***Complex 2- Final exam***

What phase of a tonic-clonic seizure does breathing cease and cyanosis develops?

Tonic

What phase of a tonic-clonic seizure is the patient in this picture in?

Tonic

What is the most common type of seizure for adults?

Tonic-clonic seizures (grand mal)

What are the two types of acute infectious meningitis?

Acute purulent meningitis (usually bacterial) Acute lymphocytic meningitis (usually viral)

Diagnostic studies for pulmonary embolism

Computed pulmonary angiography (CTPA) (but this uses contrast dye and contraindicated for pt with kidney dysfunction or allergies)

What are the two types of diffuse cerebral injuries?

Concussion Diffuse Axonal injury

Many generalized seizures may have a genetic basis with no specific underlying cause. What are these called?

"Idiopathic" (primary) seizures *They have a genetic basis but no specific underlying cause

What type of generalized seizures have a known cause?

"Symptomatic" (secondary) seizures Symptomatic seizures have numerous causes including: Vascular disease Alcohol Cerebral tumors Trauma Infection or fever Metabolic disturbances Anoxia (brain completely loses its oxygen supply) Degenerative diseases *Developmental abnormalities, such as cortical dysgenesis (abnormal development of the cerebral cortex), are common causes of childhood-onset epilepsy

positive end-expiratory pressure (PEEP) - complications

(1) Hypotension (2) decreased CO <> IV fluids need to be administered (3) dysrhythmias (4) *Barotrauma* esp << high PEEP - high ventilating pressure and low compliance, pts w/ obstructive airway disease

Endotracheal intubation - RN role

(1) Pt. asset - vitals (2) Suctioning equipment, and works (3) Administer suction PRN *w/hold intubation attempts if SaO2 <90%

BiPAP (bilevel positive airway pressure) - caution(s)

(1) aspiration (2) rebreathing CO2 (face mask) (3) secretions, poor cough

Endotracheal intubation - complications

(1) hypoxemia (s/s, bradycardia, hypotension, arrest); hypercapnia ~>> (prolonged) dysrhythmias (hemodynamic instability (2) vomit <> aspiration <> lung damage (3) disconnection, machine bad, tube obstruction (4) sinusitis (inflamed sinuses) (5) tracheoesophageal fistula >> encourage need and comfort - PRN suction only, oral care, proper pressure

Manual resuscitators (MRB)

(aka, Ambu bag, BVM apparatus) first line of defense for acute *respiratory failure* If pt conscious, squeezing in time with breaths Eventual hookup to machine for better pressure measurements

Who is most at risk for HHS?

- Middle-aged or older (55-70) - Undiagnosed Type 2 - Resides in nursing home - Often have other diseases FYI- higher mortality rate than DKA b/c older & dehydrated

True or False: Consciousness is always impaired with generalized seizures.

True

Thing to remember about IVCs (intraventricular catheters)

- Allows for simultaneous monitoring and intermittent draining of CSF - Can be inserted at bedside under sterile conditions - Can be recalibrated at bedside - Can clear intraventricular blood products

Lab differences b/t HHS & DKA

- BG greater than 600 - Plasma osmolarity higher (greater than 310-320) in HHS so extreme hyperglycemia & hypercalemia - Usually nonketotic - Not acidotic

Negatives of high PEEP (positive end-expiratory pressure) that is used to keep alveoli open and increase gas exchange?

- Can cause pneumothorax. Especially in ARDS patients. - Required chest tube. - Also, high PEEP decreases venous return to the heart so can deceased CO and decrease oxygenation to the tissues. If this happens, need to give fluids to increase volume.

Other management methods for increased ICP:

- HOB 15- 30 degrees per order - Maintain head in neutral position (promises jugular outflow) - Avoid hip flexion greater than 90 degrees - Turn every 2 hrs (pt exhales with turn) - Do passive ROM exercises - Don't cluster activities - Decreases noxious stimulati, use therapeutic touch, calm voice, periods of uninterrupted sleep, avoid painful stimuli like blood draws

How prevent ventilator-associates pneumonia (VAP)?

- Hand washing and gloves when suctioning (dah) - Good oral hygiene (at least every 8 hours) antimicrobial solutions and alcohol-free mouthwash - If enteral feeding, HOB 30-45 degrees to decreases chance of aspiration (prefer oral over nasal to reduce risk of sinusitis) - Gastrointestinal and deep venous thrombosis prophylaxis *Use of an ETT that provides a port for the CONTINUOUS ASPIRATION OF SUBGLOTTIC SECRETIONS (CASS) appears to prevent the development of VAP in the first week of intubation, and it may decrease the overall incidence of VAP but does not affect mortality or length of stay.

Manifestations of DKA

- Hyperventilation - Kussmaul's respirations & "fruity" breath (deep and rapid) as a compensatory mechanism in metabolic acidosis - Lethargy, weakness, stupor, coma - Glycosuria - Volume depletion/dehydration so hypotension & tachycardia - Hyperosmolarity - Increased anion gap (>7) - Decreased bicarbs (<10) - Decreased pH (<7.4) - Blood glucose 250-800 - Increased K+, creatinine & BUN - polyuria, polydipsia, weight loss for several days prior (remember: RAPID ONSET) - Abdominal pain (with abdominal distention) & vomiting - Flushed skin - May have normal temp or hyperthermia if severe

Second-tier therapy for increased ICP

- Hypothermia - Barbiturate coma - Optimized hyperventilation - Hypertensive CPP therapy - Decompression of craniotomy

With a chest tube, when is bubbling normal and when not?

- In water seal chamber only when patient exhales (think about exhaling and blowing bubbles). Constant bubbling in water chamber indicates air leak. Tubing may be displaces/disconnected. - Gentle bubbling is expected in the SUCTION CONTROL chamber.

Lab studies common with thyroid storm

- Increased T4 & T3 (and free T4) - Decreased thyroid-stimulating hormone (TSH) : remember, too much thyroid hormone = won't be stimulated to produce more Also, electrolyte imbalanced b/c of dehydration: Hypercalcemia r/t excessive bone resorption Hyperglycemia r/t insulin resistance/breakdown of stored glucose Hypokalemia Hypomagnesemia

Common causes of ARDS

- Influenza - Sepsis - TRALI (transfusion related injury): occurs quickly within 1-2 hours of transfusion

Diagnostic studies for thyroid storm

- Radioactive iodine uptake test- iodine is usually increased in thyroid storm - ECG may show arterial fibrillation and other dysrhythmias

Important to remember about mechanical ventilation

- Respond to every alarm - Nurse or respiratory therapist performs vent checks every 2-4 hours

Contraindications for Noninvasive ventilation (NIV)

- Risk for rebreathing PaCO2 (if full face mask) - Risk for aspiration if thick or copious secretions or poor cough reflex

Nursing priorities for patient during seizure

- Turn on side to help maintain patent airway - Don't leave alone - Don't restrain

First-tier therapy for increased ICP

- Ventricular CSF drainage - Osmotic therapy - Respiratory support - Sedation - Analgesia

Diagnostic tests for myxedema coma

- chest X-ray shows pleural effusion (h2o on lungs) - ECG shows bradycaria

Common labs seen with myxedema coma

- decreased T3 &T4 - Increased TSH - hyperkalemia (makes sense b/c everything slows down including bowels) - Hyponatremia - decreased arterial oxygen, increased carbon dioxide (makes sense b/c hypoventilation- can't blow off PaCO2)

Important suctioning considerations in for patient with increased ICP

- preoxygenate with 100% O2 - one or two catheter passes - no more than 10 sec per catheter insertion

Manifestations of adrenal crisis

- weight loss - n/v - abdominal cramping & diarrhea - Tachycardia - orthostatic hypotension - Headache/lethargy/ weakness - hyperpigmentation - hyperkalemia - hyponatremia - hypoglycemia - hypercalcemia - hypovolemia (severe dehydration) - elevated BUN

Autonomic Dysreflexia

-A syndrome that sometimes occurs after the acute phase in patients with a spinal cord lesion at or above T6 -Syndrome presents quickly and can precipitate a seizure or stroke

Mechanisms of TBI

-Acceleration Injury -Acceleration-Deceleration Injury -Rotational Forces -Coup-Contrecoup Injury -Penetration Injury

Intraventricular Catheters

-Accurate, low-cost, and reliable ICP monitor -Catheter is tubular instrument that is placed inside fluid-filled cavities in ventricles -CSF is synthesized in these cavities and flows out to circulate over surface of brain -Allows for simultaneous monitoring and treatment of ICP by intermittently draining CSF -Can be recalibrated in situ -Can help clear intraventricular blood products for hemorrhage patients -Ease of CSF sampling -Risk for catheter misplacement, obstruction, infection, and hemorrhage

Adrenal Insufficiency/Addison's Disease Assessment

-Affects glucose metabolism, fluid and electrolyte balance, cognitive state, and cardiopulmonary status -Clues to adrenal crisis include weakness, fatigue, anorexia, nausea, vomiting, diarrhea, and abdominal pain -Hyperpigmentation on elbows, knees, hands, or buccal mucosa for primary -Severe dehydration (weight loss and orthostatic hypotension)

1) Analgesics, Sedatives, Paralytics

-Analgesics limit pain caused by injuries and nursing interventions, facilitate mechanical ventilation, and potentiate effects of sedatives -Monitor for pain by assessing work of breathing, synchrony with ventilator, decrease in HR, less agitation, and cooperation with nursing interventions -Propofol is anesthetic to decrease agitation, CBF, ICP, CPP, and cerebral metabolic function -Frequent blood pressure monitoring -Neuromuscular blockading (NMD) used to induce muscle paralysis in cases of refractory ICP -For severe and refractory ICP, barbiturate coma may be used to decrease systemic metabolic activity in an attempt to preserve brain function

3) Seizure Prophylaxis - use of antiepileptic meds

-Antiepileptic agents to decrease incidence of early seizure activity -Treatment of choice for acute-onset seizure is diazepam

Myxedema Coma

-Extreme hypothyroidism; low basal metabolic rate and decreased energy metabolism and heat production -Complications include pericardial and pleural effusions, megacolon with paralytic ileus, seizures, coma, and death

Anterior Cord Syndrome

-Area of damage is anterior aspect of spinal cord -Complete motor paralysis below level of injury (corticospinal tract) -Loss of pain, temperature, and touch sensation (spinothalamic tracts) -Preservation of light touch, proprioception, and position sense

Assessment of Brainstem Responses TBI

-Assessed in the unconscious patient by testing corneal, cough, and gag reflex -CN V, VII is the corneal (eye blinking) reflex -CN IX, X is the cough and gag reflex

Cerebral Blood Flow (CBF)

-Autoregulation = ability of an organ to maintain consistent blood flow despite marked changes in arterial circulatory and perfusion pressures -For the brain, autoregulation ensures constant blood flow through cerebral vessels over a range of perfusion pressure by changing diameter of vessels in response to changes in arterial pressures -Impaired autoregulation leads to CBF changes in direct correlation with systemic blood pressure -Cough, suctioning, restlessness can cause an increase in CBF which could also increase ICP

2) Blood Pressure Management

-Blood pressure is directly related to cerebral blood volume, perfusion pressure, ischemia, and compliance -Goal of preservation of CPP and maintenance of systemic oxygenation -Maintain CI at 3 because of increased metabolic needs -Acute ischemic stroke: IV hydralazine, labetalol, nicardipine or nitroprusside -Hemorrhagic brain injury: avoid MAP greater than 110; ACE inhibitors, B-blockers -Avoid calcium channel blockers because of potential to exacerbate cerebral edema

Coup-Contrecoup Injury

-Brain bounces back and forth within the skull, striking both pols of the brain (front and back or right side and left side) -Coup refers to area of brain tissue initially making forceful contact with the inside of the skull -Contrecoup refers to second impact on brain tissue with the inside of the skull, usually on opposite side -Assessing patient struck in back of head requires clinician to evaluate for injury to posterior structures (occipital lobes and cerebellum) as well as anterior brain structures (frontal lobes)

Rotational Forces

-Brain twists within meninges and skull, resulting in stretching and tearing of blood vessels and shearing of neurons -Physical assaults and motor vehicle crashes are examples where rotation and torsion may be mechanism of injury

Diagnostic Testing TBI

-CT is performed as an initial diagnostic test to identify structural injuries in brain and intracranial bleeding -Cerebral angiography is gold standard diagnostic test to investigate injuries to cerebral blood vessels -Transcranial Doppler (TCD) ultrasonography indirectly evaluates cerebral blood flow and autoregulatory mechanisms by measuring speed with which blood travels through blood vessels

Spinal Cord Injury Mechanisms - Hyperflexion SCI Hyperflexion, or forcible forward bending, may compress vertebral bodies and disrupt ligaments and intervertebral disks

-Caused by sudden deceleration of head and neck -Often seen in patients who have sustained trauma from a head-on MVC or diving accident -Cervical region is most involved, especially at C5,C6 level -With hyperflexion to the cervical spine, there may be tearing of the posterior ligamentous complex, resulting in anterior vertebrae dislocation

Cerebral Edema

-Cerebral edema can lead to increased ICP -Presence leads to secondary complications related to expansion of brain tissue within closed space of cranium, including impaired circulation leading to secondary hypoxia -Treatment with corticosteroids and osmotic diuretics are aimed at reducing ICP

Neurogenic Shock Pathophysiology

-Characterized by hypotension, bradycardia, and hypothermia -When sympathetic tone is lost, unopposed parasympathetic response results in uncontrolled arterial vasodilation and a decrease in SVR -Simultaneous venous vasodilation results in blood pooling and decreases preload -Unopposed parasympathetic stimulation leads to bradycardia, even in the presence of falling blood pressure -Disruption of the sympathetic nervous system inhibits the stimulation of baroreceptors in the aortic arch and carotid sinus -The decrease in both stroke volume (from decreased preload) and heart rate leads to decreased CO, resulting in inadequate tissue perfusion -Hypothermia results from uncontrolled heat loss from excessive vasodilation

Parenchyma

-Compensatory mechanisms include shunting CSF into spinal subarachnoid space, increased CSF absorption, decreased CSF production, and shunting of venous blood out of skull -Failure of compensatory mechanisms leads to quick pressure increase until shifting of brain tissue toward open spaces in skull (brain herniation) occurs and blood supply to medulla is cut off

Brown-Sequard Syndrome

-Damage is located on one side of spinal cord -Increased or decreased cutaneous sensation of pain, temperature, and touch on the same (ipsilateral) side of spinal cord at the level of the lesion -Below the level of the lesion on the same side, therefore is complete motor paralysis -On patient's opposite side, below level of lesion, there is loss of pain, temperature, and touch because the spinothalamic tracts cross to the opposite side soon after entering the cord -Patient's limb with the best motor strength has the poorest sensation -Limb with best sensation has poorest motor strength

Central Cord Syndrome

-Damage to spinal cord is centrally located -Hyperextension of cervical spine often is mechanism of injury and damage is greatest to cervical tracts supply arms -Patient may present with paralyzed arms but no deficit in legs or bladder

Myxedema Coma Labs

-Decrease T4 -Decrease free T4 -Increase TSH -Hypercapnia -Hyponatremia -Hyperkalemia

Increased Intracranial Pressure

-Defined as the pressure in the cranial vault relative to atmospheric pressure May result from: Hypercarbia Hypoxia Rapid eye movement sleep Pyrexia (fever) Administration of certain anesthetics Environmental stimulation Increased metabolic rates *Rapid eye movement sleep (REM sleep or REMS) is a unique phase of sleep characterized by random rapid movement of the eyes, accompanied by low muscle tone throughout the body, and the propensity of the sleeper to dream vividly.

Hyperosmolar Hyperglycemic State (HHS) Assessment

-Dehydration, obtundation, hypothermia, toxic appearance, absent Kussmaul's respirations, nonketotic -Blood glucose 600-2000 -Arterial pH > 7.3 -Bicarbonate > 15 -Plasma osmolality is higher than in DKA and reflective of more severe dehydration, large additional "free water" deficit r/t patients NOT becoming thirsty -Patients are typically nonketotic -Acidosis may be very mild or not present at all; patient may present with azotemia, hyperkalemia, and lactic acidosis

Assessment of Level of Arousal TBI

-Determines capacity for wakefulness -First call name, then shout name, shake, and finally by applying central pain -Trapezius squeeze, sternal rub, supraorbital pressure, nail bed pressure *Movement elicited by nail bed pressure is a result of activation of a spinal cord reflex. It is useful to use a time frame for which to apply a painful stimulus, such as 15 to 30 seconds, in order to trend the quality of the response and to ensure that the injured brain is given adequate time to respond. Patients with brain injury may exhibit delayed responses to stimuli.

