Week 5 - Altered LOC & Multisystem Flashcards
what is the most common type of stroke?
ischemic
what is the most common type of stroke?
ischemic
what are 3 compartments that impact ICP?
- brain
- blood
- CSF
if ICP is increased how can it affect the brain/ what can it cause?
- meningitis
- tumor
- inflammation
- trauma
- glioma
- surgery
- abcess
- TBI
- encephalitis
if ICP is increased how can it affect the CSF/ what can it cause?
- meningitis
- infection
- hydrocephalus
- choroid plexus tumor
what does meningitis affect?
proper drainage
describe a choroid plexus tumor
tumor in ventricles of brain that affect CSF
if ICP is increased how can it affect the blood/ what can it cause?
- hemorrhagic stroke
- increased CO2
- HTN
- aneurysm
describe a hemorrhagic stroke
- weakened/ diseased blood vessels rupture
- blood leaks into brain tissue
describe an ischemic stroke
- blood clots stop flow of blood to an area of the brain
what are indications of a head wound?
- scalp wound
- fracture
- swelling
- bruising
- loss of consciousness
- nasal discharge
- stiff neck
explain the process of ICP
- SNS activation do to decreased perfusion
- brain stem pressure
- baroreceptors activated
- PNS activation
- death
what does CPP stand for?
cerebral perfusion pressure
explain cerebral perfusion pressure (CPP)
- cerebral blood flow decreases
- leads to cerebral ischemia
- pressure then put on vasculature
- once pressure stronger than MAP artery compressed
what are early warning signs of ICP?
- papilledema
- headache
- N/V
- blurred vision
- restlessness
- irritability
- confusion
what is papilledema?
swelling of both optic discs in eyes
how do you assess for papilledema?
- MRI
- CT
if someone has ICP what can make their headaches worse?
- cough
- sneezing
- exertion
what are late signs of increased ICP?
- pupil dilation
- hemiplegia
- impaired oculophalic movements
- increased motor tone
- flexion or extension to pain
- reps containing sighs, deep yawns or pauses
- Cushing’s triad
- decreased GCS
what is the Cushing’s triad reflex?
nervous system response
once ICP is increased what are the different stages of Cushing’s triad ?
stage 1
- SNS
- HTN (widening pulse pressure)
- tachycardia
stage 2
- PNS (due to HTN)
- bradycardia
Stage 3
- HTN and increased ICP makes pressure on ponds and irregular resps
describe a 6th cranial nerve palsy
- hearing loss
- facial weakness
- decreased facial sensation
- droopy eyelid
- fever
- headache
- N/V
what are some signs and symptoms of a sub arrachnoid hemorrhage (SAH)?
- worst headache EVER
- N/V
- change in LOC
- nuchal rigidity
- photophobia
what is nuchal rigidity?
stiff neck
what causes a sub arrachnoid hemorrhage (SAH)?
- aneurysm
- trauma
- bleeding disorder
- medications
- arteriovenous malformations (avm)
A TBI is more severe if LOC is lost for what?
more than 30 minutes
what are different types of TBI’s?
- concussion
- subarachnoid hemorrhage
- subdural hematoma
- epidural hematoma
what type of TBI can impair consciousness?
epidural hematoma
what do you use to identify and assess changes in LOC?
- AEIOUTIPS
- head CT
- lumbar puncture
what does AEIOUTIPS stand for?
A
- alcohol
- acidosis
E
- epilepsy
- electrolyte
- endocrine (high or low blood sugar)
I
- infection
- insulin
O
- overdose
- oxygen decrease
U
- uremia
- urosepsis
- under dose
T
- trauma
- tumor
- temperature
- toxins
- timing
I
- infection
- ICP
P
- poison
- psych
S
- stroke
- seizure
- sepsis
- shock
- syncope
how do you identify and assess for changes in LOC?
- GCS
- neuro vitals
- CAM PRISME
- VS
- NIHSS
- SST
- TORBSST
what does NIHSS assess?
- if pt if getting worse or better
- stroke scale
what is on the NIHSS?
- LOC
- gaze
- visual facial palsy
- motor arm
- motor leg
- limb ataxia
- sensation
- language
- dysarthria
- extinction/ inattention
when do you use SST?
- stroke
- tumor
- cancer
- ALS
- parkinsons
- dementia
- delirium
- critical illness
- GERD
- MS
- intubation
- SLE
- TBI
in regards to recreational substances, what will a patient’s pupils look like if they are using opioids?
pinpoint
in regards to recreational substances, what will a patient’s pupils look like if they are using cocaine, MDMA?
dilated
What is assessed in a GSC? what do we want pt to score?
