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NURS 2514 > Week 8 - Assessment > Flashcards

Week 8 - Assessment Flashcards

1
Q

define Munroe Kellie Doctrine

A
  • as one volume of the brain increases, the volume of another must decrease
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2
Q

define ICP

A
  • pressure exerted bc of the combined total volume of 3 components within the skull
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3
Q

what is an early indicator of neurological status

A
  • LOC
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4
Q

define cushing’s triad

A

manifestations that causes:

  • increased systolic BP
  • decreased HR
  • decreased RR
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5
Q

compression of which nerve causes dilated & fixed pupils

A
  • CN 3 = oculomotor
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6
Q

define decorticate

A
  • position resulting in internal rotation & adduction of arms
  • w flexion of the elbows, wrists, and fingers
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7
Q

define decerebrate

A
  • position resulting in arms stiffly extended, adducted, and hyperpronated
  • legs hyperextended with plantar flexion of the feet
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8
Q

define herniation

A
  • protrusion of brain tissue thru one of the rigid intracranial barriers resulting from increased ICP
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9
Q

list 3 intracranial barriers brain tissue may pass thru during herniation

A
  • foramen magnum
  • tentorial notch
  • falx cerebri
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10
Q

when should neuro status be checked (6)

A
  • on admission
  • baseline (start of shift)
  • loss of consciousness
  • any changes in behavior or status
  • if there is a neuro specific admission or e/c
  • after a fall
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11
Q

what mneomic is used to collect health history?

A 
A: age, allergies
M: medication
P: past medical, family, and surgical history
L: lifestyle
E: entrance complaint
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12
Q

what are the 6 components of a neuro exam

A
  • mental status
  • sensory exam
  • cranial nerves
  • cerebellar/coordination
  • motor exam
  • reflexes
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13
Q

how can we assess a pt’s mental status (5)

A
  • general appearance or behavior
  • LOC
  • cognition (orientation)
  • mood & affect
  • thought content (ex. hallucinations)
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14
Q

define mood

A
  • the emotional state that the pt tells you they feel
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15
Q

define affect

A
  • the emotional state we observe
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16
Q

what are some additional questions to ask the pt

A
  • ADLs
  • nutritional status
  • bowel & bladder status
  • motor problems
  • sleep problems
  • relationship & sexual problems
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17
Q

what are cranial nerves? how many do we have?

A
  • nerves responsible for our sensation & movement

- 12 pairs

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18
Q

cranial nerves can be..

A
  • sensory
  • motor
  • or both
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19
Q

list the 12 pairs of cranial nerves

A 
Olfactory
Optic
Oculomotor
Trochlear
Ttrigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Accessory
Hypoglossal
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20
Q

which cranial nerves are sensory vs motor? (dont need to know but i find it helpful to remember what each one does)

A 
Some
Say 
Marry 
Money
But (both)
My 
Brother
Says
Big
Brains
Matter 
More
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21
Q

what is CN 1? what type of nerve? and how do we assess it

A

olfactory –> involved in sense of smell = sensory

  • ask if they have had any changes in smell
  • assess if nostrils are patent (unobstructed)
  • test with a known odour
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22
Q

describe how to do an odour test for CN1; what is commonly used for it

A
  • have pt close eyes & plug 1 nostril
  • get them to smell the object for both sides
  • common smell used is vanilla
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23
Q

what is a common brain/head injury that results in loss of smell

A
  • skull fracture (esp. basilar)
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24
Q

what is CN 2? what type? what is it involved in?

A
  • optic

- sense of vision = sensory

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25
Q

what 3 ways can we assess the optic nerve

A
  • visual fields (peripheral)
  • optic nerve
  • visual acuity
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26
Q

what is visual acuity? how is it tested

A
  • the sharpness or clearness of vision

- uses the Snellen eye chart

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27
Q

what is peripheral vision

A
  • everything you see off to the side of your central focus while looking straight ahead
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28
Q

how is peripheral vision testes

A
  • getting the pt to cover one eye while you also cover your eye
  • place a stimulus (certain # of a fingers up) within different edges of the visual field while they look straight ahead
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29
Q

what is it called if a large part of their visual field is missing? what can cause this?