Hyperosmolar Hyperglycemic State (HHS) Management

-Directed at correcting volume depletion, controlling hyperglycemia, and identifying and treating underlying cause -Isotonic saline or hypotonic saline solution administered initially to correct fluid imbalance; may require 9-12 L overall -Low doses of insulin along with fluid replacement; continuous infusion as patients are vulnerable to sudden loss of circulating blood volume that happens with higher doses of insulin and rapid blood glucose reduction -Once patient has 250-300 glucose, stop infusion and add dextrose to IV fluids to prevent sudden drop in glucose levels - subQ insulin can now be started -Give fluids slowly to avoid complications associated with cerebral edema (seizures, altered neurologic state) -Risk for intravascular thrombosis and focal seizures because of hemoconcentration of blood and hyperosmolar state

Inhospital Management SCI

-ED assess airway and may intubate for appropriate ventilatory support (C1-C4 injury) -Circulatory status is then assessed; hypotension r/t volume loss from hemorrhage -Fluid resuscitation with IV fluids, crystalloids, or blood -Blood enhances oxygenation and may minimize secondary ischemic injury to spinal cord -Complete neurologic and orthopedic assessment and assess for additional injuries -Patient is then removed from backboard to minimize development of pressure ulcers -Administering high dosage steroids is controversial but argues that drug reduces swelling and helps minimize secondary injury by reversing intracellular accumulation of calcium, reducing risk for cord degeneration and ischemia -Therapeutic hypothermia, reduction in core body temperature, may be used to reduce nervous system metabolism (thought to decrease detrimental effects of secondary injury)

Endotracheal tubes

-ETT is inserted if the patient needs ventilation or protection of the airway from aspiration -The ETT can be inserted nasally or orally -The nurse assists by providing suction PRN, and monitoring the patients SaO2 by pulse ox as well as the HR and BP -If SaO2 falls below 90% intubation attempt should be withheld and the pt should be "bagged" (Manual resuscitation bag (MANUAL RESPIRATORY BYPASS) with mask) *used in unconscious and bleeding patient*

Nurse Management - Autonomic Dysreflexia

-Elevating the head of the bed and frequently assessing BP -Nurse quickly checks the bladder drainage system for kinks in the tubing -Urine collection bag should not be overly full -Some protocols for checking the patency of the urinary drainage system include irrigating the catheter with 10 to 30 mL of irrigating solution -If systems continue, the catheter is changed so the bladder can empty -If the urinary system is not the cause, it is necessary to check the patient for bowel impaction -Removal of impaction should not occur until symptoms subside -Foley catheter placement may be necessary for patients on a bladder management program and those who have not voided in the past 4 to 6 hours If the urinary system does not appear to be the cause of the stimulus, it is necessary to check the patient for bowel impaction. Removal of the impaction should not occur until the symptoms subside. Rectal application of dibucaine or lidocaine ointment anesthetizes the area until symptoms subside. If the patient's BP does not return to normal, sublingual nifedipine (Procardia) may be effective. A sympathetic ganglionic blocking agent, such as atropine sulfate, guanethidine monosulfate (Ismelin), reserpine, or methyldopa (Aldomet), may be useful. Hydralazine (Apresoline) and diazoxide (Hyperstat) also may help.

Assessment of Motor Function TBI

-Evaluate using staged approach -Unresponsive patient may exhibit localization, withdrawal, flexor posturing, or extensor posturing in response to noxious stimuli Localization of a painful stimulus is observed as a purposeful response in which the patient is able to locate the source of pain and move toward it with one or both extremities crossing the midline of the body. A patient may try to remove the evaluator's hand when he or she performs a trapezius squeeze, or the patient may attempt to grab medical equipment (eg, catheters or endotracheal tubes). Withdrawal response is characterized by movement away from a painful stimulus Flexor (decorticate) posturing is indicative of diffuse cortical injury and is characterized by the bending or flexing of the upper extremities and extension of the lower extremities and feet Extensor (decerebrate) posturing indicates injury to the brainstem and is observed as extension and internal rotation of the upper extremities and extension of the lower extremities and feet

Assessment of Eyes TBI

-Evaluation of pupils and extraocular movements -Cranial Nerve II (CN II); "optic nerve" - involves detection of gross visual field defects and visual acuity - Cranial Nerve III (CN III); "oculomotor nerve" - inspection of the pupil size, shape, equality, and reaction to light *Increased ICP can cause irregularities in shape, pupillary inequality (anisocoria), and sluggish or absent reaction to light. -CN III, IV, VI enable MOVEMENT of the eye

Traumatic Brain Injury Risk Factors

-Falls are leading cause, followed by unknown causes, unintentional blunt trauma, and motor vehicle-related injuries -Incidence is greater in males than females -Occurs most frequently in children younger than 5 and adolescents between 15 and 19 years -TBI in adults aged 75 years and older are normally caused by falls -Nurses play an important role in reducing incidence of head injury through teaching as well as participation in primary prevention efforts (helmet safety, violence prevention, fall prevention, and drug and alcohol awareness)

Fiberoptic Monitors

-Fiberoptic technology to measure ICP -Tip of probe has a transducer, which is inserted into brain parenchyma, ventricles it surrounds, or subdural space -Higher cost, subject to measurement drift

Management of Increased Intracranial Pressure

-First-tier therapy includes ventricular CSF drainage, administration of osmotic therapy, respiratory support, and sedation and analgesia -Second-tier therapy includes hypothermia, barbiturate coma, optimized hyperventilation, hypertensive CPP therapy, and decompressive craniectomy -Most management techniques are oriented toward control of cerebral blood volume and CSF circulation, the two major mechanisms responsible for regulation of ICP -Treatment goals for the patient with increased ICP: • Reduce ICP • Optimize CPP • Maintain adequate oxygenation • Avoid brain herniation

Spinal Shock Clinical Manifestations

-Flaccid paralysis, loss of skin reflexes and deep tendon reflexes, and loss of all sensations below the level of injury. -Absence of cutaneous and proprioceptive sensation -Hypotension and bradycardia (50 to 70 bpm) -Absence of reflex activity (areflexia) below the level of injury, may cause urinary retention, bowel paralysis, and ileus - Warm skin, and body temperature that responds to the surrounding environment (poikilothermia) -Loss of temperature control *Inability to shiver prevents ability to conserve heat in a cool environment *Inability to perspire prevents normal cooling in a hot environment -There is loss of urinary bladder tone, intestinal peristalsis, perspiration, and vasomotor tone

Two-chamber system has water seal & collection chamber

-Fluid level higher than 2 cm H2O exerts a greater negative pressure on pleural space and may prevent resolution of air leak -Water seal prevents air from traveling back into lungs (lungs like to exert a -- pressure and would help achieve this) -Detect if closed system has leaks by looking at water chamber (2 cm H20) -> constant bubbling present -With pneumothorax resolution, some bubbling is normal -When patient takes breath in (inspiration), water level goes up and exhalation water level goes down -> tidaling

Neurologic Assessment SCI

-Frequent assessment determines extent of SCI and allows for early recognition in level of consciousness that may occur secondary to TBI -Glasgow Coma Scale (GCS) to determine LOC -Standard Neurological Classification of Spinal Cord Injury to assess and document patient's level of functioning -Cranial nerve testing -Digital rectal exam to determine whether injury is complete or incomplete -Lesion is incomplete if patient can feel palpating finger or can contract perianal muscles around finger voluntarily -Preservation of sacral function may be only finding that indicates incomplete lesion -Rectal tone by itself, without presence of voluntary perianal muscle contraction or rectal sensation, is NOT evidence of incomplete spinal cord injury

Diabetic Ketoacidosis Management

-Goals are to improve circulatory volume & tissue perfusion, correct electrolyte imbalances, decrease glucose, correct ketoacidosis, and determine precipitating events -IV normal saline to reverse severity of extracellular volume depletion and restore renal perfusion -Hypotonic (0.45% NS) after intravascular volume has been restored or if serum sodium levels are greater than 155 -Albumin and plasma concentrates (plasma expanders) if low BP and other signs of vascular collapse don't respond to saline alone -Insulin administration - blood glucose should fall slowly -Once glucose is 200 to 250, decrease insulin infusion to 0.5 units/kg/hour and add dextrose to IV fluids -Helps to prevent cerebral edema that may occur when blood-brain barrier is affected by extreme fluid shifts -Replace potassium, phosphate, and bicarbonate as prescribed -Reestablish metabolic function: NG tube to decompress stomach -> increases comfort and decreases risk for aspiration

Spinal Cord Injury Mechanisms - Axial Loading (Compression) SCI Axial loading, a form of compression, is the application of vertical force to the spinal column (for instance, by falling and landing on the feet or buttocks, or by diving into shallow water).

-Happens after person lands on feet or butt after falling or jumping from a height or when there is a direct blow to the head -Injury results from column compression leading to a fracture that causes damage to spinal cord

Acceleration-Deceleration Injury

-Head in motion strikes a stationary object -Motor vehicle crash where head strikes window shield produces an acceleration-deceleration injury -Can also happen with falls or physical assaults

Three-chamber system has water seal, collection chamber, and suction control chamber

-Height of water column in third chamber (NOT wall suction) determines suction amount applied to chest tube, (most commonly -20 cm H2O) -With wet suctioning, water must be at correct level to get correct suctioning pressure -When water bubbles (normal), some can evaporate, so monitor water periodically to ensure it is at -20 cm H2O -With lower water level, you aren't getting negative suction pressure -Dry suction (waterless) systems use a spring mechanism to control the suction level and can provide higher levels setting between *-10 and -40 cm H2O*

Cardiovascular Assessment SCI

-Hemorrhagic shock (hypotension, tachycardia, cold, clammy skin) r/t intrathoracic, intra-abdominal, or retroperitoneal injury or pelvic or long bone fractures -Spinal or neurogenic shock (hypotension, bradycardia due to loss of autonomic innervation)

Mannitol

-Hypertonic saline solution to decrease cerebral edema Plasma expanding effects: Reduces blood viscosity Increases CBF Increases cerebral oxygen metabolism which allows cerebral arterioles to decrease in diameter -Lowers cerebral blood volume and ICP while maintaining a constant CBF

Adrenal Insufficiency/Addison's Disease Labs

-Hyponatremia, hyperkalemia, decreased serum bicarbonate, elevated BUN, hypoglycemia -Cortisol levels below 15 mcg/dL are indicative of adrenal dysfunction

Respiratory Assessment SCI

-Hypoventilation or respiratory failure -Risk for hypoventilation results from loss of innervation to both the diaphragm (C2-C4) and the intercostal muscles (T1-T4) -Priority assessment in patients with high cervical injuries -Paralytic ileus and gastric dilation may increase pressure on diaphragm and cause further respiratory compromise, so NG for stomach decompression may be placed

Adrenal Insufficiency/Addison's Disease Management

-Immediate goal is to administer needed hormones and restore fluid and electrolyte balance -Fluid resuscitation with normal saline and 5% dextrose solution -Prevent complications by monitoring electrolyte imbalance (hyponatremia & hypercalcemia) and respiratory and cardiovascular function -Monitor BP, HR & rhythm, skin color and temperature, cap refill, CVP, orthostatic hypotension, bradycardia, and dysrhythmias -Monitor neuromuscular signs: weakness, twitching, hyperreflexia, and paresthesia -Teach to prevent crisis: medication, stress factors, S/S of impending crisis, ID tag

Nasopharyngeal airway

-In patients who are needing frequent nasotracheal suctioning, nasopharyngeal airways are frequently used to prevent patient discomfort and airway trauma from repeated suction catheter infraction through the nares -Suctioning is best done with the red rubber catheter, more flexible and better tolerated than standard plastic catheters -Supplemental O2 is given before and after suctioning -Prior history of epistaxis or known coagulopathy should be carefully reviewed before placing a nasopharyngeal airway or performing nasotracheal suctioning that may lead to bleeding *Nasotracheal suctioning is done as a sterile procedure Use the following steps to insert a nasopharyngeal airway: 1. Determine and select the correct tube length by measuring from the tip of the nose to the earlobe. Use a tube with the largest outer diameter that fits the patient's nostril. 2. Lubricate the tube with water, water-soluble jelly, or lidocaine jelly to alleviate discomfort. 3. Reassure the patient and familiarize him or her with the procedure. 4. Insert the airway into the nostril up to the end of the nasal trumpet. 5. Have the patient exhale with the mouth closed. (If the tube is in the correct position, air can be felt exiting from the tube opening.) 6. Open the patient's mouth, depress the tongue, and look for the tube's tip just behind the uvula.

Intracranial Pressure Monitoring

-Indicated primarily to help guide therapy (based on clinical presentation, radiographic evaluation, and CT diagnosis) -Provides information to facilitate earlier interventions to prevent secondary cerebral ischemia and brainstem distortion -Provides information about likelihood of cerebral herniation and helps calculate CPP -Guides potentially harmful treatments, such as for hyperventilation, or administration of mannitol, and barbiturates

Hypertonic Saline

-Induce hypernatremia to increase CPP and decrease intracerebral pressure -Greater than 3% requires central venous access to avoid phlebitis or regional necrosis *Phlebitis - inflammation (redness, swelling, pain, and heat) of a vein *Necrosis - death of living cells or tissues

Nursing Management TBI

-Initial: (Prehospital) rapid neurologic assessment, definitive airway management and treatment of hypotension. Correct hypoxia and hypercarbia -Airway management: maintain normal ventilation or a partial pressure of carbon dioxide (normal: 35-45 mm Hg). -The goal of hyperventilation in TBI is to decrease PaCO2. Hyperventilation causes constriction of cerebral blood vessels and decreases cerebral blood volume. Decreased blood volume in the brain results in decreased ICP

Primary Brain Injury

-Injury that happens at time of trauma -Immediate disruption of skull, brain structures (meninges, blood vessels, brain tissues, neurons), and functions (blood flow, oxygenation, cellular metabolism) Scalp Laceration Skull Fracture Concussion Contusion Epidural Hematoma Subdural Hematoma Intracerebral Hematoma Traumatic Subarachnoid Hemorrhage Diffuse Axonal Injury Cerebrovascular injury

Secondary Brain Injury

-Injury to brain beginning immediately after traumatic event -Physiologic response to brain injury, including cerebral edema, cerebral ischemia, and biochemical changes -Examples of conditions causing or exacerbating secondary brain injury are uncontrolled ICP, cerebral ischemia, hypotension, hypoxemia, and local or systemic infection -Occurs as a function of the inflammatory response, reduced cerebral blood flow, and dysfunctional cerebral autoregulation causing damage to neurons -Prevention of hypotension, hypercarbia, hypoxemia, hyperthermia, and seizures is important to prevent further injury -Cerebral autoregulation is a protective mechanism that enables brain to receive constant blood flow over a range of systemic blood pressures Cerebral Edema Ischemia Herniation Syndrome Coma Persistent Vegetative State

Diabetic Ketoacidosis Pathophysiology

-Major physiologic disturbances: (1) hyperosmolality from hyperglycemia (2) metabolic acidosis (3) volume depletion from osmotic diuresis -Hyperglycemia results from insulin deficiency, gluconeogenesis, glycogenolysis, and reduced glucose utilization in peripheral tissues -Combination of insulin deficiency and enhanced effects of counter-regulatory hormones -> activation of lipase in adipose tissues -Another cause of metabolic acidosis is formation of lactic acidosis resulting from poor tissue perfusion and hypovolemia -Ketoacids are excreted in urine as sodium, potassium, and ammonium salts -> volume depletion and fluid and electrolyte loss -Osmotic diuresis = rapid urine flow and obligate loss of water and electrolytes -Water loss with DKA can be 5-8 L or 15% of total-body water -Risk for hyperkalemia r/t renal perfusion failure with not enough sodium available to get rid of equal amount of potassium

Penetration Injury

-May be caused by bullet, shrapnel, or another sharp object traveling at a velocity substantial enough to disrupt integrity of skull -Underlying brain structures may or not be injured depending on speed and trajectory of object

ICP - Hypothermia treatment

-May help reduce brain's metabolic demands during peak times of cerebral edema and brain injury -Risk for shivering which increases intracranial pressure -Essential to control fever with surface cooling and intravascular cooling devices

ICP - Respiratory Support

-Mean airway pressure is leading factor affecting ICP in patient with ventilation therapy -Any condition decreasing pulmonary compliance or use of PEEP increases mean airway pressure and decreases MAP and CPP -Normocapnia is needed for keeping stable ICP because carbon dioxide directly affects degree of vasodilation in cerebral blood vessels -Hyperventilation is temporary strategy for treatment of malignant ICP, as this decreases PaCO2 and leads to cerebral vasoconstriction -Limit suctioning because increasing intrathoracic pressures directly increases ICP -Limit duration of suction passes to no more than 5- 10 seconds to avoid hypoxia

Myxedema Coma Nursing Care

-Mechanical ventilation for hypoventilation, hypercapnia, and respiratory arrest -IV hypertonic normal saline and glucose solutions for dilutional hyponatremia & hypoglycemia -Fluid administration and vasopressors for hypotension -Administration of thyroid hormone levothyroxine and corticosteroids -Treat abdominal distention and fecal impaction -Manage hypothermia with warm blankets and socks -Seizure precautions -Prevent complications r/t aspiration, immobility, skin breakdown, infection

Spinal Cord Injury Mechanisms - Hyperextension SCI Hyperextension, or forcible backward bending, often disrupts ligaments and causes vertebral fractures. A whiplash injury is a less severe form of hyperextension, with injury to soft tissues but no vertebral or spinal cord damage

-Most common type of injury -Can be caused by fall, a rear-end MVC, or getting hit in the head -Hyperextension of head and neck may cause contusion and ischemia of spinal cord without column damage -Whiplash injuries are an example -Hyperextension injury can result in rupture of the anterior ligament

Acceleration Injury

-Moving object strikes stationary head -Bat strikes head or a missile fired into the head

Oropharyngeal airway

-Not indicated for a patient who is conscious because it stimulates gag reflex and can cause vomiting and aspiration -Oral suctioning is important because the ability to swallow can be limited -To perform oral suctioning, use a Yankauer device (tonsil-tip suction apparatus). The larger openings on the Yankauer tip allow for suctioning of thick or copious secretions better than other suction catheters designed for suctioning through endotracheal or nasotracheal tubes, which are smaller in diameter. Before placing an artificial airway, make sure any possible obstruction is cleared. Insert the oropharyngeal airway using the following three steps: 1. Gently open the patient's mouth using a crossed-finger technique or a modified jaw thrust. 2. Hold down the tongue with a depressor and guide the airway over the back of the tongue. (An optional method is to position the tip of the airway toward the roof of the mouth, with the curved end toward the roof, and gently advance the airway by rotating it 180 degrees.) 3. Monitor the patient frequently for airway patency by listening to breath sounds. Provide oropharyngeal suction as needed for emesis or oral secretions. *inserted upside down and advanced 180 degrees, can be used in adults and pediatrics*

Diagnostic Studies SCI

-Once stable, these tests may be completed safely -Radiographs of spine, chest, and other structures as clinically indicated -CT scan provides extra information about bony structures and fractures -MRI used for soft tissue injury -Somatosensory evoked potential test measures ability of spinal cord to transmit impulses along neural pathways to higher centers in the brain

Assessment of Cognitive Function TBI

-Orientation questions regarding person, time, and place -Must elicit an embroidered or specific history from patient to facilitate detection of subtle changes over time

Hypoxemic respiratory failure

-PaO2 < 60% -Caused by alterations in respiration -Can result in widespread tissue dysfunction and organ infarction (low cardiac output or cyanide poisoning that is not associated with pulmonary function) -Cyanosis, confusion, tachycardia, edema, decreased renal output

Neurogenic Shock Assessment

-Patients demonstrate decreased central venous pressure, CO, and systemic vascular resistance combined with bradycardia -Unlike many shock states in which the patient may feel cold and clammy, often the skin is warm due to massive vasodilation.

