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Nursing 4 Exam 3 > Unit 13 ALOA Structural Coma > Flashcards

Unit 13 ALOA Structural Coma Flashcards

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1
Q

What is the Monro-Kellie Hypothesis?
What should normal ICP be?
What is auto-regulation regarding this?
How can it be measured?

A

Pressure exerted by the combined volume of:

  • Blood 80%
  • Brain 10%
  • Spinal fluid 10%

Normal ICP should be 5-15

A change in one of these volumes means a change in another

Can be measured by spinal tap.

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2
Q

What are the types of skull fractures?

A

Simple- small break, no interference

Comminuted- Complex

Depressed- Complex

Basilar- Life threatening

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3
Q

What are the symptoms of a Basilar fracture?

Where do they usually happen?

A

Rhinorrhea - bloody nose

Otorrhea - ear damage, CSF

Halo Sign- from CSF leak

Raccoon eyes

Battle’s sign - bruising behind ear/near ear

They usually happen near temporal regions.

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4
Q

What is Basilar Skull fracture collaborative management?

A

Neuro checks every hr w/VS

Prevent meningitis w/antibiotic prophylaxis

Nothing in the ears

No NGT or nasal suctioning

No blowing nose only wiping

Elevate HOB 30

May need surgery to lift bone

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5
Q

What is the number one cause of traumatic brain injuries?

A

Falls

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6
Q

What are the two types of traumatic brain injuries?

A

Closed - head suddenly and violently hits an object

Open - object pierces the skull and enters the brain

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7
Q

What are symptoms of a traumatic brain injury?

A

Headache

Dizziness

Balance issues

Sensitivity to noise and light

Sleep issues

Anxiety

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8
Q

What are the 2 stages of brain injury?

What is the main goal of brain injury?

A

Primary: occurs at time of injury, infarction, disruption of blood supply, hematoma

Secondary: Progression of initial injury which leads to cellular and toxic changes causing cerebral edema and increased ICP.

Main goal is to prevent secondary injury from occurring.

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9
Q

What are the types of closed head injuries?

A

Concussion:
-disturbance of neurological function caused by trauma

Contusion:
-Bruising of brain at site of impact

Laceration:
-Tearing of surface vessels

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10
Q

What are PT considerations with closed head injuries?

A

Avoid physically demanding activities/ gradually resume

Avoid straining

Avoid sustained electronic use

Avoid alcohol and nicotine

Only take prescribed meds

Allow frequent rest

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11
Q

What is the collaborative management of closed head injury?

A

Minor injury, PT will be sent home from ED

PT/family education to:

  • call if change in behavior, speech, or vomiting
  • cognitive/physical rest

Neurocognitive Testing (Impact test) –25 min computer test that measures attention, memory, responses, and reaction times

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12
Q

What are the type of Hematomas?

A

Epidural Hematoma:

  • Extreme emergency!
  • Associated w/skull fracture usually in temporal region
  • Arterial bleed

Subdural Hematoma: (part of severe brain injury)

  • Acute
  • Subacute
  • Chronic

Intracerebral Hemorrhage

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13
Q

Describe an Epidural Hematoma.

What is the treatment?

A

Blood collection between the skull and dura

PT may have brief loss of consciousness w/return of lucid state, as hematoma expands ICP will reduce LOC

An emergency situation!! FROM Arterial Bleed!!
Symptoms develop rapidly

Treatment:

  • Reduce ICP
  • Remove the clot
  • Stop bleeding - (burr holes or craniotomy)
  • Monitoring of VS
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14
Q

What is a subdural hematoma?
Associated w/ what?
Describe acute and subacute Subdural Hematoma and treatment.
Describe chronic Subdural Hematoma and treatment.

A

Collection of blood between the dura and the brain.
40-60% fatal
FROM veins!

Associated w/ skull fractures and contusions

Acute: symptoms develop over 24 - 48 hrs
Subacute: symptoms develop 48hrs- 2 weeks
Treatment for both: Immediate craniotomy and control ICP

Chronic:
-Develops over weeks to months
-Causative injury may be minor and forgotten
-Clinical signs and symptoms may fluctuate
Treatment: evacuation of the clot

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15
Q

What is Intracerebral hemorrhage?

What is the treatment?

A

Hemorrhage occurs into the substance of brain.
May be due to trauma or a non-traumatic cause.

Treatment:

  • Supportive care
  • Control ICP
  • Administer fluids, electrolytes, and antihypertensive medications
  • Craniotomy or Craniectomy to remove clot and control hemorrhage (may not be possible due to location)
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16
Q

What is the Secondary Injury (complication of primary injury) Cerebral Edema.

A

Brain swelling which leads to ICP.

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17
Q

What is the nursing care and prevention of secondary injury cerebral edema?

A
  • HOB 30 degrees
  • Log roll when turning
  • Analgesics
  • Stool softeners to prevent straining
  • Prevent coughing/sneezing
  • Prevent valsalva maneuvers
  • Prevent pain
  • Prevent hypoxemia and hypercapnia
  • Avoid increased ICP (suctioning and turning can increase, be careful)
18
Q

What is the treatment of the secondary injury, cerebral edema?

A

mannitol -osmotic diuretic

Hypertonic solution 2-3% normal saline

Control “neuro fever” w/antipyretics, cooling blankets, etc

Maintain or slightly increase systolic BP

19
Q

What is hydrocephalus secondary injury?

What is the treatment?

A

Volume increase in CSF.

  • Increased production in ventricles
  • obstructed circulation
  • decreased absorption

Treatment: Ventriculostomy (external ventricular drain)

20
Q

What is the earliest indicators of ICP?

