Adult Health Exam 2: Neuro (Chs 56, & 60)
Glasgow Coma Scale Verbal: 5: Alert and oriented X(BLANK) 4: (BLANK) 3: Inappropriate words (ex: (BLANK-BLANK)) 2: (BLANK-BLANK) 1: No response/ (BLANK) automatically gets a 1
3 Confused word salad Incomprehensible sounds ETT
Patho of Neuro Injury Tissue injury --> Tissue Edema --> Increased ICP --> The more ICP occurs, increased pressure against major vessels/ventricles --> Decreases O2 to tissues/cells --> Cell necrosis results --> Edema increases increasing ICP even more --> Increased pressure on the brain stem (midbrain ((BLANK)rd crainial nerve effects eyes by dilating), (BLANK) (can't dilate, (BLANK) pupils medical emergency), medulla oblongota (in charge of all (BLANK) actions; projectile vomiting, RR decrease, BP, HR changes) --> Pressure on Respiratory center accumulation of CO2 resulting in massive (BLANK) --> Increased blood rushing to cranium --> Increased ICP even more --> Death results
3 pons; fixed involuntary vasodilation
To test for CSF, get a (BLANK) and do the (BLANK) test. Blood stays in the middle and the CSF halos out.
4X4 halo
It is especially important to make sure S.B. has taken her Tegretol and has a therapeutic blood (serum) level. Why? What is the therapeutic serum level? Tegretol is (BLANK-BLANK). Why do we want therapeutic level? Avoid (BLANK and BLANK).
5-12 overdosing and underdosing
What are normal values for ICP and CPP? ICP: (BLANK-BLANK) *hospital wont treat unless >(BLANK) CPP: Cerebral perfusion pressure. Means how well is your brain being perfused. Normal CPP = (BLANK-BLANK) *Think similar to MAP
5-15 20 70-100
S.B. has an ICP reading of 25 mmHg and her current blood pressure is 130/88. Calculate her CPP. Formula: MAP - ICP = CPP *Even though her CPP is normal, it is still too high because there is evidence of cell death.
77
S.B. goes to surgery for the removal of the hematoma and is transferred to ICU with an intracranial pressure (ICP) monitor in place. 6. What are the indications for placement of an ICP monitoring device to be placed? Identify the indicators present in this client. Why does she need an ICP monitor? To monitor the pressure because her GCS is <(BLANK). And if hematoma shows up in CT. Pupillary changes. Any time LOC status change, assume increased ICP.
8
Ratios in skull: Brain = (BLANK)% Blood = (BLANK)% CSF = (BLANK)%
80 10 10
A patient is suspected of having a brain tumor. The s/s include: memory deficits, visual disturbances, weakness of right upper and lower extremities and personality changes. The nurse determines that the tumor is most likely located in the a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe
A
During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for: A. patency of airway B. presence of a neck injury C. neurologic status with the Glasgow Coma Scale D. cerebrospinal fluid leakage from the ears or nose
A
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8
A
Which conditions predispose the patient to the development of a brain abscess? (Select all that apply.) A. Endocarditis B. Ear infection C. Tooth abscess D. Skull fracture E. Sinus infection F. Scalp laceration
A. Endocarditis B. Ear infection C. Tooth abscess D. Skull fracture E. Sinus infection Rationale: Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.
What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.
A. Monitor fluid and electrolyte status carefully. Rationale: Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically used in the treatment of ICP.
The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for? (Select all that apply.) A. Seizures B. Vision loss C. Cerebral edema D. Pituitary dysfunction E. Parathyroid dysfunction F. Focal neurologic deficits
A. Seizures B. Vision loss C. Cerebral edema D. Pituitary dysfunction F. Focal neurologic deficits Rationale: Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.
The patient's MRI showed the presence of a brain tumor. The nurse anticipates which treatment modality? A. Surgery B. Chemotherapy C. Radiation therapy D. Biologic drug therapy
A. Surgery Rationale: Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.
The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck
D. Resistance to flexion of the neck Rationale: Nuchal rigidity is a manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.
