Neuro Quiz

Common cause of inc ICP

* Head trauma! also d/t secondary affect of other conditions (brain tumors, subarachnoid hemorrhage)

What diagnostic procedure is AVOIDED in inc ICP

*Lumbar puncture is avoided d/t sudden release of pressure can cause brain to herniate

What is cerebral irritability?

*Pt conscious, easily disturbed by any form of simulation, hyperactive , residual headache/vertigo *gradually pulse, respirations, temp and other body functions return to normal but full recovery can be delayed for months **impaired mental function or seizures may occur as a result of irreparable cerebral damage

Open vs closed brain injury

- Closed (blunt) brain injury: Occurs when the head accelerates and then rapidly decelerates or collides with another object (wall, dashboard on a car) - Open brain injury: Occurs when an object penetrates the skull, enters the brain and damages the soft brain tissue in its path = penetrating injury OR when blunt trauma to the head is so severe that it opens the scalp

What is a skull fracture?

-Break in the continuity of the skull caused by forceful trauma. Can occur with or without damage to the brain

1st Manifestations of inc ICP

-Change in LOC -Slowing in speech -Delay in response to verbal suggestions -Restlessness -Confusion -Inc. Drowsiness *these may result from compression of the brain d/t swelling

Late signs of inc ICP

-Comatose -Abnormal motor responses: Decortication, Decerebration, Flaccidity Cushing's Reflex: Cushing's Triad:

Why is it important to manage fever in pt with inc icp

-Fever increases cerebral metabolism and the rate of cerebral edema - shiver will inc ICP

Name some nursing diagnoses for inc icp

-Ineffective airway clearance r/t diminished protective reflexes -Ineffective breathing pattern r/t neurologic dysfunction -Ineffective cerebral tissue perfusion r/t effects of inc. ICP -Deficient fluid volume r/t fluid restriction -Risk for infection r/t ICP monitoring system

What is a ventriculostomy?

-Monitors ICP -Fine bore catheter is inserted into a lateral ventricle -Connected to a fluid-filled system to a transducer which records the pressure in the form of electrical impulses -Allows CSF to drain → continuous drainage helps treat hypertension -Provides access for administering medications Complications→ ventricular infection, meningitis, ventricular collapse, occlusion of catheter, problems with monitoring system

How is cerebral edema decreased?

-Osmotic diuretics to dehydrate the brain tissue and reduce cerebral edema -Indwelling catheter to monitor I&O's -Corticosteroids help reduce edema surrounding brain tumors -Fluid restriction

What is diabetes insipidus? How to treat?

-Result of decreased secretion of ADH (Antidiuretic Hormone) -Pt has: → excessive urine output, dec. urine osmolality, serum hyperosmolarity Therapy: → Administration of fluids → Electrolyte replacement → Vasopressin

Why does brain stem herniation occur?

-Results from inc. pressure building in cranial vault d/t inc. BP → Brain tissue pushed down brain stem -Inc. pressure results in cessation of blood flow to the brain

as ICp increases.. manifestations

-Stuporous (numbness, in a daze) -Reacting only to loud or painful simuli

When would a basal skull fracture be suspected?

-Suspected when CSF escapes from the ears, nose -Halo sign **CSF leak is SERIOUS d/t occurrence meningeal infections **Persistent, localized pain suggest a fracture has occurred

What are Intracranial Pressure Waveforms

-Waves of high pressure and troughs of normal pressure indicate changes in ICP

List six treatment goals for the prompt management of increased ICP:

1) administer osmotic diuretics and corticosteroids (manitol dexamethasone), 2) restrict fluids 3) drain cerebrospinal fluid- burr holes, ventroperitoneal shunt 4) maintain systemic blood pressure 5) control fever- acetaminophen 6) reduce cellular metabolic demands

Manifestations of altered LOC

1- as state of alertness & consciousness decreases: → change in pupillary response → change in eye opening response → change in verbal response → change in motor response 2- initial changes reflect subtle behavioural changes: → restlessness → increased anxiety → pupils sluggish = slower than normal (normal = round & quick to react to light) 3- becomes comatose: → pupils fixed (no response to light) → does not open eyes → does not respond verbally →does not move extremities in response to do so

What can cause disruption to anatomic structures of brain?

