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203D > Test #1 > Flashcards

Test #1 Flashcards

1
Q

what are the 4 lobes responsible for

A

Frontal: emotions, speech, judgment, problem solving, voluntary movement

Occipital: visual information- how we process color and shape,

parietal lobe: sensory perception, spatial orientation

temporal: visual and verbal memory, allows interpretation emotions and reactions, memory

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2
Q

what is the cerebellum responsible for

A

balance coordination

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3
Q

what is the brainstem responsible for

A

breathing, heart rate, consciousness

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4
Q

what is the purpose of a neurologic assessment

A

to check for changes in LOC

  • confused?
  • lethargic/drowsy?
  • obtunded?
  • stupor?
  • deep coma?
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5
Q

what is avpu

A

pt is awake
pt responses to Verbal
pt responses to Painful
pt is Unresponsive

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6
Q

what do you do when you have a confused or combative pt

A

Look for the source that is causing the confusion or combativeness

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7
Q

if a patient comes in and has paralysis of a limb, irritable, has a hard time getting words out and has difficulty problem solving what area of the brain is most likely effected?

A

the frontal lobe

the frontal lobe is responsible for personality, emotions, intelligence
concentration, judgment
body movements and speech (speak and write)

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8
Q

if a patient is experiencing aphasia, unable to recognize faces or objects, increased aggressive behavior and problems with short and long term memory, what area of the brain is most likely effected

A

the temporal lobe

the temporal lobe is responsible for speech (understanding language), memory, hearing, sequencing and organization

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9
Q

If a patient has problems distinguishing left from right, problems with hand eye coordination, what part of the brain is most likely effected

A

the parietal lobe

the parietal lobe is responsible for sense of touch, pain and temp
distinguishing size, shape and color
spatial perception and visual perception

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10
Q

if a patient is experiencing vision defects or blind spots, illusions/hallucinations, what area of the brain is most likely effected

A

the occipital lobe

the occipital lobe is responsible for vision

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11
Q

If a patient has a difficult time swallowing, vertigo, and changes in breathing what part of the brain is most likely effected

A

the brain stem

the brain stem is responsible for breathing, heart rate, alertness and consciousness

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12
Q

if a patient comes in that is experiencing loss of balance, vertigo, slurred speech, what part of the brain is most likely effected

A

the cerebellum

the cerebellum is responsible for balance and coordination

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13
Q

what are three main things we look at for a neurologic assemssment

A

vital signs
current health
past hx and meds (that could be causing the altered LOC)

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14
Q

how do we assess cerebral function

A
  • A&O x4
  • memory
  • intellectual performance
  • judgment and insight (logical thinking)
  • language and communication (is language appropriate)
  • Mood and Affect- angry tearful etc.
  • cranial nerves
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15
Q

how do you test memory

A

Short term

  • give them 3 random words, and see if they remember
  • year, date, season, where they are

Long term-
ask them if they have kids, if they are married, etc.

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16
Q

what are the cranial nerves I-III

A

CN I = olfactory
C II = optic - visual fields
CN III = oculomotor- reflex to light, eyelid control

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17
Q

where are the cranial nerves

A

CN I and II are in the cerebrum and III-XII are in the brainstem

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18
Q

what is ptosis

A

drooping of the eyelid- CN III issue.

could be the pts baseline- need to know

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19
Q

what do CN IV V and VI do

A

IV - trochlear, VI - abducens = help move the eye

CN V - trigeminal - sensory and motor- puffing of cheeks, light touching of the face to see if pt can feel it.

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20
Q

CN VII VIII

A

cranial nerve VII is facial expression.
raise eyebrows, grimace etc.

cranial nerve VIII is vestibularchochlear = hearing.