A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? A. Serum sodium of 120 mEq/L B. Urine specific gravity of 1.001 C. Fasting blood glucose of 80 mg/dL D. Serum osmolality of 290 mOsm/kg
D. Serum osmolality of 290 mOsm/kg Rationale: Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood glucose levels occur with diabetes.
Give at least eight nursing orders that an ICU nurse might use to control or decrease the ICP. (Include those actions requiring a physician order including medications) 9. Fluid management. Ex (BLANK) may require fluids being given. Watch BP drops in this case. Look for dehydration. Watch specific gravity if its decreased (1.005). If high (1.030) more concentrated. 10. Feed patient as early as you can, need calories to heal and replacing proteins (think (BLANK-BLANK)) or the fluid leaks into the tissues *third spacing. Keep albumin/protein levels good.
DI oncotic pressure
(BLANK) *usually not used because risk of meningitis is so high with head injuries. However, if it's a tumor, these are used.
Dexamethasone
(BLANK) (Phenytoin): seizure prophylaxis
Dilantin
Because you always have trouble remembering the layers of the brain and different hematomas, you look up these before S.B. arrives. List and define the 3 major types of hematomas: (BLANK) (above the dura): 99% of the time is an (BLANK) bleed. S/S seen very quickly. S/S: unconscious, rapid decrease in (BLANK), headache, nausea, vomiting (projectile), pupils (BLANK-BLANK), pupils bigger in size 7, 8, 10 mm. Won't follow commands. Not able to talk.
Epidural arterial LOC non-reactive
John, a 40 year old pizza delivery guy, comes to the ED with a chief complaint of weakness, numbness and tingling that begin in his feet 2 days ago and is now in his hands and around his mouth and lips. He reports he had a flu-like illness two weeks ago, but now is concerned about the progressive muscle weakness and difficulty chewing that he is experiencing. His past medical history is non-contributory and his social history includes smoking 1 ppd/20 years and an occasional beer. 1. What do you think is occurring with John? (BLANK-BLANK). Notes: *(BLANK-BLANK) starting from feet to face is a sign that sets GB apart.
Guillain-Barre ascending paralysis
Because you always have trouble remembering the layers of the brain and different hematomas, you look up these before S.B. arrives. List and define the 3 major types of hematomas: (BLANK) Bleeding into the tissues. WORST prognosis of all head injuries. Severity depends on site, size, and how big the bleeding is. Also arterial vs venous. (BLANK), worst prognosis.
Intracerebral Arterial
What is most important regarding care of the ICP line? What should the wave form look like?
It has to be sterile A stair case
Why is a MRI not the test of choice for a suspected spinal injury patient?
It takes too long
Explain the Glasgow Coma Scale Number one signs of ICP: Decreased (BLANK) GCS of (BLANK) alert, oriented, good. GCS of (BLANK) is the lowest and the worst their LOC.
LOC 15 3
What are the s/s of IICP? 1. Decreased (BLANK) Assess GCS 2. (BLANK) vomiting 3. Pupillary changes (fixed, dilation, sluggish) 4. Cushings Triad ((BLANK,BLANK,BLANK)) 5. Abnormal dolls eye reflex 6. Abnormal posturing (decorticate, decerebrate) 7. Altered breathing patterns 8. Increased headache
LOC Projectile HR, BP, RR
There are several types of skull fracture associated with head trauma. Give the clinical presentations and pathophysiology pertinent in linear skull fracture, depressed skull fracture and a basilar skull fracture. 1. (BLANK): A break in the continuity of the bone, ex hairline fracture, fracture. 2. (BLANK): Inward indentation. Can lacerate arteries, tissues. ICP, bleeding, infection, hematoma. 3. (BLANK): Fractures at the base of the skull. Show distinct s/s. Worst outcome.
