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Test #1 Flashcards

1
Q

What is the parietal lobe responsible for

A

Sensory, reading, writing (sensory and academic skills)

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2
Q

What is the cerebellum responsible for

A

Coordination and voluntary movements

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3
Q

What is the temporal lobe responsible for

A

Memory, hearing, learning, feelings

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4
Q

What is the occipital lobe responsible for

A

Visual reception and interpretation and being able to read

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5
Q

What is the frontal lobe responsible for

A

Problem solving, speaking, emotions, personality (this lobe makes you, “you”)

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6
Q

What are the 4 meninges layers (protective layers of the brain) (starting from the outside and working in)

A
  • Dura mater (think tough - this is on the outside)
  • Arachnoid
  • Subarachnoid space (trabecula for fluid)
  • Pia mater (think soft - this is on the inside)
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7
Q

Forget this card

A

Forget this

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8
Q

What is the monroe-kellie hypothesis

A

That the volume in the brain is a fixed amount (it can’t accommodate for an increase in brain/fluid - something would have to decrease)

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9
Q

What can cause an increase in brain volume 2

A
  • Cerebral edema
  • Occupying lesions like hematomas or tumors
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10
Q

What can cause an increase in blood volume within the skull 4

A
  • Hypercapnia/hypoxemia (causes vasodilation, which increases cerebral blood volume)
  • Obstruction of venous outflow (positioning of the head/neck, medical devices (c-collar))
  • PEEP
  • Valsalva maneuvers (anything bearing down increases the pressure in the head
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11
Q

What can increase the cerebrospinal fluid 3

A
  • Hydrocephalus (cerebrospinal fluid isn’t draining)
  • Obstruction of cerebrospinal fluid outflow (caused by masses, lesions and infections)
  • Decreased cerebrospinal fluid absorption (caused by subarachnoid hemorrhage)
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12
Q

Why is increased ICP bad

A

Because anything that causes a high pressure in the skull disrupts the brain from getting oxygen

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13
Q

What is a normal ICP range

A

Between 5-15 mmhg

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14
Q

When are we worried if the ICP reaches a certain level

A

If ICP reaches above 15, and anything above 20 must be treated

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15
Q

How do we calculate the cerebral perfusion pressure (CPP)

A

Take the MAP - ICP

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16
Q

How do you calculate MAP

A

SBP +2(DBP) / 3

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17
Q

What is the normal cerebral perfusion pressure (CPP)

A

60-100

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18
Q

What CPP levels are we concerned about

A

Less than 50 = ischemia and neuronal death

Less than 30 = incompatible with life

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19
Q

How do you calculate MAP

A

SBP + 2(DBP)
/ 3

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20
Q

In order for autoregulation of cerebral blood flow (CBF), what does the CPP and MAP need to be? Why?

A

CPP should be within 50-150

Map should be within 60-130

Anything above or below makes it difficult for CBF to regulate

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21
Q

How does autoregulation of CBF work

A

CBF can adjust the diameter of the blood vessels supplying the brain, so this is why the pressure in vessels is important

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22
Q

Will autoregulation of CBF work if there is prolonged ischemia

A

No

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23
Q

What is CBF dependent on? What is CPP dependent on?

A

CBF is dependent on CPP, and CPP is dependent on ICP (remember CPP is MAP - ICP)

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24
Q

What are signs of increased ICP 7

A
  • Irritability (being a huge jerk) (kids - have a high pitched cry)
  • Headache
  • Vomiting
  • Decreased LOC (flat affect to coma)
  • Decrease in motor function (decorticate (flexor) and decerebrate (extensor) posture)
  • Pupil changes (blown pupils, fixed/dilated pupils) (anything abnormal with pupils, think that something is wrong in the brain)
  • Changes in VS (bradycardia in kids - huge red flag)
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25
Q

What causes a buildup of CO2?

A

Shallow breathing, not taking many breaths… (you’re not breathing off enough CO2)

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26
Q

How does CO2 affect cerebral blood flow?

A

An increase in CO2 causes the cerebral blood vessels to dilate (relax), which leads to an increase in CBF

A decrease in CO2 causes the cerebral blood vessels to constrict, which leads to a decrease in CBF

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27
Q

Why is it important to maintain a normal CO2 level for someone with a head injury

A

Because we don’t want to increase CBF in a way that will cause more edema in the brain, so we want to keep CO2 at a normal to keep vessels constricted

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28
Q

For any acute unconscious patient, what should we suspect

A

Increased ICP

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29
Q

What is the pathophysiology of ICP

A
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30
Q

An increase in ICP does what to CPP

A

It decreases CPP (remember that ICP is not allowing for proper perfusion)

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31
Q

What are signs of ICP

A
  • Irritability (brain is not getting enough glucose)
  • Headache
  • Vomiting
  • Changes in LOC
  • Loss in consciousness
  • High pitched cry (in kids)
  • Pupil changes
  • Decrease in motor function (contralateral hemiparesis or hemiplegia) (decorticate (flexor) and decerebrate (extensor) posturing)
  • VS changes (bradycardia - especially in kids, and an altered RR)
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32
Q

How would you describe decorticate and decerebrate posturing

A

Decorticate is when the arms are flexed towards your center and decerebrate is when your arms are extended out by your sides

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33
Q

What is interesting about decorticate and decerebrate

A

You can have both at the same time, where one side of your body is decorticate and the other is decerebrate

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34
Q

What is an emergent sign of brain herniation

A

Dilated pupil

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35
Q

What is cushing’s triad 5

A

Late signs of increased ICP, where there is the following:
- Increased systolic BP
- Widening pulse pressure (SBP and DBP are getting further apart)
- Bradycardia with a full and bounding pulse (tachycardia at first)
- Irregular breathing pattern (like cheynes-stokes)
- Decreased respirations

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36
Q

Why is it important to recognize cushing’s triad

A

It can indicate brainstem compression and impending death, so we treat as a medical emergency

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37
Q

What is a ventriculostomy

A

It is placed within areas of the brain and can be used to monitor ICP or drain fluid

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38
Q

If we don’t want to drain any CSF, what device can you use in the brain

A

ICP “bolt”

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39
Q

What 4 things should we know about external ventricular drains

A
  • Must be level with the tragus
  • Surgeon determines where to set the pressure
  • Must remain as sterile as possible
  • Cannot use alcohol swabs
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40
Q

How should we position someone with ICP

A
  • Keep HOB at or above 30
  • Keep head facing forward (neck at midline)
  • Keep legs flat (do not have knees bent)
    NEVER have the patient laying flat (HOB should always be elevated - we want to encourage blood flow down and away from the head)
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41
Q

Can we put someone in Trendelenburg? What about reverse Trendelenburgs?