ICP - Positioning

-Place head and neck in neutral position -HOB elevation 15-30 to promote venous drainage and decrease ICP

Diabetic Ketoacidosis Assessment

-Polydipsia, polyuria, weight loss, abdominal pain, vomiting, poor appetite, fatigue, weakness, drowsiness -May present with UTI, upper respiratory infection, and chest symptoms as infection is a precipitating factor -Hyperventilation, Kussmaul respirations and fruity breath, dehydration, abdominal distention, dry mucous membranes, flushed skin, poor skin turgor and perfusion, hypotension, tachycardia, and varying degrees of responsiveness from lethargy to coma -Blood glucose 250-800 mg/dL -Increased anion gap by > 7 mEq/L -Arterial pH < 7.4 -Bicarbonate < 10 -Moderate ketonuria or ketonemia

Neurogenic Shock Management

-Prevention and treatment of hypotension through careful fluid resuscitation is a high priority *Vasopressors may be added if fluid resuscitation does not work -The goal of pharmacology in neurogenic shock is to mimic the sympathetic nervous system *The use of agents with a-adrenergic activity, such as norepinephrine, promotes vasoconstriction, while b-adrenergic agonists, such as dopamine, increase heart rate and contractility

Adrenal Insufficiency/Addison's Disease Pathophysiology

-Primary (directly involves adrenal gland) or secondary (r/t hypothalamic-pituitary disease) -Primary adrenal insufficiency = Addison's disease -Pathology is autoimmune destruction of the gland or severe stress -Most common cause of primary adrenal insufficiency is tuberculosis -Most common cause of secondary adrenal insufficiency is iatrogenic (abrupt withdrawal of exogenous ACTH or complication of cortisol therapy) -Adrenal crisis happens if there is a change in chronic condition or massive adrenal hemorrhage

Prehospital Management SCI

-Primary survey at scene of accident includes rapid assessment of airway, breathing, and circulation -Airway patency is assessed and cervical spine is immobilized and stabilized

Cerebrospinal Fluid Circulation

-Protects brain and spinal cord from injury -Potential disturbances in production, circulation, and absorption can contribute to changes in ICP

Hyperosmolar Hyperglycemic State (HHS) Pathophysiology

-Reduction in circulating insulin, coupled with effects of counter-regulatory hormones (cortisol and epinephrine) lead to development of hyperglycemia and extreme hyperosmolar state -Patients have just enough insulin to prevent ketosis; acidosis is attributed to lactic acidosis r/t poor perfusion -Typical fluid loss is 9 L -Hyperglycemia, hyperosmolality, osmotic diuresis, and profound dehydration -> SNS -> epinephrine and cortisol -> gluconeogenesis and increase hepatic glucose production

Assessment of Respiratory Function TBI

-Respiratory failure is common in patients with severe TBI -Necessary to detect worsening neurologic injury and need for airway management and mechanical ventilation Cheyne-Stokes breathing is periodic breathing in which depth of each breath increases to a peak and then decreases to apnea Hyperventilation is sustained, regular, rapid, and deep Apneustic breathing is characterized by a long pause at full inspiration or full expiration Cluster breathing is seen as gasping breaths with irregular pauses Ataxic breathing consists of both deep and shallow breaths with irregular pauses; signals need for endotracheal intubation

Posterior Cord Syndrome

-Result of hyperextension injury at cervical level -Not common -Position sense, light touch, and vibratory sense are lost below level of injury -Motor function and pain and temperature sensation remain intact

Spinal Cord Injury Mechanisms - Excessive Rotation Excessive rotation, in which the head is excessively turned, may tear ligaments, fracture articular surfaces, and can cause compression fractures

-Results from forces that cause extreme twisting or lateral flexion of head and neck -Fracture or dislocation of vertebrae may occur

Neurogenic Shock Etiology

-Results from loss or disruption of sympathetic tone, which causes peripheral vasodilation and subsequent decreased tissue perfusion -Most common cause is a spinal cord injury above the level of T6 -Other causes include spinal analgesia, drugs, or other central nervous system problems

Hyperosmolar Hyperglycemic State (HHS) Causes

-Risk factors: middle aged or older (55-70), undiagnosed type II diabetes, residents of nursing homes, other severe medical conditions (CHF, kidney disease) -Infection (UTI, pneumonia), acute illness (CVA, MI, pancreatitis) provokes release of counter-regulatory hormones -Secondary to extreme stress associated with stroke, MI, pancreatitis, trauma, sepsis, burns, or pneumonia -Excessive exposure to carbohydrate intake: dietary supplements, TPN, peritoneal dialysis -Drugs such as corticosteroids, thiazide diuretics, sedatives, and sympathomimetics affect carbohydrate metabolism and can lead to glucose impairment

Myxedema Coma Manifestations

-Severe depression of the sensorium, hypothermia, hypoventilation, hypoxemia, hyponatremia, hypoglycemia, hyporeflexia, hypotension, and bradycardia -Patients do not shiver even though body temperature is below 80 F (26.6 C)

Thyrotoxic Crisis/Thyroid Storm

-Severe form of hyperthyroidism: excess thyroid hormones -> hypermetabolic manifestations Common Causes: -Graves disease -Exogenous administration of levothyroxine -Thyroiditis *Untreated can lead to angina pectoris, MI, HF, cardiovascular collapse, coma, and death

Diabetic Ketoacidosis Causes

-Severe insulin deficiency that leads to disordered metabolism of proteins, carbohydrates, and fats -Most common cause is infection: UTI, pneumonia -Inadequate insulin therapy, insulin noncompliance, severe illness (CVA, MI, pancreatitis), alcohol or drug abuse, trauma, certain medications (antipsychotics, steroids) -Presentation of DKA with initial type I diabetes diagnosis

ICP - Environmental Stimuli

-Stimuli can lead to pain, stress, and anxiety, which can increase cerebral metabolic rates and blood flow -Provide times for uninterrupted sleep and rest -Avoid frequent blood draws/painful procedures

Bowel and Bladder Assessment SCI

-To prevent bladder from becoming distended secondary to atonic bladder, insertion of catheter is indicated -May be imbalance between parasympathetic and sympathetic innervation to bowel and therefore a loss of voluntary control

Sensory and Motor Function

-Total loss of voluntary muscle control and sensation below level of injury suggests that lesion is complete -Complete lesions involving spinal cord regions C1 to C8 result in tetraplegia -Complete lesions involving spinal cord regions T1 to L1 result in paraplegia -In incomplete injuries, there is some motor or sensory function below the level of injury -Level of sensory loss seen in person with complete cord injury follows corresponding dermatome pathway

Patient with ARDS on a ventilator for 24 hours is at risk for?

-Volutrauma presented as a pneumothorax due to high tidal volume settings -Oxygen toxicity

Diabetic Ketoacidosis Patient Teaching

-a person with diabetes must have insulin even if no food is being taken in -the amount of insulin required when the person with diabetes is not eating is about half the total needed when eating -the amount of insulin required when a person with diabetes is fasting must be spread out as an insulin "trickle" rather than as an insulin "burst" -illness generally increases the need for insulin so that even if the person with diabetes is not eating, he or she may actually require more than 50% of the usual daily dose -always keep enough insulin on hand for daily injections -know how to reach health care provider for timely phone advice -when you are ill, adjustments for managing your diabetes may need to be made

What is the nurse responsible for when receiving a patient with a new chest tube?

-encourage cough and deep breathing every hour -check for continuous bubbling in the suction chamber -assess chest tube insertion site for subcutaneous emphysema -obtain chest x-ray

Subarachnoid, Subdural, and Epidural Monitors

-less accurate and not used much -the subarachnoid bolt or screw is inserted through a twist drill hole to the level of the subarachnoid space and secured to a saline-filled pressure tubing transducer system -epidural monitors are placed into the epidural space between the inner surface of the skull and dura mater

Lumbar Sacral

-loss of bowel and bladder control -upper body strength and sensation normal -motor weakness or paralysis and sensory loss in hips and legs

Thoracic Spine

-paralysis in legs but arms can still function -loss of bowel and bladder control -truncal instability

Preventing Falls in the Older Adult

-screen patients 65 yrs + -consider these things that might make patients at a greater risk for future falls: *Impaired vision *medications *blood pressure (postural hypotension) *balance and gait *hazards in living environment *cognitive deficits

Normal ICP

0-15 mm Hg.

Physical Examination TBI

1) Level of consciousness is the most sensitive indicator of increased ICP 2) Maximal stimulus must be applied to achieve the maximal patient response -Performing serial neurologic examinations that include evaluation of level of consciousness and motor and cranial nerve function is necessary to identify increased ICP and prevent herniation syndrome -GSC is useful for assessment trends of neurologic function over time; however, focal motor deficits are NOT taken into consideration

Nursing priorities for a chest tube

1) Monitor drainage - Should not be more than 200 mL/hour. Assess every 2 hours. - Increase= hemorrhage or sudden patency - Decrease= obstruction of drainage tube 2) Monitor water seal chamber - Filled to 2 cm of STERILE water - During inspiration, negative pressure causes water to rise. - During expiration, positive pressure causes water to fall. (no fluctuations may mean lung is re-expanded or there is a obstruction) - Should only bubble intermittently during exhale. 3) Monitor suction chamber (3-chamber system) - Wet suctioning water level is at -20 cm H2O. Will evaporate so need to check every 8 hours. Add STERILE water when needed. - Dry suctioning b/t -10 to -40 cm H2O - Should have gentle bubbling 4) Positioning client - Semi-fowlers - Turn every 2 hours to enhance fluid and air evacuation - Support or "splint" chest wall - Encourage deep breathing, coughing, and ambulation

4 factors leading to Type 2 DM

1- Impaired insulin secretion & excessive glucagon secretion (pancreas) 2- Increased hepatic glucose production (liver) 3- Increased carb absorption (intestines) 4- Decreased insulin-stimulated glucose uptake (skeletal muscles)

Goals for emergency treatment of status epilepticus

1. maintain ABCs 2. stop seizures 3. stabilize patient 4. identify and treat cause

Pharmacologic therapy with increased ICP

1. Analgesics, sedatives (Benzos. Target sedation with easy arousal w/light touch or voice), and paralytics (try non-pharm options first) - reduce agitation, pain, and discomfort - facilitate mechanical vent by suppressing coughing - limit responses to stimuli (eg suctioning) that can increased ICP 2. BP management 3. Seizure prophylaxis - use of antiepileptic meds For acute-onset, use diazepam Put pt on side, oxygen mask. Right after, obtain glucose level to see if hypoglycemia was a factor.

Complications of mechanical ventilation

1. Aspiration- potential for ARDS and pneumonia increases if aspiration occurs. Prevention: appropriate cuff inflation and always keep HOB elevated to 30 degrees. 2. Barotrauma & Pneumothorax- Positive pressure and high PEEP (esp. greater than 10-15) can spontaneously rupture alveoli (barotrauma). Air is then trapped in plural space causing lung to collapse (pneumothorax) S/S: decreased or absent breath sounds on affected side, tachycardia, tachypnea, agitation, abrupt increase in PIP. Extreme dyspnea 3. Ventilator associate pneumonia (VAP)

DKA dx criteria

1. BG 250-800 2. pH <7.4 3. Bi-carb < 10 4. Moderate ketonuria/ketonemia

HHS dx criteria

1. BG greater than 600 2. pH greater > 7.3 3. B-carb greater than 15 4. Anion gap < 12 4. Minimal ketonuria/ketonemia

What is 4 things are required for autoregulation to be functional?

1. CPP greater than 40 *If brain is injured (which requires a higher CPP), CPP will need to be at least 70. 2. MAP less than 160 3. Systolic pressure between 60-140 4. ICP less than 30 Also, factors that alter the ability of cerebral vessels to contract or dilate include: Hypoxia Hypercapnia Brain trauma

What are most nursing intervention for reducing ICP focused on?

1. Control CSF 2. Control blood volume Intervention begins when ICP is about 15

Purpose of a chest tube

1. Drain fluid or blood from plural space 2. Restore negative pressure to the plural space 3. Re-expand a collapsed for partially collapsed lung (pneumothorax) 4. Prevent reflux of draining back into the chest *Most commonly used for pneumothorax

Clinical management of increased ICP includes...

1. Hyperosmolar therapy- AKA induced hypernatremia. with hypertonic saline or mannitol to pull fluid out of cells. *Hypertonic saline refers to any saline solution with a concentration of sodium chloride (NaCl) higher than physiologic (0.9%). Commonly used preparations include 2%, 3%, 5%, 7%, and 23% NaCl. 2. Respiratory therapy- avoid hypercapnia b/c can cause vasodilation in cerebral BV. Initial treatment with hyperventilation.

What are the 3 major physiologic disturbances in DKA?

1. Hyperosmolarity from hyperglycemia 2. Metabolic acidosis from accumulation of ketoacids (insulin deficiency > cell unable to absorb glucose > activation of lipase in adipose tissue > causes breakdown of free fatty acids) BiCarb low- normal 22-27 3. Volume depletion from osmotic diuresis (leads to fluid & electrolyte depletion). Fluid loss =~6L. Happens because water is following the glucose that leaks into the urine. Risk for HYPERKALEMIA r/t reduced renal perfusion

Potential cause of increased ICP

1. Overproducton of CSF 2. Inadequate reabsorption of CSF 3. Blockage of CSF 4. Edema 5. Brain mass 6. Vasospasm 7. Vasodilation

Treatment goals of DKA:

1. PRIORITY- Improve circulatory volume (0.9 % normal saline) 2. Correct electrolyte imbalance 3. Decrease serum glucose levels 4. Correct ketoacidos 5, Determine precipitating events

Medications to treat thyroid storm

1. Propylthiouracil (PTU) -Class: antithyroid drug -Action: blocks conversion of T4 to T3 in peripheral tissues and binds to iodine to prevent synthesis of hormone -Adverse effect: hepatotoxicity *Can be used during pregnancy. *Can be given orally or rectally *Watch for liver side effects *Must take for 1 yr or longer for return to normal *Take pulse daily. reporting TI over 100 or under 60 *Check weight 3 x per day BBW : If patient takes one dose w/out food, they need to take all following doses w/out food and visa versa. 2. Iodine solutions (potassium Iodide; SSK; sodium iodine) -Action: block release of thyroid hormone -Administration: give 1 hour after administration of antithyroid medication *If pt is iodine sensitive, give lithium or steroids. 3. Propranolol (Inderal) -Class: B-blocker -Action: treats symptoms of hyperthyroidism as opposed to actual primary thyroid disease; restores cardiac function by decreasing catecholamine-mediated symptoms -Goal is to decrease myocardial oxygen consumption, decrease HR, and increase CO *Beta blockers and/or diuretics to prevent dysrhythmias 4. Dialysis can be used to remove excess hormone 5. Acetaminophen for hyperthermia (NOT aspirin b/c it increases T3 &T4 levels)

What are the goals for a patient with increases ICP?

1. Reduce ICP 2. Optimized CPP 3. Maintain adequate tissue oxygenation 4. Avoid Brian herniation

What does Glasgow Coma Scale (GCS) measure

1. best eye-opening response (4) 2. best motor response (6) 3. best verbal response (5)

Goal for thyroid storm management

1. treating the precipitating factors 2. controlling excessive thyroid hormone release 3. inhibiting synthesis of thyroid hormone 4. treating peripheral effects of thyroid hormone

Contusions; small, diffuse venous hemorrhages; and brain swelling are at their peak ____ to ____ hours after injury?

12 to 24 hours after injury

How long dose the tonic phase last?

15 seconds *Although it may persist for up to a minute

The entire tonic-clonic portion of the seizure generally lasts no more than?

60 to 90 seconds

HCO3 (bicarbonate)

22-26 mEq/L Low pH/Low HCO3 is acidotic High pH/High HCO3 is alkalotic *regulated by the kidneys (metabolic)

What typically maintains normal cerebral blood flow (CBF)?

60-100 (same as resp rate. rr/pp=same :). If less than 60, blood supply to brain is inadequate and hypoxia can occur If CPP is zero, there is no CBF

pH (ABG)

7.35 - 7.45 <7.35 = Acidic >7.45= Alkaline (Basic)

PaCO2 (Respiratory)

35-45 -controlled by respirations Low pH/High PaCO2 is acidic High pH/Low PaCO2 is alkalotic -Eliminated from the body by the lungs -Partial pressure of carbon dioxide

PaO2

80-100 mmHg - Partial pressure of oxygen measurement of amount of O2 in blood -Pa02 of 60 is equivalent to a Sp02 of 90% -When looking at ABGs, one would start to get concerned with a Pa02 less than 60 PaO2 < 80 = hypoxemia

How long do absence seizures last for?

