Adult Neuro Test 3
Autonomic Dysreflexia S/S
-Severe Pounding Headache -Hypertension -Profuse Sweating (especially forehead) -Bradycardia -Nasal Congestion -piloerection -goose flesh
hemorrhagic stroke causes
-intracerebral hemorrhage -subarachnoid hemorrhage -cerebral aneurysm -arteriovenous malformation
for hemorrhagic stroke, SBP >180 or MAP >130
-when ICP is elevated administer IV antihypertensive to maintain CPP between 61-80 (clardipine, nevidipine) -when ICP is normal: administer IV antihypertensive to maintain BP around 160/90 mm Hg or MAP around 110
Status epilepticus treatment (medications)
1. Lorazepam (Ativan, versed, Valium): if this doesn't stop the seizures in ten minutes go to next 2. Phenytoin: watch for bradycardia if seizures continue, we intubate pt: 3. Phenobarbital or propofol (sedation)
The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5 F. Which physician order should the nurse institute first?
500 mL albumin infusion intravenously
The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority?
500 ml albumin
normal CPP
70-100
a patient with a head injury has an intracranial pressure of 18 mm Hg. her blood pressure is 144/90 and her MAP is 108. What is the CPP?
90
for thrombolytic pts, maintain BP at
<180/105
which pt being cared for in the ED should the charge nurse evaluate first? A patient with a complete spinal injury at the C5 dermatome level A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula An alert patient with a subdural bleed who is complaining of a headache An ischemic stroke patient with a blood pressure of 190/100 mm Hg
A (risk for ineffective breathing patterns and should be assessed immediately for airway compromise)
After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? A patient with meningitis complaining of photophobia A mechanically ventilated patient with a GCS of 6 A patient with bacterial meningitis on droplet precautions A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patients plan of care? (Select all that apply.) Make frequent neurological assessments. Maintain CO2 level at 50 mm Hg. Maintain MAP less than 130 mm Hg. Prepare for thrombolytic administration. Restrain affected limb to prevent injury.
A, C
the nurse is caring for a pt with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?
Assess for a kinked urinary catheter and assess for bowel impaction. (autonomic dysreflexia)
how to establish brain stem death:
Coma absence of motor response absence of reflexes absence of pain response
The nurse is caring for a patient with an ICP of 18 and a GSC of 3. following the administration of mannitol, which assessment finding by the nurse requires further action? a. ICP of 10 b. CPP of 70 C. GCS of 5 D. CVP of 2
D. A CVP of 2 indicated hypovolemia
dosing for ateplase
Dosing: 0.9 mg/kg IV-- give bolus (10%) IV push over one minute then give remaining (90%) over the next 60 minutes
while caring for a patient with TBI, the nurse assesses an ICP of 20 and a CPP of 85. what is the best interpretation by the nurse?
ICP is high; CPP is normal
tx for ischemic stroke
IV Thrombotic - Tissue Plasmogen activator (TPa): helps restore cerebral blood flow, needs to be given within 3 hrs of strokes onset, and check contraindications (risk for bleeds/recent surgery)
The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?
Implement droplet precautions upon admission.
seizure meds:
Lorazepam, Diazepam, Fospenytoin, Phenytoin, Phenobarbital, Kappra (Phenytoin: only compatible w/ NS, bradycardia, gingival hyperplasia)
ischemic stroke
Most common type of stroke in older people, occurs when the flow of blood to the brain is blocked by the narrowing or blockage of a carotid artery.
tx for aneurysm subarachnoid hemorrhage
Nimodipine: specific for vasospasms -- 21 day therapy Ointment for scalp: Paprovine Euvolemic fluid challenge: normal fluid status Extra fluid: keep BP up- SBP 150/160; keep vessels open and prevents spasm
for nonthrombyltic candidates BP should be
SBP >220 and DBP >120
S/S of stroke
Severe headache, slurred speech, one sided weakness/ numbness, vision problems, ataxia, vertigo, n/v,
secondary brain injury
The "after effects" of the primary injury; includes abnormal processes such as cerebral edema, increased intracranial pressure, cerebral ischemia and hypoxia, and infection; onset is often delayed following the primary brain injury.