A
  • hemianopia

- damage to the optic nerve

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30
Q

what 3 CN play a role in the movement of the eye

A
  • 3, 4, 6 (oculomotor, trochlear, and abducens)
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31
Q

what is CN 3? what type of nerve? what is CN 3 specifically responsible for (3)

A

oculomotor –> motor

  • eyelid opening
  • pupil response to light (constriction)
  • movement of the eye
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32
Q

what is a droopy eyelid called

A

ptosis

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33
Q

what abnormalities should we look for when assessing CN 3`

A
  • dilated pupils

- ptosis

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34
Q

what is the connection between ICP and CN3`

A
  • increased ICP may put pressure on CN 3

= causing pupils to dilate & become fixed (not respond to light)

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35
Q

what should we assess regarding CN 3,4, and 6 (6)

A
  • extraocular movements (eye movement)
  • 6 cardinal positions of gaze
  • corneal light reflex
  • nystagmus
  • ptosis
  • convergence & accomodation
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36
Q

what do we look for during corneal light reflex

A
  • do both pupils restrict and restrict equally?

- was it brisk, sluggish, or fixed

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37
Q

how do we assess the 6 cardinal positions of gaze

A
  • draw an H or star with fingers

- tell the pt to not move their head, and follow your finger w their eyes

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38
Q

what do we look for during assessment of the 6 cardinal positions of gaze

A
  • are both eyes moving together & at the same time? any nystagmus?
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39
Q

what is nystagmus

A
  • uncontrolled, shaking movement of the eye
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40
Q

how do we test for convergence?

A
  • take a finger, tell the pt to look at it, and bring the object inwards to their nose
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41
Q

what is normal vs abnormal movement findings during a convergence test

A
  • normal = both eyes simultaneously move inwards toward each other (like cross eyed) to look at a close object
  • convergence insuffieniency = causes one eye to drift outward
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42
Q

what is accommodation of the eye

A
  • a reflex that changes the structure of the lens so you can see both near & far
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43
Q

how do we assess accommodation of the eye

A
  • get them to look at one thing close such as your finger
  • then the wall
    i think (??)
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44
Q

what is considered normal during assessment of accommodation

A
  • pupils should dilate when looking at something far away & constrict when looking at something close
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45
Q

what is cranial nerve 4? what does it do? what type of nerve?

A
  • trochlear –> motor

- one of the ocular motor nerve that controls eye movement –> down & in

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46
Q

what is CN 5? what does it do? what type of nerve?

A
  • trigeminal
  • sensory & motor =
  • plays role in sensation of the face
  • motor fnxn = opening & closing jaw (biting, chewing)
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47
Q

how do we assess the motor function of CN5

A
  • get the pt to clench their teeth
  • palpate the temporal & masseter muscle
  • try to push on chin to open
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48
Q

how do we assess the sensory function of CN 5

A
  • provide light touch to the forehead, cheeks, and chin using a cotton ball & ask them to close their eyes & say when you touch their face
  • assess any pain
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49
Q

what is CN 6 & what is its function? what type of nerve?

A
  • abducens
  • motor
  • role in eye movement –> turns eye outwards
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50
Q

what is CN 7? what type of nerve? what is its function?

A
  • facial nerve
  • sensory & motor
  • motor = facial expression & mobility & symmetry
  • sensation = part of the tongue (taste)
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51
Q

how do we assess cranial nerve 7

A
  • ask to raise eyebrows, smile, frown, show teeth, puff cheek
  • ask to close eyes tight and not let you open them
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52
Q

which pts might have trouble with the assessment of CN 7

A
  • stroke pt

- facial palsy pt

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53
Q

what is CN 8? what type of nerve? what does it do?

A
  • vestibulocochlear
  • sensory
  • sense of hearing & balance
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54
Q

how do we assess CN 8

A
  • thru normal convo
  • ask if there has been any changes to hearing
  • whisper voice test
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55
Q

describe how to do the whisper test

A
  • plug one of the pt’s ears

- then whisper something into the ear (at a short distance away)

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56
Q

what is CN 9? what type of nerve? what does it do?

