Test #1 Flashcards
what are the 4 lobes responsible for
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
what is the cerebellum responsible for
balance coordination
what is the brainstem responsible for
breathing, heart rate, consciousness
what is the purpose of a neurologic assessment
to check for changes in LOC
- confused?
- lethargic/drowsy?
- obtunded?
- stupor?
- deep coma?
what is avpu
pt is awake
pt responses to Verbal
pt responses to Painful
pt is Unresponsive
what do you do when you have a confused or combative pt
Look for the source that is causing the confusion or combativeness
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?
the frontal lobe
the frontal lobe is responsible for personality, emotions, intelligence
concentration, judgment
body movements and speech (speak and write)
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
the temporal lobe
the temporal lobe is responsible for speech (understanding language), memory, hearing, sequencing and organization
If a patient has problems distinguishing left from right, problems with hand eye coordination, what part of the brain is most likely effected
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
if a patient is experiencing vision defects or blind spots, illusions/hallucinations, what area of the brain is most likely effected
the occipital lobe
the occipital lobe is responsible for vision
If a patient has a difficult time swallowing, vertigo, and changes in breathing what part of the brain is most likely effected
the brain stem
the brain stem is responsible for breathing, heart rate, alertness and consciousness
if a patient comes in that is experiencing loss of balance, vertigo, slurred speech, what part of the brain is most likely effected
the cerebellum
the cerebellum is responsible for balance and coordination
what are three main things we look at for a neurologic assemssment
vital signs
current health
past hx and meds (that could be causing the altered LOC)
how do we assess cerebral function
- 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
how do you test memory
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.
what are the cranial nerves I-III
CN I = olfactory
C II = optic - visual fields
CN III = oculomotor- reflex to light, eyelid control
where are the cranial nerves
CN I and II are in the cerebrum and III-XII are in the brainstem
what is ptosis
drooping of the eyelid- CN III issue.
could be the pts baseline- need to know
what do CN IV V and VI do
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.
CN VII VIII
cranial nerve VII is facial expression.
raise eyebrows, grimace etc.
cranial nerve VIII is vestibularchochlear = hearing.
cranial nerve IX and X
IX = glossopharyngeal, - gag and swallow X = vagus - gag and cough
cranial nerve XI
spinal accessory
-shoulder shrug
if pt can do that- the diaphragm is in tact
cranial nerve XII
hypoglossal
- asking pt to portrude tongue
how to assess cerebellum
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
How do you assess sensory perception
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
Why would someone be experiencing cheyne stokes
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
What is cheyne stokes respirations
Rapid breathing increasing o2 followed by a period of apnea and decrease in O2
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
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
as the nurse, what do you need to do to prep the patient for a lumbar puncture
- 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
why would you need to do a stat finger stick with a LP
to compare the glucose in the blood to the glucose in the CSF
What are the pre and post nursing implications for cerebral angiogram
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)
What can a TCD detect
Subarachnoid hemorrhage and aneurysm because it shows the velocity of blood flow through the vessels and identifies vasospams
What type of test is done with any spinal surgery
An evoked potential
- to check the nerve pathways to make sure they are in tact
Why would you do an eeg on a pt
To identify the electrical activity in the brain / can detect seizure pattern
What are nursing implications for a pt with an eeg
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
What are nursing implicTions for a pt that is going for an MRI
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
What would mid point(progressive dilation) of the pupils indicate
Increasing intracranial pressure possibly indicating cerebral edema
If one pupil is dilate what does that indicate?
What about both pupils?
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
When and why would you use a pupillometer?