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21
Q

cranial nerve IX and X

A 
IX = glossopharyngeal, - gag and swallow 
X = vagus - gag and cough
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22
Q

cranial nerve XI

A

spinal accessory
-shoulder shrug
if pt can do that- the diaphragm is in tact

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23
Q

cranial nerve XII

A

hypoglossal

- asking pt to portrude tongue

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24
Q

how to assess cerebellum

A

if they are up out of bed they can do the romberg tests
-rub heel from opposite ankle all the way up and back down- if they can do this their coordination is in tact

  • for upper extremity coordination
  • rapid movement- flipping hands over and back again,
    fine motor test- finger to nose to examiners finger

finger coordination - bring fingers to thumb

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25
Q

How do you assess sensory perception

A

Tactile-rub on their foot
Pain vibration

Stereogenosis-identify object in their hand
Two point discrimination-know which way pattern is
Grapheshesia-know the pattern

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26
Q

Why would someone be experiencing cheyne stokes

A

The brain is putting pressure on the brain stem

If a pt is breathing this way it is a sign the patient is going to go into a coma

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27
Q

What is cheyne stokes respirations

A

Rapid breathing increasing o2 followed by a period of apnea and decrease in O2

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28
Q 
1 Lumbar puncture
2 Myelogram
3 Cerebral angiogram
4 Evoked potential
5 Trans cranial Doppler 
6 Ct scan
7 MRI
8 EEG

What do these look for

A

1-looking for infection, dx for SAH or epidural bleed
2-looking for tumors or damage in the spinal column
3-looking at the vasculature and blood flow
4-to see if the nerves are receiving the messages
5-measuring the velocity of blood flow within the brain
6-fluid and air appear dark/black
7-greater detail than CT
8-elvaluates the brains electrical response to lights and loud noises

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29
Q

as the nurse, what do you need to do to prep the patient for a lumbar puncture

A
  • make sure they sign the consent
  • pt needs to have empty bladder
  • lie in a side lying position with knees flexed or when in radiology, on their back
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30
Q

why would you need to do a stat finger stick with a LP

A

to compare the glucose in the blood to the glucose in the CSF

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31
Q

What are the pre and post nursing implications for cerebral angiogram

A 
Pre-
Make sure consent is signed. 
Verify allergies
Make sure they void 
NPO except clear liquids are ok and IV hydration is ok

Post-
Check for neuro deficits
Check/change pressure drsng/place ice
Monitor distal pulses ( there is a risk they can end up with a hematoma in the ground restricting blood flow to the LE)

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32
Q

What can a TCD detect

A

Subarachnoid hemorrhage and aneurysm because it shows the velocity of blood flow through the vessels and identifies vasospams

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33
Q

What type of test is done with any spinal surgery

A

An evoked potential

- to check the nerve pathways to make sure they are in tact

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34
Q

Why would you do an eeg on a pt

A

To identify the electrical activity in the brain / can detect seizure pattern

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35
Q

What are nursing implications for a pt with an eeg

A

Do not stimulate the pt. Limit care as best you can
Keep the patient calm
If the pt is having seizures, you want to identify the pattern of them so you need to clarify with the doctor is you are to give or hold the anticonvulsant meds

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36
Q

What are nursing implicTions for a pt that is going for an MRI

A

make sure the pt does not have any metal on or In them. I.e. Jewelry, pacemakers etc
If they have any tattoos. Older tattoos have metal in the ink (red ink)
Give the pt earplugs. Mri is loud
Ativan for sedation if they are Clausterphobic
Make sure pt has a patent saline lock for the contrast

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37
Q

What would mid point(progressive dilation) of the pupils indicate

A

Increasing intracranial pressure possibly indicating cerebral edema

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38
Q

If one pupil is dilate what does that indicate?

What about both pupils?

A

One pupil dilated indicates a hematoma or CN III damage

If both of them are it indicates a large hematoma or gerniation of the brain

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39
Q

When and why would you use a pupillometer?

A

To assess pupil change in size and reaction on a COMATOSE patient

Pupillary reaction is really the only way to assess neuro status on a comatose pt

40
Q

What are the 3 areas I have assessment on the Glasgow coma scale

A

Eye
motor
verbal

41
Q

what are the components to the eye opening portion of the GCS

A

spontaneous = 4
to speech = 3
to pain = 2
none = 1

42
Q

what are the components to the motor response portion of the GCS

A 
obeys = 6
localizes = 5
withdraws = 4
abnormal flexion = 3
abnormal extension = 2
none = 1
43
Q

what are the components to the verbal response portion of the GCS

A 
oriented convo= 5
confused convo = 4
inappropriate = 3
incomprehensible sounds = 2
none = 1
44
Q

what are the acceptable pain stimulius’ and what does it measure

A

Central- measures brain function

  • pressure to supraorbital area
  • trapezius pinch
  • sternal rub

Peripheral - reflex response via the spine
-nail bead pressure

45
Q

what does the monroe kelly doctrine state

A

the three components of the ice (brain tissue 70%, blood 12% and csf 10%) must remain constant
if one rises the others will be displaced meaning the total volume will not change