A

Never in Trendelenburg, we can put in reverse Trendelenburg

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42
Q

Besides positioning, what other nursing interventions can we do for someone with ICP 5

A
  • Avoid hyperthermia (treat with ice packs, Tylenol, fans, cooling blankets)
  • Provide bowel care to avoid straining
  • Reducing environmental stimuli
  • Maintain PaO2 of 100 or greater and CO2 between 30-35
  • Provide pain control
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43
Q

Why do we want to avoid hyperthermia in ICP patients

A

A fever can increase blood flow, which can be deadly for ICP patients

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44
Q

What is our drug of choice for head injuries

A

IV Tylenol - helps treat fever and pain, without reducing LOC

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45
Q

How can we manage an increase in ICP 7

A
  • Maintain CPP between 60-100
  • *Avoid hypotension (want to have enough pressure to overcome an increase in pressure (basically the brain is being squeezed because of an increase in ICP, so you want your BP to have enough pressure to overcome this ICP pressure)) (hypotension can cause a decrease in perfusion)
  • Monitor RR
  • Labs
  • Fluid
  • Electrolytes
  • ## Neuro checks
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46
Q

What type of fluids do we want to avoid giving in an increase ICP pt

A

Hypotonic solutions (like 5% dextrose or 0.45% sodium chloride)

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47
Q

If we have to turn a pt with ICP, how should we turn them

A

Very, very slowly

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48
Q

What is our drug of choice for pain and fevers for someone with ICP

A

IV Tylenol for pain and fever (we like this over an opioid, because it doesn’t effect their neuro or respiratory)

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49
Q

What type of fluid should ICP pts not have

A

Hypotonic, where it can cause cells to swell

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50
Q

How can we manage seizures

A
  • Benzos and anticonvulsants
  • May need to be intubated if reoccurring
  • May need continuous EEG if reoccurring
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51
Q

Why are prolonged seizures bad

A

Seizures cause you to use up a lot of glucose, and the brain needs glucose

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52
Q

What is our drug tx for ICP 4

A
  • Mannitol (osmotic diuretic, that pulls blood off the brain into vascular space)
  • Hypertonic saline 3% (movement of water out of edematous swollen brain cells and into blood vessels)
  • Corticosteroids to treat vasogenic edema (tumor in your brain), not given for head injuries
  • Vasopressors to help maintain CPP
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53
Q

What is interesting about a hypertonic solution, like 3% saline 2

A
  • It burns
  • Have to watch sodium and potassium levels very closely
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54
Q

If someone is receiving hypertonic saline, what should we be monitoring

A

Their sodium closely

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55
Q

Is early feeding important when treating a pt with increased ICP

A

Yes

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56
Q

What is good to know about mannitol 3

A
  • Requires a filter for administration
  • Look for crystal formation, which can occur if med is cold, do not give and send back to pharmacy
  • Requires close monitoring of urine output and serum sodium level
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57
Q

What is a decompressive craniectomy

A

Last line of tx for severe increased ICP, where a portion of the skull is removed to allow the brain to swell outwards

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58
Q

What are the risks associated with a decompressive craniectomy 5

A
  • Hemorrhage
  • Infection
  • CSF leak
  • Delayed wound healing
  • Sinking flap syndrome
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59
Q

What is herniation

A

When the brain swells and moves to an area of lower pressure, like moving down towards the brain stem (which is bad)

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60
Q

What is contraindicated if increased ICP is suspected? Why?

A

Lumbar puncture - you will cause a decrease in pressure when you make that puncture, and the brain will rush to that low area of pressure

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61
Q

What is brain death

A

Irreversible cessation of ALL brain activity

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62
Q

How do they test for brain death

A
  • Apnea testing
  • Reflex tests - like caloric reflex test (put ice water in ear, and the eyes deviate to the side of the cold water if they’re not brain dead)
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63
Q

With head injuries, what should you always suspect

A

A cervical spine injury until proven otherwise (any trauma that meets certain criteria gets a backboard and c-collar)

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64
Q

What are the different types of skull fractures 8

A
  • Linear
  • Depressed
  • Simple
  • Comminuted (broken in two places)
  • Compound (an opening, like a cut or where you can see the bone)
  • Open (can see the dura)
  • Closed
  • Basilar (fracture in the base of the skull)
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65
Q

What are the signs of a basilar skull fracture 2

A
  • “raccoon eyes”
  • “Battle sign” mastoid bruising behind ear
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66
Q

What are you at a huge risk for if you have a basilar fracture

A

CSF leaking and leading to an infection

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67
Q

What is the monroe-kellie hypothesis

A

That the volume in the brain is a fixed amount (it can’t accommodate for an increase in brain/fluid - something would have to decrease)

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68
Q

What is a halo test? How does it work?

A

It helps us to determine if leaking fluid is actually CSF or if it is something else, like mucous.

Take a 4x4 and swab the fluid, and if it’s CSF, then the fluid will form a halo due to the glucose (CSF fluid has glucose) (mucous doesn’t have glucose)

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69
Q

What is interesting about a hypertonic solution, like 3% saline 2

A
  • It burns
  • Have to watch sodium and potassium levels very closely
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70
Q

What is a decompressive craniectomy

A

Last line of tx for severe increased ICP, where a portion of the skull is removed to allow the brain to swell outwards

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71
Q

What are the different types of skull fractures

A
  • Linear
  • Depressed
  • Simple
  • Comminuted (broken in two places)
  • Compound (like an open, where you can see bone)
  • Open (can see the dura)
  • Closed
  • Basilar (fracture in the base of the skull)
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72
Q

What is interesting about skull fractures

A

They lessen the chance of increased ICP, because the brain has somewhere to swell

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73
Q

With an open or depressed skull fracture, what is the pt at risk for

A

Meningitis (because CSF may be open to the air)

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74
Q

If you see a pt having drainage from their ears or their nose, should you swab it

A

No - you don’t want to put your swab into their ear or their nose, instead leave a piece of gauze to collect the drainage

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75
Q

What is the difference between primary and secondary brain injury

A

Primary injury is the injury caused by the trauma, whereas secondary is complications from that brain trauma like ischemia, inflammation, etc)

