic conditions (electrolytes or poison)
-Brain tumor
-Drug & alcohol withdrawal
-Allergies
What is the main nursing intervention when a pt. is experiencing a seizure?
Keep the patient safe.
-Lay them down, turn them on their side & do not restrain them at all.
What is cephalalgia?
Headache
Classification of HA’s that have no known organic cause & includes migraine, tension HA, & cluster HA.
Primary HA
Classification of HA that is a symptom w/ an organic cause such as a brain tumor or aneurysm.
Secondary HA
What kind of dx testing can be used to evaluate underlying causes of HA’s when they are persistent?
Head CT or MRI
What one nursing education can aid in reducing the number of primary HA’s?
Stress reduction techniques
What is the normal range for ICP?
10-20 mmHg
What should the nurse calculate to determine if the patient has the needed pressure to ensure blood flow to vital organs?
Mean Arterial Pressure (MAP)
What is the equation to determine MAP?
SBP = 2(DBP) / 3
How do we calculate CPP?
MAP - ICP = CPP
What does cerebral perfusion pressure tell us?
If there is the appropriate amount of pressure for cerebral blood flow
Normal range for CPP
70-100 mmHg
How does increasing fluids and giving a patient positive inotropic agents treat low CPP?
By lowering ICP and supporting MAP
What specific treatment would the nurse give to a patient with low CPP?
Fluids and positive inotropic agents
What is the most common way to decrease ICP?
Ventriculostomy
A patient s/p car accident presents to the ER with increasing ICP, how does the nurse decrease the ICP? What medication did the physician most likely order?
Nurse: fluid restriction, elevate HOB, hypertonic saline
Doc: mannitol
If the nurse has a patient with ICP concerns, what are the trends the patient may show to watch for?
Increased SBP with widened BP
Bradycardia
Irregular respirations
Is Cushing’s Syndrome a late or early sign of ICP?
Late
Mr. King presents to the ED with headache, confusion, and lethargy s/p car accident. He is confused about the day and who the president is. He is complaining of new onset diplopia. What do you think is causing his symptoms? How would you confirm?
Increased ICP
CT of head to confirm
What are some clinical indications that ICP is increasing?
-change in LOC
-VS
-Ocular signs
Your patient presents with increasing ICP, how can you as the nurse recognize early signs of changes in LOC?
Flattening affect
Lethargy
Confusion
Stupor
Coma
If your patient is suffering from increasing ICP, how will their vital signs give you clues?
Cushing’s Triad
Changes in body temperature
Increased BP
Decreased HR
Wide pulse pressure
What is the triad of symptoms associated with Cushings Triad?
HTN/Increased BP/widened pulse pressure
Bradycardia
Decreased/Irregular RR
How is ICP measured?
Ventriculostomy - most common
Mr. Meyer presents to the ED and experiences projectile vomiting with no previous nausea and the ‘worst headache of his life’ - what do you think Mr. Meyer is experiencing?
Increased ICP
What medications may be administered to a patient with increasing ICP?
IV mannitol
Corticosteroids
Anticonvulsants
Antipyretics
Sedatives
Analgesics
The nurse has just administered lorazepam to a patient who is in status epilepticus. The patients respiratory rate drops to six per minute. The nurse will prepare to administer:
a. Naloxone.
b. 1 liter normal saline bolus.
c. Flumazenil.
d. Calcium gluconate.
Flumazenil
The nurse is aware that all of the following electrolyte imbalances can cause a seizure except for:
a. Hyponatremia.
b. Hypokalemia
c. Hypocalcemia.
d. Hypomagnesemia.
Hypokalemia
A client with a history of seizures is scheduled for an arteriogram at 1000 and is to have nothing by mouth before the test. The client is scheduled to receive phenytoin PO at 0900. The nurse should take which of the following actions?
a. Hold the 0900 am dose.
b. Give the same dosage of the drug rectally.
c. Ask the physician if the drug can be given IV.
d. Administer the drug with 30 mL of water at 0900.
