Quiz #4
Using the description of the patient's neurologic status at the beginning and end of the case study, place the patient into the appropriate level on the Ranchos Los Amigos Scale (see Table 36-5).
Level 2 on arrival: Generalized response Level 8 at end: Purposeful-appropriate EVE: you are correct because with level 2 the stimulus response is incoherent, limited and nonpurposeful with random movements or incomprehensible sounds and level 8 is because he is now alert & oriented X4 and can recall past and recent events. (1) Level I - No Response. Patient does not respond to external stimuli and appears asleep. ____ (2) Level II - Generalized Response. Patient reacts to external stimuli in nonspecific, inconsistent, and nonpurposeful manner with stereotypic and limited responses. ____ (3) Level III - Localized Response. Patient responds specifically and inconsistently with delays to stimuli, but may follow simple commands for motor action. ____ (4) Level IV - Confused, Agitated Response. Patient exhibits bizarre, nonpurposeful, incoherent or inappropriate behaviors, has no shortterm recall, attention is short and nonselective. ____ (5) Level V - Confused, Inappropriate, Nonagitated Response. Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli - Simple commands are followed consistently, memory and selective attention are impaired, and new information is not retained. ____ (6) Level VI - Confused, Appropriate Response. Patient gives context appropriate, goal-directed responses, dependent upon external input for direction. There is carry-over for relearned, but not for new tasks, and recent memory problems persist. ____ (7) Level VII - Automatic, Appropriate Response. Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry-over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired. ____ (8) Level VIII - Purposeful, Appropriate Response. Patient oriented and responds to the environment but abstract reasoning abilities are decreased relative to premorbid levels.
What benefit is there for the placement of an intraventricular catheter in this scenario?
An intraventricular catheter measures the intracranial pressure (ICP) in the skull. In this scenario the catheter is beneficial so that the nurse can monitor the pressure readings, implement interventions, and notify the doctor if needed. EVE: Additionally, the catheter may assist the patient by providing earlier drainage of the intraventricular blood products therby reducing the pressure as well.
Based on the radiologic findings and your knowledge of the pathophysiology of head injury, explain why Mr. H. has a decreased level of consciousness.
Glascow coma scale level is currently level 7 due to left frontal contusion, left temporal intracerebral hemorrhage, right subdural hematoma, depressed skull fracture, multiple facial and orbital fracture. Anything between 3-8 is considered severe and would include amnesia and unconsciousness for >24 hours.
2. The past medical history items that are most important for diagnosing Mrs. Q's condition are:
History of present illness (NOPQRST). Dizziness, Syncope, or seizures Headaches Vision or auditory changes, including sensitivity to light and tinnitus. Difficulty swallowing or hoarseness Slurred speech or word finding difficulty. Confusion, memory loss, or difficulty concentrating. Gait disturbances Motor symptoms, including weakness, paresthesia, paralysis, decreased range of motion, and tremors. Past health history Relevant childhood illnesses and immunizations. Febrile seizures, birth injuries, physical abuse or trauma. Meningitis Past acute and chronic medical problems, including treatments and hospitalizations: tumors, traumatic head injuries, hypertension, thrombophlebitis or DVT, coagulopathies, sinusitis, meningitis, encephalitis, seizures, diabetes, cancer, psychiatric disorders. Past surgeries: peripheral vascular surgeries, carotid endarterectomy, aneurysm clipping, evacuation of hematoma, HEENT procedures. Risk Factors: Diabetes, smoking, hypercholesterolemia, hypertension, drug use, alcohol use, cardiovascular disease Past diagnostic tests and interventions: electroencephalography, brain scan, carotid doppler, head and neck CT, MRI, thrombolytic therapy, cardiac catherization. Medications Allergies and reactions Transfusions Family history Health status or cause of death of parents and siblings: coronary artery disease, peripheral vascular disease, cancer, hypertension, diabetes, stroke, hyperlipidemia, coagulopathies, seizures, psychiatric disturbances. Personal and social history Tobacco, alcohol, and substance abuse Family compositions Occupation and work environment. Exposure to chemicals and toxins Living environment: physical, verbal, and emotional abuse Diet Sleep patterns Exercise and leisure activities Cultural, spiritual, and religious beliefs Sources of stress: coping patterns, and social support systems Travel: especially overseas
After Mrs. Q is stabilized in the ED, you are transferring her to the ICU. Why is it important to provide a detailed neurologic exam as opposed to simply stating a GCS score?