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76
Q

What is the lowest score you can assign someone based on the glasgow coma scale

A

3

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77
Q

What are the 3 different levels, minor, moderate and severe on the glasgow coma scale

A

Minor = 13-15
Moderate = 9-12
Severe = 3-8

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78
Q

What are diffused brain injuries

A

Generalized injuries like concussions or diffuse axonal injuries

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79
Q

What are focal brain injuries

A

Localized injuries like a hematoma or contusion

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80
Q

What if a pt has a glascow coma scale less than 8

A

We intubate (“anything less than 8 we intubate”), because we are worried that they can’t protect their airway

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81
Q

What is a concussion

A

A mild TBI, which occurs at a microscopic level and is not detectable on imagining

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82
Q

If you are suspecting a concussion, should you still get imagining

A

Yes, to rule out a more severe injury

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83
Q

How do most concussions present

A
  • May have a loss of consciousness
  • Amnesia
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84
Q

In order to be diagnosed with a concussion, what must be present

A

The pt must have at least one brain symptom, like being dazed or confused

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85
Q

What can happen to pts after they have a concussion

A

They can develop post concussive syndrome

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86
Q

What is post concussive syndrome 3

A
  • Develops 2 weeks to 2 months after the injury
  • Can last for 3 or more months
  • Causes difficulty in functioning at previous level
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87
Q

What are symptoms of post concussive syndrome 7

A
  • Headache
  • Lethargy
  • Trouble concentrating
  • *Sleep disturbances (big - if you’re not sleeping, you’re brain can’t heal)
  • Personality and behavioral changes
  • Shortened attention span
  • Changes in memory
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88
Q

What is second impact syndrome

A

When you experience a second concussion while still healing from the first concussion

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89
Q

What is chronic traumatic encephalopathy

A
  • Can only be diagnosed through an autopsy
  • Leads to permanent changes in the brain due to repeated concussions
    (think of football players)
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90
Q

What is a diffuse axonal injury (DAI)

A

Shearing forces cause damage to neurons and nearby blood vessels (twisting of the brain)

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91
Q

What can cause DAIs

A
  • High-speed acceleration
  • Deceleration
  • Rotational injuries
    (common in MVAs)
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92
Q

What does DAI cause in the brain

A

Multiple, small, diffuse hemorrhages located at the boundary of white and gray matter

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93
Q

Is a DAI found on imagining

A

It can be, but it may not be clear

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94
Q

What sucks about DAIs

A

Unpredictable outcomes, with 90% of pts remaining in a persistent vegetative state

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95
Q

What is a contusion

A

Bruise on the brain

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96
Q

Can you see contusions on imagining

A

Yes, because there will be bleeding

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97
Q

What is the issue with a contusion

A

It can “blossom”, where it keeps bleeding in the brain because there’s not really anything in the brain to stop the bleeding

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98
Q

What are the 3 mechanisms that can cause brain injuries

A
  • Acceleration and deceleration (acceleration is the brain going with the forward motion, like being hit with a bat, and deceleration is the brain moving forward and then hitting an object that stops momentum, like hitting the ground while falling)
  • Rotational (axon shearing) (like in boxing)
  • Penetrating (gun shot)
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99
Q

What is coup-contrecoup

A

Coup is when the brain goes through acceleration and hits the front of your skull, and then contrecoup is when the brain rebounds via deceleration and hits the opposite part of the skull (whip lash)

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100
Q

Basically, what is diffuse axonal injury (DAI)

A

When there is some type of brain trauma through acceleration or deceleration, for example, and causes the axons to twist and shear resulting in neuronal death because those axons have been damaged

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101
Q

What is annoying about contusions

A

They can rebleed, known as “blossom”, which leads to poorer outcomes

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102
Q

What should we monitor, besides hemorrhage, if a pt has a contusion

A

Monitor for seizures (they can be more common with frontal or temporal injuries)

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103
Q

Where are subdural hematomas located

A

Below the dura and above the arachnoid layers

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104
Q

Where are epidural hematomas located

A

Below the skull and above the dura

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105
Q

Are epidural hematomas very serious?

A

Yes

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106
Q

Where are subarachnoid hemorrhages

A

Below the arachnoid mater and above the pia mater

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107
Q

Where are intracerebral or intraparenchymal hemorrhages

A

Accumulation of blood in the tissue of the brain instead of in the layers

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108
Q

What is the issue with DAIs

A

They may occur without bleeding, which can make them difficult to see on imagining

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109
Q

What type of bleed is usually venous

A

Subdural hematoma

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110
Q

Who commonly have Subdural hematomas

A
  • Elderly (less brain tissue, which creates more space in-between the layers, which can lead to shearing if they fall)
  • Alcohol abusers
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111
Q

What are the 3 different types of Subdural hematoma and when do they occur

A
  • Acute (developing within 48 hours)
  • Subacute (developing from 48hrs-2 weeks)
  • Chronic (develops weeks after surgery)
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112
Q

What can be symptoms of an acute Subdural hematoma 7

A
  • drowsiness
  • coma
  • headache
  • confusion
  • unilateral headache
  • slowed thinking
  • agitation
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113
Q

What can be symptoms of an subacute Subdural hematoma 4

A
  • Headache
  • Mild contralateral hemiparesis (opposite sided weakness)
  • Drowsiness
  • Confusion
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114
Q

What can be symptoms of a chronic Subdural hematoma 5

A
  • Dementia
  • Headache
  • Lethargy
  • Absentmindedness
  • Vomiting
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115
Q

Does a Subdural hematoma always need to be drained

A

No, not always, they may just let the blood reabsorb

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116
Q

What is happening in an epidural hematoma

A

There’s a fracture, usually linear, that tears an artery or vein in the dura

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117
Q

What are the symptoms of an epidural hematoma

A
  • Initial LOC
  • Followed by a lucid period
  • Then another LOC
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118
Q

What is the tx for epidural hematomas

A

Rapid surgical intervention to evaluate hematoma and prevent herniation (this is a very serious injury)

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119
Q

What usually causes subarachnoid hematomas

A

Ruptured cerebral aneurysm or TBI

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120
Q

What is happening in a subarachnoid hematomas

A

Blood is leaking into the CSF

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121
Q

What is a typical presentation of a subarachnoid hematomas 5

A
  • “Worst headache of life” or also known as a “thunderclap” headache
  • Altered LOC
  • Diplopia (double vision)
  • Meningeal signs (nuchal rigidity, photophobia)
  • Seizures
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122
Q

What can cause intraparenchymal hematomas

A

Most commonly from uncontrolled HTN, ruptured aneurysms or trauma

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123
Q

What is the gold standard for evaluating a pt for a head injury (in terms of imagining)

A

CT, because it’s faster than an MRI

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124
Q

Can you get an accurate glasgow coma scale if the pt is intoxicated or on some type of drugs

A

No, it won’t be accurate if they are impaired due to a substance

125
Q

What do we do if we see CSF drainage 6

A
  • Keep HOB elevated
  • Put collection pad under nose or over ear
  • Do not put anything in nose or ear
  • No sneezing or blowing nose
  • No NG tube
  • No nasotracheal suctioning
126
Q

Should we put in an NG tube regardless if we see CSF drainage

A

NO - never put an NG tube in a pt with a suspected head injury. You can put an OG tube in.

