T4 - Care of Critically Ill Patients with Neuro Probs (Josh) Flashcards
— and — have stroke-like symptoms and serves as a ‘warning sign’ of a possible stroke.
TIA (Transient Ischemic Attack)
Reversible Ischemic Neurologic Deficit (RIND)
TIA and RIND:
TIA lasts — to —
RIND lasts — to —
minutes to less than 24 hours
less than 24 hours to less than a week
With a TIA and RIND, what is happening?
brief interruption in cerebral blood flow
TIA and RIND:
What is the treatment plan?
Complete neuro assessment
CT Scan, lab, ECG
Possible admission
Anticoagulant therapy (clopidogrel)
TIA and RIND:
What anticoagulant would we give to treat?
Clopidogrel
With — you recover.
With — you have permanent change.
TIA and RIND
CVA
Which heart arrhythmia is a concern for CVAs?
Afib
A stroke is a change in – – – to the brain.
normal blood supply
Stroke (Brain Attack):
What are he causative agents?
HTN
Arteriovenous Malformation (AVM) ***Can be congenital
What are the types of Strokes?
Ischemic (lack of blood flow)
Hemorrhagic (bleeding in brain)
Stroke:
Thrombus and Emboli are examples of which type of Stroke?
Ischemic (lack of blood flow)
Which type of Strokes have SUDDEN onset?
Which type have GRADUAL onset?
Sudden:
- Embolic (ischemic)
- Hemorrhagic
Gradual:
- Thrombotic (ischemic)
Causes of Hemorrhagic Strokes:
Aneurysm
HTN
Arteriovenous Malformation
What is an Arteriovenous Malformation?
tight cluster of arteries and veins bundled together
blood passes quickly from artery to vein without going through normal capillary network
Risk factors for Stroke
Smoking
Substance abuse
Obesity
Sedantary Lifestyle
Oral contraceptive use
Heavy ETOH use
Use of Phenylpropanolamine (PPA)
***no longer made in US
Stroke in Left Hemisphere will have which symptoms?
Aphasia, Alexia, Dyslexia
Acalculia
Right Visual Field Deficit
Anxiety, Anger, Frustration
Intellectual Impairment
Stroke in Right Hemisphere will have which symptoms?
Disorientation (left sided motor weakness)
Loss of depth perception
Unilateral body neglect syndrome
Denial of illness
Impulsiveness
Stroke:
What is the eligibility criteria for Thrombolytic Therapy?
Last seen normal (LSN) less than 3 hrs- 4.5 hrs
Less than 80 yo
No anticoagulant use (INR less than or equal to 1.7)
NIH scale less than or equal to 25
No history of both STROKE and DIABETES
Stroke:
What is the time goal for ED door to treatment?
less than 60 mins
Stroke:
How often are neuro exams given?
q 15 mins first 2 hrs
Stroke:
What are the Endovascular Interventions?
Embolectomy
- *mechanical clot removal
- *NOT common
Intra-arterial Thrombolsis
Stroke:
When can an Intra-arterial Thrombolysis be done?
with 6 hrs LSN (last seen normal)
Medication classes for Strokes
Thrombolytics
Anticoagulants (ASA, Clopidogrel)
Lorazepam (other antiepileptics)
CCBs
Stool softeners
Analgesics
Antianxiety drugs
Stroke:
Which CCB is likely to be given?
Nicardipine
Stroke:
Which surgeries are used to treat?
Carotid Artery Angioplasty with Stenting
Endarterectcomy
Extracranial-Intracranial Bypass
Stroke:
Nursing interventions
Neuro Assessments
Monitor ICP
Safety
Emotional Support
Education
Brain Tumors:
Where do primary tumors originate?
Where do secondary tumors originate?
within CNS
metastasis from other parts of body
Brain Tumors:
What are the classifications?
Benign or Malignant
Location
Cellular Origin
Anatomic Location
Brain Tumors:
What is non-surgical management?
Radiation
Chemo
Analgesics
Dexamethasone
Phenytoin
Pantoprazole
Steriotactic Radiosurgery
Brain Tumors:
Why is Dexamethasone given?
to decrease size of brain tumors
Brain Tumors:
Nursing interventions post-Craniotomy.
Fluid Balance
Incision site
Monitor ICP changes
Avoid activities that decrease ICP
DVT prophylaxis
Stress ulcers
Pneumonia
Proper positioning
***HOB 30 degrees or more
Eye care
Brain Tumors:
Post-craniotomy, what activities can be done to avoid increase in ICP?