A
  • glosspharyngeal
  • sensory & motor
  • motor = swallowing, salivation
  • sensory = tongue (taste), gag
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57
Q

what is CN 10? what type of nerve? what does it do?

A
  • vagus
  • sensory & motor
  • motor = swallowing, talking
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58
Q

how do assess CN 9 & 10

A
  • ask pt to swallow & cough
  • test gag reflex
  • ask them open their mouth wide and say “ahh”
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59
Q

what should you expect to see when asking a pt to open mouth and say “ah”

A

soft palate & uvula should rise to midline

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60
Q

what are the gag, cough, and swallow reflexes often known as? why?

A
  • protective reflexes

- prevent aspiration & choking

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61
Q

what is CN 11? what type of nerve? what does it do?

A
  • spinal accessory
  • motor
  • movement of shoulders, neck, & head
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62
Q

how do we assess CN 11?

A
  • shrug shoulders against resistance
  • assess neck muscles
  • look for symmetry
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63
Q

what is CN 12? what type of nerve? what does it do?

A
  • hypoglossal
  • motor
  • tongue movement
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64
Q

how do we assess CN 12?

A
  • ask them to stick out their tongue midline, & move side to side
  • ask them to pronounce “light, tight, dynamite”
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65
Q

what is the function of the cerebellum

A
  • coordination

- balance

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66
Q

how do we assess cerebellar function (4)

A
  • romberg test
  • heel to toe test
  • rapid alternating finger movements
  • rapid alternating hand movements (such as flipping hand over)
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67
Q

what does reflex testing tell us?

A
  • reveals intactness of reflex arc
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68
Q

what should we assess during reflex testing

A
  • compare L&R

- grade on scale of 0-4

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69
Q

what does each level of the reflex grading scale mean?

A 
4 = hyperactive
3= brisker than nomr
2 = avergae
1 = diminished
0 = no response
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70
Q

how do we assess plantar reflex

A
  • stroke lightly up latersal side of sole of foot & inward across ball of foot (make a J)
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71
Q

what is considered a normal plantar reflex? what is abnormal and what is this called?

A
  • normal = flexion of toes & inversion and flexion of forefoot
  • abnormal = toes fan out = babinski sign
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72
Q

when do we do an acute neuro assessment?

A
  • for pts with acute neuro issues who need frequent monitoring & assessment for changes
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73
Q

what does an acute neuro check look like?

A
  • does not include all components of a neuro assessment

- must be timely & efficient esp if they have a fluctuating status

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74
Q

what is included in neuro check or “neuro vitals” (6)

A
  • LOC
  • orientation
  • VS
  • motor function/abnormal posturing
  • pupillary response
  • protective reflexes
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75
Q

what protective reflexes are assessed during a neuro check (4)

A
  • gag
  • swallow
  • cough
  • blink
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76
Q

what is the most common neuro assessment tool

A

glasgow coma scale

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77
Q

why is the GCS used>

A
  • to monitor trends in LOC
  • influences treatment & decision making
  • universally used
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78
Q

what should you check prior to complete a gcs score

A
  • check for any factor that may interfere w the assessment
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79
Q

what are the 4 steps to completing a gcs assessment

A
  1. check
  2. observe
  3. stimulate (if required)
  4. rate
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80
Q

what does a GCS score of 13-15 mean

A
  • mild injury
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81
Q

what does a GCS score of 9-12 mean

A

moderate injury

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82
Q

what does a GCS score of less than 8 mean

A
  • severe injury
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83
Q

what does a GCS of 3 mean

A
  • totally unresponsive
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84
Q

what are 3 sites for physical stimulation during GCS assessment

A
  • finger tip pressure
  • trapezius pinch
  • supraorbital notch
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85
Q

what 3 things are assessed on the GCS

A
  • eye opening
  • motor response
  • verbal response
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86
Q

what does each rating of the GCS mean regarding eye movement

A
  • open spontaneously = 4
  • open to voice = 3
  • open to painful stimuli = 2
  • no response = 1
  • non testable
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87
Q

