Neuro

Cerebral edema peaks at which time point after intracranial surgery?

24 to 36 hours

Patients with a CPP of less than_______________ experience irreversible neurologic damage.

50 mm Hg

What is the normal level of CPP?

70 to 100 mm Hg

CN VI

Abducens- lateral eye movement

Early manifestations of increased ICP

Any change in condition (restlessness, confusion, increasing drowsiness) Pupil changes Weakness in one extremity or side Headache

What complications can arise from increased ICP?

Brainstem Herniation SIADH Diabetes Insipidus

used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

Burr holes

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

CN VII

Facial: muscles of facial expression, taste 2/3 anterior portion of tongue

major goals of altered level of consciousness

First priority is to obtain and maintain a patent airway, then compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care.

Assessment of intracranial surgery patient?

Frequent monitoring of ABGs and respiratory function Monitor VS and LOC frequently to watch for ICP increase Assess for bleeding/drainage, signs of CSF leak Monitor for potential seizures

How does a nurse maintain a clear airway in a patient with altered LOC?

Frequent monitoring of respiratory status Auscultating lungs Positioning to prevent accumulation of secretions and prevent obstruction of upper airway Suctioning, CPT , oral hygiene

How does a nurse maintain skin integrity in a patient with altered LOC?

Frequent skin assessments Implement turning schedule Positioning/prevent contractures Passive ROM

mild TBI

GCS 13-15

severe TBI

GCS 3-8

moderate TBI

GCS 9-12

CN XII

Hypoglossal, movement of tongue

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

ISOTONIC. Lactated Ringer's

What problems or further complications are we worried about in a patient undergoing intracranial surgery?

Increased ICP Bleeding/hypovolemic shock Fluid/-lyte imbalances Infection CSF leak Seizures

most important indicator of patient condition

Level of consciousness and level of responsiveness

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased ICP such as headache, blurred vision, vomiting, sleepy

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain CPP from 50 to 70 mmHg, elevate HOB, neutral head and neck position, stool softeners, maintain body temp, avoid stimuli, sedation for agitation

CN III

Oculomotor, pupil constriction, raise eyelids

CN X

Vagus, swallowing and speaking

Assessment of patient with altered LOC

Verbal response Alertness Motor response (posturing) Respiratory status Eye signs Reflexes

CN VIII

Vestibulocochlear (Acoustic); Hearing and Balance

Functions of occipital lobe

Visual interpretation and memory

concussion

a temporary loss of neurologic function with no apparent structural damage.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

subdural hematoma

crainectomy

surgical excision of a portion of the skull

peripheral nervous system

the sensory and motor neurons that connect the central nervous system to the rest of the body. contains cranial and spinal nerves.

Concussion is a temporary loss of neurologic function with no apparent structural damage to the brain.

true

Contusion is a bruising of the brain surface.

true

Postoperative care for patient undergoing intracranial surgery?

Detect and reduce cerebral edema Manage pain Seizure prevention Monitor ICP and neurologic status

Post-op care is aimed at what?

Detecting and reducing cerebral edema Reliving pain Preventing seizures Monitoring ICP and neurologic status

Nursing interventions for a patient with inceased ICP?

Maintain patent airway Head in neutral position and elevate HOB to promote venous drainage Avoid hip flexion, Valsalva maneuver, abdominal distention, straining, loud stimuli, shivering or fever.

Major goals for patient with increased intracranial pressure?

Maintenace of patent airway Normalization of respirations Adequate cerebral tissue perfusion

Goals for the patient with altered LOC

Maintenance of clear airway Protection from injury Maintaining fluid volume balance Maintain skin integrity Absence of corneal irritation Effective thermoregulation (prevent shivering/overheat) Absence of complications

Preoperative care for patient undergoing intracranial surgery?

Medications given to reduce risk of seizure Corticosteroids, mannitol, fluid restriction, diuretics for reducing cerebral edema, antibiotics to prevent infection, diazepam for anxiety

What medications would you expect to give to someone for perioperative care for increased ICP?

Meds to reduce risk of seizures. Corticosteroids Mannitol Diuretics Antibiotics Diazepam

How do we maintain cerebral perfusion?

Monitor for even slight changes in respiratory status Assess vitals and LOC every 15 minutes to 1 hour Reduce cerebral edema AVOID EXTREME HEAD ROTATION HOB may be flat or elevated 30 degrees

The body temperature of an unconscious patient is never taken by which route?

Mouth

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position.

Benefits of using a cervical collar?

Reduce ICP, promote venous drainage, prevent jugular vein distortion

Late manifestations of increased ICP

Respiratory changes Increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia; temperature increase Projectile vomiting Loss of brainstem reflexes: pupil, gag, corneal, and swallowing

What are some potential complications of a person with altered LOC?

Respiratory distress or failure Pneumonia Aspiration Pressure Ulcer DVT Contractures

Signs and symptoms of CSF leakage?

Salty taste in mouth Postnasal drip Clear fluid draining from nose

CN V

Trigeminal, Jaw movements, chewing, sensation in face such as touch, pain, temperature

CN IV

Trochlear, downward, inward movement of eye

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

absences of reflexes with flaccid extremities

CN XI

accessory, movement of shoulder muscles

RATIONALE: Why should we try and place the patient on their side while they're having a seizure?

allows the tongue to fall forward and facilitates drainage of saliva and mucus

What are late signs of increased intracranial pressure (ICP)?

altered respiratory patterns, slowed or slurred speech

How to assess for level of consciousness?

assess alertness and ability to follow commands, observe for eye opening, response to stimuli

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

body temperature

The CNS consists of what?

brain and spinal cord

Burr holes

circular openings for exploration or diagnosis to provide access to ventricles or for shunting procedures, aspirate a hematoma or abscess, or make a bone flap

What are the three cardinal signs of brain death?

coma, the absence of brainstem reflexes, and apnea

Functions of the frontal lobe

concentration, abstract thought, information storage, motor function, Broca area for speech, personality

Functions of temporal lobe

contains auditory receptive areas and plays a role in memory of sound and understanding language

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

contusion

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?

contusion

Which activity should be avoided in clients with increased intracranial pressure (ICP)?

enemas

What expected findings would diabetes insipidus cause?

excessive urine output decreased urine osmolality serum hyperosmolality

What is the most common cause of TBIs?

falls

CN IX

glossopharyngeal, swallowing, taste on posterior 1/3 of tongue

Early signs of increased ICP

headache, irritability, and change in LOC

most sensitive indicator of neurologic function

level of consciousness

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure?

loosening constrictive clothing providing for privacy Positioning the patient on his or her side with head flexed forward

What is the purpose of burr holes in neurosurgical procedures?

make a bone flap in the skull, aspirate a brain abscess, and evacuate a hematoma

CN I

olfactory, sense of smell

Craniotomy

opening of the skull removes tumor, decrease ICP, evacuate blood clot, control hemorrhage

CN II

optic, sense of vision

What is the purpose of ROM exercises?

prevent contractures, they are NOT done to restore skeletal integrity

Functions of parietal lobe

sensory analysis, awareness of body position in space, size and shape discrimination

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heartrate, pounding headache, sweating