for hemorrhagic stroke, SBP >200
administer IV antihypertensive drug every 5 minutes
what is your priority with SCI?
airway and immobilization
priority assessment for spinal shock:
airway, immobilization, bradycardia, hypotension tx: steroids/pressors
In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) Dolls eyes absent indicate a disruption in normal brainstem processing. Dolls eyes present indicate brainstem activity. Eye movement in the opposite direction as the head when turned indicates an intact reflex. Eye movement in the same direction as the head when turned indicates an intact reflex. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. Presence of cervical injuries is a contraindication to the assessment of this reflex.
all but D
the nurse is caring for a patient admitted to the ED following a fall from a 10 ft ladder. upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. the nurse also notes bruising behind the left ear and straw colored drainage from the left are. what is the most appropriate nursing action?
apply a small nasal drip pad
in ICP: Keep HOB- keep head- keep body- move patients- environment- keep paO2: keep o2 sats:
at 30 degrees midline midline carefully quiet above 60 above 90%
basilar fracture s/s
battle's sign and raccoon eyes
nonthrombolytic candidate tx:
blood pressure control, temperature control, aspirin 325 mg, warfarin/eliquis, will go home on Copidogrel
3 major signs of ICP:
bradycardia, widening pulse pressure, slow/irregular RR (Cheyne's stokes, cluster breathing patterns)
if ICP and MAP match=
brain death
The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
c
Pt started with a Glasgow coma scale of 15 and it is 3 an hour later. priority intervention?
call Dr
a patient's oxygen level is dropping. the nurse realizes that because of cerebral auto regulation, the following will occur?
cerebral blood vessels with dilate
oculovestibular reflex
cold water in ear canal if eyes follow: normal
Brainstem death is defined as a loss of what 3 things?
coma, absence of brainstem reflexes, apnea
Intraventricular catheter (external ventricular drain EVD) purpose:
continuous ICP measurement and drains CSF
mannitol expected outcomes:
decreased ICP, increased CPP, increased UO
SIADH s/s
decreased loc (cerebral edema/increased icp) seizures coma sodium less than 120 patient is fluid overloaded increased preload low serum osmolality high urine osmolality low to no UO
cerebral salt wasting symptoms
dehydrated low preload low NA low serum osm high urine osm high na In urine normal UO
The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action?
determine the time of onset
what should the nurse suspect when hourly assessment of UO on a post-craniotomy patient exhibits a UO from a catheter of 2000 ml for 2 consecutive hours?
diabetes insipidus
what is the first question you ask for TBI patient?
did you lose consciousness
worst brain injury
diffuse axonal injury (traumatic shearing forces; tears tissues; bleeding and anoxia; brain swells rapidly)
primary brain injury:
direct injury that occurs to the brain from impact
what is an early clinical manifestation of ICP?
disorientation and restlessness
tx for DI
electrolyte/fluid replacement Desmopressin
The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse?
ensure patency of IV line
SIAHD tx
fluid restrictions, 3% normal saline, seizure precautions
tx for CSW
fluids, replace NA (salt tabs), mineralcorticoids (fludrocortisone)
nimodipine:
for patients with subarachnoid hemorrhages, treats vasospasm
methylprednisone
for spinal cord injury patients
the nurse admits a patient to the CCU following a motorcycle crash. assessment findings by the nurse include BP: 100/50, HR: 58 bpm, RR: 30 and T: 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. which nursing action is most important to include in this patients plan of care?
frequent neurological assessments
Hyperthermia causes ICP to:
increase
The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patients blood pressure to be 160/90 mm Hg. What is the best action by the nurse?
increase the dose by 2.5 mg/hr
the nurse is caring for a mechanically ventilated patient w/ a brain injury. ABG's indicated a PaCO2 of 60. the nurse understands this value to have which effect on cerebral blood flow?
