quiz Flashcards
2 first steps in spinal cord injury
2 other steps
Immobilization and stabilization of the head (collar)
assessment of airway and breathing
initial tx for injury above T4
intubation
symptoms of spinal shock 2 and the tx
(hypotension, bradycardia)
1st: ), fluid resuscitation with crystalloid fluids and atropine
2nd: vasopressors
what is autonomic dysreflexia
where
symptoms 5
assessment
complication of spinal cord injury
sudden onset of very high blood pressure caused by bladder or bowel distention
usually in t6 or above
headache, flushed face, sweating above the level of injury/cool, clammy skin below, bradycardia
assess for retention of urine (bladder scan and bladder program)
2 complications of spinal cord injury
autonomic dysreflexia , immobility
monroe kellie hypothesis
Intracranial Volume (VIC) = volume of the brain + volume of blood + volume of CSF + volume of the lesion. – if one is off it throws others off
compliance
balancing act of keeping ICP 5-15
CPP formula, what does it determine, normal, what happens when MAP is decreased and ICP is increased
CPP DETERMINES BRAIN O2
MAP-ICP
60-65
decreased perfusion
3 things assessed in GCS- whats normal, mod, severe
eye opening, motor response, verbal response
13-15 = normal/mild injury,
9-12 = moderate injury,
8 or less, severe injury/coma
how to assess ICP 5
GCS
positioning- decorticate, decerebrate
pupillary response
babinski (if toes expand =abnormal)
cranial nerve assessment
pupillary response - dolls eye damage to
CN 2
hearing problems is what CN
CN VIII
tumor of CNVIII
acoustic neuroma
cough, gag reflex tests what CN
CN IX and X
dolls eye abormal finding
eyes dont move
cold caloric test normal finding
eyes go to ear with cold fluid
ABC waves on ICP monitor
A waves: PROBLEM (50-100) – lasts 5-20 minutes with a rapid onset
B waves: 20-50 ICP increase not an emergency – B waves usually before A waves (example is when they get suctioned after they already have high ICP)
C waves: NORMAL up to 20 – no problem
7 nursing responsibilities of ICP monitoring with device
- NEURO CHECKS HOURLY
- Monitor ICP, MAP, and CPP at least hourly.
- Monitor the effects of nursing care (repositioning, suctioning, etc.) on the patient’s ICP.
- Validate accuracy of waveforms and values.
- Maintain strict aseptic technique (infection is the primary complication of ICP monitoring).
- Ensure the dressing site is clean, occlusive, and dry.
- Assess the system for leaks of CSF.(yellow and clear)
gliomas vs mengiomas
Gliomas – malignant
Meningiomas – benign
tumor prognosis depends on
how fast and big tumor grows - even benign tumors can be fatal depending on location and speed bc they increase ICP
risk factors for brain tumors 3
inherited disease
enviornment
radiation
when does cerebral edema occur in brain tumors
1mm tumor size
what are brain tumor symptoms related to
SIZE
focal symptoms of brain tumors 8
ringing in the ears,
hearing problems/loss,
decreased muscle control,
lack of coordination,
decreased sensation,
weakness or paralysis,
difficulty with walking or speech double vision.
main pharm tx of brain tumors
glucocorticoids to decrease tissue swelling
initial tx for meningiomas tumors
surgery
dexamathasone
indication
MOA
nursing resp 3
9 SE
indicated for patients with symptomatic cerebral edema from brain tumors
It produces a reduction of cerebral edema and symptoms within 8-48 hours of first dose and effects can last as long as 72 hours.
monitoring for side effects
adjusting dose to the min needed
taper off
insomnia, visual blurring, tremor, behavioral changes, increased appetite, weight gain, hyperglycemia, hypertension, and muscle weakness in the legs.
most common cause of TBI
blunt trauma with falls most common
when is CT indicated in TBI
for minor injuries (like concussions) they are not evidence-based. They are helpful in more severe injuries, older patients, and those on anticoagulants.
if change in VS where is brain injust
brainstem - medulla
linear skull fracture
nondisplaced fracture as a result of low-impact.
depressed skull facture
depression of the bone at the point of impact, may be closed (not penetrating the dura) or open (penetrating the dura). These generally require surgery for repair of the skull and dura, and debridement of bone fragments.
basilar skull fracture
at the base of the skull; patients may develop a dural tear and have CSF draining from the nose and ears. Eventually the patient may develop “raccoon eyes” (ecchymoses around the eyes) and Battle’s sign (ecchymoses behind the ears).