Linear Depressed Basilar
11. What are the severe outcomes possible if autonomic dysreflexia is not controlled? (BLANK and BLANK) Death
MI Stroke
List four medication classifications (and give an example of each) used to control and/or decrease IICP. 1. (BLANK): Drug of choice! Osmotic diuretic (moves water from area of high concentration to low concentration) Pulls fluid from the cells, down to the vessels, and decreases the CELL size. *Have to give through (BLANK) or it crystalizes. 2. (BLANK) saline: (BLANK)% NaCl or (BLANK)% NaCl Why? Water follows sodium into the vessels. Can be used concurrently with mannitol. 3. Propofol, (BLANK): Every time they move their ICP goes up. Sedation decreases O2 demand on their brain. 4. Barbiturates: decrease O2 demand on the body; Antipyretics: Control the fever to reduce metabolic demand; Treat pain; Proton pump inhibitors; Anticonvulsants
Mannitol; filter Hypertonic; 3; 5 Versed
Caution: C-spine precautions: no (BLANK) tubes or the tube can go into the brain.
NG
What medication(s) can be used to control the autonomic dysreflexia? They are in hypertensive crisis. So take care of the BP first. THEN look for causes, remove stimulus. (BLANK, BLANK). (BLANK). Calcium channel blockers. Alpha blockers. Clonidine. Give it (BLANK) because we want it to work very quickly. Raise (BLANK) to let gravity reduce the blood in the head.
Nitroglycerin, nitroprusside Hydralazine IV HOB
Why must hyperthermia be aggressively managed in a head injured client? Because fever causes increase in (BLANK) demand; increasing ICP.
O2
S. B. is on the ventilator and is NPO. The neurosurgeon has ordered her anticonvulsant changed to Dilantin 100 IV push q 8 hours. 16. Why was she changed from the Tegretol? Why Dilantin? Tegretol comes in (BLANK), and Dilantin comes (BLANK). Push slow. Normal Dilantin level is (BLANK-BLANK) mites per mls. Don't give more than (BLANK) mgs per minute.
PO; IV 10-20; 50
(BLANK): barbiturate to reduce cerebral metabolism
Pentobarbital
2. What collaborative care for Guillan Barre is anticipated? (BLANK) washes out antibodies attacking your own body. If you can get it done within two weeks with GB it has a very good prognosis. Along with this, you can give (BLANK). Together they have a very good success rate. We are also concerned with respiratory d/t its travel up. Heart could also be affected but follow ABCs. They may need (BLANK/BLANK) support. If evidence of respiratory acidosis intubate. Hypoxemia signs? Intubate. They may need to be (BLANK) (fingers, toes) d/t contractures. Passive range of motion. Provide nutrition (tube feeding if can't eat). Prevent them going into a catabolic state. Monitor BP, ABGs, respirations, movement of extremitites, labs, nutrition.
Plasmaphoresis immunoglobulins (igg) intubation/ventilation splinted
Basilar: Fractures at the base of the skull. Show distinct s/s. Worst outcome. 1. (BLANK) (bleeding from the nose) 2. (BLANK) (bleeding from the ears) 3. (BLANK) eyes (periorbital edema/ecchymosis) Bleeding inside the eyes. 4. (BLANK) sign (post auricular ecchymosis) Bleeding behind the ears.
Rhinorrhea Otorrhea Racoons Battles
(BLANK) shock: Usually temporary d/t swelling eventually going down. Wont see low BP, or low HR. Its just flaccid paralysis below the site of injury. Almost always comes back. Lasts about 24 hours.
Spinal
Give at least eight nursing orders that an ICU nurse might use to control or decrease the ICP. (Include those actions requiring a physician order including medications) 5. (BLANK-BLANK) to prevent Valsalva maneuver. 6. Do not (BLANK-BLANK). Why? ICP needs a chance to settle down. Prevent ICP from spiking into the (BLANK)'s and (BLANK)'s. 7. Keep environment, dim, calm, and quiet. If ICP goes up with family, ask family to leave. But NEVER (BLANK) ventilator alarms. 8. Control room temp.