what does it mean if a pts eye response is non testable

A
  • eye swelling or any other physical obstruction prevents the pt from being able to open the eye
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88
Q

what responses are assessed regarding verbal response

A
  • orientated x 3 = 5
  • confused = 4
  • inappropriate words = 3
  • incomprehendible sounds ( moans, etc.)= 2
  • no response = 1
  • non testable
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89
Q

what is meant by the confused response when assessing verbal response

A
  • pt communicates coherently but not orientated

ex. facts are wrong

90
Q

what is meant by the inappropriate words response when assessing verbal response

A
  • communicating single words but they do not make sense
91
Q

what may cause a pt to be nontestable when assessing verbal response

A
  • breathing tube

- NG tube

92
Q

what responses do we assessing when assess motor response of GCS

A
  • obeys commands = 6
  • localizes = 5
  • withdraws = 4
  • abnormal flexion (decorticate) = 3
  • abnormal extension (decerebrate) = 2
  • none = 1
93
Q

what is meant by a “localizes” response when assessing motor response

A
  • brings hand toward painful stimulus
94
Q

what is meant by a withdraws response when assessing motor response

A
  • pulls away from painful stimlus
95
Q

what is abnormal flexion

A
  • decorticate

- bends arm at elbow

96
Q

what is abnormal extension

A
  • decerebrate

- extends arm at elbow

97
Q

what vital signs are imp to assess during neuro assessment

A
  • BP
  • HR
  • RR
  • temp
98
Q

what changes in BP might you see during a neuro assessment? why?

A
  • increased systolic BP
  • increased ICP causing decreased O2 to the brain & the body reacts by increasing BP to try and get more blood to the brain
99
Q

what changes in temp might you see during a neuro assessment ? why?

A
  • increase in temo

- if any damage to the hypothalamus

100
Q

what changes in RR might you see during a neuro assessment? why?

A
  • decreased & cheyne stokes respirations

- due to pressure on the brainstem causing depression of the medullary resp. center

101
Q

what changes in HR might you see during neuro assessment? why?

A
  • decreased HR

- increased BP triggers baroreceptors which decrease HR

102
Q

what acronym is used for pupillary response

A

PERRLA

103
Q

what does PERRLA stand for

A

pupils equal, round, reactive to light, accomodation

104
Q

what cranial nerve is responsible for pupillary response?

A
  • CN 3
105
Q

describe how to assess pupillary response

A
  • measure pupil size before & after shining light

- note the response: brisk, sluggish, or incomplete

106
Q

what is mydriasis

A
  • abnormal pupil dilation

- can be uni or bilateral

107
Q

what is miosis

A
  • abnormal constriction of pupil

- can be uni or bilateral

108
Q

what is normal pupil size

A

between 2 - 4

109
Q

where do we assess motor function

A
  • upper & lower limbs
110
Q

describe how to assess the upper limbs (2)

A
  • hand grasps (bilat at the same time)

- assess palmar drift

111
Q

what is palmar drift

A
  • tell pt to close their eyes & put their hands on

- watch to see if one side drifts down

112
Q

what does palmar drift assess for

A
  • stroke
113
Q

how do we assess lower limbs for motor function? (2)

A
  • push pedals (bilat at the same time)

- leg drift

114
Q

what 2 types of posturing do we want to assess for? which is “better” and which is worse

A
  • decorticate = slightly better

- decerebrate

115
Q

what are the 3 protective reflexes

A
  • cough
  • gag
  • swallow
116
Q

what do the protective reflexes protect against

A
  • aspiration
117
Q

what cranial nerve are involved in the protective reflexes

A

9 and 10

118
Q

excitaroy neurons release the nt

A

glutamate

119
Q

inhibitory neurons release the nt

A
  • GABA
120
Q

true or false, a pt experiencing a tonic-clonic seizure is experiencing a focal seizure

A
  • false
121
Q

what is an absence seizure

A
  • seizure common in children
  • often looks like they are “daydreaming” or staring into space
  • lasts about 10 secs and occurs multiple times throughout the day
122
Q

describe what we should ask about regarding PMHx during a seizure assessment

A
  • neuro diseases
  • head trauma
  • infection
  • perinatal history
  • hypoglycemia
  • electrolyte imbalances
  • anything causing hypoxia
123
Q

what should we ask regarding FHx when doing a seizure assessment

A

-family history of seizure disorders?