5 to 10 seconds *some may last for 30 seconds or more and can occur 100 or more times a day

What IV solution is administered for a patient in status epilepticus to prevent hypoglycemia?

50% dextrose

Uncompensated (r/t ABGs)

Abnormal pH and EITHER PaCO2 or HCO3 is abnormal (example) pH: 7.52 (alkalosis) PaO2 94 (normal) PaCO2: 25 (decreased) HCO3: 24 (normal) uncompensated respiratory alkalosis

Ventilator-associated pneumonia (VAP)

A health care-acquired infection ("nosocomial") that develops in a person requiring invasive mechanical ventilation (via endotracheal intubation or tracheotomy tube) for at least 48 hours -A patient should be suspected of having VAP when chest radiography shows new or progressive and persistent infiltrates Other S/S: Temp higher than 100.4 or Leukocytosis Also, if two of the following occur: New-onset purulent sputum New cough or dyspnea Bronchial breath sounds Worsening gas exchange.

Treatment for pneumothorax

A large pneumothorax or significant symptoms usually requires treatment with thoracostomy, or the placement of chest tubes. Surgical intervention may be necessary to prevent recurrent spontaneous pneumothorax. Oxygen administration If it is only 15-20% then no medical intervention Above 20% chest tube is placed If no chest tube available in emergency situations, use a large bore needle or plastic intravenous catheter inserted through the chest wall When a tube is placed in the pleural cavity to remove air or fluid, it must be sealed to prevent air from also entering the tube and, in essence, creating an open pneumothorax. Chest tubes are sealed with a Heimlich (one-way) valve or connected to a closed-drainage system with a "water seal." The valve or water seal prevents air from entering the chest cavity during inspiration and allows air to escape during expiration

What may be performed to assess spinal fluid for CNS infections (increased WBCs) or tumors (increased protein levels)?

A lumbar puncture

Glasgow Coma Scale (GCS)

A neurological scaled used to determine the level of consciousness of a patient. High is good. 0-15

What are the systemic effects of acute brain injury from neurogenic pulmonary dysfunction?

Abnormal respiratory patterns Reduced residual capacity with retention of PaCO2 Vasodilation and increased ICP Pulmonary edema

Diagnosis of respiratory failure

ABG Chest radiography CT CBC ECG

Partially compensated - All 3 values (pH, PaCO2,HCO3) will be abnormal

Abnormal pH and BOTH CO2 and HCO3 are abnormal (example) PaO2: 94 (normal) pH: 7.48 (alkalosis) PaCO2: 25 (decreased) HCO3: 20 (decrease) partially compensated respiratory alkalosis

Status epilepticus can be associated with what types of seizures?

ANY SEIZURE *Most often in tonic-clonic *It is a neurologic emergency and requires immediate treatment

What is autoregulation?

Ability of an organ to maintain consistent blood flow despite changes in arterial circulation and perfusion pressure.

Mental Status Assessment Assess appearance, including dress, hygiene, grooming, gait, and posture. The patient should be appropriately dressed and clean, with normal gait and posture. Assess behavior, including actions and affect, content and quality of speech, and level of consciousness (LOC). Use the Glasgow Coma Scale (see Table 41-5) to document findings. A score of 15 on the Glasgow Coma Scale indicates the patient is alert and oriented

Abnormal Findings: • Unilateral neglect (inattention to one side of body) may occur with some strokes. Poor hygiene and grooming may be seen in patients with dementing disorders. • Abnormal gait and posture may be seen in transient ischemic attacks (TIAs), strokes, and Parkinson's disease. • Emotional swings or changes in personality may be observed in patients who have had a stroke. • The face appears masklike (very little expressive movement of facial muscles) in patients with Parkinson's disease. • Apathy is seen in dementing disorders. • Aphasia (defective or absent language function) may occur in TIAs and strokes. Aphasias are seen with damage to the left cerebral cortex. Aphasias are more often seen with strokes of the left hemisphere than the right hemisphere. • Dysphonia (change in the tone of the voice) is common in strokes. Dysphonia is seen with paralysis of the vocal cords (cranial nerve X). • Dysarthria (difficulty speaking) is seen with lesions of upper and lower motor neurons, the cerebellum, and the extrapyramidal tract. • Damage to the brainstem and/or cerebral cortex may alter LOC. • Drowsiness and decreased LOC may be associated with brain trauma, infections, TIAs, strokes, and brain tumors. • Level of consciousness, ranging from confusion to coma, is usually altered with a stroke.

Manifestations of a simple partial seizure involving the sensory portion of the brain may include?

Abnormal sensations or hallucinations

What are the characteristics of a pre-seizure aura prior to having tonic-clonic (grand mal) seizures?

Abnormal uneasiness Abnormal gustatory (taste) sensation Abnormal visual sensation Abnormal auditory sensation Abnormal visceral sensation (pain, bloating, etc.) *metallic taste in the mouth, a smell of burning rubber, or seeing a bright light

Common cause of secondary adrenal insufficiency

Abrupt withdrawal of ACTH b/c of steroid use

You walk into a patients room that has a past history of seizures and patient is smacking their lips and eyelids are fluttering. What type of seizure would you expect?

Absence seizure

What type of generalized seizure is more common in children than older adults?

Absence seizures

Etiology of Type 1 DM

Absolute deficiency of insulin production

Does high PaCO2 cause acidosis or alkalosis?

Acidosis Controlled by respiratory system and responds w/in minutes. Hypoventilation means retaining PaCO2 so, acidosis. Hyperventilation means blowing off PaCO2 so alkalosis.

Respiratory Acidosis - Acute vs. Chronic

Acute Respiratory Acidosis • Headache • Warm, flushed skin • Blurred vision • Irritability, altered mental status • Decreasing level of consciousness • Cardiac arrest Chronic Respiratory Acidosis • Weakness • Dull headache • Sleep disturbances with daytime sleepiness • Impaired memory • Personality changes

If responsive, with what type of subdural hematoma (acute or chronic) will the patient complain of a unilateral/ipsilateral headache (only on affected side)?

Acute Subdural Hematoma

What type of subdural hematoma (acute or chronic) are usually located at the top of the head, and develops within 48 hours of the initial head injury?

Acute Subdural Hematoma

With what type of subdural hematoma (acute or chronic) do hemiparesis and respiratory pattern changes occur?

Acute Subdural Hematoma

With what type of subdural hematoma (acute or chronic), a lucid period may occur, the patient commonly develops drowsiness, confusion, and enlargement of the ipsilateral pupil within minutes or hours of injury?

Acute Subdural Hematoma

ARDS (acute respiratory distress syndrome)

Acute respiratory insufficiency marked by progressive hypoxia. Develops within 4-48 hours Inflammatory response causes pulmonary edema and leads to pulmonary fibrosis (decreased compliance). Need to use pressure vent (not volume) to protect lung from trauma Causes of ARDS: Direct injury- smoke inhalation, near drowning, aspiration Indirect injury- sepsis, toxins, ischemia

Acceleration-deceleration injury (linear injury) Strain on cerebral tissue produces injury by compression, tension, or shearing. Acceleration-deceleration injury (linear injury) is responsible for what types of TBI? (2)

Acute subdural hematoma Diffuse axonal injury

Emergency treatment for status epilepticus

Airway O2 Intubation, if necessary EEG monitoring Catheter for incontinence CT scan Lumbar puncture if CNS infection

Does high HCO3 cause acidosis to alkalosis?

Alkalosis Controlled by kidneys and takes days to respond

Modes of Positive Pressure Ventilator Operation Synchronized intermittent mandatory ventilation

Allows the patient to breathe spontaneously, without ventilator assistance, between delivered ventilator breaths. "mandatory" or ventilator-controlled breaths are delivered at a preset rate, volume, and/or pressure, coordinated with the patient's inspiratory efforts. This mode of ventilation is used to support ventilation, to exercise respiratory muscles between ventilator-assisted breaths, and during the weaning process.

Tidal volume

Amount of air that moves in and out of the lungs during a normal breath; without conscious effort; usually 8-10 mL/kg of body weight

What is PaO2? What is normal range?

Amount of oxygen dissolved in plasma. It is the partial pressure created when oxygen is dissolved in the bloodstream (and reflects SaO2) which is necessary for gas exchange in the alveoli. Normal = 80-100 mmHg

What is an indirect measure of the quantity of ketoacids present?

Anion gap (sodium)-(chloride+HCO3) Normal value <15

Sepsis bundle

Antibiotics therapy Fluid resuscitation Steroids Activated protein C DVT prophylaxis Peptic ulcer prophylaxis

What are the most common causes of epilepsy in older adults? (2)

Arteriosclerosis of the cerebrovascular system Stroke

Respiratory assessment

Ask if dyspnea occurs, when, how long it has, does it wake them up at night, if there are precipitating factors, length of episodes and what alleviates symptoms. Ask if there is cheat pain with dyspnea, details about pain. Ask if there is sputum; color, amount, what body part it comes from, if it contains blood

How does the nurse troubleshoot an obstruction in the chest tube?

Assess and document drainage characteristics while remaining alert to changes (i.e., sudden increase indicates hemorrhage or sudden patency of a previously obstructed) Reposition pt to alleviate— if clot is visible, straighten tubing between chest and CDU and raise tube to enhance effects via gravity (DO NOT STRIP)

Nursing priories for pt with PE and on anticoagulation?

Assess for contraindications such as bleeding, PUD, hx of stroke, recent trauma Monitor PT and INR for warfarin aPTT, PT and CBC for heparin Side effects such as thrombocytopenia, anemia, hemorrhage Remind pt to check mouth and skin daily for bruising and bleeding Use electric razors and soft toothbrushes Avoid blowing nose hard Encourage mobility, fluids, compression stockings, do not cross legs

Assist control mode ventilation vs. synchronized intermittent mandatory ventilation FYI- both are considered volume control mode

Assist control- Pt. can breath faster but the vent will then automatically give the set volume. Used when first intimated or too weak to breath on own. SIMV- Pt. can breath above set rate (like assist control) but tidal volume can change from what is set. Patient decides tidal volume. Uses in weaning.

Why is prone positioning used for ARDS patients?

Assists with drainage from the dorsal (lower) lung regions, also improves pulmonary gas exchange

Type 1 DM- destruction of which cells?

Autoimmune dysfunction involving the destruction of beta cells of the pancreas, which produce insulin in the islets of Langerhans of the pancreas. Immune system cells.

Why does ketosis seldom occur in patients with Type 2 DM?

B/c the patient still secretes enough insulin to avoid critical illness. When type 2 DM patients have severe complications, it's usually b/c of other health issues like MI, infection, or trauma.

Emergency meds for status epilepticus

Benzodiazepines: lorazepam (Ativan); diazepam (Valium)

Common Medication used in Type 2, MOA, & SE

Biguanides (Metformin) - reduced hepatic glucose production - increased insulin sensitivity (promotes weight loss) Can't use with CONTRAST MEDIUM & be careful in patients with RENAL DISEASE. SE: lactic acidosis & GI issues

During initial assessment for Acute respiratory failure the patient is showing Drowsiness, Confusion, Silent chest. What actions should the nurse take?

Consult ICU Start SABA and O2 Prepare patient for intubation

How does auto regulation normally maintain Cerebral blood flow (CBF)?

By changing the diameter of cerebral vessels in response to changes in arterial pressure. When impaired, CBF fluctuates in direct correlation with systemic BP. So any activity that causes increase in BP (coughing, suctioning, restlessness) can increases CBF and therefore increases ICP.

Cerebral Perfusion Pressure (CPP)

Cerebral perfusion pressure is the blood pressure gradient across the brain EQUATION: CPP = MAP - ICP -When CPP < 60, inadequate blood supply to brain and risk for neuronal hypoxia and cell death -When CPP > 100, risk for hyperperfusion and increased ICP -When MAP = ICP, CPP is 0, indicating no cerebral blood flow (CBF) -With low MAP (hypotension) and normal ICP, patient may still have impaired CPP

A partial seizure in which consciousness IS ALTERED is called?

Complex partial seizure

Causes of respiratory acidosis

CNS depression, head trauma, oversedation, anesthesia, high cord injury, pneumothorax, hypoventilation, bronchi obstruction, atelectasis, pulmonary infections, HFR, pulmonary edema, pulmonary embolus, MG, MS

What is the most common type of seizure in older adults?

Complex partial seizure

CPAP vs. PEEP

CPAP -Assists spontaneous breathing patients to improve their oxygenation by elevating end-expiratory pressure in the lungs throughout the respiratory cycle PEEP -Keeps alveoli stented open and recruit alveolar units that are totally or partially collapsed during any mode of ventilation in order to improve oxygenation -Positive pressure exerted at the end of exhalation; pressure in lungs maintained at end of expiration

Adrenal Insufficiency/Addison's Disease Diagnostic Test

CT may be done to detect tumors or other pathology of adrenal and pituitary gland

Risk factors for pulmonary embolism

Cancer, surgery/trauma, prolonged immobilization, pregnancy, contraceptives, blood clotting disorders, venous thromboembolism, a fib, HF, obesity, smoking

What is a potent vasodilator of cerebral vessels?

Carbon dioxide. Vasodilation > increased CBF > increased ICP

Contraindications albuterol

Cardiac tachydysrhytmias, severe CAD, HTN, hyperthyroid, DM, seizure disorders

S/S ARDS

Cardinal sign= refectory hypoxemia (doesn't matter how much O2, doesn't improve PaO2) Add PEEP to help. More time and more surface area for gas to perfuse. Initially patient tries to breath more deeply which leads to respiratory alkalosis

What type of TBI affects the entire brain and is caused by a shaking motion, with twisting movement (rotational injury) as the primary mechanism of injury?

Diffuse Cerebral Injury (concussion and diffuse axonal)

Intracranial Dynamics

Cerebral Blood Flow (CBF) Cerebrospinal Fluid Circulation Parenchyma

How is CPP calculated?

Cerebral Perfusion Pressure (CPP) = MAP-ICP

Intracranial Pressure (ICP) The pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and, at rest, is normally 0-15 mmHg for a supine adult. -Concepts of ICP and its management are based on the principle that the skull is a rigid box, a nonexpansile, noncontractile space -Three intracranial sections: (1) blood maintained in blood vessels (2) cerebrospinal fluid (CSF) (3) brain parenchyma

Cerebrospinal Fluid (CSF) → The brain parenchyma refers to the functional tissue in the brain that is made up of the two types of brain cell, neurons and glial cells. Damage or trauma to the brain parenchyma often results in a loss of cognitive ability or even death.

What are signs considered in late findings of increased ICP?

Changes in vital signs Variations in respiratory patterns occur, eventually resulting in complete apnea. Cushing triad is considered a sign of impending herniation; this triad consists of: 1) Increased systolic pressure (resulting in an increased or "widened" pulse pressure) ex. 198/72: 198-72=126 pulse pressure Pulse pressure >60 is "widened" 2) Bradycardia 3) Decreased/irregular respirations *It is of critical importance to identify early signs of increased ICP (such as change in level of consciousness) in order to prevent herniation syndrome. The examination findings of a patient with increased ICP differ significantly from those of a patient with herniation syndrome

Cerebral Perfusion Pressure (CPP) Pathophysiology

Compliance is defined as the ability to change volume related to change in pressure -The purpose of controlling and decreasing ICP is due to the maintenance of cerebral oxygenation by adequate cerebral blood flow (CBF), which is estimated clinically by the measurement of CPP Autoregulation is the active, energy-requiring process to constrict or dilate vessels in order to maintain a steady state of intravascular blood flow based on changing ICP -Autoregulation system does NOT function at pressures less than 40 -Because an injured brain requires a higher CPP than a normal brain, a minimum CPP of 70 is needed for maintenance of adequate cerebral perfusion and potentially improved outcomes for patients with brain injuries -With severe brain damage, CBF may be reduced at relatively normal levels of CPP -Cause is impedance to the flow of blood across cerebrovascular bed -With impaired autoregulation, CBF may not increase despite increases CPP Increased ICP leads to: Ischemia Anoxic injury Decreased compliance Herniation

Respiratory assessment inspection

Check for: Cyanosis Labored breathing Diameter of chest Chest deformities and scars Posture Trachea position Respiratory rate and effort Duration of inspiration versus expiration Thoracic expansion Note pt extremities for clubbing, cyanosis, edema

Diagnostic for pneumothorax

Chest radiograph (if tension then physical exam)

In vagal nerve stimulation therapy where is the flat, round battery inserted?

Chest wall, and electrodes are threaded under the skin and wound around the vagus nerve in the neck.

Manifestations of what type of subdural hematoma (acute or chronic) develop slowly and may be mistaken for the onset of dementia in the older adult. Slowed thinking, confusion, drowsiness, and lethargy are common early manifestations. Other manifestations include headache, dilation and sluggishness of the ipsilateral pupil, and possible seizures.

Chronic Subdural Hematoma

What type of subdural hematoma (acute or chronic) is often associated with relatively minor trauma such as a fall or may occur spontaneously in the older adult or in patients with bleeding disorders?

Chronic Subdural Hematoma

What type of subdural hematoma (acute or chronic) is seen most often in older adults and people who have some brain atrophy with subsequent enlarged epidural space?

Chronic Subdural Hematoma *develop over weeks or months

A patient having a tonic-clonic seizure has their eyes rolled back and is frothing from the mouth. What phase?

Clonic

What phase of a tonic-clonic seizure is the patient in this picture in?

Clonic

The patient having a tonic-clonic seizure with alternating contraction and relaxation of all muscles in all the extremities, along with hyperventilation is in what phase?

Clonic *legs appear bent and arms flexed inward

TBI may cause problems with what four factors?

Cognition Movement Sensation Emotions

Complications associated with myxedema coma?