- eyes opening response
- verbal response
- motor response
want pt to score high, if low means altered LOC
what’s included in a focused neuro assessment?
- how are they presenting
- mobility
- concentration
- speech
- swallow
- eye contact/ movement
- decision-making
- impulsiveness
- VS
what do you to diagnose a change in LOC?
- head CT
- MRI
- lumbar puncutre
- X-ray
- EEG
- labs
what specific labs are you looking at when diagnosing a change in LOC?
- ECG
- INR
- CBC
what are you trying to asses for with a lumbar puncture for a change in LOC?
- meningitis
- cancers
- bleeding
- GBS
- MS
what complications can result from a head injury?
- re-bleed
- neuro deficits
- seizure
- epidural tear
- CSF leak
- post confusion syndrome
- acute intracranial hypertension (AIH)
- autonomic dysreflexia
- neurogenic shock
- death
describe post concussion syndrome
- > 90 days or lasts longer than expected
what are the signs and symptoms of post concussion syndrome?
- headaches
- dizziness
- fatigue
- irritability
- anxiety
- trouble falling asleep or sleeping to much
- loss of concentration/ memory
- ringing in ears
- blurry vision
- noise/ light sensitivity
what is autonomic dysreflexia?
- injury T6or above
- SNS response to noxious stimuli
- bladder
- bowel
- break down of skin
what do you need to monitor for a pt with altered level of consciousness ?
- external ventricular drain
- lumbar drain
- urinary output
- cranial nerves
- vitals
- MSKL system
- bladder
- bowels
If someone has a drain in their brain what are they at risk of?
high risk of infection
What do we want someones ICP to be? when is it abnormal? When is it concerning?
normal < 15mmHg
abnormal 15-20mmHg
concerning >20 mmHg
when monitoring a pt with a stroke what we want their systolic BP to be? why?
< 160 or risk for re-bleed
what are some nursing interventions and precautions we should take for clients with a changed level of consciousness?
- decrease stimuli
- educate family and pt
- HOB 30-45 degrees
- safe mobility
- stool softeners
- antiemetics
- hyperventilating
- align head and neck
- no flexion, blowing nose, sneezing, coughing
- fluid interventions
what are some treatments patients with a change in LOC could have?
- lumbar puncture
- tPA
- EVT
- coiling
- clipping
- craniotomy
- burr holes
what does EVT stand for? what does it treat? When is it done? What does it put the pt at risk for?
- endovascular treatment
- thrombectomy
- normally within 6 hours
- puts pt at risk for intraccerebral bleed
describe coiling, what is the purpose of it?
- prevents clots from forming
- prevents entry of blood into weak space
- done through artery
describe clipping, how is it done?
- clip off broken area
- via craniotomy
what are some treatments to avoid for elevated ICP?
- lumbar puncture
- HYPOtonic solution
why do you not want to do a lumber puncture to treat ICP?
- possible risk of herniation if CSF pressure drops to low
- mass effect caused by mass or hemorrhage
what medications can be used to treat Changes in LOC?
- osmotics
- diazepam
- dilantin
- lorazepam
- acetazolamide
- hydralazine
- labetalol
- desopressin
- dexamethasone
- phenobarbital
- antihypertensives
- antiplatelets/ anticoagulants
- lipid lowering agents
- antiarrhythmics
- anti-anxiety
in regards to medications that can be used to treat changes in LOC what do osmotics do?
- lower ICP
what are examples of osmotic medications that are used to treat changes in LOC?
- mannitol
- 3% hypertonic solution
what does mannitol do when given to a pt with a change in LOC? How is it given? when does it start to work?
- decrease ICP
- only given IV
- works within 30-60 minutes
what are side effects of mannitol?
- peripheral edema
- pulmonary edema
- works
in regards to medications that can be used to treat changes in LOC what does diazepam or dilantin do?
prevents seizure
in regards to medications that can be used to treat changes in LOC what does lorazepam do?
treats seizure
in regards to medications that can be used to treat changes in LOC what does acetazolamide do?
- decrease CSF
in regards to medications that can be used to treat changes in LOC what does hydralazine and labetalol do?
- lower BP due to vazodilation
in regards to medications that can be used to treat changes in LOC what does desmopressin do?
- treats diabetes for urine output over 9L/dauy
- improves clotting
in regards to medications that can be used to treat changes in LOC what does dexamethasone/ phenobarbital do?
- prevents seizures
- decreases brain activity
- treats swelling
what are examples of blood thinners?