It is important to provide a detailed neurologic exam as opposed to simply stating a GSC score because it only provides a general idea of the patients last evaluated assessment of any impairments they may have. A detailed nerologic evaluation of a critically ill patient should include assessment of mental status, motor funtion of which extremties, pupil response and sizes and which cranial nerves are affected. Also reflexes and sensation along with vital signs to follow over a period of time. You as a nurse will be able to know what specific changes have occurred from the previous assessment. Next you would notify the doctor of these new changes and the time frame that it has occured. Found in Morton page 641 EVE: I would complete the comprehensive assessment of her neuro status and use the handoff tool when giving report to the next person.
When S.W. questions, via word board, whether she will require mechanical ventilation for the rest of her life, what is the nurse's best response?
No she will not require mechanical ventilator for the rest of her life. T3/T4 injury - respiratory function: phrenic nerve functions independently. some impairment of intercostal muscles. Anything above T6 results in paralysis of inspiratory and expiratory muscles. EVE: Amara, you are correct because innervation to the diaphragm is intact, as it is innervated at the C4-C5 level, she should not require mechanical ventilation after she recovers from the recent trauma. She can be taught techniques to maximize her respiratory efforts.
What interventions do you anticipate if Mrs. Q's neurologic status continues to decline?
The doctor could order a head CT, or MRI which is superior to the head CT in that it can detect early diagnosis of cerebral infarction, small tumors and hemorrhages. Remember that it is not applicable to all patients because in case they have a pacemaker, metal implantable device or surgical clips. The MRI is not recommened. A (PET) Positron emission tomography which has the capability to measure cerebral blood flow is not very cost effective for patients. Other interventions would be blood studies, IV, pulse ox, and oxygen which is patients number one priority for her airway. Found in Morton page 685. EVE: Mrs. Q is at risk for a compromised airway and respiratory failure, and her GCS score is declining; anything below 8 indicates a coma, and thus she is likely to be intubated. Her blood pressure is elevated and continues to climb; in the presence of intact autoregulation this can cause increased ICP. She will likely be started on intravenous antihypertensive medication. When stable enough, she will be brought emergently to the CT scanner.
Name two interventions that could be used when interacting with patients in these categories.
There are several interventions that the nurse or anyone can use when interacting. These range from a variety of things such as, always remain calm. Give time for the patient to respond do not rush the patient as this will increase their anxiety even more than it already is. Use gestures, demonstrations, and only the most necessary words when giving directions. There is a table on page 726 (Ranchos Los Amigos Scale) that gives guidelines for interacting with the patient. EVE: David, all I need to add here is that everyone should know what the Rancho levels include. Thank you.
Correlate S.W.'s clinical presentation to her T3-T4 level of injury.
"no voluntary movement of the legs or feet" - Motor function = paraplegia: loss of everything below the midchest region, including trunk muscles. Sensory Function = Loss of sensation below the midchest area. "able to shrug her shoulders and had intact sensation to about nipple line" "shrugs shoulders and discriminates between sharp and dull sensations at the corresponding level of injury" - Motor function = intact: control of function to the shoulders, upper chest, arms, and hands. Sensory function = Intact: everything to midchest region, (T4 supplies nipple area) "Foley catheter draining clear, yellow urine" - no bowel or bladder function (Table 37-1) pg. 731 EVE: Clinical manifestations demonstrated by S.W. that are consistent with injury to T3-T4 include weak respiratory effort due to loss of intercostal muscles and loss of movement of the lower extremities.
A 22-year-old male is admitted after sustaining a severe traumatic brain injury. An ICP monitor is placed and the initial reading is 28 mmHg. What nursing measures can be instituted initially to treat the elevated ICP? What would be the next steps pharmacologically and operatively to decrease the ICP? Describe early and late signs of increased ICP.