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
What are the 3 areas I have assessment on the Glasgow coma scale
Eye
motor
verbal
what are the components to the eye opening portion of the GCS
spontaneous = 4
to speech = 3
to pain = 2
none = 1
what are the components to the motor response portion of the GCS
obeys = 6 localizes = 5 withdraws = 4 abnormal flexion = 3 abnormal extension = 2 none = 1
what are the components to the verbal response portion of the GCS
oriented convo= 5 confused convo = 4 inappropriate = 3 incomprehensible sounds = 2 none = 1
what are the acceptable pain stimulius’ and what does it measure
Central- measures brain function
- pressure to supraorbital area
- trapezius pinch
- sternal rub
Peripheral - reflex response via the spine
-nail bead pressure
what does the monroe kelly doctrine state
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
what is normal ICP range
5-15mmHg
or
60-150mmH2O
what is CPP and how do you figure out what the CPP is
cerebral perfusion pressure
it is the pressure needed to ensure blood flow to the brain
CPP = MAP - ICP
what is the normal CPP range
70-90mmHg
anything less than 50 = ischemia and neuronal death
anything less than 30 is incompatible with life
what does increased CSF fluid do in the brain
it causes enlargement of the ventricles (csf circulates through them)
this can cause downward herniation of the brain and brainstem
what are the 3 mechanisms to control autoregulation
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-
how do you calculate the MAP
SBP + 2xDBP/3
how does the body compensate by cerebral blood flow
increases bp (increases MAP)- causes cerebral vessels to vast constrict or decreases bp (decreases MAP) and causes cerebral vessels to vasodilate
what is the normal MAP
70-90mmHg
what is the normal PaO2 and PaCo2
o2= 80-100 co2 = 35-45
what is the earliest sign of increased ICP
restlessness, confused lethargy, agitation
decerebrate and decorticate are what
decerebrate = extension of arms
decorticate - pull arms into the core
what is cushings triad
the pt responds to decompensation by
systolic hypertension with a widening pulse pressure, bradycardia,
bounding pulse and
altered respirations
how do you determine pulse pressure
systolic - diastolic
what does cushings triad indicate
there is a lot of pressure on the brain stem
what are late s/s of Increased ICP
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
how is someone pronounced brain death
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
what is a positive dolls eyes response
the eyes move in the direction opposite that the head is moving
what is a negative dolls eyes response
eye moves in the direction of the head
what is a negative dolls eyes reflex
signifies severe brain damage or brain death
what are cardinal signs of a new neurological change in the unconscious pt
- sluggish pupils
- loss of cough and gag
- loss of reflex
- s/s cushing triad (increase BP, bradycardia, widening pulse pressure)
what would you see with a pt that has a basilar skull fracture
- racoon eyes
- battle signs (ecchymosis behind the ear)
how can you tell if a pt has a CSF leak
they will have rhinorrhea (csf from the nose)
otorrhea (csf from the ear
if the pt who has a skull fracture, what would you want to do if they had a runny nose
check the nasal drainage for glucose b/c snot does not have glucose in it, but csf does
what is the pt at risk for with a csf leak
meningitis, so prophylactic abx should be given
what is a concussion
the jarring of the brain
may lose consciousness
what is a contusion
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
what are signs a person with a contusion
stupor/confusion headache inappropriate language headache N&V
these pts will have a GCS of 10-15
regarding a brain bleed- who is in most immediate danger
a pt with an epidural bleed because it is an arterial bleed
what are the classifications of subdural hematomas
acute- 24-48 hours
subacute 2days to 2 weeks
chronic- greater than 2 weeks
s/s of subdural hematoma
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.
what do you need to monitor for a pt with intracerebral bleed
seizure precautions - due to the edema in the brain causing it to misfire
ABCs- will need intubation
what happens to a pts behavior when they have an epidural hematoma.
why does this happen
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
what s/s does a pt have with an epidural bleed
HA, confused, drowsy
rapid change in LOC
contralateral hemiplegia/paresis
pupil dilation-ipsilateral
what type of tx do we do for hydrocephalus
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
what are things you need to do for the pt for a post op bone flap
- 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”
what does a vp shunt do
drains csf fluid into peritoneal cavity
what are nursing interventions of brain injured pts
- 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
how do we prevent the brain injured pt from further injury
- 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
why don’t you want to give a brain injured pt an enema
enema will stimulate vagus nerve and cause ICP issues
what are ways to treat elevated ICP
Drain CSF- via drain medications- manitol, sedation, paralytics hypothermia surgery hyperventilation (ONLY as a last resort)
why do we put pts in an induced coma and how do we do this
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
what meds help decrease ICP
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)
what serum osmolality should the pt be at
280-300 mOsm/L
what is DI
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
how do we tx DI
desmopressin - synthetic ADH
what is SIADH
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
what is the tx of SIADH
fluid restrictions and diuretics
what do you do for DVT prophylaxis on a pt with a brain bleed
you need to get the OK from the neurosurgeon to give the anticoags
what is a concern r/t nutrition with a pt that is unconscious and has brain injury
ileus
if a pt has an OG/NG tube, with an order, you can trickle nutrition (10mL an hour) to keep stomach working.
what lab level you do you need to keep tract of (r/t to nutrition)
albumin
low albumin levels will cause fluid shift into the tissues and increase cerebral edema