- plavix
- warfarin
- Xarelto
what can be used to induce a medical coma? why?
- phenobarbital
- decreases brain activity resulting in decreased cerebral metabolism and decreased pressure
what conditions can cause mutlisystem impacts/ failures?
- COPD
- pneumonia
- PE
- GI bleed
- diarrhea
- perforation
- sepsis
- TBI
- stroke
when someone has a TBI was does this cause to be released into the circulation?
inflammatory and autonomic mediators
what releases cytokines when there is a TBI?
- spleen
- lymph
why do the spleen and lymph release cytokines? what if they release to many?
- help control inflammation
- if to many are released cause inflammation and autoimmune
what are signs and symptoms of high cytokine levels in the body?
- high fever
- inflammation
- severe fatigue
- severe nausea
what is hypercytokinemia?
- cytokine storm
- can be severe/ life threatening
- can lead to multiple organ failure
what are IL in regards to WBCs? what do they do?
- proteins
- regulate inflammation
what can increase cytokine release?
neuronal and glial death from injury
IL 6, 8, 10 increases are associated with what?
multisystem organ dysfunction with TBI
what are risk factors for ARDS?
- pulmonary infiltrates
- poor oxygenation
- acute onset
- capillary injury
- alveolar damage
what are S/S of ARDS?
- RR >24
- use of accessory muscles
- increased WOB
- MAP <65
- decreased LOC
- not responding to O2 and increasing O2 needs
what does a MAP of <65 indicate?
hypotension
non hydrostatic pulmonary edema is caused by what?
loss of normal osmotic gradient that normally opposes fluid movements in lungs due to inflammation
what are the risks of ARDS with a TBI?
- age
- injury
- severity
clinical management strategies for ARDS with a TBI are aimed at what?
induce hypertension
what are relevant labs to assess for ARDS in someone with a TBI?
- ABGs
- D-Dimer
What diagnostics are assessed for ARDS in a someone with a TBI?
- labs
- CXR
- PaO2/ FiO2
in a pt with a TBI, what early signs can the pt show us that would make us suspect they might have ARDS?
- tachypnea
- hypoxia
- respiratory alkalosis
what are the 5 different ranges for PaO2/ FiO2 and what do they tell us about the pt?
healthy 300-500 mmHg
mild 200-300mmHg
moderate 100-200mmHg
severe <100 mmHg
unhealthy <300 mmHg
what does the lab test D-dimer indicate?
clots forming
if the patient is in hypercapnia respiratory failure, how do we know this just based off of the PaCO2 and PaO2?
PaCO2 > 45mmHg AND PaO2 < 60mmHg
what are nursing interventions for ARDS?
- PEEP
- prone position
- ECMO
- maintain fluid balance with diuretics
what does PEEP stand for?
Positive
End
Expiratory
Pressure
what is the purpose of PEEP?
helps to open un alveoli
how long can we place someone in the prone position for?
12 hours or less
when would we use EMCO for ARDS?
only in severe cases
when using diuretics to maintain fluid balance, what we we need to watch for?
- hyponatremia
- hyperglycaemia
- neuromuscular weakness
what medication is contraindicated with swelling for TBI and puts the patient at an increased risk of death ? (This pt would also have ARDS)
corticosteroids
how do you treat ARDS?
- treat underlying issue first then based on that will determine what meds are needed
- each case is different
what does DIC stand for?
disseminated intravascular coagulation
What are the signs and symptoms of DIC?
- bleeding
- microclots
- sepsis
- irregular HR
- hypotension
- lethargy
- oliguria
- tachycardia
- pulse paradoxes
- hypoxia
What is the most common cause of DIC?
sepsis
what are different cardiovascular problems that could arise when talking about multi system
- DVT
- PE
- decreased cardiac output
- CVS shock/ dysfunction
- micro clotting
- DIC
- bleeding
what is the concern about micro clots when they break down in the cardiovascular system?
- fibrin degradation products are produced and have anticoagulation properties
How do you diagnose disseminated intravascular coagulation (DIC)?
- low platelet count
- elevated D-dimer
- decreased fibrinogen
- prolonged clotting time (PT, PTT, INR)
- BNP
What is stress cardiomyopathy?
overworked CVS due to SNS activation
what can stress cardiomyopathy lead to?
- hypotension
- decreased CBF
- secondary injury
in your nursing assessment when looking at the cardiovascular system, what in your assessment identifies concern?
pulses paradoxus
describe pulses paradoxus
BP decreases in inhalation
what is the best single test to look at when diagnosing DIC?