124
Q

what should we ask regarding lifestyle during a seizure assessment

A
  • drug use
  • risk taking behaviors
  • contact sports
125
Q

what are the 2 types of seizures

A
  • generalized

- focal

126
Q

what is a generalized seizure

A
  • one that effects both sides of the brain

- bilateral synchronous epileptic discharges in the brain

127
Q

what are 6 types of generalized seizures

A
  • absence
  • tonic-clonic
  • atonic
  • clonic
  • tonic
  • myoclonic
128
Q

what is an absence seziures? who is it common in?

A
  • brief starring spell that only lasts a few seconds

- mostly in kids

129
Q

what is a myoclonic seizure

A
  • sudden excessive jerking of body & extremities
130
Q

what is a tonic seizure

A
  • sudden onset of maintained increased muscle tone (stiffening) in the extensor muscles
  • usually causes the pt to fall
131
Q

what is a clonic seizure

A
  • loss of conciousness

- sudden loss of muscle tone followed by limb jerking

132
Q

what is an atonic seizure

A
  • “drop attack”

- tonic episode or paraoxysmal loss of muscle tone that begins with person falling to the ground

133
Q

what is a tonic-clonic seizure

A
  • periods of tonic phases (stiffening)

- followed by period of clonic phase (jerking of extremities)

134
Q

what is a focal seizure

A
  • seizure that begins in one hemi
135
Q

what are 2 types of focal seizures

A
  1. simple

2. complex

136
Q

what is a simple focal seizures

A
  • where the person remains conscious

ex. sudden unexplained feelings, nausea

137
Q

what is a complex focal seizure

A
  • change or loss of LOC

ex. lipsmacking, automatisms

138
Q

what are 2 nursing priorities for tonic clonic seizures

A
  • airway

- safety (particularly the head)

139
Q

define status epilecticus (2)

A
  • 2+ seizures in 5 minutes

- when a seizure goes on or longer than 5 min

140
Q

what are the consequences of status epilecticus (3)

A
  • hypoglycemia
  • acidosis
  • loss of airway
141
Q

the nurse is caring for a pt who has been seizing for 5 min. the most appropiate med to administer is??

A

lorazepam

142
Q

why would you choose lorazpem over diazepam

A
  • lasts longer in the system & is the go to drug for status epilepticus
143
Q

what should you take note of during nursing assessment of seizures

A
  • antecedent events
  • precipitating factors
  • time it started & length of tie
  • postictal stages
  • vital signs
  • posturing & movements
144
Q

what diagnostics are done for seizures

A
  • comprehensive history & physical
  • seizure history
  • blood work
  • ct, mri
  • EEG
145
Q

what should we note regarding seizure history

A
  • what happened before

- seizure event description

146
Q

what should we assess for blood work r/t seizures

A
  • Na
  • Ca
  • blood glucose
147
Q

what is an EEG

A

electroencephalogram

148
Q

how do drugs prevent seizures?

A
  • by preventing the excitation of neurons
149
Q

what are 5 main MOAs of AED

A
  • suppress Na influx
  • suppress Ca influx
  • promote K eflux
  • antagonize glutamate
  • potentiate GABA
150
Q

what do most AED require monitoring of? why?

A
  • plasma drug lvl monitoring

- to help control seizures quickly

151
Q

describe pt adherence for AEDs

A
  • requires continuous & regular therapy
152
Q

describe the withdrawal of AEDs

A
  • must be withdrawn slowly

- otherwise they could experience withdrawal, rebound seizures, or statis epilepticus

153
Q

what does epilepsy & AEDs carry a risk of for all pts? how does this affect our monitoring?

