MS Exam 2 Ch 3 ATI

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? SATA A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive med." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

A, B, D, E

Glasgow Coma Scale

Assessment that concentrates on neurologic function and useful to determine level of consciousness and monitor response to treatment. Reported as a number that allows providers to immediately determine if neurologic changes have occurred.

A nurse is assessing a client for changes in the LOC using GCS. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS score should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

B

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

B

A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following instructions should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure" B. "Try to stay awake most of the night prior to the procedure" C. "The procedure will take approximately 15 mins" D. "You will need to lie flat for 4 hrs after the procedure"

B

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SATA A. Use GCS when assessing the client B. Assist client to a supine position C. Admin an opioid med D. Encourage client to increase fluid intake E. Instruct client to perform deep breathing and coughing exercises

B, C, D

Lumbar puncture Postprocedure

CSF is sent to pathology dept for analysis Monitor puncture site. The client should remain side lying for several hours to ensure that the site clots and to decrease the risk of a post-lumbar headache, caused by CSF leak Normal activities may be resumed after prescribed bed rest is complete as long as in stable condition

Cerebral computed tomography scan

CT scan provides cross-sectional images of the cranial cavity. A contrast medium can be used to enhance images.

Postprocedure Cerebral Angiography

Closely monitor area to ensure that clotting occurs Movements are restricted depending on type of procedure used to seal the artery to prevent rebleeding at the catheter site Place an ice pack on insertion site

Electroencephalography

EEG - noninvasive procedure that assesses the electrical activity of the brain and is used to determine abnormalities in brain wave patterns. Provides information about ability of the brain to function and highlights areas of abnormality

MRI Intraprocedure

Ensure client remains supine with head stabilized MRI scanning is noisy, and earplugs or sedation may be provided

Lumbar Puncture Nursing Actions

Ensure that all of the client's jewelry is removed and that the client is wearing only a hospital gown Instruct client to void prior to procedure clients should be positioned to stretch the spinal canal; this can be done by having the client assume a cannonball position while on one side

GCS Scale

Eye Opening (E) - best eye response with responses ranging from 4-1 4=eye opening occurs spontaneously 3=eye opening occurs secondary to sound 2=eye opening occurs secondary to pain 1=eye opening does not occur Verbal (V) - best verbal response with responses ranging from 5-1 5=conversation is coherent and oriented 4=conversation is incoherent and disoriented 3=words are spoken, but inappropriately 2=sounds are made, but no words 1=vocalization does not occur Motor (M) - best motor response with responses ranging from 6-1 6=commands are followed 5=local reaction to pain occurs 4=general withdrawal from pain 3=decorticate posture (adduction of arms, flexion of elbows and wrists) is present 2=decerebrate posture (abduction of arms, extension of elbows and wrists) is present 1=motor response does not occur E+V+M=Total GCS High number = good

EEG Intraprocedure

Generally takes 45-120 mins No risks associated with this procedure With the client resting in a chair or lying in bed, small electrodes are placed on the scalp and connected to a brain wave machine or computer Electrical signals produced by the brain are recorded by the machine or computer in the form of wavy lines to document brain activity Notations are made when stimuli are presented or when sleep occurs (flashes of light or pictures can be used during the procedure to assess the client's response to stimuli)

Intracranial Pressure Monitoring

ICP monitor is a device inserted into the cranial cavity that records pressure and is connected to a monitor that shows a picture of the pressure waveforms Insertion is performed by a neurosurgeon. This procedure is rarely used unless pt is comatose

Indication for Cerebral Angiography

Identify aneurysms Define vascularity of tumors (useful for surgical planning) Also used to therapeutically inject medications that treat blood clots or administer chemotherapy

Lumbar puncture Complications

If clotting does not occur to seal the dura puncture site, CSF can leak, resulting in a headache and increasing the potential for infection Encourage the client to lie flat in bed. Provide fluids for hydration, and administer pain med Prepare the client for an epidural blood patch to seal the hole in the dura if the headache persists

MRI Postprocedure

If contrast media is injected, monitor the site to ensure that clotting has occurred and monitor for any indications of an allergic reaction If sedation is administered, monitor the client until stable

PET and SPECT Postprocedure

If radioisotopes are used, assess for allergic reaction There is no follow-up care after a PET/SPECT scan Because the tracer is glucose-based and short-acting (less than 2 hr) it is broken down within the body as a sugar, not excreted

ICP Monitor Complications

Insertion and maintenance of an ICP monitoring system can cause infection and bleeding Follow strict surgical aseptic technique Perform sterile dressing changes per facility protocol Keep drainage systems closed Limit monitoring to 3-5 days Irrigate the system only as needed to maintain patency