Stool softeners cluster care; 30; 40 mute
Because you always have trouble remembering the layers of the brain and different hematomas, you look up these before S.B. arrives. List and define the 3 major types of hematomas: (BLANK) (below the dura) Three categories. (BLANK) (look the same as epidural bleeds) 48 hours, (BLANK) (2-14 days), and (BLANK) (over months, weeks). *(BLANK and BLANK), same symptoms, different time rates.
Subdural Acute; subacute; chronic Acute and subacute
8. What is the non-surgical management of Spinal Cord Injury? (BLANK), (BLANK) to prevent secondary injury.
Traction realignment
For a suspected spinal injury patient: Get a CT of the spinal cord and (BLANK) of the thoracic area. Apply a (BLANK-BLANK) and (BLANK-BLANK) patient until spinal cord injuries are ruled out.
X-ray C collar log-roll
Prazosin is an
alpha 1 blocker
Why are the elderly and alcoholics at risk for chronic subdural hematoma? The older you get your brain (BLANK). The (BLANK) space is greater with age. More space it can bleed into. Always rule out head injury even with (BLANK) patients. (BLANK) are injury prone.
atrophies subdural dementia; Alcoholics
What is the significance of the midline shift that was apparent on S.B.'s initial CAT scan? The shift can push the brain off to one side. There is too much (BLANK). (BLANK) ICP.
bleeding Increased
10. For patients with lesions (injury) at T6 or above, there is the potential for autonomic dysreflexia (AD) in response to noxious stimulation. Describe the autonomic dysreflexia this client might have if he had a spinal cord injury at this level. Lack of reflexes. Usually after 24 hours they come back. But sometimes these reflexes can come back with a vengeance, resulting in too much = autonomic dysreflexia. The most common cause is (BLANK and BLANK). If the injury is above T6, probably (BLANK). An overstretched bladder, the stimulus will travel up the spinal cord, and when it hits the (BLANK of BLANK) it is like a road block, it cant go up to the brain to tell the body what it needs to do. The body gets confused. So the vessels start to (BLANK). So all the vessels start to constrict. This makes BP go UP. They go into (BLANK-BLANK). Ex: 300 systolic, VERY high.
bowel and bladder paraplegic site of injury vasospasm hypertensive crisis
Explain decerebrate and decorticate posturing Decerebrate the problem is in the (BLANK-BLANK). Decorticate posturing the problem is in the (BLANK).
brain stem cortex
Nifedopine is a:
calcium channel blocker
List at least 3 Nursing Diagnoses for this client. 1. Decreased (BLANK-BLANK) 2. Decreased intracranial (BLANK-BLANK) 3. Risk for (BLANK) syndrome
cerebral perfusion adaptive capacity disuse
Explain Dolls Eyes phenomena Doll's eyes: Normal is when eyes (BLANK to the BLANK). When there is Neuro damage, the eyes (BLANK) and go the direction of where the head is (BLANK-BLANK) because the muscles are weak. Positive dolls eyes = (BLANK).
come to the center lag; pointed to normal
Glasgow Coma Scale Motor response: 6: follows all (BLANK) ex (BLANK-BLANK), squeeze fingers 5: (BLANK) pain (knows exactly where the pain is coming from, ex: will move nail bed away) 4: (BLANK) from pain (ex: Cant localize, so will withdraw the whole hand) 3: (BLANK/BLANK) posturing *coming toward the core, inward, internally *adduction 2: (BLANK) posturing *going away from the core, outward, *abduction 1: no response/flaccid
commands; thumbs up Localizes Withdraws decorticate/flexion decerebrate
7. What is the surgical management of Spinal Cord Injury? If spinal cord is compressed, the goal is to (BLANK) the spinal cord. Stabilization of the spine as well.
decompress
What causes autonomic dysreflexia? Bowel and bladder. So if they need a (BLANK-BLANK). *Check if it's kinked and fix it. Address (BLANK). UTI, itching, tight socks, tight pants. Could be air coming off the vent. Any kind of uncomfortable stimuli.