A
  • depression

- monitor for anziety, agitation, depression, and suicidal ideation

154
Q

what do several AEDs decrease the effectiveness of

A
  • birth control pills
155
Q

can AEDs be used if the pt is pregnant? why or why not?

A
  • no

- they are teratogenic = harmful to the fetus

156
Q

what is the MOA of valproic acid (3)

A
  • suppresses Na influx
  • suppresses Ca influx
  • augment the inhibitory influence of GABA
157
Q

what is valproic acid used for

A
  • all major seizure types
158
Q

describe side effects of valproic acid (2)

A
  • few side effects

- NV (take w food)

159
Q

what are 2 contraindications for valproic acid?

A
  • metabolized by the liver = be careful for pts w liver disease
  • highly teratogenic
160
Q

what pt education should be provided for valproic acid since it is highly teratogenic

A
  • must take folic acid supplements
161
Q

what is phenobarbital

A
  • barbituate used for seizures
162
Q

what is the MOA of phenobarbital

A
  • potentiates the effects of GABA
163
Q

describe the side effects of phenobarbital (5)

A
  • lots of side effects
  • drowsiness
  • sedation
  • physical dependence
  • decrease synthesis of vit K = risk of bleeding
164
Q

what types of seizures is phenobarbital used for

A
  • partial & generalized

- NOT for absence

165
Q

what are some contraindications for phenobarbital (2)

A
  • teratogenic

- avoid taking w other CNS depressants

166
Q

what is a benefit to phenobarbital

A
  • long half life
167
Q

what is lorazepam

A
  • a type of benzo
168
Q

what is the MOA of lorazepam

A
  • potentiates the effects of GABA
169
Q

what is lorazepam used for

A
  • status epilepticus & acute seizures
170
Q

describe the side effects of lorazepam (3)

A
  • drowsiness
  • sedation
  • physical dependence (not as much as phenobarbital)
171
Q

what is 1 contraindication for lorazepam

A
  • avoid taking w other CNS depressants
172
Q

what is keppra

A
  • AED with unknown MOA
173
Q

describe the side effects of Keppra (3)

A
  • drowsiness
  • weakness
  • does not impact congition or focus
174
Q

what is 1 contraindication for Keppra

A
  • can cause kidney injury
175
Q

describe the interaction between Keppa and other drugs

A
  • does not interact

- does not effect birth control effectiveness

176
Q

what is phenytoin

A
  • a type of hydantoin
177
Q

what is the MOA of phenytoin

A
  • suppresses action potentials thru inhibiting Na channels
178
Q

what is phenytoin used for

A
  • all major forms of epilepsy
  • NOT for absence
  • especially effective against tonic-clonic
179
Q

describe plasma levels of phenytoin

A
  • very sensitive
  • small changes in dosage above the therapeutic range can cause toxicity
    = narrow therpeutic range
180
Q

list side effects of phenytoin (6)

A
  • nystagmus
  • sedation
  • ataxia
  • diplopia
  • cognitive impairment
  • gingival hyperplasia
181
Q

what are 2 contraindications / interactions for phenytoin

A
  • teratogenic

- can decrease vit K dependent clotting factors

182
Q

what can administering phenytoin via IV cause (3)

A
  • dysrhythmias
  • hypotension
  • “purple glove syndrome”
183
Q

what are 3 important things to note for adminstering phenytoin IV

A
  • inject slowly
  • dilute w saline
  • never mix with dextrose solutions (will precipitate and destroy the vein)
184
Q

what kind of IV do you want to use for phenytoin? why?

A
  • central line or large peripheral IV

- can cause extravasation

185
Q

what 2 drugs increase phenytoin lvls in the blood

A
  • diazepam

- valproic acid

186
Q

what 3 things can reduce phenytoin levels in the blood

A
  • carbamazepine
  • phenobarbital
  • alcohol
187
Q

what is the MOA of topiramate (4)

A
  • potentiates the effects of GABA
  • blocks sodium channels
  • block calcium channels
  • blocks glutamate receptors
188
Q

describe the side effects of topiramate (5)