127
Q

What is meningitis

A

Inflammation of the meninges from an infection (usually bacterial or viral)

128
Q

What can help decrease the prevalence of meningitis

A

Vaccinations

129
Q

What types of viruses can cause meningitis 3

A
  • Herpes
  • Measles
  • Mumps
130
Q

Is meningitis considered a medical emergency? Why or why not?

A

Yes - because it can lead to an increase in ICP, which may lead to herniation
- Can also get sepsis really quickly (especially in kids)

131
Q

Where are risky places to get meningitis

A

Usually in places where people are living close together, like in dorms

132
Q

What are the symptoms of meningitis 7

A
  • Fever
  • Headache
  • Nuchal rigidity (having pain/stiffness when you put your chin to your chest)
  • Photophobia
  • Petechial rash (bacterial)
  • Abnormal behavior
  • LOC changes
133
Q

What is a symptom of meningitis in kids

A
  • A high pitched, shrill cry
  • Bulging fontanels
134
Q

What type of precautions should you be on for someone with meningitis

A

Droplet

135
Q

What type of airflow should you have for meningitis

A

Negative airflow, so the air doesn’t leave the room (air can come in, but doesn’t go out)

136
Q

How do we diagnosis meningitis

A

Lumbar puncture to check for WBCs

137
Q

How do we treat meningitis

A

Broad spectrum antibiotics that cross the blood brain barrier (pt will usually have a PICC)

138
Q

In order to help avoid spinal headaches after a lumber puncture, what should we have the pt do

A

Lay flat

139
Q

What are the two body movement signs that may indicate meningitis

A
  1. Kernig sign (if you put your knee at 90 degree and then try and extend it up towards you, it’s painful)
  2. Brudzinski sign (flexing your chin to your chest is painful)
140
Q

What can commonly cause a brain abscess

A
  • Infection from ear, tooth, mastoid or sinus (infection can spread)
141
Q

What is encephalitis

A

Inflammation of the brain

142
Q

Can encephalitis be deadly

A

Yes

143
Q

encephalitis can be caused by many different things, including viruses, what are some of the viruses that can cause it

A
  • West nile (caused by mosquitos - always suspect this in pts over 50 years old and it’s summer time)
  • Chickenpox
  • Measles
  • Mumps
  • Herpes
144
Q

What do a lot of people with spinal cord injuries die from

A

Pneumonia and septicemia (like from UTIs)

145
Q

What are 3 ways to classify spinal cord injuries

A
  1. Degree of injury
  2. Level of injury
  3. Mechanism of injury
146
Q

What are the two different types of degree of injury

A
  1. Complete spinal cord injury (loss of all voluntary motor and sensory function across the entire level of the spinal cord injury below the level of injury, like being severed or having a gun shot). Ex - paraplegics, quadriplegics)
  2. Incomplete spinal cord injury (loss of only some of the sensory and motor function below the level of injury, caused by partial damage to the spinal cord (you’re a paraplegic, but may have some feeling in parts of your legs)
147
Q

What happens if the spinal cord injury is at T1 or above

A

you’re a quadriplegic

148
Q

What happens if the spinal cord injury is between T1-T6

A

You’re a paraplegic (lose upper chest and down)

149
Q

What happens if the spinal cord injury is between T6-T12

A

Paraplegic (lose from the waist down)

150
Q

What happens if the spinal cord injury is from L1-L5 down

A

You’re a paraplegic below the waist

151
Q

If a pt has a c-spine injury, what should we be worried about

A

Their respiratory - since they might have paralysis in that area

152
Q

What part of the spine is most vulnerable to injury

A

Cervical

153
Q

An injury to c1 or c2 may be fatal due to what

A

Damage to the respiratory drive

154
Q

Where at in the spinal cord separates a quadriplegic from a paraplegic

A

Any injury above T1 (so all of c-spine), causes a person to become a quadriplegic.
Any injury at T1 or below causes a person to become a paraplegic

155
Q

Are lap belts still at risk for causing an injury

A

Yes, seatbelts should be cross body

156
Q

What is the difference between the primary injury and the secondary injury in terms of spinal cord injuries

A

The primary injury is the specific injury that caused the damage to the spinal cord, while the secondary injury is the body’s response to that injury, like swelling

157
Q

What are the 5 different mechanisms of primary injuries

A
  1. Hyperflexion (caused by sudden deceleration, where the head is thrown forward - the spine goes forward)
  2. Hyperextension (caused by forward and backwards motion, like whiplash)
  3. Flexion-rotation (caused by excessive twisting, like from sports accidents or from not wearing a seatbelt)
  4. Compression (like if you dive and hit the ground)
  5. Distraction (excessive stretching, like from a hanging)
158
Q

What is the issue with swelling in the spinal cord?

A

The swelling is going to go up or down the spinal cord, which can cause damage to the surrounding cord

159
Q

Besides inflammation, what are two other examples of a secondary injury

A
  • Hemorrhage
  • Ischemia
160
Q

What is difficult to do if there is a lot of swelling from a secondary injury

A

It can make it difficult to determine the prognosis and full extent of the permanent injury until the swelling has gone down. This is why providers won’t make a prognosis until after72 hours due to the swelling. (think of people getting into accidents and thinking they’re paralyzed, but maybe that changes after a couple of days due to the swelling going down)

161
Q

What are unstable spinal fractures

A

Where the bony structures and/or ligaments are unable to support and protect the injured area - these patients require stabilization

162
Q

What is the preferred imagining for spinal injuries

A

CT

163
Q

What type of imagining is more common in cervical spine injuries? Why?