increased cerebral blood volume due to vessel dilation (cerebral vessels dilate when Co2 levels increase)
complete spinal cord injury
injury in which there is complete loss of sensation and muscle control below the level of the injury
BP meds that do not affect brain
lebetalol, nicradipine, clevidipine (for aneurysms, lipid emulsion)
epidural hematoma
lose consciousness initially, then regain consciousness briefly rapid bleed lens shaped hemorrhage on CT poor prognosis
status epilepticus tx
maintain patent airway Immediate control of seizures Suction at bedside IV site in place
the nurse admits a pt to the ED w/ a suspected CSI. what is the priority nursing action?
maintain proper head and neck alignment
The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first?
mannitol
what is the diuretic of choice is used in ICP patients?
mannitol
spinal shock s/s
marked bradycardia, hypotension
C1-C3 injury requires
mechanical ventilation
patient w/ head injury is at risk for:
meningitis/infection
components of a neuro assessment:
mental status language skills memory cranial nerve functioning motor status (5/5 scale) motor status reflexes sensory functioning
The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action?
monitor blood pressure
a patient with SCI at level C3-C4 is being cared for in the ED. what is the priority assessment?
monitor respiratory effort and oxygen saturation level
The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?
monitor the patients airway patency
pain medications:
morphine (spinal cord injuries) dilaudid, fentanyl (increased ICP)
Dexamethasone:
not for tx of ICP after the patient has a craniotomy/brain tumor patients to decreased inflammation
the nurse is caring for a pt who was hit on the head w/ a hammer. the pt was unconscious at the scene briefly but is now conscious upon arrival at the ED with a GCS of 15. one hour later, the GCS is 3. what is the priority nursing action?
notify the Dr
eligibility for thrombolytics
onset of stroke s/s less than 3 hours clinical diagnosis of ischemic stroke (ct/mri) age greater than 18 measurable deficit on NIHSS scale
T1-T6
paralysis below midchest
T7-T12
paralysis below waist
L4-L5
paralysis in lower extremities, lower legs, ankles and feet
S1-@5
paralysis of rectum and bladder, feet and ankles
C5
partial shoulder function, partial elbow fx
C7
partial shoulder, elbow, hand and wrist fx
C^
partial shoulder, wrist and elbow fx
Autonomic Dysreflexia tx
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
while caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left nare. what is the best nursing action?
place a nasal drip pad under the nose
DI s/s
polyuria polydipsia diluted urine excessive thirst normal NA high serum osm low urine osm HIGH URINE OUTPUT
sedation in brain injury patients
propofol, Phenobarbital, precedex
the nurse is caring for a mechanically ventilated patient w/ an ICP of 18. the nurse needs to perform an hourly neuro assessment, suction the ET tube, perform oral care and reposition the pt to the left side. what is the best action by the nurse?
provide rest periods between nursing interventions. (spacing interventions is the priority)
noneligibility for thromb
rapidly improving stroke SBP >185 or DBP >119 glucose <50 or >500 recent MI seizure at onset of stroke any bleeding surgery within the last 14 days
The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) Use of a heparin flush solution Manually flushing the device prn Recording ICP as a mean value Use of a pressurized flush system Zero referencing the transducer system
recording ICP as a mean value zero referencing the transducer system
while caring for a pt with a closed head injury, the nurse assesses the pt to be alert with a BP of 130/90, HR: 60, RR: 18 and T: 102. to reduce the risk of ICP in this pt, what is the priority action?
reduce ambient room temperature and administer antipyretics
C4
respiratory difficulty and paralysis of all 4 extremities
subdural hematoma
slow venous bleed that may take weeks to show signs
C8
some hand weakness but should maintain normal arm fx
Embolic Stroke (Ischemic)
stroke from clot formation
lacunar stroke (ischemic)
stroke from small vessels: diabetes, hypertension
The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first?
the nurse should administer lorazepam as ordered then phenytoin
the nurse is caring for a pt with diminished LOC and who is ventilated. while performing ET suctioning, the patient reaches up in an attempt to grab the suction catheter. what is the best interpretation by the nurse?
the patient is exhibiting purposeful movement
Oculocephalic Reflex (Doll's Eyes)
turn head quickly normal = eyes should move to opposite side abnormal = eyes stay on side you turn it to
if CO2 rises it causes:
vasodilation