1- edema 2- trauma 3- pressure from tumors 4- increase or decrease in blood 5- increase or decrease in CSF

3 locations of intracranial hematoma

1- epidural (above the dura)** extreme emergency 2- subdural (below the dura) 3- intracerebral (within the brain)

Assessment of altered LOC patient:

1- evaluation of mental status 2- cranial nerve function 3- cerebellar function (balance and coordination) 4- reflexes 5- motor and sensory function 6- Glasgow coma scale [eye opening, verbal, motor response scale 3-15]

What can cause altered LOC

1- neurologic (hear injury, stroke) 2- toxicologic (drug & alcohol overdose) 3- metabolic (hepatic or renal failure, diabetic ketoacidosis)

Medical managemet to determine and treat cause of altered LOC

1- obtain & maintain A/W 2- circulatory status → monitor BP & HR to ensure perfusion to brain and body 3- IV → access for fluids & IV meds 4- nutritional support ASAP 5- neurologic care 6- other medical interventions aimed at pharmalogical management of complications & prevention

Complication of altered LOC

1- respiratory failure 2- pneumonia 3- pressure ulcers 4- aspiration

What diagnostics can be used for altered LOC patient

1- scanning 2- imaging 3- tomography → CT (computed tomography) → MRI (magnetic resonance imaging) → PET (position emission tomography) 4- electroencephalography 5- lab tests

What are the 3 types of waves in icp waveforms?

1-A Waves = Plateau waves -Indicate changes in vascular volume within the intracranial compartment which are beginning to compromise cerebral perfusion -May increase in amplitude and frequency reflecting cerebral ischemia and brain damage 2-B Waves -Shorter with smaller amplitude -If seen in patients with depressed consciousness, they may precede the appearance of A Waves -Seen in patients with intracranial hypertension and decreased intracranial compliance 3-C Waves -Small, rhythmic oscillations with frequencies of approximately six/min -Related to rhythmic variations of arterial blood pressure and respirations

What are the 3 components that create ICP

1-Brain tissue (1400g) 2-Blood (75mL) 3-CSF (75mL)

What compensatory mechanisms occur to prevent inc icp

1-Displacing CSF 2-Inc. absorption of CSF 3- Dec cerebral perfusion- autoregulation: change diameter of blood vessels

How are skull fractures classified?

1-Linear 2-Comminuted 3-Depressed 4-Basilar **May be Open or Closed** 1-Open = indication of scalp laceration or tear in dura 2-Closed = Dura is intact

What happens in inc ICP if uncontrolled?

1. Dec. Cerebral perfusion 2.Stimulates further swelling (edema) 3. Shifts brain tissue through openings in the rigid dura resulting in HERNIATION

Complications of brain injury

1. Decreased cerebral perfusion 2. Cerebral edema and herniation 3. Impaired 02 and ventilation 4. Impaired fluid, electrolyte, and nutritional imbalance 5. Risk for posttraumatic seizures

Head injury occurs in primary injury and secondary injury. Explain.

1. Primary Injury -Initial damage to the brain that results from the traumatic event -Ex: Contusions, lacerations, torn blood vessels, penetration 2.Secondary Injury -Evolves over the hours and days after initial injury -D/t brain swelling and ongoing bleeding

Nursing postoperative management includes:

1. detecting and reducing cerebral edema 2. relieving pain 3. preventing seizures 4. monitoring inc icp and neuro status

Name the three criteria used to assess level of consciousness using the Glasgow Coma Scale:

1. eye opening 2. verbal responses 3. and motor responses to verbal commands or painful stimuli

What are complications of inc ICP

1.Brain Stem Herniation 2.Diabetes Insipidus 3. SIADH (Syndrome of Inappropriate Antidiuretic Hormone)

What are 3 types of scalp injury?