foley catheter constipation
Dilantin (phenytoin) has important considerations when being used to treat a seizure disorder. Describe the safe administration of IV Dilantin in detail. Push SLOW. Can cause (BLANK-BLANK), renal impairment, arrythmias. Liver problems. Have to monitor CBC every time you give it to make sure you have enough (BLANK). S/S bruising, petechiae. (BLANK-BLANK) syndrome very rare side effect *can get it from pushing Dilantin too fast.
heart blocks platelets Purple glove
SCI T.W. is a 23-year-old male who fell 50 feet from a chairlift while skiing and landed on hard-packed snow. He was airlifted to the local trauma unit at the hospital. 1. What are the main causes of spinal cord injury? motor vehicle collisions (38%), falls (30%), violence (14%), sports injuries (9%), and other miscellaneous causes (9%). Note: The (BLANK) the injury, the worst the outcome. (BLANK) is an important landmark because if above this, most dangerous. C1 and C2 control everything, they could end up a quadriplegic. C3-5 "(BLANK the BLANK-BLANK)" this zone controls (BLANK). C (BLANK-BLANK) hand motions, fine motor movements. T(BLANK-BLANK) thoracic muscles. T(BLANK-BLANK) abdominals. L1-5 hamstrings, quads, leg movements, sexual function.
higher T6 keep the diaphragm alive; respiration 6-8 1-6 6-12
5. What is the initial goal of treatment in the acute phase of spinal cord injury (SCI)? Prevent further damage to the spinal cord. Maintain ABCs. Make sure to control their (BLANK) (neurogenic shock). Goal: Systolic >(BLANK), and HR >(BLANK).
hypotension 90 60
Give at least eight nursing orders that an ICU nurse might use to control or decrease the ICP. (Include those actions requiring a physician order including medications) 1. Airway (ensure patent airway) *intubate if needed 2. Give O2, prevent (BLANK AND BLANK) *don't let them breathe outside normal range >(BLANK) nor <12. 3. Monitor vital signs and neuro status HOURLY, q15, q30 depending on patient needs. 4. Keep HOB elevated (BLANK) degrees, NO more than (BLANK) (or can create that bend) and keep in neutral position.
hypoxemia and hypercapnia; 30 30; 45
3. What are the nursing goals for John's care (Guillain Barre)? Protecting vital functions until ready to come off the vent. Prevent (BLANK) (higher risk with ventilation). Prevent (BLANK) (if they vomit, can go into the lungs). Promote nutrition and mobility.
infection aspiration
The risk of skull fractures is that they can (BLANK) the artery. Can lead to increased ICP from bleeding, hematoma. Can lead to infection, and (BLANK).
lacerate meningitis
Explain Cushings Triad There is a change in vital signs when *hitting the (BLANK-BLANK). 1: Systolic (BLANK) w/WIDE (BLANK-BLANK). Ex 160/80 --> 185/70 --> 190/60 2. (BLANK) with a (BLANK) pulse. 3. Decreased (BLANK) (ex: 12, 8, 4)
medulla oblongata hypertension; pulse pressure Bradycardia; bounding respirations
3. What might be the result to an injured person if appropriate care with movement did not occur before to a hospital? Injury could (BLANK-BLANK-BLANK) the spine
move further up
6. T.W. is hypotensive and bradycardic when you receive him in ICU. Why? Describe in detail and include treatments for this. The reason (BLANK) shock happens is you lose nerve control regulating BP. The vessels lose vascular tone. (BLANK) nervous system is deactivated (normally speeds things up). So the (BLANK) takes over, and it slows things down. This is the only shock you will have low AND low hr. These are the two hallmark signs of neurogenic shock. We can give (BLANK) for the low BP. For the low HR we can give (BLANK).