A

Angiography - to see vertebral artery injury

164
Q

Why don’t we want to give metformin before imagining

A

It can be really hard on the kidneys

165
Q

Why do we want to know details about the event that caused the spinal cord injury

A
  • We want to know the mechanism of action, so we can better determine what happened to their spine.
166
Q

Can you rule out a spinal cord injury on someone who is intoxicated or on drugs

A

No, you have to assume they have a spinal cord injury until they are sober enough to do assessments on

167
Q

What 2 things do you need to clear a pt from a c-spine

A
  1. Look at imaging
  2. Do an in-depth physical assessment (like assessing dermatomes)
168
Q

What is a SCIWORA? What does it mean? Who commonly has them?

A

Spinal cord injury without radiographic abnormality.

Means that a CT does not show evidence of a spinal cord injury, but there may actually be a spinal cord injury (like to the ligaments), which is why it is important for us to do a physical exam as well to clear c-spine injuries.

Common in pediatrics.

169
Q

If a pt has a complete cord injury at c5 or above, what should we do

A

Intubate

170
Q

What tests should we be doing to assess for spinal damage 5

A
  • Hourly neuro checks
  • Check respiratory looking at expiratory volumes, ABGs
  • Check motor status using the 5pt scale checking against both gravity and resistance
  • Sensory status using dermatomes
  • Reflexes like deep tendon reflexes and perineal reflexes (which may indicate that bowel and bladder training may be feasible)
171
Q

What are cardiac symptoms associated with spinal cord damage

A

Any injury above T6 can lead to dysfunction of the SNS, which can lead to vasodilation, bradycardia and hypotension (neurogenic shock)

172
Q

What are urinary symptoms associated with spinal cord damage

A

Neurogenic bladder (might need to straight cath, might have a foley)

173
Q

What are GI symptoms associated with spinal cord damage

A
  • Neurogenic bowel
  • Decreased gastric emptying
  • Paralytic ileus
174
Q

Can spinal cord injured pts have poikilothermia? What is it?

A

Yes - it is where they cannot regulate their temperature, because peripheral temperature sensations cannot reach the hypothalamus.

They also cannot shiver or sweat below the injury.

175
Q

Will metabolic needs increase or decrease with a spinal cord injury

A

They’ll increase, because the body is trying to heal

176
Q

Can spinal cord injured patients have pain?

A

Yes, it can be either nociceptive (like in a muscle) or neuropathic, which can be at or below the level of injury

177
Q

Know the dermatones (what happens at C-spine injuries, T-spine injuries, etc)

A
178
Q

Where is T4 dermatome? What about T10?

A

Right at the nipple. Belly button.

179
Q

What is spinal shock? Is it permanent?

A

Absence of all reflexes, flaccidity and loss of sensation below the injury. No - it’s not permanent. It can last for days to month.

180
Q

When is the onset of spinal shock

A

30-60 minutes after an injury.

181
Q

What is neurogenic shock

A

Basically decreased cardiac output which can lead to hypovolemic shock, where there is a loss of sympathetic nervous system control

182
Q

At what location on the spine or above do we typically see neurogenic shock

A

T6 or above

183
Q

What is happening in hypovolemic shock

A
  • Veins dilate
  • Blood pools
  • Decreased venous return
  • Hypotension
  • Bradycardia
  • Hypothermia
  • Unable to sweat below the injury
184
Q

With a possible c-spine injury, can you use head tilt-chin-lift? If not, what can you use instead?

A

NO - use jaw thrust

185
Q

What are the 2 surgical interventions for SCIs (spinal cord injuries)

A
  • Decompression surgery possibly to help remove fragments
  • Surgical intervention to fuse spinal segments or place rods
186
Q

Is it possible to use corticosteroids in SCIs

A

Yes and no - we can use them to decrease the likelihood of a secondary injury, but they also increase the risk of pneumonia, delayed wound healing and electrolyte imbalances

187
Q

What are 3 different devices we can use to stabilize a c-spine injury

A
  • Gardner-wells tongs
  • Clam shell
  • Halo
188
Q

What is some good care for a halo vest

A
  1. Report if pins are loose or there are signs of infection
  2. Clean area around pins with chlorhexidine, water or half strength peroxide and apply antibiotic ointment
    - Have pt lie down to loosen one side of vest and clean skin and check skin for breakdown, and then repeat on the other side
    - Dry with vest with hairdryer if it becomes wet or damp
    - Keep wrenches nearby in case of emergency
189
Q

What is the most common cause of death among those with SCIs

A

Respiratory issues

190
Q

If a pt is injured at c1-c2, what will they need respiratory wise

A
  • Mechanical ventilation
  • Tracheostomy
    (because they have a loss of respiratory muscle function, known as the phrenic nerve)
191
Q

If a pt is injured at c3-c6, what will happen respiratory wise 3

A
  • Diaphragmatic paralysis
  • Hypoventilation
  • Decreased vital capacity and tidal volume due to impaired intercostal muscles
192
Q

If someone with a SCI is bradycardic, what should we have at the bed side?

A

Atropine (help increase HR)

193
Q

Besides atropine, what other cardiac interventions may we do for someone with an SCI 3

A
  • Temporary or permanent pacemaker
  • May need IV fluids
  • Vasopressors for hypotension (these constrict the blood vessels)
194
Q

What is our SBP goal for someone with an SCI

A

Above 90, as anything below 90 indicates poor perfusion

195
Q

What is our MAP goal for someone with an SCI

A

85-90

196
Q

Why might excessive suctioning be bad for an SCI pt

A

It can cause a vagal response, which may decrease their HR even more

197
Q

What are GI interventions we could do for someone with decreased motility or distension 2

A
  • Can give metoclopramide to increase peristalsis
  • Use a NG tube for decompression
198
Q

When should nutrition be started for an SCI pt

A

Within 72 hours

199
Q

What volume of bladder should we keep less than for an SCI pt

A

Less than 500 mls

200
Q

What is a blood complication for someone with an SCI

A

They meet the criteria for Virchow’s triad, because they have venous stasis, hypercoagulation and endothelial injury

201
Q

How long should enoxaparin be given for someone with an SCI

A

For at least 8 weeks

202
Q

What is an autonomic dysreflexia

A

There’s something that may be bothering the pt’s body, like a full bladder, and they don’t know it because they can’t feel it, which leads to an overexaggerated response from the SNS

