Test 3
Cheyne-stokes breathing
An abnormal pattern of breathing characterized by a gradual increase in depth and sometimes in rate to a maximum depth, followed by a decrease resulting in apnea, usually seen in comatose individuals having diseased nervous centers of respiration
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.
Assess verbal response and orientation Alertness Motor responses Respiratory status Eye signs Reflexes Postures Glasgow Coma Scale
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
Body Temp
Altered LOC Interventions: Maintaining an airway
Maintaining an airway: -Frequent monitoring of respiratory status including auscultation of lung sounds -Positioning to prevent accumulation of secretions and prevent obstruction of upper airway—HOB elevated 30°, lateral or semiprone position -Suctioning, oral hygiene, and CPT (chest physiotherapy)
Altered LOC Interventions: Maintaining fluid status
Maintaining fluid status: -Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O -Administer IVs, tube feedings, and fluids via feeding tube as required—monitor ordered rate of IV fluids carefully
Vesicant
Medication that causes tissue damage or blistering effect
Pancuronium Bromide (Pavulon) Vencuronium Bromide (Norcuron)
Muscle relaxant injection to lightly sedate or paralyze PTs with increased ICP to prevent coughing, sneezing, and thrashing. PT must be on ventilator.
Opioid emergency
Naloxone 2mg intranasal or 0.4mg IM can be repeated after 4 mins
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
Subdural
Romberg Test
The Romberg test is an appropriate tool to diagnose sensory ataxia, a gait disturbance caused by abnormal proprioception involving information about the location of the joints. It is also proven to be sensitive and accurate means of measuring the degree of disequilibrium caused by central vertigo, peripheral vertigo and ...
Infiltration
The administration of nonvesicant medication or fluids in to surrounding tissues.
S/E of nitroprusside
by product of breakdown is cyanide use <72 hours monitor cyanide by thiocyanate and lactate levels too high dose= hypotension
diabetes insipidus
damage to hypothalamus causes large amounts of dilute and odorless urine to be produced. PTs are thirsty.
Persistent vegetative state
devoid of cognitive function but has sleep-wake cycles
Apraxia
difficulty doing purposeful movements
Cushing's Triad
Hypertension Bradypnea Bradycardia
Tetraplegia
another term for paraplegia .
hypertonia
spastic and/or rigid muscle tone
GCS eye opening
spontaneously 4 to speech 3 to pain 2 none 1
LATE loc changes
-Respiratory and vasomotor changes VS: Increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia; temperature increase -Cushing's triad: bradycardia, hypertension, bradypnea -Projectile vomiting -Further deterioration of LOC; stupor to coma -Hemiplegia, decortication, decerebration, or flaccidity -Respiratory pattern alterations including Cheyne-Stokes breathing and arrest -Loss of brainstem reflexes—pupil, gag, corneal, and swallowing
EARLY loc changes
-Restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements -Pupillary changes and impaired ocular movements -Weakness in one extremity or one side -Headache—constant, increasing in intensity or aggravated by movement or straining
Norepinephrine
0.1-0.5 mcg/kg/min
Magnesium Sulfate
1-2g over 5-20 mins
Medicate to decrease ICP (4 meds)
1. Hyperosmotic diuretics (Mannitol): draws fluid out of the brain 2.Diuretics (Lasix): removes excess fluid 3.Steroids (dexamethasone, Decadron): decreases swelling 4.Barbiturates: decreases metabolism, prevents seizures, and decreased BP
CVA diagnostics (5)
1. MRI or CT 2. Angiography 3. Brain scan (PET) 4. EEG 5. Lumbar puncture
CVA anti-platelet meds (4)
1.aspirin 2.dipyridamole (Persantine) 3.clopidogrel (Plavix) 4.ticlopidine (Ticlid)
Glascow coma scale
15 > no impairment 3< brain death
Normal ICP
15mmHg
Naloxone
2mg intranasal 0.4 mg IM may repeat after 4 mins
Nitroglycerin
5-100mcg/min Q 5-10 mins based on BP relief of acute angina and hypertension onset: 2-5mins
Normal Cerebral Perfusion Pressure (CPP)
70-100
Battle Sign
Bruising on mastoid process
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
Burr holes
Positioning in bed-flexion of neck, hips, head turned to side, Trendelenburg Suctioning
Causes increased ICP
Alkalosis
Causes vasoconstriction. Reached through hyperventilation on ventilator. Helps reduce ICP pressure.