NO LAYING FLAT, COLD CALORIC TEST OR NG TUBE
epidural bleed
: arterial, fast onset of s/s (usually unconscious with quick periods of wakefulness), surgery needed ASAP
subdural bleed and acute subdural
more common in TBI (below dura), result from coup and countercoup injury, VENOUS leaking, slower and progressive onset, more time to treat (don’t always need surgery)
acute: collection of thick, jellylike blood within 24-48 hours after injury. Patients present with loss of consciousness, deteriorating GCS and often focal signs (hemiparesis, dysphagia). If untreated, ICP will increase. Emergent craniotomy is indicated for clot evacuation.
subarachnoid bleed
arterial, not always associated with TBI(can be caused by aneurysm), FAST onset, “worst HA of my life” , need surgery ASAP
intracranial bleed
not always TBI(may be a hemorrhagic stroke), venous with TBI, Slower onset, or hemorrhagic stroke is arterial and more immediate s/s – MAYBE surgery
risk factors for severe TBI 6
patient age
GCS
pupil size and response
extracranial injury
CT scan findings
hypotension
2 ABG goals for brain injury pt
CO2 35-40 (hyper/hypocarbia can inc ICP)
PO2 > 96 (hypoxia can inc ICP)
nurse resp for suctioning patient to prevent inc ICP 4
preoxygenate to 100% before and after
sedate before
limit to 10 sec
observe PEEP bc it can dec BP
MAP goal
70-90
if MAP is <70, or SBP <90
fluid volume status should be assessed, and isotonic fluids are given to maintain balance
if Na levels low, use of hypertonic saline
NO VASOPRESSORS
when is ICP tx initiated
when ICP is > 20
4 meds to manage ICP
sedation and pain relief- benzos and propofol
pain management - morphine, NO FENTANYL
hypertonic saline
mannitol
mannitol
MOA
nurse rep. 7
osmotic diuretic that decreases ICP while reducing cerebrovascular resistance and increasing cerebral blood flow.
USE A IN LINE FILTER, monitor for hypotension, urine output, fluid vol status, monitor serum osmolality (GOAL 300-320 NORMAL), monitor hyponatremia, hypokalemia
hypertonic saline
MOA
nurse resp 5
Saline decreases ICP while increasing CPP by mobilization of H2O and reduction of cerebral H2O content. It also increases BP due to plasma expansion.
> 2% should be given through a central line(because its irritating to vein
monitor serum Na levels every 6 hours to maintain 145-155 mmol/L(bc if its normal at 135-145 then that’s not good because were giving Na) ,
assess fluid volume status (weight, CVP, I&O),
monitor serum osmolality every 12 hours,
GO SLOW
nursing resp of cerebrospinal fluid drainage 5
leveling the transducer and stopcock with the tragus of the ear
monitoring amount and characteristics of drainage hourly(shouldn’t be cloudy, purulent, bloody),
temporarily turning off drainage to measure ICP hourly,
maintaining strict aseptic technique (use of a mask and sterile gloves) ,
changing drainage containers ONLYwhen needed to reduce system exposure to air to reduce infection.
when is hyperventilation used
purposeful reduction in pCO2 in patients with increased ICP. – this is only done when they have risk for aneurysm - ONLY IN EMERGENCIES
when is High-dose barbiturate therapy/barbiturate coma used
patients have elevated ICP resistant to other treatment or in patients with uncontrolled seizures. It works by reducing cerebral metabolic rate and reducing cerebral blood flow and BP.
nurse resp of High-dose barbiturate therapy/barbiturate coma use 7
monitor hemodynamic stability,
monitor ICP (the patient must have a monitor in place because normal methods to assess neurological function are not possible),
monitor ECG, for hypoventilation and hypoxia,
utilize the ventilator bundle,
monitor the temperature and maintain it (hypothermia is common with barbiturate coma),
assess for bowel sounds (ileus is common bc things are slowed down),
protect the patient’s corneas.
targeted hypothermia
Done with COOLING FAST AND WAMRING SLOW – cooling banket, ice packs (monitor electrolytes during this+BG) to get temp to 35
Warming: WARM SLOW to 36-37 using antipyretics
decompressed craniotomy
used in patients resistant to all other measures to decrease ICP.