Normal intracranial pressure ranges from 0-10 with an upper limit of 15. First Tier therapy includes ventricular cerebrospinal fluid drainage, administration of osmotic therapy, respiratory support, and sedation and analgesia. Second Tier therapy includes hypothermia, barbiturate coma, optimize hyperventilation, hypertensive cerebral perfusion pressure (CPP) therapy and decompressive craniectomy. Hypertonic saline is a mainstay for the treatment of patients with intracranial edema. Mannitol, a hypertonic crystalloid solution that decreases cerebral edema, is also used as first Tier therapy for reducing intracranial pressure after brain injury. Hyperventilation is a temporary strategy for the treatment of malignant intracranial pressure. 2) Analgesics like fentanyl and morphine are used to limit pain, facilitate mechanical ventilation, and potentiate the effects of sedatives for a patient with a brain injury. Benzodiazepines used as a sedative potentiate the effects of analgesic agents. Propofol is a anesthetic that is administered as a continuous infusion to decrease agitation in the critically ill patient. Neuromuscular blockading (NMB) agents are used to induce muscle paralysis in cases of refractory intracranial pressure. For the patient with severe and refractory elevated intracranial pressure, and induced barbiturate, maybe attempted to decrease systemic metabolic activity in an attempt to preserve brain function. 3) Signs of increased intracranial pressure can include restlessness, nausea, headache, somnolence, and pupillary changes. The Cushing Triad is a classical syndrome of the increased intracranial pressure and includes increased pulse pressure, decreased pulse, and changing respiratory pattern with pupillary changes. Pg. 668 EVE: Nursing measures to decrease ICP include HOB elevation, neck midline, having no constricting devices around the neck, and providing a quiet environment. Pharmacologic measures include hyperosmolar therapy, analgesics, sedatives, and paralytics. Operative interventions include ventriculostomy and decompressive craniectomy. Early signs of increased ICP include restlessness, confusion, lethargy, nausea, vomiting, headache, weakness, and sluggish pupil. Late signs are dilated nonreactive pupil, obtunded (People who are obtunded have a more depressed level of consciousness and cannot be fully aroused.), coma, and posturing.
Name at least three multisystem complications from having a severe TBI that Mr. H. may experience.
The patient may also experience uncontrolled intracranial pressure, stroke, and hypotension. EVE: the complication I was looking for though include, ARDS, Neurogenic Pulmonary Edema, DVT, Pressure ulcers, hypermetabolic state and contractures even though he is only 30 years old.
Describe the rationale for rapid blood pressure reduction in patients with intracerebral hemorrhage.
A common cause of intra cerebral hemorrhage is high blood pressure. By rapidly decreasing the blood pressure you are treating the cause of the hemorrhage and decreasing the rate/strength of the blood entering the hemorrhage. EVE: Bria, decreasing the BP also reduces chance of rebleeding as well
Because of H.B.'s increased intracranial pressure (ICP), what type of fluid would the nurse anticipate infusing?
Page 668- Clinical Management Intracranial hypertension can be managed through the administration of hypertonic saline or mannitol, a hypertonic crystalloid solution. EVE: the reason these IV solutions work is because it expands plasma volume and draws fluid out of the brain.
H.B.'s tumor lies in the right parietal lobe. If the tumor had been located within the cerebellum, what symptoms might H.B. have experienced?
Page 679- Picture Cerebellum- Disturbed gait, impaired balance, incoordination EVE: #3 the cerbellum is the balance center and that is why those symptoms you mention may occur
For patients with cerebral edema, a corticosteroid is often administered to reduce edema. Why are type 2 histamine receptor blockers prescribed in conjunction with a corticosteroid?
Page 680- Pharmacologic Management Type 2 Histamine receptor (H2) blockers are often prescribed for the patient taking steroids. They are used to prevent gastrointestinal (GI) symptoms that can be associated with prolonged steroid used. EVE: #1 the symptoms you should mention are GI bleeding and ulcers
A 54-year-old man with a history of myasthenia gravis is admitted to the hospital with a myasthenia exacerbation. The patient is ordered plasmapheresis. Discuss the purpose of plasmapheresis and how it works. Explain the importance of monitoring fatigability and vital capacity. Define myasthenic crisis.
