Week 5 THURS Flashcards
adult neuro
What is a priority nursing intervention for a pt who is unconscious?
maintain pt airway
During an active seizure the nurse should?
place client on their side, remove dangerous objects, and protect their head
What intervention should the nurse implement to prevent increases in ICP?
Elevate HOB 30 degrees
What is the earliest sign of increased ICP?
Change in LOC
A client is sitting in a chair and begins having a tonic-clonic seizure. What is the most appropriate nursing response?
- carefully move client to a flat surface and turn them on their side
A client has an altered LOC due to blunt force trauma to the head. The nurse should first gauge the clients LOC on the result of what diagnostic tool?
Glasgow Coma Scale
What score indicates severe impairment of neurologic function on the GCS?
3
Assessing a clients pupils, what reaction would confirm increasing ICP?
- fixed and dilated
- unequal response
the cranial vault contains three components which are……
- blood 10-12%
- CSF 8-10%
- brain tissue 80%
T or F CSF is the most easily displaced fluid in the cranial vault
TRUE!
The pressure that soft contents of cranial vault against the rigid cranial bones
Intracranial pressure
What is normal Intracranial pressure?
0-15mm HG
- anything above 20 for five minutes or more needs to be treated
2 Factors that impact neurological status
- intracranial pressure
- cerebral perfusion pressure
the amount of pressure required to provide blood flow to the brain
cerebral perfusion pressure
MAP-ICP=?
CPP> cerebral perfusion pressure
Normal adult range for CPP?
70-100
If any one component increases, 1 or 2 of the other components need to decrease— failure to maintain balance (greater than 100% or less than 100%) = higher ICP or lower ICP
Monroe Kellie hypothesis
Increased intracranial pressure has 3 factors that are increased
- increased brain volume
- increased cerebral blood volume
- increased CSF
What happens if CPP falls too low?
the brain and brian tissue are not perfused
ICP= 30, BP=120/80, MAP= 93
what is the CPP?
120+2(80)/3
CPP=93-30= 57
If ICP is HIGH then CPP is LOW
and if MAP is LOW then CPP is LOW .Tor F
True!
this is the rule of thumb for relationships
Interventions for low CPP
Raise HOB, Head alignment, limit stimulation, Mannitol(osmotic diuretic), fluid restriction, avoid any vasopressors
Interventions for high CPP
Fluid Bolus, vasopressors
HIGH CBV and CBF s/s
High systemic BP, avoid systemic acifosis, high metabolic rate (fever, pain), high cerebral edema
LOW CBV and CBF s/s
Hypotension, systemic alkalosis, cerebral edema, low CO, cerebral vasoconstriction, low metabolic rate (sedation, hypothermia, paralysis)
Early S/S of HIGH ICP
HA, visual disturbances, N/V - Seizures, decreased LOC
Dizziness, small change in VS - posturing, fixed/ dilated pupils
Changes in PERRLA> sluggish - Cushing Triad:
restlesness/ irritability - decorticate/ decerebrate posturing
Vomiting w/out nausea
Peds: sunset eye, bulging fontanels
Wide suture lines, high pitched cry
Late S/S of HIGH ICP
Seizures, decreased LOC
posturing, fixed/ dilated pupils
Cushing Triad:
decorticate/ decerebrate posturing
A decrease in ADH leads to increase urine out put and polyuria, polydipsia, etc describes what complication of IICP
- neurogenic diabetes insipidus
“dry inside” - can’t keep enough fluid in body before it is flushed out
too much ADH prevents production of urine and leads to retention of excess water in the body describes what complication of IICP
Syndrome of inappropriate antidiuretic hormone
“ soaked inside”
- can’t urinate> fluid volume overload
Inadequate cerebral perfusion can lead to …..
Ischemia> brain tissue dies
1 sign of increased ICP is….