Removal of part of the skull bone
If used, it should be done when early signs of brain herniation are present (unilateral fixed or dilated pupil)
-NO POSITIONING ON SIDE OF OPENING
-monitor for infection
-monitor for hydrocephalus
- fluid collection
-CSF leaks
-seizures
4 non pharm techniques to avoid inc ICP
HOB 30 degrees
DON’T CLUSTER CARE: turning the patient should be spaced from other activities
use of stool softeners or laxatives to avoid valsava maneuver
Keeping external stimulation to a minimum limits rise in ICP. Do not have rounds in the room with the patient because it can raise ICP
nutriton for TBI patient
full caloric replacement no later than 9 days after injury and all patients should receive enteral nutrition within 72 hours.
Feedings should start slowly (25 mL/hour) with increases of 25 mL each 12 hours as tolerated until full caloric requirements are met.
*Nursing responsibilities include monitoring patient tolerance and glucose levels. (Glucose levels over 200 should be prevented, with insulin used as needed.)
3 psychoscial support for TBI
Effective communication
Chaplain
Family involvement in routine care like hygiene
coma stumulation
Only 1 person should speak at a time, and only 1 form of stimuli provided at a time AFTER THEY ARE RESTED and after 72 hours of stabilization
phenytoin
moa
nurse resp
AE
blocking the repetitive action of the sodium channel, used to control and prevent seizures
careful administration through a patent IV,
administered only with normal saline,
administered slowly to prevent bradycardia, hypotension, heart block, and ventricular fibrillation.
The nurse must monitor the patient’s ECG and BP during administration and for at least an hour after.
AE: dyrhyth, stevens johnson
status eliticus defintion
over 5 minutes of continuous seizure activity or seizures occurring in succession for 20-30 minutes without a return to consciousness.
end of life definition
period of time during which an individual copes with declining health related to a terminal illness or frailties due to advanced age
3 goals for end of life
Provide comfort and supportive care during the dying process
Improve the quality of remaining life
Help ensure a dignified death
palliative care intention 3
focus on control of patients’ symptoms, relief of patients’ and families’ suffering, and enhancement of patients’ quality of life.
it is a continuum
does not speed up or slow down death
5 triggers for palliative care consultation
Death expected in the next 12 months
Admission related to hard to control physical or psychological symptoms
Out of hospital cardiac arrest
ICU stay of greater than 7 days
Disagreement about medical, resuscitation, and non-oral feeding/hydration interventions.
what is advanced directive
legally enforceable document outlining the patient’s preference for specific treatments to be provided or withheld and/or to designate an individual to make decisions for them (termed a healthcare proxy) if they are not able.
- they can change their mind
5 family needs at end of life
with patient
be helpful
assured of comfort
informed
comforted and allowed to express their emotions
brain death defintiion and 3 criteria
irreversible loss of brain function, including function of the brainstem.
Three criteria are necessary to declare brain death:
Coma (no movement)
Absence of brainstem reflexes – pupils > 4 mm and not responsive to light
Apnea – remove from vent -> 100% oxygen via T-piece for 8 minutes and observed for respiratory movement. The patient must have normal BP and temperature
bereavment vs grief
Bereavement – an individual’s emotional response
Grief – The lived experience in response to a loss.
what is meningitis
the inflammation of the meninges and the underlying subarachnoid space that contains CSF
what is meningitis tx
culture then abx before results
abx + seroid (dexamaethasone)
CSF in meningitis
decreased glucose < 40, high protein (>50), high WBC (1,000-10,000) = cloudy
meningitis symptoms
include neck stiffness,
fever,
change in mental status,
nuchal rigidity,
positive Kernig’s(To elicit the Kernig’s sign, patient is kept in supine position, hip and knee are flexed to a right angle, and then knee is slowly extended by the examiner.The appearance of resistance or pain during extension of the patient’s knees beyond 135 degreesconstitutes a positive Kernig’s sign)
Brudzinski’s signs(Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed),
seizures,
focal signs
papilledema.
what is key to meningitis tx
prevention
dexamaethasone MOA
interrupt the neurotoxic effects resulting from lysis of bacteria during the first days of antibiotic use.
2 causes of seizures
brain tumors and TBI
one time seizure tx
NOT anticonvulsive therapy
5 nursing resp for seizures
Assessing for any warning signs a seizure might occur, including presence of aura.
Assessing for a trigger.
Noting what the patient did during the seizure – how the seizure started and progressed.
Noting how long the seizure lasted.
Maintaining patient safety.
first line seizure tx med
valproic acid
main sources of discomfort in comfort care
- pain (opioids)
- dyspnea (morphine/lorazepam based on RDOS scale >3 requires tx! )
- thirst (oral care)
if agreement on end of life care cannot be reached, what should you do
ethics comittee