Stool softeners to avoid valsalva
Antiemetics for N/V
Antipyretics/cooling blankets for fever
Brain Tumors:
Which procedure goes through the nose?
Which tumor is it used specifically for?
Transphenoidal Hypophysectomy (TPH)
Pituitary Tumor
Brain Tumors:
What are complications from surgery?
Air embolism
CSF Leak (meningitis)
Diabetes Insipidus (messing with hypothalamus)
Visual Disturbances
Brain Tumors:
Post op care
HOB increase to 35-40 degrees
Hourly UOP
Monitor electrolytes
Avoid straining
Monitor for visual disturbances
Brain Tumors:
We are concerned about Diabetes Insipidus. What UOP will this have?
400 mL/hr
***normal is 0.5-1 mL/kg/hr
Brain Tumors:
Post-op, why do we want them to avoid blowing their nose?
avoid any straining to prevent rise in ICP
Cerebral Aneurysms:
Which type is behind the eye?
Which type is in the Circle of Willis?
Fusiform
Berry
Subarachnoid Hemorrage (SAH) from Cerebral Aneurysm:
What are physical assessments of SAH?
Severe, sudden Headache
Brief loss of consciousness
N/V
Kernig’s Sign, Brudzinskis Sign, Photophobia
Cerebral Aneurysm:
What do we suspect if client presents and says, ‘I’m having the worst headache of my life.’
Subarachnoid Hemorrhage (SAH)
Cerebral Aneurysm:
Why have positive Kernig’s and Brudzinskis with a SAH?
blood in meninges irritates them, giving meningitis symptoms
Cerebral Aneurysm:
What will a Lumbar Puncture reveal with SAH?
blood inCSF
Cerebral Aneurysm:
What is gold standard for diagnosing SAH?
Cerebral Angiogram
Cerebral Aneuysm:
What is treatment plan for SAH?
craniotomy with aneurysm clipping within 48 hours post bleed
***SAH is an emergency
Cerebral Aneurysm:
What is treatment after clipping the SAH?
HHH
- Hypertensive (increase BP and CO)
- Hypervolemic (volume expanders – albumin)
- Hemodilution (fluids)
Cerebral Aneurysm:
Post op from SAH clipping, what is our concern?
not bleeding, since they’re stable
our biggest concern is VASOSPASM, so we keep BP HIGH
Cerebral Aneurysm:
What is Endovascular Coiling?
filling the aneurysm with thin coil that will close it off
Brain Abscess:
What causes a BA?
Which areas of brain are most common?
purulent infection of brain
frontal and temporal most common
Stroke:
S/S of Left Hemisphere Stroke
Inability to discriminate words and letters
Intellectual Impairment
Deficits in right visual field
Stroke:
S/S of Right Hemisphere Stroke
Disorientation
Constant smiling
Deficits in left visual field
What is earliest indicator of increased ICP?
agitation and confusion
ICP:
What is the Monroe-Kellie Hypothesis?
due to the fact that the brain is closed system with tissue (brain) and fluids (blood and CSF)…
…an increase in any one MUST be compensated with a decrease in one or more of the other components
ICP:
Bran takes up — us space
Blood takes up — of space
CSF takes up — of space
80 percent
10 percent
10 percent
***any change in one must be compensated by changes in others
ICP:
What is normal ICP?
5-15 mmHg
ICP:
When would you treat increases in ICP?
ICP greater than 20 mmHg that is sustained for 5 mins
ICP:
What does an ICP of 10-20 mmHg indicate?
borderline.. it is compensating
over 20mmHg you start treating it
ICP:
What is severely high ICP?
greater than 40 mmHg
Cerebral Blood Flow (CBF):
What is the name of the pressure gradient that drives CBF?
CPP (Cerebral Perfusion Pressure)
CBF:
What is Autoregulation?
the ability of cerebral blood vessels to contract of dilate to deliver just the right amount of blood flow to the brain tissues
CBF:
What four factors can we controle to improve autoregulation?
Hypoxia
Hypercapia (CO2 is a vasodilator)
Hypotension
Hypovolemia
CBF:
What factors influence Autoregulation of blood flow?
Acidosis (dilates)
Alkalosis (constricts)
Metabolic Rate
CBF:
If Metabolic rate increases, what happens to CBF?
