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1st Semester Nursing > Patho: Consciousness, Stress And Pain > Flashcards

Patho: Consciousness, Stress And Pain Flashcards

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1
Q

What is the tentorial plate?

A

Fibrous membrane of the dura mater

Separates supra-tentorial (cerebrum) from Infratentorial (cerebellum and brain stem)

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2
Q

What primary functions are associated with the Supratentorial region? What important brain structures should we know about?

A

Higher thinking, plus vision, hearing, speech, reasoning, fine motor control and learning. (All cerebrum)

ALSO, Hypothalamus and Thalamus. These process and transmit sensory info.

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3
Q

What structures and functions should we associate with Infratentorial regions?

A

Cerebellum: regulating and maintaining muscle movement.
Cerebellum: RAS (mass of nerve cells, helps coordinate movement and balance).

Brainstem: Relay center, regulates breathing, Heart Rate, Wake/Sleep cycles.

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4
Q

What is the Monroe-Kellie hypothesis?

A 
When something (a mass, blood, etc) intrudes upon the brain, there must be displacement of brain tissue. 
Skull doesn’t allow for expansion, so, fluids will compensate (venous and CSF) at first, but if swelling continues/worsens, tissue will displace onto the brain stem.
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5
Q

What happens (to fluids) in the Compensated State?

A

Brain attempts to maintain normal ICP
Fluids displaced first:
-Venous volume —-> back pressure to Jugular (maybe JVD)
-Arterial volume —-> back pressure to Carotid
-this puts pressure on carotid baroreceptors, DECREASING HR (d/t CNX stimulation)
-CSF —-> down the spinal column. Severe headaches from pressure.

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6
Q

What is normal ICP? When does displacement begin?

A

Normal ICP is 0-15 OR 5-15.

Compensation starts at above 15 - fluids are easiest and will displace first.

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7
Q

What happens (in the brain) in the Decompensated State?

A

Mass taking up lots of space - and there’s not enough venous/arterial/CSF fluid to displace and compensate.

Brain tissue is displaced downward, herniating onto brainstem.

Decrease in venous and arterial volume leads to a decrease in CPP (which leads to ischemia)

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8
Q

What is CPP? How do you calculate it? What is normal? What happens if it’s too low or too high?

A

Cerebral Perfusion Pressure (relates to perfusion of the brain).

MAP - ICP = CPP
Normal: 70-90 mm Hg

Too low (below 60) leads to ischemia
Too high (above 90) leads to vascular damage (inflammation, irritation, and longer-term: arteriosclerosis)
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9
Q

Cerebral autoregulation: what will blood vessels in brain do if there is increased cardiac output?

A

Vasoconstriction

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10
Q

Cerebral autoregulation: What will blood vessels in brain do if there is increased CO2?

A

Vasodilation

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11
Q

Cerebral autoregulation: What will blood vessels do if there is a Nitric Oxide depletion?

A

Vasoconstriction

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12
Q

Cerebral autoregulation: what will blood vessels in brain do if there is acidosis?

A

Vasodilation

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13
Q

Cerebral autoregulation: what will blood vessels do in a state of hypocapnia?

A

Constrict

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14
Q

Cerebral autoregulation: What will blood vessels in brain do in a state of hypoxemia?

A

Vasodilation

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15
Q

Cerebral autoregulation: what will blood vessels in brain do with PNS activity

A

Vasodilation

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16
Q

Cerebral autoregulation: What will blood vessels in brain do if there is SNS activation?

A

Vasoconstriction

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17
Q

When is cerebral autoregulation dysfunctional? What should we monitor, knowing this?

A

In patients with increased ICP, the autoregulation process is dysfunctional.

Monitor CO2, O2, Cardiac Output.

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18
Q

How does cognition differ from sensory perception?

A

Sensory perception is being able to receive and translate sensory input

Cognition is processing of all of the informational input

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19
Q

What are orientation questions you can use to assess LOC?

A

Name? Place? Time? Who is the president? What did you eat for your last meal?

20
Q

What types of reasoning questions would you ask to assess level of consciousness?

A

If there was a fire in your home, what would you do?

What would you press if you needed to call me? (Or even, where is your call light?)

21
Q

Would supratentorial damage affect cognition, sensory perception, or both?

A

Both

22
Q

What neurologic function assessments do we do and in what order?

A
  1. LOC (person, place, time, situation, reasoning)

2a. Pattern (rate and rhythm) of breathing
2b. Sensory impairment (input/interpretation and motor responses)

  1. Pupil responses (reaction to light and oculomotor movement).
23
Q

Where are the eye nerves and what nerves control which function? Why is this important to know?

A

Nerves for the eyes are at the brainstem.

CN3: pupil reactivity to light
CN 3, 4, 6: oculomotor movement

Important because once the pupils are affected, you’re already showing either herniation onto or damage to the brainstem. LATE sign.

24
Q

You’re checking pupils for reactivity and only one eye is reactive? What might this mean?

A

Herniation of brain tissue onto ONE side only.

Herniation would be the same side as the dilated eye

25
Q

What is the first sign of brain injury? Is this for supra-tentorial or infra-tentorial?

A

1st sign = alterations in consciousness (arousal, wakefulness, awareness).