46
Q

what is normal ICP range

A

5-15mmHg
or
60-150mmH2O

47
Q

what is CPP and how do you figure out what the CPP is

A

cerebral perfusion pressure
it is the pressure needed to ensure blood flow to the brain

CPP = MAP - ICP

48
Q

what is the normal CPP range

A

70-90mmHg
anything less than 50 = ischemia and neuronal death
anything less than 30 is incompatible with life

49
Q

what does increased CSF fluid do in the brain

A

it causes enlargement of the ventricles (csf circulates through them)
this can cause downward herniation of the brain and brainstem

50
Q

what are the 3 mechanisms to control autoregulation

A

1- CSF regulation- either decrease production or increase absorption

2- Cerebral blood flow- vasodilator or constrict to maintain constant blood flow

3-metabolic auto regulation-

51
Q

how do you calculate the MAP

A

SBP + 2xDBP/3

52
Q

how does the body compensate by cerebral blood flow

A 
increases bp (increases MAP)- causes cerebral vessels to vast constrict
or 
decreases bp (decreases MAP) and causes cerebral vessels to vasodilate
53
Q

what is the normal MAP

A

70-90mmHg

54
Q

what is the normal PaO2 and PaCo2

A 
o2= 80-100
co2 = 35-45
55
Q

what is the earliest sign of increased ICP

A

restlessness, confused lethargy, agitation

56
Q

decerebrate and decorticate are what

A

decerebrate = extension of arms

decorticate - pull arms into the core

57
Q

what is cushings triad

A

the pt responds to decompensation by
systolic hypertension with a widening pulse pressure, bradycardia,
bounding pulse and
altered respirations

58
Q

how do you determine pulse pressure

A

systolic - diastolic

59
Q

what does cushings triad indicate

A

there is a lot of pressure on the brain stem

60
Q

what are late s/s of Increased ICP

A 
headache
fixed or dilated pupils
loss of gag
hyperthermia (brain is no longer functioning appropriately)
projectile vomiting
loss of motor or sensory- hemipalegia
cardiac changes
61
Q

how is someone pronounced brain death

A 
need 2 Meds
pupils are fixed
absence of cereal/gag reflex or cough
no spontaneous movement
no response to pain
the pt must be normothermic

diagnostic tests -
tcd- looking for blood flow
cerebral angiogram- best way- done in cath lab to see for any blood flow
eeg- would be flat

62
Q

what is a positive dolls eyes response

A

the eyes move in the direction opposite that the head is moving

63
Q

what is a negative dolls eyes response

A

eye moves in the direction of the head

64
Q

what is a negative dolls eyes reflex

A

signifies severe brain damage or brain death

65
Q

what are cardinal signs of a new neurological change in the unconscious pt

A
  • sluggish pupils
  • loss of cough and gag
  • loss of reflex
  • s/s cushing triad (increase BP, bradycardia, widening pulse pressure)
66
Q

what would you see with a pt that has a basilar skull fracture

A
  • racoon eyes

- battle signs (ecchymosis behind the ear)

67
Q

how can you tell if a pt has a CSF leak

A

they will have rhinorrhea (csf from the nose)

otorrhea (csf from the ear

68
Q

if the pt who has a skull fracture, what would you want to do if they had a runny nose

A

check the nasal drainage for glucose b/c snot does not have glucose in it, but csf does

69
Q

what is the pt at risk for with a csf leak

A

meningitis, so prophylactic abx should be given

70
Q

what is a concussion

A

the jarring of the brain

may lose consciousness

71
Q

what is a contusion

A

bruising of the brain
can also have petechial hemorrhages

this can cause herniation of the brain because where all the pettechail hemorrhages are cause the inflammation process to occur causing swelling,
also if there is a large bruise, bleeding it can cause pressure causing herniation

72
Q

what are signs a person with a contusion

A 
stupor/confusion
headache
inappropriate language
headache
N&V

these pts will have a GCS of 10-15

73
Q

regarding a brain bleed- who is in most immediate danger

A

a pt with an epidural bleed because it is an arterial bleed

74
Q

what are the classifications of subdural hematomas

A

acute- 24-48 hours
subacute 2days to 2 weeks
chronic- greater than 2 weeks

75
Q

s/s of subdural hematoma

A

deterioration with change in the LOC
intermittent HA
drowsy
confused

the size of the hematoma depends on the symptoms
1 or both pupils may dilate or become fixed.