A plasmapheresis may be indicated in patients who are in crisis or who are otherwise used for treatment. This treatment is indicated to remove circulating anti-AChR antibodies from the plasma, which results in clinical improvement. This procedure is performed through a dual-lumen central vascular access device, which is similar to a dialysis catheter. This can be used as an outpatient procedure but is typically performed as an emergent procedure. The patient's circulating blood volume is removed through one of the lumens filtered and then returned through the second lumen. The patient's plasma is removed, and albumin is returned along with the solid components of the patient's blood. This procedure can take several hours, and the patient is monitored for hypotension. Electrolytes and clotting factors are evaluated after each treatment. Myasthenia Gravis is an autoimmune disorder characterized by weakness and fatigability of the skeletal muscles. This disease involves a reduction in the number of acetylcholine receptors at the neuromuscular junction caused by antibodies against acetylcholine. The purpose of this treatment is to remove the acetylcholine antibodies that the body of a person with Myasthenia Gravis creates and by removing the persons plasma through this process it can also help eliminate these antibodies. As mentioned above this procedure is typically performed on a person who is experiencing a crisis. A Myasthenic crisis is characterized by respiratory failure along with a sudden exacerbation of weakness in other muscle groups. This can be caused by a lack of medication or a lack of responsiveness at the neuromuscular junction to cholinergic treatment or a worsening of the disease process. The patient is unresponsive to an increase in anticholinesterase medications and can experience severe weakness, dysphagia and respiratory compromise. Frequent vital capacity checks should be performed and when the FVC falls below 15 mL/kg, the patient should be intubated. Any patient with myasthenia gravis with uncertain respiratory status should be admitted to the ICU to permit close monitoring of FVC, negative inspiratory force, and anxiety, as well as to facilitate a physical examination. Vital capacity and fatigability should be monitored because during a myasthenic crisis is characterized by respiratory failure and severe weakness which in turn could lead to patient death if they are not monitored. It is important to ensure that the person with this disease process remains safe even during the exacerbations they may have during the course of their lives and the course of their disease. Page 706-709
Why would H.B. be placed on an insulin sliding scale for blood glucose control?
Page 698- Under Assessment Hyperglycemia in acute stroke patients increases cerebral infarction size and hyperglycemia is believed to aggravate cerebral ischemia worsens neurologic outcomes with and without preexisting diabetes mellitus. In the critical care unit, the upper limit of glycemic control should be 110mg/dL. Strict glycemic control in the intensive care setting may be achieved with a continuous infusion or sliding-scale regimen.
How does intracerebral hemorrhage lead to increased intracranial pressure?
As a hematoma or collection of blood forms it increases the intracranial pressure. Enclosed within the skull, clotted blood and fluid build up increasing pressure that can crush the brain against the bone. EVE: Amber thank you for answering this question. I would expand on this however to include that intracranial hemorrhage is a sudden expanding lesion within the brain parenchyma. It is a space-occupying lesion that occurs quickly and without time for the other intracerebral components to compensate. Additionally, there is surrounding cytotoxic edema further leading to increased intracranial pressure.
A 65 year old female is brought to the ED for complaints of a persistent headache and ataxia (the loss of full control of bodily movements.). A CT scan of the brain reveals a left cerebellar infarct with mass effect on the brain stem and fourth ventricle. Describe the symptoms this patient is at risk for developing.
The brain stem contains respiratory and autonomic control centers. It is also important in coordinating activity of the cerebellum with the rest of the brain. 10 out 12 cranial nerves originate from this area. The most prominent symptoms of cerebellar infarct would be disturbances of gait, equilibrium ataxia, inability to perform rapid repetitive movements, and characteristic intention tremors. The mid brain is involved in pain suppression and the flight or fight response. This patient would have trouble with eye and head movement, startle reflex, forehead, cheek, jaw, (trigeminal nerve) eye movement to the sides (abducens nerve) facial movements (facial nerve). The medulla oblongata is the most inferior part of the brain stem. The central canal of the spinal cord continues upward into the medulla where it forms the cavity of the fourth ventricle. This patient could have trouble swallowing and, tasting due to damaged glossopharyngeal and vagus nerves. She would develop jerky, uncoordinated muscle movements on top of her ataxia, she could also develop breathing problems, heart problems, blood pressure regulation difficulties, vomiting, hiccuping, coughing, and sneezing problems from the medulla part of the brain stem.
How should the nurse respond to S.W.'s questions about the possibility of getting pregnant and having children in the future?
The nurse should respond to S.W. that she can get pregnant and have children even with her SCI. On page 744-745 of our textbook, it explains this in more detail. Since she had a complete cord transection at the T3-T4 level, she will have painless labor (but could have abdominal spasms or leg spasms, back pain, and difficulty breathing as signs of labor). Autonomic dysreflexia (Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure) is a complication for women who are in labor with injuries above T4 to T6, so this will need to be addressed to reduce complications. She will be able to breastfeed and has intact sensation to this area. During her pregnancy, there are increased risk for UTI's, pressure sores, and anemia, so careful monitoring and attention will need to take place. EVE: She is also at risk for dysreflexia and DVT's.