Coma, siezures, pericardial & pleural effusions, and megacolon with paralytic ileus

Status epilepticus

Continued seizure (neural excitation) activity or repetitive seizures (more than 2) without recovery over 30 minutes.

What is a bruise of the surface of the brain, typically accompanied by small, diffuse venous hemorrhages?

Contusion

Intracerebral hematomas may be single or multiple, and are associated with?

Contusions

What meds are used to treat cerebral edema?

Corticosteroids Osmotic diuretics- increase plasma osmolarity which pulls fluid out of brain tissue & into circulating blood.

Adverse effects ipratropium

Cough, nervousness, nausea, GI upset, headache, dizziness

What is Cushing triad?

Cushing's triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing's triad consists of: 1) Bradycardia (also known as a low heart rate) 2) Decreased/Irregular respirations 3) Widened pulse pressure *A widened pulse pressure occurs when there is a large difference between the systolic blood pressure (the blood pressure when the heart is contracting) and the diastolic blood pressure (the blood pressure when the heart is relaxing)

Massive embolism s/s

Cyanosis Restlessness Anxiety Confusion Hypotension Cool clammy skin Decreased UO Pleuritic chest pain Hemoptysis

When ICP monitor indicated change in ICP, what is the first thing the nurse does?

Determines whether the reading is accurate.

What medications can be given intravenously, and the dose repeated in 10 minutes if necessary to stop seizure activity in status epilepticus?

Diazepam (Valium) - most common Lorazepam (Ativan)

TBI - Diffuse cerebral injury: Diffuse axonal injury Diffuse axonal injury (DAI) is a brain injury in which a high-speed acceleration-deceleration injury, typically associated with motor vehicle crashes, causes widespread disruption of axons in the white matter. Focal lesions may be found in the corpus callosum, midbrain, and brainstem. An immediate loss of consciousness occurs. DAI accounts for approximately 50% of primary brain injuries and accounts for 35% of deaths from all TBIs

Diffuse axonal injury is the shearing (tearing) of the brain's long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull. DAI usually causes coma and injury to many different parts of the brain.

What pupillary reactions should the nurse assess for increased ICP?

Diminished, with sluggishly reactive pupils and eventually fixed, dilated pupils. Frequently, because of the potential for injury to be ipsilateral (same side as injury), one pupil dilates before the other one does, resulting in unequal pupils.

Cognitive deficits that may result from diffuse cerebral injury include?

Disorientation Confusion Short attention span Problems with memory and learning Perceptual problems Poor judgment

Inverse I:E ratios

Duration of inspiration to expiration; usually 1:2 to 1:1.5 Inverse I:E ratios (most have shorter I and longer E to allow time for air to passively leave lungs) are often used with pressure-control in ARDS patients to improve oxygenation. Helps to expand stiff alveoli which allows for more opportunity for gas exchange and prevents alveolar collapse. But must watch out for hyperinflation and barotrauma and pneumothorax! Can occur in ARDS patient when high PEEP is used.

Dose status epilepticus occur before, during or after seizure activity?

During

S/S of hypoxemia

Dyspnea Cyanosis Restlessness Confusion Anxiety Delirium Tachypnea Tachycardia HTN Dysrhythmias Tremor

S/S of hypercapnia

Dyspnea Headache Hyperemia HTN Tachycardia Tachypnea Impaired consciousness Papilledema Asterixis

Manifestations of respiratory acidosis

Dyspnea, restlessness, headache, tachycardia, confusion, lethargy, dysrhytmias, distress, drowsiness, decreased responsivness

S/S of pulmonary embolism

Dyspnea, tachypnea, tachycardia, chest pain, mild fever, hypoxemia, apprehension, cough, diaphoresis, decreased BS over area, rales, wheezing

Sensitivity

Effort required by patient to initiate a ventilator-assisted breath

ARDS and vent settings?

Either Assist Control Ventilation or Synchronized Intermittent Mandatory Ventilation may be used along with PEEP or CPAP in treating ARDS. -Maintain tidal volume as low as possible to avoid volutrauma -Incorporate PEEP during mechanical ventilation settings to maintain blood and tissue oxygenation *PEEP decreases cardiac output and increases the risk of barotrauma, necessitating close monitoring. -Set FiO2 at lowest possible level to maintain PaO2 > 60 and SaO2 at or >90%) -Administer Pressure Control Ventilation PVC to limit peak inspiratory flow when necessary -Administer sedation

After the first seizure occurrence, a CT scan or MRI is obtained to assess for a structural lesion. What is the next test obtained to screen for interictal seizure discharges (electrical abnormalities present in between seizures) and to measure cerebral excitability?

Electroencephalogram (EEG) *These techniques (CT, MRI, EEG) can help determine whether the seizures have focal origins or are more generalized

ventilator-associated pneumonia (VAP) protocol

Elevate HOB 30-45 degrees Daily weaning assessment SBT Daily sedation withholding DVT prophylaxis Peptic ulcer prophylaxis

An excessive imbalance or excitation and inhibition of what part of the brain are of the brain causes generalized seizures?

Entire cerebral cortex

What type of hematoma develops in the potential space between the dura and the skull, which normally adhere to one another?

Epidural hematoma

What are the hypersensitive neurons that initiate seizure activity called?

Epileptogenic focus

hypercapnia

the abnormal buildup of PaCO2 in blood; excessive PaCO2 in blood ~>> PaCO2 > 45

What is the nurses priority for a patient in status epilepticus?

Establishing and maintaining the airway

Injury from seizures most commonly occurs to the? (2)

Face and neck

Having a seizure disorder at an older age increases the risk of?

Falls and fractures and threatens independence

True or False: Older adults tend to have shorter post-seizure manifestations than do younger adults

False Older adults tend to have longer post-seizure manifestations than do younger adults

True or False: Acceleration-deceleration injuries (linear injury) are more severe than Rotational injuries?

False Rotational injury occurs when the brain rotates within the skull and hits bony buttresses in the cranial vault; these injuries are more severe than those from linear injuries.

Are the most serious axonal injuries located farthest or closest to the brainstem?

Farthest *Frontal and temporal axonal tracts being most vulnerable to injury

Many fast-acting drugs are lipid soluble and have a tendency to redistribute from the plasma to the?

Fat and muscle

Aside from individualized triggers, what are general triggers of seizures? (7)

Fatigue Hypoglycemia Fever Alcohol consumption Constipation Hyperventilation Menstruation

Isolated seizure episodes may occur in otherwise healthy people for a variety of reasons, including? (5)

Fever Infection Metabolic disorder Endocrine disorder (such as hypoglycemia) Exposure to toxins

What happens to the pupils of a patient in the tonic phase?

Fixed and dilated

Epidural hematoma manifestations include?

Fixed, dilated pupil on the same side as the hematoma (ipsilateral) Hemiparesis (weakness) or hemiplegia (paralysis) of the entire side of the body on the opposite side of the hematoma (contralateral). Headache Vomiting Possible seizures

Nursing priority treatment DKA? Why? How much??

Fluid replacement to reverse severity of extracellular depletion and restore renal perfusion. 1 L in first hour (if normal cardiac function) or until HR, BP, and urine flow indicate hemodynamic stability. Average rate is 15-20 mL/kg. Patients have typically lost between 6-10 L. Hypotonic (0.45% half saline) at 150-250 mL/hr can be used after intravascular volume is restored or if sodium level is greater than 155.

Seizures occur when there is an excessive imbalance in excitation and inhibition in which two areas of the brain?

Focal areas of the cerebral cortex (causing focal or "partial" seizures) Entire cerebral cortex (causing generalized seizures)

Thyrotoxic Crisis/Thyroid Storm Nursing Care

Focuses on cardiovascular function, fluid and electrolyte balance, and neurologic status Assess BP, HR & rhythm, RR, & extra heart sounds every hour Monitor temperature every hour because patient is at risk for hyperthermia (administer Acetaminophen, NOT aspirin r/t increase in T3/T4) Give tepid baths or cooling blanket but not to point of shivering and piloerection IV fluids needed for hyperthermia, tachypnea, diaphoresis, and diarrhea Seizure precautions and calm environment Assess airway patency with decreasing LOC Administer glucose solutions, nutritional support, vitamin supplementation, and sedation r/t increase metabolic needs Risk for hyperglycemia r/t corticosteroids and glucose-rich nutrients

Oxygen Concentration (FiO2)

Fraction of inspired oxygen; the concentration of oxygen in the air we breathe -Adjustment of oxygen percentage -Changes are based on ABGs and SaO2. Usually adjusted to keep <90% SaO2 -FiO2 greater than 60% is dangerous, risk of Oxy toxicity.

Modes of Positive Pressure Ventilator Operation Assist control mode ventilation (ACMV)

Frequently used to initiate mechanical ventilation and when the patient is at risk for respiratory arrest (e.g., overdose or head injury). Assisted breaths are triggered by inspiratory effort; however, if the respiratory rate falls below a preset number (e.g., 14 per minute), "mandatory" or ventilator-controlled breaths are delivered. All breaths, assisted and controlled, are delivered at a specific tidal volume or pressure and inspiratory flow rate.

What are the systemic effects of acute brain injury from decreased gastric motility and increased gastric acidity?

Gastritis Gastric ulcers

The patient's level of consciousness may be assessed by using what scale?

Glasgow Coma Scale

Most common cause of hyperthyroidism that can lead to thyroid storm

Graves disease that is undiagnosed Other: - too much levothyroxine (Synthroid to treat hypothyroidism - contrast dye or amiodarone (anti arrhythmic) - goiter - thyroid cancer - thyroiditis

Metabolic acidosis

HCO3 <22 (pH <7.35) << Excessive production of acids or inadequate concentration of bicarbonate for the concentration of acid within the serum Manifestations Metabolic acidosis affects the function of many body systems. Its general manifestations include weakness and fatigue, headache, and general malaise. Gastrointestinal function is affected, causing anorexia, nausea, vomiting, and abdominal pain. The level of consciousness declines, leading to stupor and coma. Cardiac dysrhythmias develop, and cardiac arrest may occur. The skin is often warm and flushed. Manifestations of compensatory mechanisms are seen. The respirations, known as Kussmaul's respirations, are labored, deep, and rapid. The patient may complain of shortness of breath or dyspnea. See the Manifestations box below. • Anorexia, nausea and vomiting • Abdominal pain • Weakness and fatigue • General malaise • Decreasing levels of consciousness • Dysrhythmias, bradycardia • Warm, flushed skin • Hyperventilation (Kussmaul's respirations)

Metabolic alkalosis

HCO3 > 26 (pH > 7.45) Excessive loss of nonvolatile acids or excessive production of bicarbonate Manifestations and Complications Manifestations of metabolic alkalosis (see the following box) occur as a result of decreased calcium ionization and are similar to those of hypocalcemia, including numbness and tingling around the mouth, fingers, and toes; dizziness; Trousseau's sign; and muscle spasm. As the respiratory system compensates for metabolic alkalosis, respirations are depressed and respiratory failure with hypoxemia and respiratory acidosis may develop. • Confusion • Decreasing level of consciousness • Hyperreflexia • Tetany • Dysrhythmias • Hypotension • Seizures • Respiratory failure - *Depressed respirations* (shallow breathing)

Albuterol pt teaching

Hand hygiene Avoid triggers of spasm Keep medication on hand Drink fluid to thin secretions Avoid caffeine Follow instructions

Because of the lack of warning with tonic-clonic seizures what can occur secondarily to seizure activity? (4)

Head injury Fractures Burns Motor vehicle crashes

Treatment for pulmonary embolus

Heparin and thrombocytes agents SB LMWH, IV heparin, SQ Fonda Anticoagulation therapy provided for duration of time r/t age, comorbidities, and likeliness of recurrence An inferior vena cava filter is recommended to prevent pulmonary embolism in patients with contraindications to heparin therapy (risk for major bleeding or drug sensitivity). Placement of an inferior vena cava filter is also recommended in patients with recurring thromboembolism despite adequate anticoagulation

Increased Intracranial Pressure Complications

Herniation -Displacement of tissue through structures within the skull -Result of increased ICP

What are the systemic effects of acute brain injury from stress response to trauma? *Systemic Effects of Acute Brain Injury

Hyperglycemia

What are the systemic effects of acute brain injury from stimulation of the sympathetic nervous system, increasing the serum catecholamine levels?

Hypertension EEG changes Dysrhythmias (bradycardia, sinus tachycardia)

What characterizes adrenal insufficiency

Hypoadrenalism or hypocorticism

Hypoxemic respiratory failure vs Hypercapnic respiratory failure

Hypoxemic means defect in oxygenation; hypercapnic means defect in ventilation

Hypoxemic respiratory failure vs. hypercapnic respiratory failure

Hypoxemic- Too little PaO2 caused by pneumonia, V/Q mismatch, ARDS, PE Hypercapnic- Too much PaCO2 caused by COPD, drug overdose, neuromuscular disease

In status epilepticus what may occur if the convulsive activity is not halted? (5)

Hypoxia Acidosis Hypoglycemia Hyperthermia Exhaustion

Cause and mechanisms of secondary injury include the effects of? (3)

Hypoxia Ischemia (heart muscle doesn't get enough oxygen) Inflammation

I II III IV V VI VII VIII IX X XI XII

I = Olfactory (smell test) II = Optic (visual acuity and visual fields) III = Oculomotor (pupil constriction and extraocular movements) IV = Trochlear (extraocular movements; inferior adduction) V = Trigeminal (corneal reflex (eye blinking); clenched teeth and light touch) VI = Abducens (extraocular movements; lateral adduction) VII = Facial (corneal (eye blinking) reflex; facial movements, "close eyes and smile") VIII = Acoustic (hearing and Romberg test) IX = Glossopharyngeal (gag reflex) X = Vagus (cough reflex; unuvalar and palate movement, "Say ahh"; ) XI = Spinal sensory (Turn head and lift shoulders to resistance) XII = Hypoglossal (stick tongue out)

Management of adrenal crisis

Immediate goal: - replacement of hormones, fluid, and electrolytes

Tension pneumothorax - Manifestations

In addition to manifestations of pneumothorax, hypotension and distended neck veins are evident as venous return and cardiac output are affected. The trachea is displaced toward the unaffected side as a result of the mediastinal shift. Signs of shock may be present.

Modes of Positive Pressure Ventilator Operation Pressure-control ventilation (PCV)

In contrast to pressure support ventilation, PCV (pressure-control ventilation) controls pressure within the airways to reduce the risk of airway trauma (e.g., following thoracic surgery). Ventilation is time triggered and time cycled, but pressure is limited. The ventilator maintains a preset airway pressure throughout inspiration. Because all breaths are controlled by the ventilator, heavy sedation may be required to prevent competition between inspiratory effort and ventilator control.

Repeat boluses or a continuous infusion must be administered judiciously because the drugs saturate fat, and muscle causing plasma levels to increase or decrease?

Increase

What are the systemic effects of acute brain injury from stimulation of the sympathetic nervous system, which stimulates the adrenal cortex and medulla to increase glucocorticoid and mineralocorticoid levels? *Systemic Effects of Acute Brain Injury

Increased metabolism of carbs, fats, and proteins Retention of sodium and water

What are the systemic effects of acute brain injury from stimulation of the sympathetic nervous system?

Increased metabolism of carbs, fats, and proteins Retention of sodium and water Tachypnea Hypertension EEG changes Dysrhythmias (bradycardia, sinus tachycardia)

Cushing Triad, classical syndrome of increased ICP, includes? (3)

Increased pulse pressure Decreased pulse Change in respiratory pattern with pupillary changes • Hypertension • Bradycardia • Bradypnea

Indications for a chest tube

Injury, surgery, or any disruption of integrity of lungs and chest cavity Hemothorax Pneumothorax Tension pneumothorax Bronchopleural fistula Pleural effusion Chylothorax

What are the systemic effects of acute brain injury from immunosuppression?

Infection

Thyrotoxic Crisis/Thyroid Storm Risk Factors

Infection Shock Trauma Stress Coexistent medical illness Pregnancy Exposure to cold B-blockers

Most common cause of DKA

Infection- mostly UTI & pneumonia Other causes: - Undetected DM - Insulin noncompliance or inadequate therapy - Severe illness (CVA, MI, pancreatitis) - Alcohol/drug abuse - Trauma - Medications like steroids & antipsychotics

Most common cause of HHS

Infection- usually UTI or pneumonia (same as DKA) other - Severe illness (CVA, MI, pancreatitis) - Secondary to extreme stress from illness - Excessive exposure to carbohydrates (enteral tube feeding, peritoneal dialysis, supplements) - Drugs like corticosteroids, thiazide diuretic

Signs of increased ICP

Initial Signs: Restless Confusion Combativeness Later signs: Nausea Headache Pupillary changes, from slight ovoid shape to complete loss of pupillary tone and reactivity Somnolence (Sleepiness, the state of feeling drowsy, ready to fall asleep) Lethargy Obtundation Coma

What can insulin do to potassium?

Insulin drives K+ into the cell which can lead to hypokalemia- can lead to cardiac arrest w/o K+ replacement. Hold insulin if K+=<3.3 FYI- acidosis drives K+ out of the cell so can be hyperkalemic during DKA due to metabolic acidosis. So can low fluid volume, renal insufficiency, and hyperosmolarity.

Etiology of type 2 DM

Insulin resistance

What is the other medical term for increased ICP?

Intracranial hypertension

There are situations in which AEDs are unable to control epilepsy. Attempts at monotherapy and adjunctive therapy have been exhausted and multiple drug regimens have failed; seizure activity has compromised a patient's quality of life. In these cases, seizures are _________________, and surgery is considered to obtain seizure control.

