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