neurogenic Sympathetic parasympathetic dopamine; atropine
2. List the care needed for T.W. at the site of the accident including care before moving him for transport. 5. Once airway is clear, oxygenation is the priority ((BLANK-BLANK), intubation if needed) 6. Circulation, start IVs *Nothing less than a (BLANK) d/t needing lots of fluid. Need at least a (BLANK)g for blood. 7. Give fluids 8. Control bleeding with direct pressure 9. Transport gently
non-rebreather 18; 20
13. List the potential causes of autonomic dysreflexia and give the treatment (or prevention) of each cause. Bowel and bladder number one. But any kind of injury, and/or (BLANK-BLANK).
noxious stimuli
4. What nursing interventions are necessary to assist in John's care? Assess, monitor paralysis, assess (BLANK) function, monitor ABGs, assess gag reflex, corneal reflex (use (BLANK-BLANK)), monitor BP, if low give (BLANK). Monitor for infection, nutritional support, maintain blood sugars, measure residual (Check how much is left in the stomach at regular intervals) Check every (BLANK) hours. How much residual is okay? Rule of thumb, anything greater than (BLANK) the rate, they arent tolerating very well. If you pull out 10, too much. Prevent contractures and psychosocial support.
respiratory artificial tears vasopressors 4 twice
S. B. is a 28-year-old female. She is married and has a PMH of seizure disorder controlled with Tegretol. Her last seizure was 5 years ago. She was involved in a motor vehicle crash (MVC). S.B. was ejected form the car and found unconscious by the emergency medical service. She was placed on a spinal board and a cervical collar was applied. She was immobilized on a long backboard. S.B. was transported to the nearest ER where the neurosurgeon is available on call. Assessment findings: B/P 160/90, HR 100, R 4/min and stertorous, temperature is 36.7 C. Pupils are reactive with L> R. Glasgow Coma Scale is 7. What are the expected findings? Bleeding, midline of the brain (BLANK). Contusion. Hematoma. Cerebral (BLANK). (BLANK) sided brain injury (the clue is Left pupil is bigger than the right).
shift edema Left
Glasgow Coma Scale Eyes: 4: eyes open (BLANK) 3: eyes open to (BLANK-BLANK) 2: eyes open to (BLANK-BLANK) 1: No response
spontaneously verbal response painful stimuli
Epidural hematoma: Treatment: Priority is (BLANK). May need a (BLANK) (where you take the bone flap out to allow brain to swell to reduce brain cell death). Can also do a (BLANK) (gold standard) aka (BLANK-BLANK) ((BLANK-BLANK-BLANK)). They drill a hole in the skull, will help you monitor ICP. It's a drain, so if the ICP goes up, you can open the drain a little bit, let some of it flow out, then close it. Regulate ICP.
surgery craniotomy ventriculostomy; EVD drain (external ventricular drain)
Subdural Hematoma Treatment: Evacuation of hematoma, so (BLANK). If its small, body can absorb it. But if its acute, usually (BLANK).
surgery; surgery
Why are hypotonic-producing IV solutions like D5W avoided in this patient? Hypotonic solutions (BLANK) the cells. (BLANK) ICP
swell; Increases
The brain is a closed circuit. There are two openings. The (BLANK-BLANK) (super small) and the (BLANK-BLANK) (big opening) *will result in brain death if herniation goes through the (BLANK-BLANK). *The higher the ICP, the more the brain herniates (BLANK) through the midbrain, pons and medulla oblongata through the foramen magnum and this = (BLANK-BLANK).
tentorial notch Foramen Magnum; forman magnum downward brain death
Why is increased ICP (IICP) so clinically important? Decreased (BLANK-BLANK) if ICP is high. 1. Arterial pressure (need good BP) 2. Venous pressure (need fluid coming back to the heart) 3. Abdominal/thoracic pressures The more (BLANK) in the stomach, the more backup raising ICP. 4. Posture (monitor bends in body) 5. Temperature ((BLANK) increases ICP, fever increases metabolic demands, brain demands more energy, increases ICP) 6. Blood gasses ((BLANK and BLANK) BOTH increase ICP. Maintain normal pH level, CO2) Respirations important here.