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Change in LOC
Warning sign after head injury
Change in LOC *drowsiness, confusion, difficult to arouse seizure bleeding or water drainage from ear or nose Pupils slow to react or unequal visual problems loss of sensation to any extremity slurred speech projectile vomiting
A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply.
Correct response: Slurred speech Vomiting Weakness on one side of the body
Which are risk factors for spinal cord injury (SCI)? Select all that apply.
Correct response: Young age Alcohol use Drug abuse
A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as ordered by the physician to decrease the blood pressure?
Hydralazine hydrochloride (Apresoline) IV administered slowly
Altered LOC interventions: maintaining body temp
Maintaining body temperature: -Adjust environment and cover patient appropriately -If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling -Monitor temperature frequently and use measures to prevent shivering
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural Hematoma
given for tachycardia
adenosine procainamide hydrochloride verapamil diltiazem amiodarone digoxin beta blockers magnesium sulfate
edrophonium chloride antidote
atropine
given for bradycardia
atropine epinephrine dopamine
hypoxemia
too little O2 in bloodstream. Causes vasodilation and increased ICP
Phentolamine
treatment for extravasation of vasopressors
Coma
unconsciousness, unarousable unresponsiveness
Akinetic mutism
unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
Phelbitis
vein inflamation
Monro-Kelli Hypothesis
volume of the brain + volume of the CSF = volume of the intra cranium
angiography
x-ray examination of blood vessels after injection of radio-pague dye
Autonomic dysreflexia
autonomic dysreflexia develops in individuals with a neurologic level of spinal cord injury at or above the sixth thoracic vertebral level (T6). Autonomic dysreflexia causes an imbalanced reflex sympathetic discharge, leading to potentially life-threatening hypertension
asystole and PEA pulseless electrical activity
epinephrine
V-fib and pulseless tachycardia
epinephrine amiodarone lidocaine magnesium sulfate
Hypercapnia
excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration. Causes vasodilation and increased ICP
Mannitol
Hyperosmotic diuretics : draws fluid out of the brain 0.25 to 1g kg/dose. Q 6-8 hrs PRN
Epinephrine dosages
IV/IO: 1mg Q 3-5 mins (1mg/10ml) Flush with 20ml NS (central line preferred) ET: 2-2.5 mg Q 3-5mins dilute in 5-10ml SW or NS
Sodium Nitroprusside
Potent vasodilator used in severe hypertension >180/110 0.5mcg/kg/min max dose 10mcg/kg/min mixed with 5% dextrose in brown bag no sunlight exposure/ bad after 24 hours should be light brown color if other color, it has been contaminated do not mix other meds in same line arterial line required to monitor BP
Most commonly abused opiates
heroin morphine fentanyl codeine meperidine oxycodone hydrocodone/dihydrocodeinone hydromorphone oxymorphone
Valsalva maneuver
impedes blood flow from head. Causes increase in ICP.
Locked-in syndrome
inability to move or respond except for eye movements due to a lesion affecting the pons
LOC
is a continuum from normal alertness and full cognition (consciousness) to coma. Altered LOC is not the disorder but the result of a pathology
CVA right side=
left sided weakness perceptual difficulties (vulnerable to accidents)
hypotonia
low muscle tone
GCS motor response
obeys commands 6 localizes to pain 5 withdraws from pain 4 flexion to pain 3 extension to pain 2 none 1
GCS verbal response
oriented 5 confused 4 inappropriate 3 incomprehensible 2 none 1
Hemiplegia
paralysis of one side of the body
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon's eyes and Battle sign
CVA left side=
right sided weakness aphasia
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client
vomits