What is the latest sign of ICP?

A

Mental status changes

Cushing’s triad (arterial hypertension and widening PP, bradycardia, bradypnea)

21
Q

What is the secondary injury Diabetes Insipidus and SIADH?

A

DI: Lacks antidiuretic hormone to there is urine, urine, urine! very diluted urine!

Syndrome of Inappropriate ADH(SIADH):

  • too much ADH
  • stops urine/holds onto fluid
22
Q

Describe DI vs SIADH.

A

DI:

  • Dilute urine
  • High serum Na+
  • High serum osmolarity
  • Low urine gravity
  • THIRSTY
  • Rx: Vasopressin
SIADH:
-Concentrated urine
-Low serum Na+
-Low serum osamlarty
-High urine gravity
-Thirsty
Rx: Hypertonic saline, fluid restriction
23
Q

Describe the secondary injury brain herniation.

A

-Displacement of brain tissue into the spinal canal.

  • Essentially brain pushed down onto brain stem.
  • Often results in death
  • Presents w/abnormal posturing, GCS 3-5
24
Q

What are the clinical manifestations of ICP?

A 
Decrease in GCS
ALOA
Headache
Vomiting 
Abnormal speech
Motor/sensory issues
Change in cardiac rate/rhythm
Change respiratory patterns
25
Q

Any ICP over what is considered increased?

What flexions will ICP?

A

16

Neck and hip flexion

26
Q

What is Cushing’s triad?

A
  1. Arterial hypertension with widening PP
  2. Bradycardia
  3. Bradypnea
27
Q

What are nursing interventions for all brain injuries?

A
  • Neuro assessment hourly
  • Monitor for ICP
  • Elevate HOB 30
  • Maintain head in neutral position
  • Log roll when turning
  • Avoid straining, breath holding exercise, isometric exercise, and extreme hip flexion
  • Alternate activity with rest periods
  • Temp control
  • Prevent or treat pain/seizures/agitation
  • Strict fluid restrictions
  • Limit environmental stimulus
28
Q

What is a method to temporarily reduce ICP?

A

Intubation with mechanical ventilation:

  • Hyperventilate to get PaCO2 between 35-30
  • If suctioning, do NOT suction for more than 10 secs at a time, utilize hyper-oxygenation before and after procedure
29
Q

What is the systolic BP goal for/during a brain injury?

A

120-140

30
Q

What are medications for brain injury?

A

Diuretics:

  • mannitol (osmotic diuretic)
  • furosemide (loop diuretic)

Corticosteroids:
-dexamethasone (prevents further swelling)

Anticonvulsants:
-phenytoin (given through IV, monitor for heart block, mix only in NS)

Antihypertensives:

  • Beta blockers
  • Calcium channel blockers
  • ACEis

Analgesics, Anesthetics, Sedatives:

  • propranolol
  • barbiturates
  • pentobarbital
31
Q

What is ICP monitoring?
What is there a high risk for?
What are the advantages?

A
  • Burr hole in skull, continuous monitoring of ICP done with screw or bolt
  • High risk for infection

Advantages:

  • Pressure can be recognized and treated before clinical symptoms appear
  • Allows drainage of CSF via 3 stopcock
  • Cerebral perfusion pressure can be calculated and treatment adjusted
  • Effects of nursing interventions on ICP can be monitored
32
Q

How is cerebral perfusion pressure calculated?
What is the normal?
How is mean arterial pressure calculated?
What is the normal?
What should it be maintained above?
What does maintenance of CPP do?

A

MAP-ICP = CPP

Normal CPP 60-100

MAP= Systolic + Diastolic x 2 divided by 3

Normal is 70 -100
(should be maintained above 70-80)

Maintenance of CPP reduces mortality in severe head injury

33
Q

What is associated w/ poor prognosis in head injuries?

A

Systemic hypotension is associated with poor prognosis in head injury

34
Q

What are the risk factors of hemorrhagic stroke?

A
  • Uncontrolled HTN
  • Overtreatment w/ Anticoagulants
  • Overweight/Obese
  • High cholesterol
  • Cardiovascular disease
  • Diabetes
  • Age 55 and older
  • Smoking
  • Heaving drinking
  • Males and A.A’s more at risk
35
Q

What are a couple causative factors of a hemorrhagic stroke?

A
  • Aneurysm

- Arteriovenous malformation

36
Q

What does a transcranial doppler do?

A

Assess blood flow through arteries in brain, therefor assessing for vasospasms

37
Q 
How can the following help decrease ICP?
antipyretics
docusate sodium
lorazepam
insulin
A

antipyretics: by decrease fever you decrease ICP

docusate sodium: prevents straining which helps lower ICP

lorazepam: decreases agitation which decreases ICP
insulin: controls BS which decrease ICP

38
Q

What is triple H therapy and what is it for?

A

Hypervolemia
Hypertension
Hemodilation

Therapy used to prevent vasospasms after aneurysm subarachnoid hemorrhage; PT stays in ICU for 2 weeks.

39
Q

What is nimodipine and what is it used for?

A
  • A calcium channel blocker used to decrease vasospasms;

- take for 21 days on empty stomach.

40
Q

What is subarachnoid hemorrhage?

A

Blood between pia and arachnoid membranes.

Causes: Head trauma, etc

S and S’s: Headache, dull pain, nausea, dizziness, unequal pupils

41
Q

What are vasospasms?

A

Abnormal narrowing or constriction of arteries due to irritation by blood in the subarachnoid space.

(blood is putting pressure on the vessels which correlates with ICP)

Nursing 4 Exam 3 (7 decks)

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