Intractable

Extracorporeal lung support for ARDS

Involves use of large vascular cannula to remove blood from pt; pumping device and circuit circulate blood and one or two "artificial" lungs remove CO2 and oxygenate blood Allow lungs to rest

Bronchodilators & Mucolytics in ARDS

Ipratropium (Atrovent) - anticholinergic bronchodilator- Inhibits bronchoconstriction and mucus secretion, anticholinergic; must use with other bronchodilator Albuterol (ProAir, Ventolin) - treat or prevent bronchospasm with asthma pt, prevent exercise induced bronchospasm Pt teaching: - avoid excessive high temperature - Rinse mouth frequently - Use and candy to avoid dry mouth - void before taking - visit eye doc - notify doc if fever, fluid intake is diff than output, severe weakness

Administration albuterol

MDI has fewer systemic effects Use albuterol before any other inhaler because allows for better absorption due to more open airway Wait 5 min between different inhalers Only use when needed, overusafe lead to loss of bronchodilators effect

In a simple partial seizure the altered motor activity that spreads sequentially to adjacent parts is called?

Jacksonian march or Jacksonian seizure

Myxedema Coma Medications

Levothyroxine (Synthroid) -Class: thyroid drug -Action: increases metabolic rate in body's tissues, increasing oxygen consumption, respiratory rate, and heart rate -Adverse: S/S of hyperthyroidism -Teaching: life long therapy needed, take in morning on empty stomach

Mechanical ventilation for ARDS

Lung protective ventilation strategies limit ventilator induced lung injury (VILI) These include low tidal volumes (less than 6 ml/kg bw), use of adequate PEEP to reduce risk of using high FiO2 and oxygen toxicity; limiting plateau pressures to 30 cm H20

BiPAP (bilevel positive airway pressure)

Machines cycles to provide a set positive inspiratory pressure when inspiration takes place *with augmentation* and then during expiration to deliver a lower set end expiratory pressure -Inspiratory pressure support level (IPAP) -Expiratory pressure (EPAP) *Used in treatment of pt with chronic respiratory insufficient to manage acute or chronic respiratory failure without intubation and mech ventilation.

ARDS Interventions

Maintain lowest airway pressures, PEEP, tidal volumes, through use of pressure limiting modes of mech vent Prevention of VAP done by using in-line suction catheters Endotracheal tube allows for removal of pooled subglottic secretions to reduce VAP Monitor for nasal secretions Oral care Elevate HOB 30 degrees Feed with postpyloric feeding

What plays a major role in decreasing incidence of ventilator-associates pneumonia (VAP)?

Maintenance of natural gastric acid barrier in the stomach. Don't take antacids b/d decrease gastric acidity.

How does the nurse monitor the water seal of the chest tube?

Make sure chamber is filled to the 2 cm line, only sterile water, never leave tubing clamped, notice respiratory fluctuations (absence of fluctuations means there is an obstruction), should NOT see continuous bubbling in the water seal of the chest tube (means tube is displaced or d/c)

What are nursing priorities of the pt with chest tube being transferred?

Make sure drainage unit is below level of chest, tubing is not kinked, suction maintained as needed, frequently assess for air leaks, dressing integrity, water seal, water level, and drainage

Hypercapnia respiratory failure

Manifested by an increase in CO2 in the arterial blood -Electrolyte imbalance, Somnolence or coma CAUSES -Caused by hypoventilation of the alveoli -Depression of respiratory center by drugs -Diseases of the medulla -Infections or trauma of the CNS -Abnormalities of the spinal conducting pathways -Diseases of respiratory muscles -Large airway obstruction

Pressure limit

Maximal pressure within airways that will terminate a ventilator breath

Why is obtaining patient history important for ARDS?

May help determine precipitating factors which can then be treated.

Specific damage following craniocerebral injuries is related to? (3)

Mechanism of the injury (how it occurs) Nature of the injury (type) Location of the injury (where it occurs)

Epidural hematomas usually result from a skull fracture that tears an artery. Most often what artery?

Middle meningeal artery

Common causes Addison

Most common cause: autoimmune adrenalitis (gradual destruction of adrenal gland) Second most common is Tuberculosis - sepsis & shock - malignancies - AIDS - fungal infections - surgical removal

What are chest tube complications?

Most serious complication is tension pneumothorax Only clamp if you need to locate air leak source or to replace CDU If chest tube becomes dislodged— insertion site is quickly sealed off using petroleum gauze covered with dry gauze and occlusive tape dressing to prevent air from entering pleural cavity

L4-S5

Motor Function Paraplegia: Incomplete Segmental motor control L4 to S1: Abduction and internal rotation of hip, ankle dorsiflexion, and foot inversion L5 to S1: Foot eversion L4 to S2: Knee flexion S1-S2: Plantar flexion (ankle jerk) S2-S5: Bowel/bladder control Deep Tendon Reflexes: S1-S2 (ankle jerk) Sensory Function: Lumbar sensory nerves innervate the upper legs and portions of the lower legs L5: Medial aspect of foot S1: Lateral aspect of foot S2: Posterior aspect of calf/thigh Sacral sensory nerves innervate the lower legs, feet, and perineum Respiratory Function: No interference with respiratory function Voluntary Bowel and Bladder Function Bowel and bladder control possibly impaired S2-S4 segments control urinary continence S3-S5 segments control bowel continence (perianal muscles) Rehabilitative Potential: Can walk with braces or may use W/C Can be relatively independent

T1-T6

Motor Function Paraplegia: Loss of everything below the midchest region, including the trunk muscles Intact: Control of function to the shoulders, upper chest, arms, and hands Sensory Function Loss of sensation below the midchest area Intact: Everything to the connected to midchest region: arms and hands (T1 and T2 supply the inner aspect of the arm; T4 supplies the nipple area) Respiratory Function Phrenic nerve functions independently Some impairment of intercostal muscles Voluntary Bowel and Bladder Function: No bowel or Bladder "function" Rehabilitative Potential Full control of upper extremities and completely independent in W/C Full-time employment possible Independent in managing urinary drainage and inserting suppositories Able to live in a dwelling without major architectural changes

L1-L3

Motor Function Paraplegia: Loss of most control of legs and pelvis Intact: Shoulders, arms, hands, torso, hip rotation and flexion, and some leg flexion Deep Tendon Reflexes: L2-L4 (knee jerk) Sensory Function: Loss of sensation to the lower abdomen and legs Intact: All of the above plus some sensation to the inner and anterior thigh (L3 supplies the knee) Respiratory Function: No interference with respiratory function Voluntary Bowel and Bladder Function: No bowel or Bladder control (same as C1-C6) Rehabilitative Potential: Independent for most activities from W/C

T6-T12

Motor Function Paraplegia: Loss of motor control below the waist Intact: Shoulders, arms, hands, and long trunk muscles Sensory Function: Loss of sensation below the waist Intact: Shoulders, chest, arms, and hands (T10 supplies the umbilicus; T12 supplies the groin area) Respiratory Function: No interference with respiratory function Voluntary Bowel and Bladder Function: No Bowel or Bladder "function" Rehabilitative Potential In addition to the previously described capabilities, patient has complete abdominal and upper back control. Good sitting balance (allows for greater ease of W/C operation and athletics)

What must happen before a patient can be extubated (removed from the ventilator)?

Must be able to maintain own airway as evidence by appropriate LOC and presence of gag and cough reflexes. Cuff-leak test should be performed. Should have leak when ETT is occluded. If not, then edema may be present.

C6

Motor Function Tetraplegia (quadriplegia): Loss of all function below the shoulders and upper arms; lacks elbow, forearm, and hand control Intact: Deltoid, biceps, and external rotator muscles of shoulders Deep Tendon Reflexes: C5, C6, bronchioradialis Sensory Function Loss of everything listed for a C5 lesion, but better arm and thumb sensation Intact: Head, shoulders, arms, palms of hands, and thumbs (C6 supplies the forearm and thumb) Respiratory Function: Phrenic nerve intact, but not intercostal muscles Voluntary Bowel and Bladder Function: No bowel or Bladder control Rehabilitative Potential Needs assistive devices to use arms (may be able to help feed, groom, and dress self) Needs a motorized wheelchair W/C Dependent for all transfers

C5

Motor Function Tetraplegia (quadriplegia): Loss of all function below the upper shoulders (clavicles) Intact: Sternomastoids, cervical paraspinal muscles, and the trapezius; can control head Deep Tendon Reflexes: C5, C6, biceps Sensory Function Loss of sensation below the clavicle and most portions of arms, hands, chest, abdomen, and lower extremities Intact: Head, shoulders, deltoid, clavicle, portion of forearms (C5 supplies the lateral aspect of the arm) Respiratory Function: Phrenic nerve intact, but not intercostal muscles Voluntary Bowel and Bladder Function: No bowel or Bladder control Rehabilitative Potential Use of extremity-powered devices to achieve some upper limb control Head control facilitates wheelchair (W/C) balance Adaptive tools, held in mouth, for typing and writing Some adaptive tools and use of special computer technology

C8

Motor Function Tetraplegia (quadriplegia): Loss of motor control to portions of the arms and hands Intact: Some voluntary control of elbow extensors, wrist, finger extension, and finger flexors Sensory Function: Loss of sensation below the chest and in portions of hands Intact: Sensation to face, shoulders, arms, hands, and part of chest (C8 supplies the little finger) Respiratory Function: Phrenic nerve intact, but not intercostal muscles Voluntary Bowel and Bladder Function: No bowel or Bladder "function" Rehabilitative Potential Able to push up in the W/C Improved sitting tolerance Can grasp and release hands voluntarily Independent in most ADLs from W/C Independent in use of W/C Can use hands for catheterization and rectal stimulation for bowel movements

C7

Motor Function Tetraplegia (quadriplegia): Loss of motor control to portions of the arms and hands Intact: Voluntary strength in shoulder depressors, shoulder abductors, internal rotators, and radial wrist extensors Deep Tendon Reflexes: C7, C8, triceps Sensory Function Loss of sensation below the clavicle and portions of arms and hands Intact: Head, shoulders, most of arms and hands (C7 supplies the middle finger) Respiratory Function Phrenic nerve intact, but not intercostal muscles Voluntary Bowel and Bladder Function: No bowel or Bladder "function" Rehabilitative Potential Can perform some activities of daily living (ADLs) Can use wrist extensor with a special splint to induce finger flexion Can push a W/C with special hand grasps May be able to drive a specially equipped car

L3-L4

Motor Function: Paraplegia: Loss of control of portions of lower legs, ankles, and feet Intact: All of the above, plus increased knee extension Sensory Function: Loss of sensation to portions of the lower legs, feet, and ankles Intact: All of the above, plus sensation to the upper legs Respiratory Function: No interference with respiratory function Voluntary Bowel and Bladder Function: No bowel or Bladder control (same as C1-C6) Rehabilitative Potential Voluntary control of hip extensors; weak abductors Walking with braces may be possible

C1 to C4

Motor Function: Tetraplegia (quadriplegia): Loss of all motor function from the neck down Deep Tendon Reflexes: All lost Sensory Function: Loss of all sensory function in the neck and below (C4 supplies the clavicles) Respiratory Function: Loss of involuntary (phrenic) and voluntary (intercostals) respiratory function; ventilatory support and a tracheostomy needed Voluntary Bowel and Bladder Function: No bowel or bladder control Rehabilitative Potential: May be discharged home on a ventilator with home care

AEP drugs act in the _____________ cortex of the brain to reduce the spread of electrical discharges from the rapidly firing epileptic foci in this area?

Motor cortex

Injuries of the spinal cord have the potential to affect? (5)

Movement Perception Sensation Sexual function Elimination

Management of myxedema coma

Multisystem approach - vent to control hypoventilation - hypertonic solution and glucose to correct hyponatremia and hypoglycemia - Vasopressor to help with hypotension Meds: - thyroid hormones Levothyroxine - READ IN DRUG BOOK - corticosteroids

Albuterol adverse effects

Muscle tremor Tachycardia cardia Angina Palpitations Agitation Anxiety Insomnia Seizures, tremors Dysrhytmias Cardiac arrest (Due to excess cardiac and CNS stimulation)

What are examples of individualized triggers that provoke a seizure in those that have epilepsy?

Music Odors Flashing lights

SPI - MANIFESTATIONS/COMPLICATIONS BY BODY SYSTEM Integumentary • Decubitus (pressure) ulcers Neurologic • Pain • Areflexia • Hypotonia • Autonomic dysreflexia Cardiovascular • Spinal shock • Paroxysmal hypertension • Orthostatic hypotension • Cardiac dysrhythmias • Decreased venous return • Hypercalcemia Respiratory • Limited chest expansion • Decreased cough reflex • Decreased vital capacity Gastrointestinal • Stress ulcers • Paralytic ileus • Stool impaction • Stool incontinence Genitourinary • Urinary retention • Urinary incontinence • Neurogenic bladder • Impotence • Testicular atrophy • Inability to ejaculate • Decreased vaginal lubrication Musculoskeletal • Joint contractures • Bone demineralization • Osteoporosis • Muscle spasms • Muscle atrophy • Pathologic fractures • Paraplegia • Quadriplegia *Flip to see definitions

NEUROLOGIC: Areflexia is a condition in which your muscles don't respond to stimuli. Areflexia is the opposite of Hyperreflexia (muscles overreact to stimuli). *A reflex is an involuntary and rapid movement of a part of your body in response to a change in environment (stimuli) Hypotonia is decreased muscle tone. Normally, even when relaxed, muscles have a very small amount of contraction that gives them a springy feel and provides some resistance to passive movement. CARDIOVASCULAR: Paroxysmal hypertension is episodic and volatile high blood pressure, which may be due to stress of any sort, or from a pheochromocytoma, a type of tumor involving the adrenal medulla. GASTROINTESTINAL: Paralytic ileus is a condition in which the muscles of the intestines do not allow food to pass through, resulting in a blocked intestine. Fecal (stool) impaction is a mass of dry, hard stool that cannot pass out of the colon or rectum. GENITOURINARY: Neurogenic bladder is bladder dysfunction (flaccid or spastic) caused by neurologic damage. Symptoms can include overflow incontinence, frequency, urgency, urge incontinence, and retention Impotence refers to the inability to have an erection of the penis adequate for sexual intercourse. Also called erectile dysfunction. Testicular atrophy refers to the shrinking of the testicles

While monitoring the patient during the seizure the nurse or family should?

NEVER LEAVE THE ROOM

Contraindications ipratropium

Narrow angle glaucoma, BPH, bladder neck obstruction

After initiation of insulin and blood glucose is 200-250, what is necessary?

Necessary to decrease insulin infusion and add dextrose to prevent hypoglycemia and cerebral edema due to extreme fluid shifts.

Completely compensated

Normal pH, BOTH CO2 and HCO3 are abnormal (example) PaO2: 94 (normal) pH: 7.44 (normal but tending toward alkalosis) PaCO2: 25 (decreased, primary problems) HCO3: 18 (decreased, compensatory response) completely compensated respiratory alkalosis

Pharmacological treatment for ARDS

Nitric oxide: inhaled. Causes vasodilation and used to treat pulmonary hypertension Neuromuscular blocking agents: Vecuronium (Norcuron) Rocuronium (Zemuron) Sedation agents: propofol (if use neuromuscular blocking agents, sedation is required) Bronchodilators & Mucolytics: albuterol; Ipratropium (Atrovent) - reduce inflammation & reduce secretions IV corticosteroids: Corticosteroids may be used late in the course of ARDS to improve oxygenation and lung mechanics when fibrotic changes occur. Heparin: for DVT prophylaxis

Rate

Number of ventilator-delivered breaths per minute; usually 12 to 15 in adults using ACMV, may be lower in SIMV

GCS Assessment - Best Motor Response What are the responses/scores? (6)

Obeys commands = 6 Localizes pain = 5 Flexion-withdrawal = 4 Abnormal flexion = 3 Abnormal extension = 2 No response = 1 (Record best upper arm response)

Acceleration injury

Occur when a moving object strikes the stationary head (eg, a bat striking the head or a missile fired into the head).

When is myxedema coma most commonly seen

Older female patient in winter months after certain precipitating factors including stress, extreme cold, or trauma

O,O,O,T,T,A,F,A,G,V,S,H

On Old Olympus Towering Tops A Finn And German Viewed Some Hops

Indications for Chest Tube Removal

One day after cessation of air leak Drainage of less than 50 to 100 mL of fluid/d One to three days after cardiac surgery Two to six days after thoracic surgery Obliteration of empyema cavity Serosanguineous drainage from around the chest tube insertion site Chest tube partially migrated out with holes visible (may re-quire a new chest tube insertion)

In the tonic phase of a tonic-clonic (grand mal) seizure, postural control is lost, and the patient falls to the floor in what posture?

Opisthotonic posture

GCS Assessment - Best Verbal Response? What are the responses/scores? (5)

Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 No response = 1 (Record T if an endotracheal or tracheostomy tube is in place)

Indications for oropharyngeal airway, nasopharyngeal airway, and endotracheal tube

Oropharyngeal- ONLY when patient is unconscious and does NOT have a gag reflex. Nasopharyngeal- Alert patient with excessive secretions Endotracheal tube- For ventilation to protect the airway from aspiration. (the others do not eliminate aspiration potential)

Chest percussion

Over the rib cage - clapping the chest wall to help lungs drain with the force of gravity - 3-5 min per position NEVER over spine, sternum or below thoracic cage. *Only on the rib cage

While reviewing an epileptic patients record you see that they are prescribed phenytoin. What adverse effect should you be aware of?

Overgrowth of gum tissue around the teeth *Gingival hyperplasia

Ventilated patients with high oxygen concentration for long periods of time are at risk for?