tissue perfusion bends shivering acidosis and alkalosis
What patient care/patient teaching is needed if the patient is taking Dilantin? Oral hygiene because it increases risk of (BLANK-BLANK). Can cause acne. Urine discoloration (pink or brown). Purple glove syndrome. SJS. Avoid (BLANK and BLANK) meds with caution talk to Dr. Avoid (BLANK)
tooth decay alcohol and OTC antacids
S.B. is intubated and can be hyperventilated to assist in the control of increased ICP. 12. What is the rationale for this therapy? What is a potential complication of hyperventilation? Blowing off CO2 to help decrease the ICP. Too less of CO2 can cause (BLANK). *hyperventilation is used (BLANK-BLANK) only.
vasoconstriction short term
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to: A. keep the head of the bed flat B. elevate the HOB to 30 degrees C. maintain patient on the left side with the head supported on a pillow D. use a continuous-rotation bed to continuously change patient position
B
A nursing measure that can reduce the potential for seizures and increased ICP in the patient with bacterial meningitis is: A. administering codeine for relief of head and heck pain B. controlling fever with prescribed drugs and cooling techniques C. maintaining strict bed rest with the head of the bed slightly elevated D. keeping the room dark and quiet to minimalize environmental stimulation
B
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? A. Tachycardia B. Hypotension C. Increased cardiac output D. Peripheral vasoconstriction
B
A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. Place packing in the patient's nares. B. Apply a loose gauze pad under the patient's nose. C. Place the patient in a modified Trendelenburg position. D. Ask the patient to gently blow the nose to clear the drainage.
B. Apply a loose gauze pad under the patient's nose. Rationale: Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the provider immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and the patient should not sneeze or blow the nose.
The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) A. Judgment B. Eye opening C. Abstract reasoning D. Best motor response E. Best verbal response F. Cranial nerve function
B. Eye opening D. Best motor response E. Best verbal response Rationale: The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
Vasogenic cerebral edema increases intracranial pressure by: A. shifting fluid in the gray matter B. altering the endothelial lining of cerebral capillaries C. leaking molecules from the intracellular fluid to the capillaries D. altering the osmotic gradient flow into the intravascular component
B. altering the endothelial lining of cerebral capillaries
The nurse is caring for a patient who is admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of ICP? A. tachypnea B. bradycardia C. hypotension D. Narrowing pulse pressure
B. bradycardia Rationale: Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
autonomic dysreflexia After patient is in hypertensive crisis, ex: systolic 300>. (BLANK) try to compensate. They take the message up to the brain. So messages are sent to slow down, but then THOSE hit a roadblock at the site of injury. So you are (BLANK) above the site of injury. Decreased (BLANK), sweating. However, (BLANK) is what is going to kill them. Hair rising, facial flushing, decreased HR. Nasal congestion, anxiety, nausea. These are signs the brain has told the body to slow things down.
Baroreceptors vasodilated HR vasoconstriction
A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurses FIRST priority is to: A. Call the healthcare provider B. check the patients temperature C. measure the patients blood pressure D. elevate the HOB to 90 degrees
C
The nurse is alerted to a possible acute subdural hematoma in the patient who A. has a linear skull fracture crossing a major artery B. has focal symptoms of brain damage with no recollection of a head injury C. develops decreased LOC and a headache within 48 hours of a head injury D. has an immediate loss of consciousness with a brief lucid interval followed by decreased LOC
C
The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? A. patient with a skull fracture whose nose is bleeding B. an older patient with a stroke who is confused and whose daughter is present C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale D. patient 2 days postoperative after a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis
C
2. List the care needed for T.W. at the site of the accident including care before moving him for transport. 1. Put the (BLANK-BLANK) on - part of airway in ABCs 2. (BLANK) the airway 3. If airway is not open you can (BLANK-BLANK-BLANK-BLANK) or jaw thrust. (BLANK-BLANK) for spinal cord injury because you don't want to move their neck. 4. Log roll patient
C collar Stabilize head tilt chin lift; Jaw thrust
Nursing management of a patient with a brain tumor includes SATA: A. discussing with the patient methods to control inappropriate behavior B. using diversion techniques to keep the patient stimulated and motivated C. assisting and supporting the family in understanding any changes in behavior D. limiting self-care activities until the patient has regained maximum physical functioning E. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs
C, E
9. What is the essential nursing management of the client with Spinal Cord Injury? • Immobilize spinal cord with (BLANK-BLANK-BLANK) • (BLANK) if needed to take care of airway • Provide O2, HIGH O2 • Monitor BP and HR because we don't want them going into (BLANK) shock.*Urine output decreases, BUN and creatinine go up. Bowel sounds are hypoactive. LOC changes. • Give (BLANK-BLANK) (This comes first) Why? You have to be sure the vessels are filled properly. *Make sure they are full before you squeeze them with ((BLANK)) • PT • OT
C-spine collar Intubate neurogenic IV fluids dopamine
The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. Document the ICP reading in the chart. B. Determine if the patient has a headache. C. Assess the patient's level of consciousness. D. Position the patient with head elevated 60 degrees.