3 basic types of ICP Monitors

Intraventricular catheter (ventriculostomy) - fluid filled catheter is inserted into the anterior horn of the lateral ventricles through a burr hole. Cath is connected to a sterile drainage system with a three-way stopcock that allows simultaneous drainage of CSF and monitoring of pressures by a transducer connected to a bedside monitor Subarachnoid screw or bolt - hollow, threaded screw or bolt is placed into the subarachnoid space through a twist-drill burr hole in the front of the skull, behind the hairline. Bolt is connected to a fluid filled tubing to a transducer leveled at the approximate location of the lateral ventricles Epidural or subdural sensor - fiber-optic sensor is inserted is inserted into the epidural space through a burr hole. The fiber-optic device measures changes in the amount of light reflected from a pressure-sensitive diaphragm in the catheter tip. The cable is connected to a precalibrated monitor that displays the numerical value of ICP. This method of monitoring is noninvasive because the device does not penetrate the dura.

ICP Monitor Intraprocedure

Local anesthetic used to numb the area if GCS indicates some LOC (8-11) Insertion and care of any ICP monitoring device requires surgical aseptic technique to reduce risk for CNS infection

Magnetic Resonance Imaging Scan (MRI)

MRI of the head provides cross-sectional images of the cranial cavity. A contrast medium may be used to enhance the images Unlike CT scans, MRI images are obtained using magnets, thus the consequences associated with radiation are avoided. This makes this procedure safer for women who are pregnant. The use of magnets precludes the ability to scan a client who has an artificial device (pacemakers, surgical clips, intravenous access port)

ICP Monitor Postprocedure

Maintain system integrity at all times System contamination can cause serious life-threatening infections Inspect insertion site at least every 24 hrs for redness, swelling, drainage. Change sterile dressing covering the access site per facility protocol ICP monitoring equipment must be balanced and recalibrated per facility protocol After the insertion procedure, observe ICP waveforms, noting pattern of waveforms and monitoring for increased ICP Assess the client's clinical status and monitor routine and neurologic vital signs every hour as needed

Preprocedure Cerebral CT scan

NPO 4 hrs prior assess for shellfish and iodine allergy assess bun and creatinine to ensure kidneys can excrete contrast media Supine position Head is secured to prevent unnecessary movement during procedure Remove client jewelry

Pre-Procedure Cerebral Angiography

NPO 4-6 hrs prior Assess hx of allergies Assess Bun and blood creatinine to determine kidney's ability to excrete the dye Do not wear jewelry Mild sedative for relaxation occasionally given Head will be immobilized during procedure, pt needs to remain still Void immediately prior to procedure Following dye injection, common for pt to feel sensation of warmth behind the eyes and over the face, jaw, tongue and lips and experience metallic taste

XR Postprocedure

No postprocedure care is required

ICP Monitoring Interpretation of findings

Normal ICP is 10-15 mm Hg. Persistent elevation of ICP minimizes cerebral circulation, which will result in brain death if not treated urgently

MRI Considerations

Remove any transdermal patches with a foil backing, as these can cause burn injuries Ensure that the client's jewelry is removed prior to and wear a hospital gown to prevent metal from interfering with the magnet. NPO 4-8 hrs prior Determine if client has hx of claustrophobia, and explain the tight space and noise Ask the client about any implants containing metal (pacemaker, orthopedic joints, artificial heart valves, intrauterine devices, aneurysm clips) Ensure all people who will be in the scanning area while the magnet is on remove all jewelry, electronics, and phones to prevent damage to themselves or the magnet Place pillows in the small of the client's back to prevent back pain from lying supine. The head must be secured to prevent unnecessary movement during procedure

EEG Postprocedure

Resume normal activities or routine following EEG

Complications Cerebral Angiography

Risk for bleeding or hematoma formation at the entry site Check site frequently. Check affected extremity distal to the puncture site for adequate circulation (color, temperature, pulses, cap refill) If bleeding occurs, apply pressure over the artery and notify provider

Intraprocedure Cerebral Angiography

Secure pt head on exam radiography table Catheter is placed into an artery (usually groin or neck), dye is injected, x-ray pics are taken Once all pics are taken, catheter is removed and an arterial closure device is used or pressure is held over the artery to control bleeding by thrombus formation sealing the artery

Lumbar puncture Intraprocedure

The area of the needle insertion is cleansed, and a local anesthetic is injected The needle is inserted and the CSF is withdrawn, after which the needle is removed A manometer can be used to determine the opening pressure of the spinal cord, which is useful if increased pressure is a consideration

Interpretation of GCS findings

The best score is 15. A score less than 8 is associated with severe head injury and coma A score of 9-12 indicates a moderate head injury A score greater than 13 is associated with minor head trauma Less than 8, intubate