1.Isolated Scalp Trauma -Minor head injury -Many blood vessels constrict poorly = scalp bleeds profusely when injured 2. Large avulsions of Scalp-Can be life threatening and should be treated as an emergency. 3. Subgaleal Hematomas -Hematomas below the outer covering of the skull -Absorb on their own and do not require specific treatment

How is increased ICP managed?

1.Treat promptly- Invasive monitoring of ICP!! 2.Decrease cerebral edema+ Lower volume of CSF 3.Decreasing cerebral blood volume while monitoring cerebral perfusion! TREATMENT 1.Administering osmotic diuretics & corticosteroids 2.Restrict fluids 3.Draining CSF 4.Controlling fever 5.Maintain systemic BP and 02 6.Decreasing cellular metabolic demands

How is ICP monitored?

1.Ventriculostomy* study this one 2. Subarachnoid Bolt 3.Epidural Monitoring 4.Fibreoptic Monitor

What is Cushings triad

1.Widening Pulse Pressure -Hypothalamus activates the SNS causing peripheral vasoconstriction = Inc. CO 2.Bradycardia -Inc. BP caused by CNS ischemia stimulates the baroreceptors = Dec. HR 3.Irregular Breathing -D/t decreased perfusion to brain stem d/t edema

The normal range of intracranial pressure (ICP) is:

10-20

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

The Glasgow Coma Scale is used to determine the level of consciousness. A score considered indicative of a coma is:

5

To prevent decreased cerebral perfusion pressure after brain injury, the nurse knows that cerebral perfu- sion pressure must be at a minimum reading of:

60mmHg

What is normal CPP

70-100

List three major potential complications in a patient with a depressed level of consciousnes

: pneumonia, aspiration, and respiratory failure

Intracerebral Hematoma

= bleeding into the substance of the brain d/t head injuries (bullet wounds; stab), systemic hypertension(ischemic stroke), rupture of a saccular aneurysm , vascular anomalies, intracranial tumours Onset is insidious. Tx: supportive care, control of ICP, careful administration of fluids, electrolytes and antihypertensive meds, surgical intervention → craniotomy or craniectomy permits removal of blood clot and control of hemorrhage but may not be possible b/c of the inaccessible location of the bleeding or the lack of a clearly circumscribed area of blood that cannot be removed

what is the most important consideration of any head injury ?

= is the brain injured

Decerebrate

A result of ICP, affects midbrain and brainstem. Abnormal body posturing indicated by rigid extension of arms and legs, downward pointing of toes, and backward arching of head

Decorticate

A result of ICP, affects the cortex. Hands are on the chest, clenched fists. Abduction of arms.

What is cerebral edema?

Abnormal accumulation of water or fluid in the intracellular space, extracellular space or both -Associated with inc. brain tissue volumes

What is mannitol

An osmotic diuretic that decreases water reabsorption (especially in proximal tubule and descending loop of Henle) by diluting medullary osmotic gradient and increasing filtrate concentration.

What is glasgow coma scale?

Based on a. Eye opening 1-4(no, pain, voice, spont) b. verbal responses 1-5 (no, incomprehendable sounds, inapropriate, confused, a+o) c. motor responses 1-6 (No, pain decer, pain decor, withdraw pain, localizes pain, obeys comands) -Lowest score is 3-Highest score is 15 -Score of 8 or less is acceptable for indicating severe head injury

Subdural Hematoma

Blood gathers between the Dura matter and the Arachnoid space. Bleeding from veins. Increase in intracranial pressure. Damage to brain. Some people (elerly) have chronic subdural hematomas. Tx: surgical evacuation of the clot- multiple burr holes or a craniotomy (if cannot be suctioned or drained through burr hole)

Respiratory difficulty and paralysis of all four extremities occur with spinal cord injury:

C6

Epidural Hematoma

Clinical presentation: Often initial unconsciousness, then lucid interval, then decreased levels of consciousness & coma. Death may occur in 2-12 hours due to herniation. This is usually caused by tearing of the middle meningeal artery Tx: Burr holes, remove clot, control bleed, drain inserted

What is a head injury? What is cause?