203
Q

What area on the spine injury may be impacted by autonomic dysreflexia

A

T6 or above are at risk

204
Q

What are signs of autonomic dysreflexia 6

A
  • *Hypertension due to vasoconstriction below the level of injury (anything about 20-40 above their normal SBP)
  • Sweating
  • Goosebumps
  • *Sudden headache
  • Blurred vision
  • Anxiety
205
Q

Does the parasympathetic nervous system respond to autonomic dysreflexia

A

Yes, it causes vasodilation, flushing, pupil constriction, stuffy nose, and decreased HR above the level of injury

206
Q

What are our interventions for autonomic dysreflexia

A

***Determine the cause right away (like emptying the bladder)
If uncorrected, it could lead to stroke, MI or death

207
Q

What are common causes of autonomic dysreflexia 7

A
  • Bladder distension
  • Bowel impaction
  • Temperature changes
  • Tight irritating clothing
  • Pain
  • UTIs
  • Pressure ulcers
208
Q

Where might someone with an SCI have neuropathic pain

A

Just above, at the level of or below the level of injury

209
Q

What drugs can we give for neuropathic pain

A
  • Neurontin
  • Lyrica (gabapentin)
  • Pregabalin
210
Q

Pts with SCI can get spasticity, this can help with venous return, but can make movements more difficult, what can be done?

A
  • ROM
  • Antispasmodic drugs like baclofen and botulinum toxin
211
Q

What are the six syndromes associated with incomplete spinal cord injury

A
  1. Central cord
  2. Anterior cord
  3. Brown-sequard
  4. Posterior cord
  5. Cauda equina
  6. Conus medullaris
212
Q

What is central cord syndrome? What causes it? What are symptoms? 5

(**Know this one)

A
  • Damage to the central spinal cord most often in the cervical region
  • Caused by hyperextension
  • Motor weakness in the upper extremities
  • Burning pain in upper extremities
  • Lower extremities are usually not affected
213
Q

What is anterior cord syndrome? What causes it? What are symptoms?

(don’t need to know)

A

Damage to anterior spinal artery resulting in decreased blood flow to the anterior spinal cord (front)

Flexion injuries

Loss of motor function, pain, temperature below the level of injury

Will have a preserved sense of touch proprioception (position sense), pressure and vibration

214
Q

What is posterior cord syndrome? What causes it? What are symptoms

(don’t need to know)

A

Damage to the back of the spine

Caused by acute compression (very rare)

Loss of proprioception (where body is in space) and vibration below the level of injury.

Will have intact pain, motor function and light touch

215
Q

What is brown-sequard syndrome? What causes it? What are symptoms?

(don’t need to know)

A

Damage to half of the spinal cord.

Caused by penetration

Ipsilateral (same side) loss of motor function, proprioception, light touch and vibration.

Contralateral (opposite side) loss of pain and temp below the level of injury.

216
Q

What is conus medullaris? What are symptoms?

(don’t need to know)

A

Damage to the lowest part of the spinal cord

  • Motor function in legs may be preserved, weak or flaccid
  • Decreased loss of sensation in bowel or bladder
  • Impotence
217
Q

What is cauda equina syndrome? What can cause it? What are symptoms? 6

(** know this one because it’s common)

A

Damage to cauda equina (lumbar and sacral nerve roots)

Can be a complication of herniated disc.

-Asymmetrical distal weakness
- patchy sensation in lower extremities
- may cause flaccid paralysis of lower extremities,
-complete loss of sensation in the saddle area,
-flaccid bladder and bowel,
-severe, radicular, asymmetric pain

218
Q

What if a pt, who just had an SCI, asks you their prognosis?

A

Tell them that it is too early to know, it will take at least 72 hours if not more to determine a prognosis

219
Q

What can spinal cord tumors cause in the spinal cord

A

Compression

220
Q

What are symptoms of spinal cord tumors 5

A
  • *Low back pain (most common early symptom)
  • Numbness
  • Tingling
  • Weakness
  • Loss of manual dexterity and clumsiness
221
Q

What is the gold standard to determine if a pt has a spinal tumor

A

MRI

222
Q

Is chemo helpful with spinal tumors

A

No

223
Q

What are signs of brain tumors

A

Anything we see with ICP
- Changes in LOC
- Cognition
- Headaches
- Seizures
- Personality changes

224
Q

What is trigeminal neuralgia

A

A sudden, usually unilateral , severe, brief, stabbing, recurrent episodes of pain in the distribution of the trigeminal nerve.

225
Q

What are the symptoms of type 1 trigeminal neuralgia

A

abrupt onset of waves or excruciating pain burning, knifelike, or lightening like shocks in the lips, upper or lower gums, cheek forehead or side of the nose.

226
Q

What are the symptoms of type 2 trigeminal neuralgia

A

constant aching, burning, crushing or stabbing pain (more chronic)

227
Q

How long are trigeminal neuralgia attacks

A

Seconds to 3 minutes

228
Q

What is our drug therapy for trigeminal neuralgia

A

Help with pain using the below drugs:
- Antiseizure drugs
- Tricyclics

229
Q

What is Bells palsy

A

An acute, usually temporary, facial paralysis resulting from damage or trauma of the facial nerve (CN VII)

Usually affects only one side of the face, but both sides can be affected

230
Q

Who is at risk for developing bells palsy

A

Peak incidence is between ages 15 and 60 with high incidence in pregnancy and in persons with URI’s (upper respiratory infections), obesity, diabetes and hypertension.

231
Q

What do they think the cause of bells palsy is

A

Cause is unknown but some think it is a reactivation of HSV and/or herpes zoster, or demyelination

232
Q

Are there definitive tests for bells palsy

A

No, just a physical diagnosis (there aren’t any tests)

233
Q

How do we treat bells palsy

A

Treat the symptoms, like protecting the eye, because the eyelid might not be able to close, so you want to keep it moist.

Can use steroids and acyclovir in some.

234
Q

How long do bells palsy symptoms last

A

48-72 hours.