C. Ask the physician if the drug can be given
A 68-year-old patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?
a. Assess pupil reaction to light.
b. Check oxygen saturation.
c. Verify Glasgow Coma Scale (GCS) score.
d. Palpate the head for hematoma or bony irregularities.
Check oxygen sats
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
a. The bedrails at the head and foot of the bed are both elevated.
b. The patient receives a regular diet from the dietary department.
c. The lights in the patient’s room are turned off and the blinds are shut.
d. Unlicensed assistive personnel enter the patient’s room without a mask.
Enters room without a mask
A client calls the telephone triage nurse to report fever, nausea, chills, and malaise. The nurse instructs the client to come immediately to the emergency room when he relates he also has which of the following
a. A headache.
b. A stiff, sore neck.
c. A heart rate of 106.
d. A roommate with the same symptoms.
Stiff, sore neck
A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Minimize contact with the patient to decrease sensory input.
d. Keep the room well-lighted to improve patient orientation.
Encourage family to stay with the patient
The nurse observes a patient ambulating in the hospital hall when the patient’s arms and legs suddenly jerk and the patient falls to the floor. The nurse will first
a. assess the patient for a possible head injury.
b. give the scheduled dose of divalproex.
c. document the timing and description of the seizure.
d. notify the patient’s health care provider about the seizure.
Assess for head injury
After evacuation of an subdural hematoma, a patient’s intracranial pressure (ICP) is being monitored with a ventriculostomy. Which information obtained by the nurse is most important to communicate to the health care provider?
a. Pulse 102 beats/min
b. Temperature 101.6 degrees F
c. Intracranial Pressure 15 mmHg
d. Mean arterial pressure 90 mmHg
Fever
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
a. Head turned to the side
b. Head midline
c. Neck in neutral position
d. Head of bed elevated 30 degrees
head to the side
A client is brought to the emergency department in the midst of a persistent tonic-clonic seizure. Lorazepam is administered intravenously. The nurse knows that the purpose of this medication is to:
a. slow cardiac contractions.
b. relax peripheral muscles.
c. dilate the airway.
d. provide amnesia of the seizure episode.
relax peripheral muscles
In providing for the safety of the client during a generalized seizure, the nurse performs which of the following interventions?
Positions the client on his back.
Gently placed a padded tongue blade between the teeth.
Applies oxygen immediately via mask.
Protects the client from injury.
protects client from injury
The nurse is instructing the client who has been in the hospital with bacterial meningitis and will be going home soon. Which of the following will be of the highest priority?
Eat a high-protein, high-calorie diet.
Exercise daily, beginning with active ROM.
Take all of the antibiotics as directed until completely gone.
Get at least 8 hours of sleep per night with frequent rest periods during the day.
Take abx as prescribed until gone
Signs of a possible stroke include (Select all that apply)
Face Drooping
Arm Weakness
Speech Difficulty
Visual Disturbances
All
Which of the following interventions will be used to treat bladder control issues in the stroke patient? (Select all that apply):
Ensure adequate fluid intake
Insert indwelling Foley catheter
Palpate for bladder distention
Toileting every 2 hours
All except the catheter
The nurse is educating a patient that experienced a transient ischemic attack (TIA). More education is needed based on which of the following statements?
I will take my aspirin daily as prescribed.
Hemorrhagic strokes are not related to TIA’s.
Many will go on to experience an ischemic stroke.
The symptoms of a TIA are different from a stroke
The symptoms of a TIA are different from a stroke
Which of the following is true of dysarthria?
It affects the muscles that control speech
It occurs with receptive aphasia
It occurs with global aphasia
It does not affect the muscles that control the tongue.
It affects muscles that control speech
onsiderations for a patient with dysphagia following a stoke include which of the following (Select all that apply):
Assess level of consciousness, gag reflex and swallowing ability
Avoid liquids or use thickeners
Perform mouth care before feeding
Place food on affected side of mouth
A, B,C