Oxygen toxicity *To prevent this, FiO2 should be decreased as tolerated to lowest possible setting as long as PaO2 > 60

Management of respiratory acidosis

Oxygen, bronchodilator, mechanical ventilation may be indicated; if pulmonary infection, treat

Respiratory alkalosis

PaCO2 <35 (pH > 7.45) << hyperventilation, excessive elimination of PaCO2 from serum Manifestations The manifestations of respiratory alkalosis include lightheadedness, a feeling of panic and difficulty concentrating, circumoral and distal extremity paresthesias, tremors, and positive Chvostek's and Trousseau's signs. The patient also may experience tinnitus (ringing in the ears), a sensation of chest tightness, and palpitations (cardiac dysrhythmias). Seizures and loss of consciousness may occur. • Dizziness • Numbness and tingling around mouth, hands, and feet • Palpitations • Dyspnea • Chest tightness • Anxiety/panic • Tremors • Tetany • Seizures, loss of consciousness

Respiratory Acidosis

PaCO2 >45 (pH <7.35) << inadequate amount of PaCO2 being eliminated (pulmonary malfunction or excessive production of PaCO2) Manifestations The manifestations of acute and chronic respiratory acidosis differ. In acute respiratory acidosis, the rapid rise in PaCO2 levels causes manifestations of hypercapnia. Cerebral vasodilation causes manifestations such as headache, blurred vision, irritability, and mental cloudiness. If the condition continues, the level of consciousness progressively decreases. Rapid and dramatic changes in ABGs can lead to unconsciousness and ventricular fibrillation, a potentially lethal cardiac dysrhythmia (cardiac arrest). The skin of the patient with acute respiratory acidosis may be warm and flushed, and the pulse rate is elevated. The manifestations of chronic respiratory acidosis include weak-ness and a dull headache. Sleep disturbances, daytime sleepiness, impaired memory, and personality changes also may be manifestations of chronic respiratory acidosis.

Normal values for ABGs

PaO2: 80-100 SaO2: 93-99% pH: 7.35-7.45 PaCO2: 35-45 HCO3: 22-26

Definition of Acute Respiratory Failure (ARF) Acute respiratory failure is defined as the rapid onset of inadequate gas exchange, demonstrated by hypoxemia in which PaO2 is 50mm Hg or less, or hypercapnia in which PaCO2 is 50 mm Hg or greater with a pH of 7.25 or less

PaO2= 50 or less PaCO2= 50 or more pH= less than 7.25

Pressure control modes, like PSV (pressure-support ventilation) help increase what?

Patient-ventilator synchrony. Promotes patient comfort by decreasing the resistance of the ETT. Also used for weaning by increasing the endurance of the respiratory muscles by gradually decreasing the pressure.

SaO2

Percentage of arterial oxygen bound to hemoglobin. Measured via ABGs Normal = 93%-99%

What are the manifestations of post-concussion syndrome?

Persistent headache Dizziness Irritability Insomnia Impaired memory and concentration Learning problems

What medication is administered IV for longer term control of seizures in status epilepticus?

Phenytoin (Dilantin) *Phenobarbital may also be administered to patients in status epilepticus

Stage 3 ARDS - 2 to 10 days (proliferative)

Physical Examination • Decreased air entry bilaterally • Impaired responsiveness (may be related to sedation necessary to maintain mechanical ventilation) • Decreased gut motility • Generalized edema • Poor skin integrity and breakdown • SIRs presentation with hemodynamic instability Diagnostic Test Results • ABG: Worsening hypoxemia • CXR: Diffuse alveolar infiltrates, air bronchograms, decreased lung volumes • Chemistry: Signs of other organ involvement: decreased platelets and Hgb, increased white blood cell count, abnormal clotting factors • Hemodynamics: Unchanged or becoming increasingly worse

Stage 1 ARDS - first 12 hours

Physical Examination • Restlessness, dyspnea, tachypnea • Moderate to extensive use of accessory respiratory muscles Diagnostic Test Results • ABG: Respiratory alkalosis • CXR: No radiographic changes • Chemistry: Blood results may vary depending on precipitating cause (eg, elevated white blood cell count, changes in Hgb) • Hemodynamics: Elevated PAP, normal or low PAOP

Stage 2 ARDS - 24 hours (Exudative)

Physical Examination • Severe dyspnea, tachypnea, cyanosis, tachycardia • Coarse bilateral crackles • Decreased air entry to dependent lung fields • Increased agitation and restlessness Diagnostic Test Results • ABG: Decreased SaO2 despite supplemental oxygen administration • CXR: Patchy bilateral infiltrates • Chemistry: Increasing metabolic acidosis depending on severity of onset • Hemodynamics: Increasingly elevated PAP, normal or low PAOP

Stage 4 ARDS - More than 10 days (fibrotic)

Physical Examination • Symptoms of MODS, including decreased urine output, poor gastric motility, symptoms of impaired coagulation OR • Single-system involvement of the respiratory system with gradual improvement over time Diagnostic Test Results • ABG: Worsening hypoxemia and hypercapnia • CXR: Air bronchograms, pneumothoraces • Chemistry: Persistent signs of other organ involvement: decreased platelets and Hgb, increased white blood cell count, abnormal clotting factors • Hemodynamics: Unchanged or becoming increasingly worse

Long Term consequences of ARDS

Physical and psychological disability's Muscle wasting and weakness Anxiety

Pneumothorax Signs: P-THORAX

Pleuretic pain Trachea deviation Hyperresonance Onset sudden Reduced breath sounds (& dyspnea) Absent fremitus X-ray shows collapsed lung

How may volutrauma present with ARDS?

Pneumothorax, pneumomediastinum, subcutaneous emphysema or interstitial emphysema

Manifestations of diabetes mellitus

Polyuria Polydipsia Polyphagia Weight loss Blurred vision- type 2 Fatigue- type 2

Tube removal

Position patient in Fowlers or semi-Fowlers (head of bed elevated 45 to 90 degrees) Premedication pain medication Remove dressing and clean area Suture is clipped, tube is removed in one quick movement at the end of expiation with pt using the valsalva maneuver to prevent air from going back into pleural cavity Auscultate lung sounds immediately after Apply sterile dressing Chest radiograph *Remember - remove at end of expiration with Valsalva maneuver to prevent air from going back into pleural space.

Postural drainage

Position patient on their side with good lung down b/c shunting is decreased

positive end-expiratory pressure (PEEP)

Positive end-expiratory pressure - common mechanical ventilator setting in which airway pressure is maintained above atmospheric pressure Mechanical maintenance of pressure in the airway at the end of expiration to increase the volume of gas remaining in the lungs Prevents collapse and recruits alveoli, allowing diffusion of gases across the alveolar-capillary membrane (avoid collapse of alveoli at end of expiration) Re-inflates collapsed alveoli, maintains the alveoli in an open position, and improves lung compliance. This decreases shunt and improves oxygenation Recommend values: 10-15 cm H20

What symptoms my occur after the ictal period of a seizure?

Postictal phase of lethargy and disorientation

Chest physiotherapy

Postural drainage, positioning, chest percussion and vibration; pt should be placed with good lung side down to improve oxygenation

Nursing role in chest tube placement

Prepare family and pt; informed consent, answer questions Fowlers or semi-Fowler's End of chest tube and drainage system sterile Petroleum gauze at incision site Connections taped to prevent air leaks Radiograph postinsertion to confirm positioning Pain management; narcotics NSAIDs and lidocaine Chest tube output assessment q 2 h

Key diagnostic feature of DKA

Presence of serum ketones and metabolic acidosis Other studies: - CBC & tissue cultures for infection - Chest x-ray to rule out acute infection - ECG

Indications for ICP monitoring

Primarily used to guide therapy in people with: Severe brain injury (Glasgow 3-8 even with abnormal CT or normal CT if older than 40, posturing, or SBP<90) *Need 2 of 3 Indicated with: brain surgery brain injury brain tumor stroke cardiac arrest NOT indicated for mild to moderate brain injury (Glasgow 9-15)

Primary or Secondary? "Injury results from the impact"

Primary A blow to the head, even with no break in the skull, can cause serious and diffuse brain injury. Injury to axons disrupts oligodendroglia, and direct mechanical disruption is caused by debris and leakage.

Causes of adrenal insufficiency

Primary- Addison disease

Cushing Triad

Protective reflex to respond to increased ICP This syndrome usually occurs only in association with posterior fossa lesions *Tumors in the posterior fossa are considered critical brain lesions, primarily because of the limited space within the posterior fossa and the potential involvement of vital brain stem nuclei. *Less likely with the more commonly observed supratentorial mass lesions, such as expanding tumors or subdural hematomas. When these classical signs do accompany a supratentorial lesion, they are associated with a sudden pressure increase and usually herald a state of decompensation. Brain damage usually is irreversible if prolonged, and death is imminent without rapid intervention.

Cough and deep breathing

Promote lung expansion, mobilize secretions, prevent s/e of retained secretions (atelectasis and pneumonia) Pt should be encouraged to complete hourly

Sedation agents in ARDS

Propofol (Diprivan) - helps facilitate patient-ventilator synchrony, decreasing the work of breathing and facilitating ventilation *if continuous sedation is required, propofol or dexmedetomidine rather than midazolam Used to facilitate patient ventilator synchrony; decrease work of breathing Work by paralyzing the muscles, they do not sedate or relive pain though Improve comfort and reduced respiratory effort which in turn decreases oxygen demand

Modes of Positive Pressure Ventilator Operation Bilevel Positive Airway Pressure (BiPAP)

Provides positive airway pressure during inspiration AND airway support during expiration. Bilevel Positive Airway Pressure (BiPAP) ventilation is primarily used at night with a tight-fitting mask (nasal, facial, or oral). Bilevel ventilation is a ventilator mode with high PEEP and low PEEP. Three modes of ventilation can be used with BiPAP: 1) Spontaneous breathing (S) 2) Timed mode (T), in which pressure supported breaths are delivered at a predetermined rate 3) Spontaneous/timed (S/T), in which the ventilator switches to timed mode if spontaneous breathing falls below a preset rate.

Modes of Positive Pressure Ventilator Operation Continuous positive airway pressure (CPAP)

Provides positive pressure to the airways of a spontaneously breathing patient. CPAP may be used with either endotracheal intubation or a tight-fitting face mask. All breathing is spontaneous (patient triggered) and pressure controlled. CPAP is used to help maintain open airways and alveoli, decreasing the work of breathing.

Modes of Positive Pressure Ventilator Operation Independent lung ventilation

Provides separate ventilation for each lung. Indications include unilateral lung disease. It can be used after lung transplantation to address pulmonary pressure differences between the native lung and allograft. It requires a double-lumen endotracheal tube and two ventilators. Patients may require heavy sedation.

Modes of Positive Pressure Ventilator Operation High-frequency ventilation

Provides small gas volumes delivered at a rapid rate. It is indicated in patients who are hemodynamically unstable and intolerant of conventional mechanical ventilation. Use requires sedation and possibly pharmacologic paralysis

Modes of Positive Pressure Ventilator Operation Noninvasive ventilation (NIV)

Provides ventilator support using a tight-fitting face mask, thus avoiding intubation. Its primary use is to support patients with obstructive sleep apnea, neuromuscular disease, or impending respiratory failure (e.g., advanced COPD). Noninvasive ventilation (NIV) also can be used for patients in respiratory failure who refuse intubation. The degree of success varies, primarily limited by patient intolerance due to the physical and psychologic discomfort of wearing a mask when dyspneic. Noninvasive ventilation (NIV) tends to be more successful in patients without significant underlying lung disease (e.g., respiratory failure related to neuromuscular disease).

What type of seizures can often be clinically differentiated from epilepsy because they may involve asymmetrical motor activity, side-to-side head movements, and purposeful activity?

Pseudoseizures

Risk for ARDS

Pt over 65 with severe acute illness Infectious pneumonia Direct: aspiration, lung contusions, toxic inhalation, upper airway obstruction, SARS coronavirus, pulmonary edema, etc. Indirect: sepsis, burns, trauma, bone marrow transplantation, drug or alcohol OD, cardio bypass, pancreatitis, fractures, venous air embolism, amniotic fluid embolism

Pulmonary embolism

Pulmonary embolism (or thromboembolism) is obstruction of blood flow in part of the pulmonary vascular system by an embolus. Thromboemboli, or blood clots, that develop in the venous system (deep venous thrombosis or DVT) or right side of the heart are the most frequent cause of pulmonary embolism The most common symptoms are dyspnea and pleuritic chest pain. Anxiety, a sense of impending doom, and cough are also common. Diaphoresis and hemoptysis may develop. Massive pulmonary embolus can cause syncope and cyanosis. On examination, tachycardia and tachypnea are noted. Crackles may be heard on auscultation of the chest, and a cardiac gallop (S3 and possibly S4) may be noted. A low-grade fever may develop. It is difficult to differentiate pulmonary embolism from myocardial infarction or pneumonia by manifestations.

Most common precipitating factor of myxedema coma?

Pulmonary infection other: - trauma - stress - infections - drugs (narcotics or barbiturates) - surgery - metabolic disturbances

AEDs generally act in one of two ways?

Raising the seizure threshold Limiting the spread of abnormal activity within the brain

Vent Settings

Rate Tidal Volume Oxygen Concentration (FiO2) I:E Ratio Flow rate Sensitivity Pressure Limit

In an emergency in the absence of intravenous access how can benzodiazepines such as diazepam (Valium) be administered?

Rectally

Typically, in simple partial seizures the motor portion of the cortex is affected causing what manifestations?

Recurrent muscle contractions of the face or a contralateral part of the body, such as a finger or hand.

During a complex partial seizure, consciousness is impaired and the person may engage in?

Repetitive, non-purposeful activity, such as lip smacking, aimless walking, or picking at clothing *These behaviors are known as automatisms

Modes of Positive Pressure Ventilator Operation Positive end-expiratory pressure (PEEP)

Requires intubation and can be applied to any of the previously described ventilator modes. With PEEP, a positive pressure is maintained in the airways during exhalation and between breaths. Keeping alveoli open between breaths improves ventilation-perfusion relationships and diffusion across the alveolar-capillary membrane. This reduces hypoxemia and allows use of lower percentages of inspired oxygen. PEEP is particularly useful for treating ARDS.

Adrenal Insufficiency/Addison's Disease Risk Factors

Severe infection, septic shock, trauma, surgery, or some other additional form of stress

All of the following occur in the postictal period or phase EXCEPT? Headache Muscle aches Restlessness Fatigue

Restlessness *The person is relaxed and breathes quietly

What are the initial signs of increasing ICP? (3)

Restlessness Confusion Combativeness

What are the systemic effects of acute brain injury from altered release of antidiuretic hormone from the posterior pituitary?

Retention of water/or Diuresis Diabetes insipidus

Spinal Cord Segments

SCIs can also be classified according to the segment of the spinal cord that is affected: • Upper cervical (C1-C2): Atlas fractures, atlantoaxial subluxation, odontoid fractures, and hangman's fractures • Lower cervical (C3-C8) • Thoracic (T1-T12) • Lumbar (L1-L5) • Sacral (S1-S5) 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal

What can happen when a person has ARDS?

SIRS (systemic inflammatory response syndrome) which can lead to MODS (multisytem organ dysfunction)

Systemic Inflammatory Response Syndrome Criteria

SIRS is manifested by two or more of the following: • Temperature greater than 100.4°F (38°C) or less than 96.8°F (36°C) • Heart rate greater than 90 beats/min • Respiratory rate greater than 20 breaths/min or an arterial carbon dioxide tension (PaCO2) less than 32 mm Hg White blood cell count greater than 12,000 cells/mm3 or less than 4,000 cells/mm3 OR more than 10% immature (band) forms

Traumatic brain injury (TBI); also called craniocerebral trauma, refers to any injury of the? (3)

Scalp Skull (cranium or facial bones) Brain

Primary or Secondary? "progression of the initial injury resulting from events that affect perfusion and oxygenation of brain cells"

Secondary

What are the psychic manifestations caused by disruptions in the function of the autonomic nervous system?

Sense of déjà vu (a feeling that "this has happened before") Inappropriate fear or anger

A partial seizure in which consciousness is not altered is called?

Simple partial seizure

A seizure is a single event of abnormal electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function. This abnormal neuronal activity, which may involve all or part of the brain and disturbs? (4)

Skeletal motor function Sensation Autonomic function of the viscera Behavior, and/or level of consciousness

Diffuse axonal injury is not easily identified through radiographic imaging in the first 24 hours. However, what type of hemorrhages may be visualized deep in the white matter, a finding that increases suspicion that DAI has occurred?

Small punctate hemorrhages

What does a pulse oximeter measure?

SpO2 (an indirect measure of SaO2) which is the amount of oxygenation within the blood stream. It measures the arterial saturation of Hgb.

Physical deficits from a diffuse cerebral injury include?