235
Q

What organs can be donated 6

A
  1. Heart
  2. Lungs
  3. Liver
  4. Kidneys
  5. Intestine
  6. Pancreas
236
Q

What tissues can be donated 5

A
  1. Cornea
  2. Tendons
  3. Valves
  4. Skin
  5. Bones
237
Q

What organ are over 83% of people on a waiting list for

A

Kidneys

238
Q

When should you call the donor referral line 3

A

Call on ventilated patients within one hour if they have any of the following:
1. Glasgow coma score at or below 5
2. Absence of one or more brainstem reflexes (pupils fixed, no corneal reflexes, no cough, no gag, no spontaneous movement or response to painful stimuli, no spontaneous respirations)
3. Anticipated end-of-life discussions

239
Q

What are the 2 definitions of death

A
  1. Irreversible cessation of circulatory and respiratory functions

or

  1. Irreversible cessation of all functions of the entire brain, including the brain steam.
240
Q

What are the 2 types of donors

A
  1. Brain dead donor
  2. Donor after cardiac death
241
Q

When is a person considered to be a donor after circulatory death

A

When they are likely to die within 120 minutes of extubating

242
Q

After a person passes away due to donation after circulatory death, when are organs recovered

A

After 5 minutes (they wait 5 minutes before they begin to recover the organs)

243
Q

What group maintains the national waiting list

A

UNOS (United Network for Organ Sharing)

244
Q

What is organ allocation based on

A
  • Severity of patient’s medical condition
  • Tissue match
  • Patients waiting time
  • Blood type
  • Body size
  • Immune status
  • Geographic distance
  • Is the patient well enough for transplant
245
Q

How long can a heart, lungs, liver and kidney last

A
  • Heart 4-6hrs
  • Lungs 4-6hrs
  • Liver 12-24hrs
  • Kidneys 24-36hrs
246
Q

If a donor dies by cardiac death, are they likely to donate organs?

A

No, typically organs are only recovered from brain dead patients, instead, cardiac death patients can donate tissues

247
Q

What does the term graft mean

A

Transfer of tissue from one person to another

248
Q

What is an autograft

A

When tissue is transferred from one part of a patient’s body to another (like skin after burns)

249
Q

What is an allograft

A

Transferring an organ from one person to another

250
Q

What is a heterograft

A

Transferring tissue between two different species

251
Q

What are the 4 criteria to determine if someone is brain dead

A
  1. Acute CNS catastrophe
  2. No other medical things going on that may mimic brain death
  3. No drug intoxication or poisoning
  4. Core temp greater than or equal to 90 degrees
252
Q

What are the 3 cardinal signs of brain death

A
  1. Coma or unresponsiveness
  2. Absence of brainstem reflexes (not responding to anything, even pain)
  3. Apnea (when disconnected from the ventilator they do not show any signs of trying to breath and their PaCO2 rises to 60)
253
Q

What are some goals to maintain our donor 5

A
  • Keep MAP between 60-110
  • Keep ph between 7.3-7.5
  • Keep sodium below 155
  • Keep glucose below 150
  • Keep urine output at 0.5ml/kg/hr
254
Q

What does the body try to do when it goes brain dead

A

It releases catecholamines, which increase HR and BP to try and get the body to perfuse, after those run out it will go into hypotension (why she said to have the vasopressors ready to combat the drop in pressure)

255
Q

Besides pressure increasing, what else happens within the body once it goes brain dead 2

A
  • Hypothermia (may have hyperthermia)
  • ## ADH is no longer secreted, so you can become DI (give vasopressin, (mimics ADH))
256
Q

So what will we do if our pt becomes hypotensive 3

A
  • Give fluids
  • Give levothyroxine
  • Give dopamine to mimic catecholamines
257
Q

What 3 tests do we do to determine if a donor matches a recipient

A
  1. Tissue typing
  2. Cross matching
  3. ABO typing
258
Q

What is tissue typing

A

Determining the human leukocyte antigen (HLAs) compatibility, which is where the body has antigen on each of our selves, and this allows us to recognize things in our body as “self”, anything that doesn’t match is considered foreign

259
Q

What is crossmatching

A

Where you mix the donor and recipients blood together to see if it forms a panel of reactive antibodies (PRAs), where the normal value should be 0%, anything above may indicate an issue.

260
Q

What is a graft rejection? What are the 3 different types.

A

Where the body recognizes the new tissue or organ as foreign, triggering an immune response.

  1. Hyperacute rejection
  2. Acute rejection
  3. Chronic rejection
261
Q

What is happening in hyperacute rejection

A

Very aggressive immune response that happens within minutes or hours following a transplant. It’s where antibodies were already formed prior, which leads to a rapid trigger of the immune response (luckily, it is pretty rare now)

262
Q

What is happening in an acute rejection

A

Occurs within days - weeks.

T cells and macrophages begin to destroy the graft

It can be stopped and the organ can be preserved if treated promptly

263
Q

What is happening in a chronic rejection

A

Slow response that may take years to destroy an organ

264
Q

What are 4 complications from immunosuppressants

A
  1. Infection
  2. Malignancy (because you’re immune system is being suppressed, it can’t fight off cancer)
  3. Organ dysfunction (immunosuppressants can cause dysfunction in organs)
  4. Hyperglycemia
265
Q

What is the leading cause of death in recipients

A

Infection

266
Q

How can a recipient get an infection

A

Think of CREDIT

C = community acquired (where the infection is coming from the recipient’s community, like a cold virus, GI pathogen, etc)

R = Reactivation of previous infection (pathogens reactivating from a donor state, like HIV, or herpes, these may also come from the donor organ)

E = epidemiologic exposure (exposure coming from the recipient’s environment, like through gardening, sexual history, pets, etc)

D = donor derived infections

I = Iatrogenic (infections acquired in the hospital)

T = Travel

267
Q

Because recipients are on immunosuppressants, what might indicate an infection

A

A low grade fever, like at 100.5

268
Q

What is the number one immunosuppressant? What does it do? What are the two common drugs?

A

Calcineurin inhibitors

They stop the production of T cells

Two examples are tacrolimus and cyclosporine (cyclosporine does not play nicely with other drugs)

269
Q

What is some good pt teaching with steroids 3

A
  • Do not abruptly stop taking
  • Take with milk or food
  • Take at the same time everyday
270
Q

How are cytotoxic drugs (like mycophenolate mofetil) used

A

Targets B and T cells and stops their production (remember this drug targets specific cells)

271
Q

What are monoclonal antibodies (basiliximab) and polyclonal antibodies? what are they used for?

A

Targets T cells and are primarily used for renal graft rejection

272
Q

What are hematopoietic stem cell transplants

A

Healthy stem cells are infused into a recipient to restore normal bone marrow growth.