D-Dimer
what does the lab test BNP tell us about?
- heart failure
- acute PE if high
what tests can be used to diagnose DIC?
- ECHO
- ECG
- TEE
what does ECHO tell us about when using it to diagnose DIC?
- Cardiac output
- blood flow
- cardiac tamponade
what does ECG tell us about when using it to diagnose DIC?
rhythm
what the diagnostic test TEE. What does it stand for?
- Transesophageal Echocardiogram
- special type of echocardiogram
what are you focusing on if you have to resuscitate a pt?
C - circulation
A - airway
B - breathing
if someone has a cardiovascular system problem what are your priorities ?
- hemodynamic stability
- maintain cardiac output
- maintain oxygenation
- protect lungs
- cardiac meds
- antiplatelets
- anticoagulants
what causes poor perfusion?
- sepsis
- stroke
- hemorrhage
- trauma
- MAP <60 mmHg
what are the 2 different formulas you can use to calculate MAP?
MAP = DP+1/3(SP-DP)
OR
MAP = DP+1/3(PP)
how do you treat for pulmonale?
- prevention
- maintain lung function
- oxygenation
what causes for pulmonate?
- pulmonary hypertension
- any valve problem
why can FFP cause hypocalcemia?
citric acid from plasma binds to calcium in blood resulting in less calcium to be available for use
what are signs and symptoms of changes in the neuro system?
- declining GCS
- sings of increasing ICP
- hypoxemia
if someone has a thunderclap headache how would they describe it?
- severe/ sudden headache
- worst headache ever
what are the main concerns with the neurological system?
- neurogenic shock
- SNS blocked below injury
what in your nursing assessment could be used to identify concerns with the neurological system?
- GCS
- asking questions
- watching the pt move
- ins/ outs
- oxygenation
- auscultate lungs
what are relevant labs to assess if you have concerns with the neurological system?
- increased WBC
- RBC
- ABG imbalances and electrolytes
what is hypercarbia?
increase in carbon dioxide in bloodstream
what can hypercarbia cause?
- vasodilation
- refractory HTN > increases ICP
what can respiratory acidosis cause in the neurological system?
- altered LOC
- confusion
- coma (due to high potassium)
what can respiratory alkalosis cause in the neurological system?
- palpitations
- convulsions
- tetany
what is tetany?
low potassium and calcium
what is wernickes aphasia?
speaking in long complete sentences that have no meaning
what is global aphasia?
can only vocalize a few words
what is Broca aphasia?
- difficulty getting words out
- struggling to find the right words
what is dysarthria?
slurring speech
What are the main concerns with the GI/ GU system?
- AKI
- GI atrophy
- slowed peristalsis
what are signs and symptoms of changes in the GI/ GU system?
- fluid overload
- decreased output
- metabolic acidosis
- constipation
- urinary retention
- S/S of UTI
what does GI atrophy increase?
- permeability
- risk for bacteria
what in your nursing assessment could be used to identify concerns with the GI and GU?
- metabolic acidosis
- high potassium
- altered LOC
- confusion
- disorientation
what assessment findings would you see in someone who has failure or damage to liver?
- juandice
- ascities
- more confusion from build up of ammonia
how do you get rid of high levels of ammonia in the body?
administer lactulose
what are relevant labs and diagnostics you would want to look at when assessing an issue with the GI/ GU?
kidneys
- GFR
- BUN
- creatinine
liver
- ALT
- AST
- GGT
- bilirubin
- ammonia
what diagnostics would be ordered to assess an issue in the GI/GU ?
- CT
- abd x-ray
- renal ultrasound
if someone has a GI/GU problem, what are your priorities?
- flush system
- bowel care
- foley care
- monitor Ins/outs
- nutritional support
what are the main concerns with the integumentary and musculoskeletal systems?
- pressure injury
- muscular atrophy
what are signs and symptoms to watch for around changes in the integumentary and musculoskeletal systems?
- deconditioning
- incontinence associated dermatitis
- orthostatic hypotension
- dislocation
- drop foot
if someone has a integumentary and musculoskeletal problems, what are your priorities?
- passive and active ROM
- turning/ positioning Q2H
- OT and PT consults
- hygiene
- bowel/ bladder care
- skin assessments
describe rhabdomylosis
increased myoglobin from muscle breakdown in blood
what does rhabdomylosis indicate?
tissue damage
what can rhabdomylosis lead to? what does it make urine look like?
- leads to AKI
- urine becomes cola brown
what does elevated CK over 5,000U/L mean?
- severe muscle injury
- risk to kidneys