BOTH for supra- and for infra-tentorial

26
Q

How will manifestations of supratentorial injury differ from those of Infratentorial injury?

A

Supra-tentorial injury will appear as:

  • change in LOC, memory
  • change in motor control and interpreting sensation
  • change in respiratory pattern

Infra-tentorial injury will appear as:

  • all of supra-tentorial signs PLUS
  • oculomotor and pupil response problems
  • heart rate problems
  • decline in consciousness
27
Q

What is the RAS?

A

Reticular Activating System
Cluster of nerve cells at the core of the brainstem
Regulates sensory input messages

Alterations can be due to inflammation, bleeding, tumors, trauma

28
Q

What categories are assessed on the Glasgow Coma Scale? When would you want to get a GCS score?

A

Eye opening response (assesses supra-tentorial damage + RAS)
Best verbal response (supra-tentorial damage only)
Best motor response (supra-tentorial damage only)

Get GCS score with ANY neurologic deficit so we can track.
3-15 (higher is better).

29
Q

What breathing pattern alterations would be a sign of supratentorial damage?

A

Early: yawning/sighing

Worsening: Cheyne-Stokes (variable apneic periods interspersed with hyperventilation).

30
Q

What breathing pattern alterations would be associated with Infratentorial damage? (Why?)

A

Cause: Pressure at the central chemoreceptors from herniation onto the brainstem causes ischemia to the capillaries: inflammatory response, lactic acid formation and acidosis.

Central Neurogenic Hyperventilation (overcompensating chemoreceptors)

Apneusis/Agonal Breathing: Ischemia deeper in the brainstem. Breath in, hold 2-3s, exhale, hold 4-6s. At this point = impending death. Damage is too deep for repair.

31
Q

What is an uncal herniation? What’s the first thing it will affect?

A

Brain tissue herniation through the “uncus” (onto the brainstem).

1st nerve it affects is CN3.
Likely to show first as a same-sided pupillary problem.

32
Q

Can blood loss affect pupillary response?

A

Yes - blood loss and shock can also lead to ischemia at the brainstem.

33
Q

What is the Doll’s Eyes Test?

A

Done in unconscious patients
Tests to see if eyes move along with head movement (bad sign)
Indicates damage to CN 3, 4, 6

34
Q

What is the Ice Caloric or Cold Caloric?

A

Ice water into the ear (of an unconscious patient).
Eyes should move symmetrically toward the cold
One-sided movement is okay, but not great
Negative movement = impairment to 3, 4, 6

35
Q

What are CN 3, 4, 6?

A

CN3: oculomotor
CN4: trochlear (non-consensual movement if damaged)
CN6: abducens (by this point, pt is unconscious)

36
Q

What do we need to know about assessing motor responses?

A

-Helps evaluate level of dysfunction
-Helps identify side of the brain
(Crossing over at the corticospinal tract in the medulla means that damage to one side of brain means motor problems on the opposite side of the body).

-Right sided damage = left-sided deficits (place water and restraints accordingly)

Ask: Smile, raise eyebrows, grip hands

37
Q

What happens to body in the Compensated State? (Stage 1 vs Stage 2?)

A

Stage 1: ICP = 15ish-19ish.
-ALL VITALS STILL NORMAL

Stage 2: ICP = 19ish-20ish
-Episodes of confusion and restlessness (other vitals still normal)

38
Q

What happens to the body in the Decompensated State? (Stage 3-Stage 4)

A

At 20+ ICP (and increasing…)

LOC: Lethargy —> Obtunded —> Coma
Pupils: Reactive —> unreactive
RR: Normal —> cheyne-stokes —> apneusis
BP: Systolic Increases, Diastolic Decreases
Pulse Strength: Full (d/t backpressure), Bradycardic

39
Q

What is Cushing’s Triad?

A

Describes the three primary symptoms that happen in decompensation. (Not all three have to be present!)

Bradycardia
Wide Pulse Pressure
Decrease in Resp Rate with periods of apnea

40
Q

Why is Bradycardia a symptom of decompensation?

A

Pushback of blood from the brain (from increased ICP) overrides the pressure from the beating heart.

This pressure is sensed by the carotid baroreceptors at CNX and they slow the SA node.

41
Q

Why does decompensation lead to a wide pulse pressure?

A

Pressure builds in the aortic arch, overstretching it. This decreases its compliance, which transmits the higher systolic that results throughout the vascular system.

Looks like isolated systolic hypertension.

42
Q

How will cerebral autoregulation affect the brain’s vascular system when it starts to have periods of apnea?

A

The brain will sense CO2/pH and vessels will vasodilate.

(Vasodilation will decrease the MAP, but we need to increase MAP to allow blood to get to the brain - it has to overcome the ICP.

43
Q

What is the minimum MAP needed to perfuse the brain?

A

60 mm Hg

Normal MAP is 65-110

44
Q

What are some ways to promote cerebral vasoconstriction?

A

Hyperventilate the patient (this brings down CO2, causing alkalosis and constriction)

Elevate the BP

Give Norepinephrine

45
Q

How would you promote cerebral vasodilation?

A

(Most potent: CO2 and pH)

  • elevate the CO2 levels
  • promote acidosis
  • promote slight hypoxia
  • create slight fever
  • give nitroglycerin or morphine

1st Semester Nursing (5 decks)

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