These are often cancer pts like leukemia, multiple myeloma, and lymphomas, where the replenishment of healthy bone marrow allows them to receive larger doses of chemo

273
Q

What is the difference between autologous and allogeneic transplantations

A

Autologous are from self, while allogeneic are from none-self

274
Q

What is graft versus host disease

A

Complication from allogeneic stem cell transplant patients, where the donor T cells see the recipient’s tissues as foreign and start to attack

275
Q

How can we prevent graft versus host disease

A

Provide prophylaxis tx with immunosuppressants or remove T cells from the graft prior to insertion

276
Q

What are acute signs of graft versus host disease 4

A
  1. Skin rash and blisters
  2. Severe abdominal pain
  3. Severe diarrhea
  4. Liver injury
277
Q

What are chronic signs of graft versus host disease 5

A
  1. Skin rash and itching
  2. Skin texture and color changes
  3. Skin scarring
  4. Dry mucous membranes and eyes
  5. Liver injury
278
Q

What does the U.S. Office of Minority Health (OMH) do?

A
  • Provide policy makers and others concerned with health disparities a better appreciation of the issues.
  • Understand better the interrelationship of all the variables.
  • Provide a research format and direction for data input.
  • Give building blocks to the community stakeholders so they can contribute input and improve structure.
  • Improve the systematic planning of data collection, interventions, and evaluation
279
Q

What are unavoidable and acceptable health disparity categories

A

Age, genetics (emergency room is full of older adults, but this is because they have more problems as they age, which is acceptable) (we should not be concerned with these, this is just part of life)

280
Q

What is unavoidable and unacceptable category

A

A certain population like hispanics, are more prone to getting diabetes (which is unavoidable), however, inappropriate diabetes is unacceptable (this is a concern for nurses)

281
Q

What is the avoidable and acceptable category

A

Having a natural disaster occur and having unequal health outcomes for residents in the same area (acceptable), whereas if a plan had been in place to avoid these unequal outcomes than that would make it avoidable.
(this one is confusing - pretty rare too)

282
Q

What is avoidable and unacceptable

A

High cost of health care, no health care insurance, lack of transportation, mistrust of the healthcare system

283
Q

What is health status disparities

A

The variation in rates of disease occurrence and disabilities between socioeconomic and/or geographically defined population groups

284
Q

What are healthcare disparities

A

Differences in access to or availability of facilities and services

285
Q

What is a health gradient

A

A series of progressively increasing or decreasing differences between populations

Reflects the relationship between health and income at the population level with health gradually improving as income improves

286
Q

What is a social gradient

A

a gradient in health that runs from top to bottom of the socioeconomic spectrum….The social gradient in health means that health inequities affect everyone (when someone doesn’t get care, everyone is affected (the whole healthcare system is impacted)

287
Q

What term can we use to analyze underlying factors that contribute to disparities in health outcomes

A

Social capital

288
Q

What is social capital

A

Person’s or community’s capacity to obtain support from available social connection

289
Q

How does culture influence social capital? What if a person is separated from their culture?

A

A person’s cultural identity provides a sense of connection to a community of individuals who share a culture, which can lead to an increase in social capital and often improved health

Being separated from your culture can cause a person to experience isolation, which increases their vulnerability

290
Q

What is social justice

A

Since health disparities represent a lack of equality in health outcomes among groups, it is important to adopt a doctrine of social justice related to health and to strive to promote equal opportunities to maximize the health of individuals and communities

A state or doctrine of eqalitarianism

291
Q

What influences the vulnerability at the population level

A
  • Social determinants of health including economic and environmental factors
  • Social capital
  • Health system determinants
  • Individual risk factors and population-level factors influence the vulnerability of at-risk groups
292
Q

What are three determinants of vulnerability

A
  • Marginalization
  • Discrimination
  • Stigma
293
Q

What is marginalization

A

a social process through which a person or group is on the periphery of society based on identity, associations, experiences, or environment

294
Q

What factor is perhaps has the most influence on health status

A

Economic

295
Q

How do you determine socioeconomic status

A

Measure of income, education and occupation

296
Q

What are 4 definitions of homelessness

A
  • An individual or family who lacks a fixed, regular, and adequate nighttime residence, such as those living in emergency shelters, transitional housing, or places not meant for habitation, or
  • An individual or family who will imminently lose their primary nighttime residence (within 14 days), provided that no subsequent housing has been identified and the individual/family lacks support networks or resources needed to obtain housing, or
  • Unaccompanied youth under 25 years of age, or families with children and youth who qualify under other Federal statutes, such as the Runaway and Homeless Youth Act, have not had a lease or ownership interest in a housing unit in the last 60 days, and who are likely to continue to be unstably housed because of disability or multiple barriers to employment, or
  • An individual or family who is fleeing or attempting to flee domestic violence, has no other residence, and lacks the resources or support networks to obtain other permanent housing.
297
Q

What are outcomes of adults experiencing homelessness

A
  • Limited access to health-care
  • Excessive disease burden
  • Shorter life expectancy
  • Consumption of significantly more health-care resources when they do finally receive care
298
Q

What is a food swamp

A

Access to more unhealthy food than healthy foods

299
Q

What is the housing-first model

A

Promotes providing immediate housing with supportive services

300
Q

What is an immigrant

A

Legally emigrates from one country to another to take up permanent residence

Lawful, permanent resident alien: a person who is not a citizen but entered the country with a valid visa and obtained a work permit as well as permission to stay indefinitely

301
Q

What is a migrant

A

One who moves from place to place to obtain work, often in a country that is not his or her own (may or may not be legal)

(migrants are at increased risk for exploitation and human trafficking/slavery

302
Q

What is the issue with migrants

A

migrant workers are at increased risk for exploitation because of limited social protection, inequalities in the labor market and increased risk for human trafficking/modern slavery

303
Q

What is a refugee

A

a person outside of his or her country of nationality who is unable or unwilling to return because of persecution or a well-founded fear of persecution

(like people fleeing from the earthquake)

304
Q

What is an asylee

A

a person currently in-country “who is unable or unwilling to return to his or her country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, or membership in a particular social group of political opinion

305
Q

What are children who live in refugee camps at risk for

A

Stunted growth due to chronic malnutrition

306
Q

What is the difference between incarcerated and correctional population

A

Incarcerated are living in prisons or jail, while correctional includes both incarcerated as well as people on probation or parole

307
Q

The United States has 5% of the world’s population and 25% of its prisoners!

A
308
Q

Do LGBTQ elders tend to be mistrustful of mainstream medical and social services? Why?

A

YES!

often wary of sharing their sexual orientation with their medical and social service providers or of seeking out such services when needed

past experience of insensitivity and discrimination by health-care and social service providers

202A (5 decks)

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