Includes Injury of scalp, skull and brain Most common cause of brain injuries: falls, MVI's, Intentional injury

Cushings Triad

Increased systolic BP, widened pulse pressure; bradycardia; irregular respirations- this is a late sign of ICP

The first priority of treatment for a patient with altered level of consciousness is:

MAINTAIN PATENT AIRWAY

A brain injury can cause serious brain damage because:

Obstructed blood flow can decrease tissue perfusion, thus causing cellular death and brain damage.

Chronic subdural hematoma

Occurs in smaller veins, with the hematoma progressing over weeks to months. Common in elderly and alcoholic -resembles other conditions and may be mistaken for a stroke. bleeding = less profuse, compression of the intracranial contents.

Normal CPP

Pressure of blood flow into the brain CPP = MAP-ICP Normal = 70-100 mmHg **Patients with less than 50 mmHg = Irreversible damage

Potential collaborative problems for a patient with an altered level of consciousness would include:

Respiratory distress, pneumonia, aspiration, pressure ulcer, and deep vein thrombosis

How is brudzinskis sign assesed?

To assess for Brudzinski's sign, the nurse would ask the patient to flex his neck. If flexion of the knees and hips occurs at the same time, the test is considered positive for bacterial meningitis.

How is Kernigs sign assessed?

To assess for Kernig's sign, the nurse would ask the patient to extend one leg while the opposite thigh is flexed on the abdomen. Inability to do this is considered positive for bacterial meningitis.

What is SIADH?

Too much ADH released -Volume overload -Urine output diminishes -Serum sodium concentration becomes dilute Treatment: Fluid restriction

What is Cushings Reflex

Triggered by Ischemia (CPP decreases below 40) -Cushing's reflux is the brain's response to inc. ICP to inc. blood flow → causes inc. MAP

The earliest sign of increased ICP is:

a change in the level of consciousness (LOC)

How do you maintain a clear a/w

a- elevate HOB 30 degrees b- position pt lateral or semiprone - permits jaw & tongue to fall forward c- suctioning & oral hygiene [before & after suctioning pt is hyperoxygenated & hyperventilated to prevent hypoxia] d- chest physiotherapy & postural drainage e- chest auscultated every 8 hrs - to detect adventitious breath sound or absence of breath sounds f- mechanically ventilated

Mnfts of brain injury

altered LOC, confusion, pupillary abnormalities (change in shape, size, and response to light), altered or absent gag reflex, absent corneal reflex, sudden onset of neurologic deficits (motor weakness or absence), change in vital signs (altered resp pattern, HTN, bradycardia, hypothermia, hyperthermia) vision and hearing impaired, sensory dysfunction, headache, vertigo,movement disorders , seizures, behavioural changes

A cerebral hemorrhage located within the brain is classified as:

an intracerebral hematoma.

What is probably happening if pt comatose with localized signs (abnormal pupillary & motor responses)

assume neurological disease is present until determined otherwise

The most severe form of meningitis is considered to be:

bacterial

What is a halo sign?

blood stain surrounded by a yellowish sign may be seen on pillows → CSF leak

The primary, lethal complication of ICP is:

brain herniation resulting in death.