Decreased LOC
assessment of cerebral perfusion (neuro) includes
- LOC
- pupillary reaction
- Vital signs
- Cranial nerve reflexes
- ICP monitoring
- observation of pt
Glasgow coma scale
- scale to assess LOC
- measures eyes, motor, and speech
- < 8, intubate
factors that influence changes in LOC
- cerebral blood flow
- decreased cerebral perfusion pressure
- increased intracranial pressure
Fixed and dilated pupils means…
severe ischemia
- calling code if you see this
Unequal pupils means…
- lesion or herniation
- make sure to know pts baseline prior
Pinpoint pupils mean…
- lesion or pt just took opioids
- lots of pain meds cause pinpoint pupils
Any trauma to scalp, skull or brain caused by an external physical force
Traumatic Brain injury(TBI)
What are the 3 points in time when death from a head injury may occur
- immediately: primary injury
- several hours after primary injury: secondary injury
- about 3 weeks after injury> multi system failure
Classifications of TBI
- focal> localized
- diffuse> generalized
Bruising of the brain tissue caused by blunt force trauma, falls, mva, penetrating wounds
contusion
The Meninges> layer of skin
Dura matter, arachnoid matter, pia mater> PAD(brain to skull)
Injury causes bleeding thats collected between the dura mater and inner aspect of the skull
epidural hematoma
- above dura!
Blood between the dura and arachnoid layers. bleeding from bridging veins that connect the cerebral venous sinuses to the superficial veins of the skul
Subdural hematoma
- acute, subacute, and chronic
Medical management for hematomas
- surgical evacuations> burr holes, craniotomy, ICP monitor placement
- frequent neuro checks
- proper head position; HOB > 30 degrees
Diffuse brain injuries
- concussion and diffuse axonal injury
sudden, temporary, mechanical injury with disruption of neutral activity and change in LOC
- blow to the head, neck, face
concussions
1 goal in immediate care for pts with TBI
- prevent further injury!
Widespread damage to axons in white matter of cerebral hemispheres, basal ganglia, thalamus, and brainstem
- shearing forces may disrupt the structure of neurons and blood vessels
Diffuse axonal injury
- sympoms appear 12-24 hrs after injury
A temporary(transient) episode of neurological dysfunction
- treat as a medical emergency!
Transient Ischemic Attack (TIA)
What should you assess when a pt has a tbi or head trauma
- LOC
- presence of carotid bruit
- palpate carotid artery
- check if jugular is distened
- health hx
- ct scan
- ekg
- cerebral carotid angiogram
Nonmodifiable risks for TIA and stroke
- age
- gender
- race/ethnicity
- heredity
Modifiable risk for TIA and stroke
- HTN
- alcohol
- smoking
- obesity
- oral contraceptives
- cardiac disease
- cardiac stenosis
- cocaine use
- sleep apnea
An acute neurologic deficit that occurs when impaired blood flow to localized area of the brain results in injury to the brain tissues
Stroke
Ischemic stroke
- blood clot causes stroke
- blood supply to part of the brain is suddenly interupted
hemorrhagic stroke
- occurs when there is a bleeing into the brain tissue or cranial vault
Causes of stroke in adults
- HTN
- SMOKING
- Alcohol
- A fib
- blood vessel abnormalities
- high cholesterol levels
Warning signs of a stroke
BEFAST
- balance
- eyes
- face
- arms
- speech
- time to call 911
Medical management for an ischemic stroke
- tPA> clot buster
- heparin
- mechanical thrombectomy
What should you avoid giving to a pt with an ischemic stroke
- avoid giving glucose-containing IV fluids> stroke may convert to hemorrhagic w/ glucose
Medical management for a hemorrhagic stroke
- coiling/ stenting/ clipping
- craniotomy/ burr hole
- reverse clotting factors
Blood in space between the brain and the arachnoid membrane
subarachnoid hemorrhage
The consequences of a ruptured aneurysm
- blood into subarachnoid space
- inflammatory response cause IICP
T or F tPA should be given to a patient with a hemorrhagic stroke
FALSE!!
- tPA should never be given! Can increase bleeding