If Metabolic rate decreases, what happens to CBF?
increases
decreases
CBF:
Since Acidosis dilates vessels, what doe it do to cerebral blood volume?
increases
***in same manner, Alkalosis decreases cerebral blood vol
CBF:
How is Cerebral Perfusion Pressure (CPP) calculated?
CPP = MAP - ICP
CBF:
What CPP levels are we looking for?
Normal = 70-95 mmHg
***CPP less than 60 = hypoperfusion of brain
***CPP less than 40 = brain ischemia
ICP:
Why does increased CO2 cause an increase in ICP?
it’s a vasodilator
What is mortality rate for someone with both Hypoxia and Hypotension?
greater than 75%
What is treatment for Hypoxia and Hypotension?
Early resuscitation using 100% FiO2
MAP:
What is target MAP?
greater than 90
Optimize MAP:
How do you treat hypotension?
DA or Dobutamine
***target MAP is 90 or more
Optimize MAP:
How do you prevent HTN?
Nicardipine 25 mg in 250 mL
**CCB
Fluid Balance:
What do we want to keep the serum osmalirity level at?
less than 315
Mannitol:
How much can be given in 24 hrs?
do not exceed 200 G in 24 hrs
***hold if serum osmolarity is greater than 315
Increased ICP:
What is first s/s of increased ICP?
decreased LOC
Increased ICP:
What is Herniation?
complication of increased ICP where tissue from one compartment of brain shifts to another
***leads to coma, loss of reflexes, posturing, loss of brainstem function, and death
ICP:
Nursing interventions
Monitor serum electrolytes
Monitor serum Dilantin/Phenobarbitol levels
CVP monitoring
Diuretics
Keep SBP 140-160
Hyperventilation
Antiseizure meds
Antipyretics/Cooling blanket
HOB 30-45 degrees
Avoid activities that increase ICP
Traumatic Brain Injury (TBI):
Contact, Accel-Deceleration, or Rotational injuries are examples of — TBI
Cerebral Ischemia is an example of — TBI
Primary
Secondary
TBI:
What is Mild TBI?
Altered or Loss of Consciousness less than 30 mins with normal CT or MRI
GCS of 13-15
Post Traumatic Amnesia less than 24 hrs
TBI:
What is Moderate TBI?
Altered or Loss of Consciousness less than 6 hrs with abnormal CT or MRI
GCS of 9-12
Post Traumatic Amnesia less than 7 days
TBI:
What is Severe TBI?
Altered or Loss of Consciousness greater than 6 hrs with normal CT or MRI
GCS of less than 9
Post Traumatic Amnesia greater than 7 days
Skull Fracture:
Racoon Eyes are a sign of a fracture of which area?
Frontal or Orbital Fracture
Skull Fracture:
Battle Sign (bruising behind ears) are a sign of fracture where?
Basilar Skull Fracture
Contusions:
What are clinical manifestations of Contusion?
Focal findings
Disturbance in LOC
Seizures common
Lacerations:
With a brain laceration, which will we see on opposite side of body as lesion?
What will we see on same side of body lesion?
Hemiplegia (paralysis on side of body)
Dilated pupil
Subdural Hematoma time-frame:
Acute SDH is —
Subacute SDH is —
Chronic SDH is —
first 48 hrs
2 days to 2 wks
2 wks to several months
Subdural Hematoma:
Which type of vessel is ruptured/torn?
venous
Epidural Hematoma:
Which type of vessel is ruptured/torn?
artery
***middle meningeal artery
Epidural Hematoma:
Why might they not seek help?
LOC changes quickly, then they recover lucidity so they think they’re ok
Afterwards, there is rapid deterioration
***Epidural Hematoma is arterial bleeding!!
Epidiural Hematoma:
What will eyes look like?
dilated, fixed pupil on same side of injury
Which hemorrhage is often associated with Cerebral Contusions?
Subarachnoid Hemorrhage
Which hemorrhage results from a brain laceration?
Intracerebral Hemorrhage
***most often in Frontal and Temporal areas
Diffuse Axonal Injury (DAI):
What is DAI?
brain injury in which damage in the form of extensive lesions in white matter tracts occurs over a widespread area.
Diffuse Axonal Injury:
What is Mild?
Moderate?
Severe?
Mild = coma 6-24 hrs (follows commands by 24 hrs)
Moderate = coma greater than 24 hours with NO brainstem signs
Severe = prolonged coma with prominent brainstem signs