76
Q

what do you need to monitor for a pt with intracerebral bleed

A

seizure precautions - due to the edema in the brain causing it to misfire
ABCs- will need intubation

77
Q

what happens to a pts behavior when they have an epidural hematoma.
why does this happen

A

they can pass out- wake up lucid and then rapidly deteriorate

the body is compensating for the bleeding, the body is absorbing more CSF and producing less CSF to make room for the excess pressure in the skull but eventually the body is no longer able to do this and that is when they rapidly deteriorate

78
Q

what s/s does a pt have with an epidural bleed

A

HA, confused, drowsy
rapid change in LOC
contralateral hemiplegia/paresis
pupil dilation-ipsilateral

79
Q

what type of tx do we do for hydrocephalus

A

removal of the CSF
-ventriculostomy/ vp shunt

surgical decompression by

  • bone flap- allowing the brain to expand
  • craniotomy-evacuation of hematoma or tumor removal
  • burr holes -evacuation of hematomas
80
Q

what are things you need to do for the pt for a post op bone flap

A
  • keep the patients head aligned
  • do not turn the head to the side of the bone flap- place towels/pillows so pt doesn’t roll to that side
  • asses the area for softnesss, perfusion
  • hang sign over bed “do not turn head to operative side”
81
Q

what does a vp shunt do

A

drains csf fluid into peritoneal cavity

82
Q

what are nursing interventions of brain injured pts

A
  • monitor LOC
  • frequent vitals- want them all NORMAL
  • IV isotonic solutions- dont want to have too much fluids- don’t want pt to have cerebral edema
  • monitor I&O
  • give pain meds
  • give coma inducing drugs if required
  • ROM
83
Q

how do we prevent the brain injured pt from further injury

A
  • prevent hypotension (keeping MAP 70-90)
  • keep CPP, ICP normal
  • elevate HOB 30 degrees
  • prevent skin breakdown, can turn them slightly as tolerated for short increments
  • prevent respiratory complications- can suction- don’t stimulate cough
  • DO NOT give enemas
84
Q

why don’t you want to give a brain injured pt an enema

A

enema will stimulate vagus nerve and cause ICP issues

85
Q

what are ways to treat elevated ICP

A 
Drain CSF- via drain
medications- manitol, sedation, paralytics
hypothermia
surgery
hyperventilation (ONLY as a last resort)
86
Q

why do we put pts in an induced coma and how do we do this

A

to rest the brain
-goal is to reduce the amount of cerebral metabolic demand thus reducing ICP

we do this by using meds such as propofol

87
Q

what meds help decrease ICP

A

Steroids- reduces cerebral edema r/t anti inflammatory effects (monitor glucose)

diuretics- lassie, mannitol, 3% saline- we really want pt to have NS though (monitor I&O, Na+, K+)

opioids- morphine

anti convulsants/seizure meds (decrease seizure threshold)

88
Q

what serum osmolality should the pt be at

A

280-300 mOsm/L

89
Q

what is DI

A

Diabetes insipidus
= low specific gravity in urine
-LARGE output of urine not reflective of meds
-urine will be very diluted but the blood serum will be very high

*pt will be dehydrated

90
Q

how do we tx DI

A

desmopressin - synthetic ADH

91
Q

what is SIADH

A

syndrome of inappropriate ADH
-excessive ADH- pt is holding onto all the fluid
=high specific gravity in urine
-no urine output
-urine is very concentrated and blood serum is diluted

*urine output <20mL /hour

92
Q

what is the tx of SIADH

A

fluid restrictions and diuretics

93
Q

what do you do for DVT prophylaxis on a pt with a brain bleed

A

you need to get the OK from the neurosurgeon to give the anticoags

94
Q

what is a concern r/t nutrition with a pt that is unconscious and has brain injury

A

ileus

if a pt has an OG/NG tube, with an order, you can trickle nutrition (10mL an hour) to keep stomach working.

95
Q

what lab level you do you need to keep tract of (r/t to nutrition)

A

albumin

low albumin levels will cause fluid shift into the tissues and increase cerebral edema

203D (1 decks)

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