List three primary complications of increased ICP:

brain stem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH)

Bacterial meningitis alters intracranial physiology, causing:

cerebral edema, raised intracranial pressure, increased permeability of the blood-brain barrier

Coma

clinical state of unconsciousness where a pt is unaware of self or the environment for a prolonged period of time (days-months-years)

Intracranial hematoma:

collections of blood that develop within the cranial vault = most serious brain injuries

The three cardinal signs of brain death are:

coma, hypertension, bradycardia, and bradypnea

In the patient who has no protective reflexes.. what is nurses main goal

compensate for the absence of these protective reflexes → unconscious pt = protective reflexes (coughing, blinking, swallowing) are impaired & until pt becomes conscious and oriented the nurses main GOAL = taking responsibility between life or death

Locked in Syndrome

condition resulting from a lesion in the pons, which a pt lack ALL distal motor activity (paralysis) BUT cognition is intact

Persistent Vegetative State

condition which pt is wakeful but devoid of conscious content, without cognitive or affect mental function

Flaccid posturing

dead- brain stem herniation

List five collaborative problems that a nurse should assess for a patient with a brain injury:

decreased cerebral perfusion; cerebral edema and herniation; impaired oxygenation and ventilation; impaired fluid, electrolyte, and nutritional balance; and risk of post-traumatic seizures

After concussion, a patient needs to know to seek medical attention if any of the following six symptoms occur:

difficulty in awakening, difficulty in speaking, confusion, severe headache, vomiting, and weakness on one side of the body

how is cerebral perfusion maintained?

fluid volume and Inotropic Agents (dobutamine hydrochloride) -Effective CO maintains cerebral perfusion >70mmHg

Five symptoms of postconcussion syndrome are:

headache, dizziness, lethargy, irritability, and anxiety

The most serious brain injury that can develop within the cranial vault is a:

hematoma, either epidural, subdural, or intracerebral

Level of Conciousness

is the most important indicator of neurological dysfunction

A characteristic sign of a basilar skull fracture is:

leakage of cerebrospinal fluid from the ears and the nose

What is a cerebral contusion?

more severe injury in which the brain is bruised, with possible surface hemorrhage. Pt unconscious for more than a few seconds or minutes **clinical signs & symptoms depend on the size of the contusion and the of amount associated cerebral edema (lay motionless, involuntary evacuation of bowels & bladder,faint pulse, shallow respirations, BP and temp subnormal, cool, pale skin, appears similar to shock. Can slip back into unconciousness

What is post concussion syndrome?

occurs after minor trauma w/ sxs of HA, dizziness, weakness, sleep troubles and problems concentrating. It will resolve on its own

List six signs of bacterial meningitis that a nurse should assess:

severe headache, high fever, a stiff neck (nuchal rigidity), photophobia, a positive Kernig sign, and positive Brudzinski sign

Akenetic Mutism

state of unresponsiveness to the environment; pt makes no movement or sound but sometimes opens eye

What is a concussion?

temporary loss of neurologic function with no apparent structural damage. Involves a period of unconsciousness lasting from a few seconds to a few minutes and does not reccur

What is probably happening if pt comatose & pupillary light reflexes are preserved

toxic or metabolic disorder

How is CSF drained?

ventriculostomy drain

What is Diffuse Axonal Injury

widespread damage to axons in the cerebral hemispheres, corpus callosum and brain stem - results in: axonal swelling and disconnection. Pt has no lucid intervals, decerebrate/decorticate, coma, global cerebral edema.

Potential collaborative problems for a patient with an altered level of consciousness

would include: respira- tory distress, pneumonia, aspiration, pressure ulcer, deep vein thrombosis, and contractures.

Management of non depressed skull fractures

→ Do not require surgical treatment → Nursing monitoring then d/c home

Management of base of skull fractrues

→ HOB elevated 30 degrees to reduce ICP and promote spontaneous closure of leak

Management of depressed skull fractures

→ Usually require surgery → Scalp is clipped and cleaned with saline → If significant edema, repair may be delayed for 3-6 months → Abx treatment started immediately

Altered LOC

→ pt is not oriented → does not follow commands → needs persistent stimuli to achieve a state of alertness

Why would resp failure occur in someone that has altered LOC

→ shortly after unconsciousness → if pt cannot maintain effective resp then support care to ventilate