Spastic paralysis Peripheral nerve injury Swallowing disorders Visual and hearing impairments Taste and smell disorders

Flow Rate

Speed at which air is delivered -Mechanical Ventilator determines alveolar ventilation. These two parameters are adjusted according to the PaCO2. Increasing the minute volume decreases the PaCO2 and vice versa. -In the pressure ventilator, the inspiratory time determines the duration of inspiration by regulating the gas flow rate. PEAK FLOW RATE -Higher the flow rate, the faster peak airway pressure is reached and the shorter the inspiration. The lower the flow rate, the longer the inspiration. -Velocity of gas flow per unit of time and is expressed as liters per minute. -If auto peep, inadequate expiratory time, peak flow is increased to shorten inspiratory time so the patient can exhale completely ***RR X TV (tidal volume)= MV (minute volume)

Spinal Shock

Spinal shock is a condition that occurs immediately or within several hours of an SCI; it is caused by the sudden cessation of impulses from the higher brain centers. Because of a decrease in sympathetic innervation to the vascular system, massive vasodilation occurs, which initiates a series of events including decreases in preload and stroke volume. The loss of sympathetic nervous system function, accompanied by unopposed parasympathetic nervous system stimulation to the heart, leads to a decrease in heart rate, and also further decreases stroke volume. The vasodilation also leads to a decrease in afterload. Because of the changes in innervation, the patient develops hypotension and bradycardia. Spinal shock is a unique shock state, as there is NOT the reflex tachycardia that usually accompanies the decrease in blood pressure. Characteristics include the loss of motor, sensory, reflex, and autonomic function below the level of the injury, with resultant flaccid paralysis, and loss of bowel and bladder function. Additionally, the body's ability to control temperature is lost, and the patient's temperature tends to equilibrate with that of the external environment (poikilothermia) If the SCI produces an incomplete transection, the suppression of function below the level of injury is temporary, lasting a few days to weeks or months. The duration of spinal shock is variable, depending on the severity of the insult and the presence of other complications. The return of perianal reflex activity signals the end of the period of spinal shock. Reflexes associated with the area surrounding the injured area. The manifestations of return of function includes bladder tone, hyperreflexia (muscle spasms), and sacral reflexes. Flaccid paralysis is then followed by spasticity-hypertonicity

GCS Assessment - Eyes Open What are the responses/scores? (4)

Spontaneously = 4 To speech = 3 To pain = 2 No response = 1 (Record C if eyes are closed by swelling)

What type of hematoma develops between the dura mater and the arachnoid mater?

Subdural Hematoma

Thyrotoxic Crisis/Thyroid Storm Manifestations

Subtle manifestations: Anterior neck pain Thyroid enlargement Exophthalmos (protrusion of one or both eyes) or other eye symptoms Pregnancy History of goiter Family history of thyroid disease Sweating Heat intolerance Nervousness Increased bowel sounds Extreme manifestations: Temperature greater than 104 F (40 C) in the absence of an infection Tachycardia CNS dysfunctions- agitation, restlessness, delirium, seizures, coma

What are absence (petit mal) seizures characterized by?

Sudden brief cessation of all motor activity accompanied by a blank stare and unresponsiveness.

What occurs in the tonic phase of a tonic-clonic (grand mal) seizure?

Sudden loss of consciousness and sharp tonic muscle contractions

Physical findings of spontaneous pneumothorax

Sudden pleuritic chest pain in affected lung, SOB, often while at rest. The respiratory and heart rates increase as gas exchange is affected. Chest wall movement may be asymmetrical, with less movement on the affected side than the unaffected side. The affected side is hyperresonant to percussion, and breath sounds may be diminished or absent. Hypoxemia may develop, although normal mechanisms that shunt blood flow to the unaffected lung often maintain normal oxygen saturation levels. Hypoxemia is more pronounced in secondary pneumothorax.

ICP - Decompressive Craniectomy

Surgery based on theory that ICP can be reduced through surgical release of rigid skull

Complications of ARDS

Systemic Inflammatory Response Syndrome Ventilator-induced lung injury Immobility due to critical illness Most serious is Multiple Organ Dysfunction Syndrome due to hypoxemia, hypoxia, persistent inflammatory response

Disruptions in the function of the autonomic nervous system cause what manifestations? (3)

Tachycardia Flushing Hypotension and/or hypertension

Tension pneumothorax

Tension Pneumothorax develops when injury to the chest wall or lungs allows air to enter the pleural space but prevents it from escaping. Pressure within the pleural space becomes positive in relation to atmospheric pressure as air rapidly accumulates with each breath. The lung on the affected side collapses, and pressure on the mediastinum shifts thoracic organs to the unaffected side of the chest, placing pressure on the opposite lung as well. Ventilation is severely compromised, and venous return to the heart is impaired. Tension pneumothorax is a medical emergency requiring immediate intervention to preserve respiration and cardiac output.

Most common complication of chest tube?

Tension pneumothorax - can occur if if there is an obstruction in draining system. -locate source of an air leak if bubbling occurs in water seal chamber -Replace chest tube drainage unit -Only clamp chest tube momentarily

True or False: Epilepsy that begins in older adults is often easier to control with antiepileptic drugs (AEDs) than that in younger people. However, some AEDs decrease the effect of statins used to treat elevated cholesterol levels

True

Generalized seizures involve both hemispheres of the brain as well as deeper brain structures, such as the? (3)

Thalamus Basal ganglia Upper brainstem

end-tidal carbon dioxide

The amount of carbon dioxide present at the end of an exhaled breath.

True or false? ventilator-associates pneumonia (VAP) rates are high among critically ill patients who are mechanically ventilated.

True. Must be vented for at least 48 hours to be considered ventilator-associates pneumonia (VAP)

Best predictor for future development of Type 1 DM is what?

The expression for multiple antibodies including....Islet cell autoantibodies, islet cell antibodies, insulin antibodies

What is the Monro-Kellie doctrine? What are the 3 things within the skull the determine pressure?

The idea that the skull is a rigid box, nonexpendable, and non-contractible and intracranial volume is fixed. Blood volume, CSF and Brain tissue, are balanced in a state of dynamic equilibrium--if an increase in one occurs, the volume of one of the other components must decrease or ICP will increase.

Clinical features of epilepsy are based on what factors?

The location of the epileptiform discharge and the type of event

The patient having a tonic-clonic seizure with legs fulling extended are in what phase?

Tonic

Who is thrombolytic therapy indicated for?

Those with massive PE, hemodynamically unstable, not prone to bleeding

Manifestations of Thyroid Storm & Myxedema coma

Thyroid Storm (hyperthyroidism) Everything up Myxedema Coma (hypothyroidism) Everything down Also..... Thyroid storm Metabolic acidosis Cardiovascular collapse Depressed LOC Psychosis Myxedema Coma Resp & metabolic acidosis Cardiovascular collapse Depressed LOC Seizure/coma Hypothermia - but do not shiver

Classification of Seizure Types Generalized: involves both hemispheres; loss of consciousness; no local onset in the cerebrum. Tonic-clonic (grand-mal) Clonic Tonic Myoclonic Atonic Absence (petit mal) Match the following symptoms with the correct type of generalized seizure? —brief staring, usually without motor involvement —sudden, brief body jerks —symmetrical, bilateral semirhythmic jerking —loss of consciousness; stiffening; forced expiration (cry); rhythmic jerking —sudden increased tone and forced expiration —sudden loss of tone; falls

Tonic—sudden increased tone and forced expiration Clonic—symmetrical, bilateral semirhythmic jerking Myoclonic—sudden, brief body jerks Atonic ("drop attacks")—sudden loss of tone; falls *Tonic-clonic (grand-mal)— loss of consciousness; stiffening; forced expiration (cry); rhythmic jerking *Absence (petit mal)—brief staring, usually without motor involvement

Causes of Acute Respiratory Failure (ARF)

Trauma/injury to the chest wall, lungs, and airways, or as a result of pulmonary disease Upper airway obstruction Surgery Heart failure Decreased SaO2 despite oxygen administration Hypercapnia Decreased blood pH Infection Recreational drug use

Nitric oxide in ARDS

Used to promote dilation in pulmonary vesicles; this means vesicles will expand and allow pulmonary pressure to decrease Inhaled gas that causes selective pulmonary vasodilation and thus reduces effects of pulmonary HTN

Airway clearance adjunct devices

Used when coughing efforts are limited d/t disease, injury, or surgery; various devices used to cause airway vibration to loosen secretions

Prone positioning

Used with critical ventilated patients; nurse should elevate HOB 30 degrees for all pt on ventilators; mobilization of pt using continuous lateral rotation therapy CLRT improves oxygenation and blood flow; must turn pt every 2 hours

When does hyperglycemic hyperosmolar state (HHS) occur in a person with Type 2 DM and why?

Usually when they become critically ill. Insulin resistance and relative insulin deficiency means circulating insulin is insufficient to prevent hyperglycemia.

ARDS priorities

VAP protocol, sepsis protocol, tight glucose control, postpyloric feeding, subglottic suction, electrolyte replacement

What are the systemic effects of acute brain injury from Increased platelet, plasma fibrinogen, and thromboplastin levels?

Vascular occlusion Anemia Decreased clotting and prothrombin times Disseminated intravascular coagulation (DIC)

Neuromuscular blockers in ARDS

Vecuronium (Norcuron) Rocuronium (Zemuron) The use of vecuronium and other neuromuscular blocking agents is often necessary because inhalation or intravenous anesthetics alone may not produce the skeletal muscle relaxation a surgeon needs when performing an operation. Muscles may need to be relaxed, so that proper exposure occurs. Also, absolutely no movement is essential for delicate repairs. In addition, neuromuscular blocking agents facilitate easy tracheal intubation and mechanical ventilation by relaxing the vocal cords, jaw, and associated respiratory muscles. Adverse Effects Nondepolarizing neuromuscular blocking agents can result in allergic reactions during anesthesia such as anaphylaxis or mild dermatologic conditions such as urticaria or erythema. The actions of nondepolarizing neuromuscular blocking agents such as vecuronium may persist after emergence from anesthesia and manifest in the PACU. This may occur after improper reversal or no reversal. This persistent or return of weakness after assumed recovery from the effects of nonpolarizing neuromuscular blocking agents is known as recurarization.

Virchow's triad

Venous stasis, hypercoagulability, endothelial damage

Which patients are at risk for oxygen toxicity?

Vented patients with high oxygen concentration for a long time. Concern when FiO2>60%

Modes of Positive Pressure Ventilator Operation Pressure support ventilation

Ventilator-assisted breaths are delivered when the patient initiates an inspiratory effort. The cycle is flow limited; inspiration is terminated when inspiratory airflow falls below a preset rate. This mode decreases the work of breathing. It can be used in combination with Synchronized intermittent mandatory ventilation (SIMV) when the respiratory drive is depressed. Ventilatory support can be gradually with-drawn during weaning. Weaning is the primary use for pressure support ventilation (PSV). Initially, PSV is set slightly below the peak inspiratory pressures required during volume-cycled ventilation. Pressure support levels are gradually decreased, often in a cyclic pattern of periods of minimal support alternating with higher support to recondition respiratory muscles. When the PSV level is just enough to overcome endotracheal tube resistance, support is discontinued and the patient is extubated. Remember..... - Allows preset pressure delivered during spontaneous ventilation - Used only for spontaneously breathing patients. - The inspiratory and expiratory pressures are selected, and there are no mandatory machine breaths. -Patients find this to be a more comfortable mode of mechanical ventilation. However, pressure support ventilation should only be used for patients with a stable respiratory drive (not sedated heavily) and stable lung compliance. -Pressure support ventilation is typically used for patients who are weaning from mechanical ventilator support.

What does the word "concussion" mean?

Violent shaking *A concussion involves temporary axonal disturbances.

Pulmonary embolism - Virchow's Triad

Virchow's triad of factors has long been believed to contribute to venous thromboembolism. 1) Venous stasis 2) Hypercoagulability 3) Vascular endothelium damage

Warfarin antidote

Vitamin K

Volume control vs. Pressure control vents

Volume control- a designated volume of air is delivered with each breath. Volume is controlled, pressure is variable. Inspiratory pressure changes with each breath. So need to closely monitor so PIP (peak inspiratory pressure). Pressure control- delivers a selected gas pressure early in the inspiration and sustains that through inspiration. Pressure is controlled, volume is variable. Volume will change based upon resistance or compliance. So need to closely monitor tidal volume.

Monroe-Kellie Doctrine

Volume of intracranium: Intravascular cerebral blood volume (3%-10%) + CSF volume (8%-12%) + Brain tissue volume, which itself contains more than 80% water -As long as total intracranial volume remains the same, ICP stays constant -To maintain equilibrium, there cannot be any increase in volume of one of these components without a compensatory decrease in the other two -Any alterations in the volume of any of these three components within the cranium vault, without a response from the other two components, may lead to a change in ICP -ICP measurements normal range is 0-15 mmHg; ICP greater than 15 mmHg is intracranial hypertension = increased ICP

Pneumothorax

When air enters pleural space between visceral and parietal pleurae, producing partial/complete lung collapse

When is pressure-control ventilation used? *Opposite of pressure support ventilation!!!!!!!!!

When there is a risk for barotrauma like in ARDS when a patient has persistent oxygenation problems despite high FiO2 (amount of O2 delivered by vent) and high PEEP (positive end-expiratory pressure). Often sedation is used b/c patient-ventilator asynchrony can result in drops in SaO2

Diffuse axonal injuries prolongs or disables signal conduction from the white matter to gray matter in the brain? OR Diffuse axonal injuries prolongs or disables signal conduction from the gray matter to white matter in the brain?

White matter to Gray matter, and is thought to occur with rotational and acceleration- deceleration forces, or unrestricted head movements that create the shearing of the axons

Possible behavioral deficits from diffuse cerebral injury include?

agitation, impulsivity, depression, and social withdrawal

Focal brain injuries are specific brain lesions confined to one area of the brain. They include?

contusions and hemorrhage/hematomas

A _____________________ is necessary to evacuate chronic subdural hematomas because the hematoma tends to solidify, making it difficult or impossible to remove through burr holes

craniotomy

hypoxemia

deficient amount of oxygen in the blood low *PaO2*

hypoventilation

deficient movement of air into and out of the lungs, causing *hypercapnia* (High PaCO2 = hypercapnia)

What should the nurse do first when assessing for increased ICP?

establish a baseline neurologic assessment of the patient to which further deterioration or improvement can be compared

What part of the brain do intracerebral hematomas typically occur?

frontal or temporal lobes

Drugs that may be used with adults having/preventing either partial or mixed seizures include? (4)

gabapentin (Neurontin) lamotrigine (Lamictal) oxcarbazepine (Trileptal) topiramate (Topamax)

For further testing, depth electrodes are surgically placed bilaterally, targeting what areas of the brain? What are the possible complications of this type of monitoring test?

hippocampus amygdala lobes frontal lobes Infection Hemorrhage Mass effect from cerebral edema

What is the purpose of bronchial hygiene therapy?

improve mobilization of secretions prevent accumulation of secretions improve ventilation

What does smoking do in the lungs?

increases mucus production by killing the cilia

When CPP decreases, cardiovascular system responds by ________________ systemic pressure.

increasing

What are the initial motor responses of a patient with increasing ICP?

localized response to painful stimuli (i.e., moved an upper extremity above the clavicle in order to remove the stimuli), which progresses to abnormal flexion or abnormal extension (Decorticate; Decerebrate)

Focal effects of the contusion may cause?

loss of reflexes hemiparesis (muscular weakness of one-half of the body) abnormal posturing

What is the medical term for absence seizures?

petit mal seizures

Heparin antidote

protamine sulfate & monitor aPTT

Myxedema Coma Risk Factors

pulmonary infections, stress, exposure to extreme cold temperatures, trauma, infection, drugs (narcotics & barbiturates), surgery, metabolic disturbances

End-tidal carbon dioxide (ETCO2) monitoring is clearly indicated for patients who present with:

respiratory distress

Kussmaul respirations

s/s of *metabolic acidosis* Labored, deep and rapid breathing; usually the result of an accumulation of certain acids - Remember with metabolic acidosis a patient has Kussmaul respirations (deep & fast) to try and blow off the acidic CO2.

ABGs (arterial blood gases)

sample of arterial blood used to determine adequacy of oxygenation *artery usually radial (forearm) (+ fiberoptic sensor inside)

What ions, regulated by receptor channels and flow across the membrane when receptors are activated by voltage changes and neurotransmitter modulation, can possibly lead to seizures? (4) *S.P.C.C

sodium (Na+) potassium (K+) calcium (Ca2+) chloride (Cl-)

hyperventilation

the condition of taking abnormally fast, deep breaths >> (PaCO2 <35) being eliminated ~>> *respiratory alkalosis*

Endotracheal intubation - what, why

the passage of a tube through the nose (*nasotracheal*) or mouth (*orotracheal*) into the trachea to establish or maintain an open airway <> ventilation <> protection of airway from aspiration

Why is a Swan-Ganz line sometimes placed for ARDS?

to monitor pulmonary artery pressures and cardiac output.

Why would Low-molecular-weight heparin (enoxaparin/Lovenox) be ordered for ARDS?

to prevent thrombophlebitis and possible pulmonary embolus or disseminated intravascular coagulation (DIC), a possible complication of ARDS.

Manifestations - Bacterial Meningitis The patient with bacterial meningitis typically presents with fever and chills, severe headache, back and abdominal pain, and nausea and vomiting. The older adult may not have a high fever, but may instead exhibit confusion. Meningeal irritation causes nuchal rigidity (stiff neck), a positive Brudzinski sign (neck flexion that causes hip and knee flexion), and a positive Kernig's sign (inability to extend knee while hip is flexed at a 90-degree angle). Photophobia and possibly diplopia (double vision) are present. In meningococcal meningitis, skin hemorrhages and ecchymosis occur related to the vasculitis caused by the rapidly replicating pathogens. IICP may be present and cause decreased LOC, seizures, changes in vital signs and respiratory pattern, and papilledema (swollen optic nerve of the eyes)

• Restlessness, agitation, and irritability • Severe headache • Chills and high fever • Confusion, altered LOC • Photophobia (aversion to light) • Diplopia (double vision) • Seizures • Signs of IICP (widened pulse pressure, bradycardia, respiratory irregularity, decreased LOC, headache, vomiting) In meningococcal meningitis: Skin hemorrhages Petechial rashes (pinpoint, round spots on skin) Ecchymosis (bruising) Signs of meningeal irritation: 1) Nuchal rigidity - inability to flex the neck forward due to rigidity of the neck muscles 2) Positive Brudzinski sign - passive forward flexion of the neck causes the patient to involuntarily raise the knees or hips in flexion 3) Positive Kernig's sign - resistance (or pain) with passive extension of the knees while hip is flexed at a 90-degree angle