XR Preprocedure

There is no specific preprocedure protocol for XRs that do not use contrast. XRs often the first diagnostic tool used after an injury (such as rule out cervical fracture in head trauma) Determine whether the client is pregnant Remove client's jewelry and ensure no clothes cover the area Explain that the amount of radiation used in contemporary XR machines is very small

PET and SPECT Intraprocedure

While the pictures are being obtained, the client must lie flat with the head restrained This procedure is not painful and sedation is rarely necessary

XR Indications

XR of the skull and spine can reveal fractures, curvatures, bone erosion and dislocation, and possible soft tissue calcification, all of which can damage the nervous system

Radiography (X-Ray)

XR uses electromagnetic radiation to capture images of the internal structures of an individual A structure's image is light or dark relative to the amount of radiation the tissue absorbs. Image is recorded on a radiograph, which is black and white image that is held up to light for visualization. Some recorded digitally and available immediately

Intraprocedure Cerebral CT scan

client must lie supine head stabilized sedation can be provided

ICP Monitor Preprocedure

head is shaved around the insertion location. site is cleaned with an antibacterial solution

GCS Indications

helpful in determining changes in LOC for clients who have head injuries, space-occupying lesions or cerebral infarctions, and encephalitis. Complications related to neurologic injuries can occur rapidly and require immediate treatment.

Indications for an EEG

most commonly performed to identify and determine seizure activity, but they are also useful for detecting sleep disorders and behavioral changes

Postprocedure Cerebral CT scan

no follow-up care associated with CT scan monitor for allergic reaction to contrast media and change in kidney function monitor client until stable if sedative is given

PET and SPECT scans

nuclear medicine procedures that produce three-dimensional images of the head. These images can be static (depicting vessels) or functional (depicting brain activity) A glucose-based tracer is injected into the blood stream prior to PET scan. This initiates regional metabolic activity, which is then documented by the PET scanner. A radioisotope is used for SPECT scanning. A CT scan may be performed after a PET/SPECT scan, as this provides information regarding brain activity and pathological location (brain injury, death, neoplasm)

Lumbar puncture (spinal tap)

procedure during which a small amount of CSF is withdrawn from the spinal canal and then analyzed to determine its constituents

XR Intraprocedure

procedure is quick, but client is to remain still during

Cerebral Angiography

provides visualization of the cerebral blood vessels. Digital subtraction angiography hides the bones and tissues from the images, providing x-rays of only the vessels apparent Detects defects, narrowing, or obstruction of arteries or blood vessels in the brain Performed within the radiology dept because iodine-based contrast dye is injected into an artery during the procedure

EEG Preprocedure

review meds with the provider to determine if they should be continued prior to EEG Wash hair to eliminate all oils, gels, and sprays. Stay awake prior to the test. Being sleep-deprived provides cranial stress, increasing the possibility of abnormal electrical activity, such as seizure potentials, occurring during procedure To stimulate electrical activity during the test, you might be exposed to bright flashing lights, or asked to hyperventilate for 3-4 mins Avoid taking any stimulant or sedative med 12-24 hrs prior

Lumbar Puncture Preprocedure

risks vs benefits should be discussed with pt prior to. Can be associated with rare but serious complications, such as brain herniation, especially when performed in the presence of increased ICP For clients who have bleeding disorders or who are taking anticoagulants can result in bleeding that compresses spinal cord.

Manifestations of ICP

severe headache, deteriorating LOC, restlessness, irritability, dilated or pinpoint pupils, slowness to react, alteration in breathing pattern (Cheyne-Stokes respirations, central neurologic hyperventilation, apnea), deterioration in motor function, and abnormal posturing (decerebrate, decorticate, flaccidity)

PET and SPECT indications

these scans captures regional metabolic processes, which is most useful in determining tumor activity and/or response to treatment. PET/SPECT scans are also able to determine the presence of dementia, indicated by the inability of the brain to respond to the tracer

MRI Indications

used to detect abnormalities, monitor response to treatment, and guide needles used for biopsies MRIs are capable of discriminating soft tissue from tumor or bone. This makes the MRI scan effective in determining tumor size and blood vessel location

Lumbar puncture indications

used to detect presence of some diseases (multiple sclerosis, syphilis, meningitis), infection, and malignancy. lumbar puncture may also be used to reduce CSF pressure, instill a contrast medium or air for diagnostic tests, or administer medication or chemotherapy directly to spinal fluid

Indications of Cerebral CT scan

used to identify tumors, infarctions, detect abnormalities, monitor response to treatment, and guide needles used for biopies

Indications for ICP monitor

useful for identification and treatment of increased intracranial pressure. Comatose or clients with GCS 8 or lower are candidates.

PET and SPECT Preprocedure

uses radiation, thus the risks and benefits to a client who might be pregnant must be discussed Assess for hx of diabetes. Alterations to medications in DM clients may be necessary to avoid hyperglycemia or hypoglycemia before and after this procedure