C. Assess the patient's level of consciousness. Rationale: The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.
A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse give first? A. Codeine B. Phenytoin C. Ceftriaxone D. Acetaminophen
C. Ceftriaxone Rationale: Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).
A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. High blood flow to the brain B. Normal intracranial pressure C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow
C. Impaired blood flow to the brain Rationale: Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.
In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A. Seizures will develop within weeks or months. B. The family will be unable to cope with role reversals. C. There are often residual changes in personality and cognition. D. Referrals will be made to eliminate residual deficits from the damage.
C. There are often residual changes in personality and cognition. Rationale: In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.
The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A. Administer IV mannitol as ordered. B. Ventilator use to hyperoxygenate the patient. C. Use strict aseptic technique with dressing changes. D. Be aware of changes in ICP related to cerebrospinal fluid leaks.
C. Use strict aseptic technique with dressing changes. Rationale: The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.
4. What is the diagnostic test of choice to determine the spinal cord injury? (BLANK-BLANK), why? Because an MRI takes too long and the person would need to be stable. (BLANK-BLANK) cervical x-ray is used as well.
CT scan Cross lateral
S. B. is a 28-year-old female. She is married and has a PMH of seizure disorder controlled with Tegretol. Her last seizure was 5 years ago. She was involved in a motor vehicle crash (MVC). S.B. was ejected form the car and found unconscious by the emergency medical service. She was placed on a spinal board and a cervical collar was applied. She was immobilized on a long backboard. S.B. was transported to the nearest ER where the neurosurgeon is available on call. Assessment findings: B/P 160/90, HR 100, R 4/min and stertorous, temperature is 36.7 C. Pupils are reactive with L> R. Glasgow Coma Scale is 7. 1. What is the test of choice to determine the type of injury S.B. has sustained?
CT scan (with or without contrast)
A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects: A. a severe decrease in cerebral perfusion pressure B. an alteration in the production of cerebrospinal fluid C. the loss of autoregulatory control of intracranial pressure D. a normal balance among brain tissue, blood and cerebrospinal fluid
D
During routine assessment of a patient with Guillan Barre syndrome, the nurse finds the patient is short of breath. The patients respiratory distress is caused by: A. elevated protein levels in the CSF B. immobility resulting from ascending paralysis C. degeneration of motor neurons in the brainstem and spinal cord D. paralysis ascending to the nerves that stimulate the thoracic area
D
The nurse prepares to give temozolomide (Temodar) to a patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A. Serum potassium and serum sodium levels B. Urine osmolality and urine specific gravity C. Cerebrospinal fluid pressure and cell count D. Absolute neutrophil count and platelet count
D. Absolute neutrophil count and platelet count Rationale: Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/µL and platelet count greater than 100,000/µL.
A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.
D. Malnutrition promotes continued cerebral edema. Rationale: A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral nutrition. Excess intravenous fluid administration will also increase cerebral edema.