A
  • few
  • fatigue
  • difficulty conc
  • weight loss
  • depression
189
Q

what does topiramate have a higher risk of versus other AEDs

A
  • higher risk of suicide
190
Q

what is a contraindication of topiramate

A
  • if pts have kidney disease
191
Q

what is gabapentin

A
  • an adjunctive therapy for seizures
192
Q

what is the MOA of gabapentin

A
  • GABA analog
193
Q

describe side effects of gabapentin (4)

A
  • mild to mod
  • drowsy
  • dizziness
  • considered v safe
194
Q

what is 1 contraindication w gabapentin

A
  • elderly pts eliminate the drug more slowly & more suspectible to side effects
    = greater risk of falls
195
Q

describe interactions w gabapentin

A
  • does not interact w other med
196
Q

what is the MOA of carbamazepine

A
  • suppression of sodium channels (and therefore delays the activation)
197
Q

describe side effects of carbamazepine

A
  • minimal effect on cognitive function

- bone marrow suppression

198
Q

what are contraindications of carbamazepine

A
  • should not be taken w grapefruit (effects how it works)
  • should not be given to pts with pre-existing hematologic disorders
  • teratogenic
199
Q

what should you monitor for a pt on carbamazepine

A
  • CBC

- for leukopenia, anemia, and thrombocytopenia

200
Q

what do you need to safely care for a pt at risk of seizure?

A
  • lorazepam
  • BG monitor
  • pillow
  • suction
  • hand sanitizer
  • padding for side rails
  • pen & paper to document
201
Q

what are ur assessment priorities for acute neuro assessment

A
  • airway
  • breathing
  • circulation
  • VS
  • LOC
  • orientation
  • pupils
  • protective reflexes
  • motor
  • other signs of trauma (leaking CSF, bruising)

see notes for more info on why

202
Q

what does battle signs bruising & raccoon eye bruising often occur with?

A
  • basilar skull fracture
203
Q

what else should you monitor for with a basilar fracture

A
  • leakage of CSF or blood
204
Q

what are 2 indicators of CSF

A
  • will be positive for glucose

- halo sign

205
Q

what 2 meds can be used to decrease ICP

A
  • mannitol

- diuretic

206
Q

what is mannitol

A
  • an osmotic diuretic
207
Q

how do you assess the protective reflexes

A
  • ask them to swallow
  • ask them to cough
  • can use a tongue depressor or oral suction to elicit a gag
208
Q

what are the indications for mannitol

A
  • treatment of elevated ICP
  • edema
  • increased intraocular pressure
  • oliguric renal failure
209
Q

what is the MOA of mannitol

A
  • inhibits reabsorption of water & lytes

- pulls water out of the brain

210
Q

how is mannitol best used

A
  • by bolus administration where an acute reduction in ICP is required
211
Q

what occurs immediately after bolus admin of mannitol

A
  • circulating volume increases

= decreased blood viscosity & increased cerebral blood flow & O2 delivery

212
Q

how long does it take for mannitol’s osmotic properties to take effects

A
  • 15-30 min

- when it sets up an osmotic gradient and draws water out of neurons

213
Q

how is mannitol excreted? what does this mean

A
  • urine

= increased serum & urine osmolality

214
Q

how can hypovolemia be avoided with mannitol

A
  • the infusion of isotonic fluids
215
Q

what is an epidural hematoma

A
  • bleeding between the dura mater & inner surface of the skull
216
Q

what is a subdural hematoma

A
  • bleeding between the dura mater & arachnoid mater
217
Q

what is a intracerebral hematoma

A
  • bleeding within the brain itself
218
Q

true or false; compression of cranial nerve will affect constriction of the pupils

A
  • true
219
Q

true or false; decerebrate posturing is more serious than decorticate

A

true

220
Q

true or false; a CT scan is the most appropriate diagnostic test for diffuse injuries such as diffuse axonal injuries

A

false

221
Q

during an assessment, the pt suddenly stares off, body begins to stiffen, lost consciousness, and then his arms and legs start jerking

what is happening

A

tonic clonic seizure

222
Q

what drug can cause gum changes

A
  • phenytoin

NURS 2514 (75 decks)

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