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High Acuity Exam 3 > Chapter 15: Determinants and Assessment of Cerebral Perfusion > Flashcards

Chapter 15: Determinants and Assessment of Cerebral Perfusion Flashcards

1
Q

What does the Monro-Kellie Hypothesis state?

A

An increase in either brain volume, cerebral blood volume, or cerebral spinal fluid must be compensated by decrease in another

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2
Q

What can cause a change in brain volume and what happens as a result?

A 
Cerebral edema (d/t trauma of BBB, metabolic abnormalities, or drugs) or 
space-occupying lesions can cause a change in brain volume. This can lead to herniation of the brain.
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3
Q

What can cause a change in blood volume and what happens as a result?

A

Hypercapnia, hypoxemia, loss of autoregulation, or venous outflow obstruction can cause a change in blood volume. Cerebral vasodilation, passive cerebral vessels, increased cerebral blood volume, or herniation can occur as a result.

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4
Q

What can cause a change in CSF and what happens as a result?

A

Obstruction, decreased absorption, or increased production can cause a change in CSF. Hydrocephalus or herniation can occur as a result.

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5
Q

What are the early signs of increased ICP?

A

Agitation/irritability or change in mentation, HA, delayed response to verbal commands, speech changes, vomiting, seizures, photophobia, lethargy

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6
Q

What are the late signs of increased ICP?

A

Changes in LOC, decrease in glasgow coma scale, pupil changes, cushing’s triad (HTN w/ widening pulse pressure, bradycardia, changes in respiration (bradypnea at first and then tachypnea as ICP goes up)

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7
Q

What is the formula to calculate CPP?

A

CPP = MAP - |CP

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8
Q

What is normal CPP, normal ICP, and normal MAP?

A

80-100, 0-15, 70-105.

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9
Q

What CPP ensures adequate cerebral oxygenation? What happens if higher or lower?

A

> 70, loss of autoregulation and inadequate cerebral tissue oxygenation.

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10
Q

What is the first sign of neurologic deterioration?

A

LOC

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11
Q

What does AEIOU stand for and what are they causes for?

A

Alcohol, epilepsy, insulin, opiates, uremia are causes of impaired consciousness.

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12
Q

What does TIPSS stand for and what are they causes for?

A

Tumor, injury, psychological, stroke, sepsis are causes of impaired consciousness.

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13
Q

What are the two components of consciousness?

A

Arousal (alertness) and content (awareness)

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14
Q

What does full consciousness mean?

A

Alert; oriented to time, place, and person; comprehends spoken and written words

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15
Q

What does confusion mean?

A

Unable to think rapidly and clearly; easily bewildered, with poor memory and short attention span; misinterprets stimuli; judgement is impaired

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16
Q

What does disorientation mean?

A

Not aware of or not oriented to time, place, or person.

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17
Q

What does obtundation mean?

A

Difficult to arouse, need constant stimulation to follow a simple command.
Drift back to sleep once stimulation stops.

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18
Q

What does stupor mean?

A

Lie quietly w/minimal spontaneous movement.
Respond slowly and purposeful to pain stimuli, will try and push you away.
Stop when stimuli ceases.

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19
Q

What does semicomatose mean?

A

Does not move on their own and doesn’t respond to simulation although painful stimulation may cause person to stir, moan, or withdrawal but not be aroused.

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20
Q

What does coma mean?

A

Sleep like state
Unresponsive
No commands
Non purposeful pain response.

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21
Q

What is deep coma?

A

Completely unarousable and unresponsive to any stimulus. No reflexes.

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22
Q

What is the most used assessment tool for changes in arousal and can only be used in acute stages of head injury?

A

Glasgow coma scale

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23
Q

Scores of less than 7 on the glasgow coma scale mean what?

A

Person is in coma state and should be intubated

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24
Q

Who can we not use glasgow coma scale on?

A

Can’t be used on: periorbital edema (can’t open eyes), intubated (can’t speak), hemiparesis/paraplegia

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25
Q

What steps do you use to determine what stimulus arouses a patient?

A

Address the patient by name. If there is no response shake arm or shoulder gently, if no response light pain, if no response deep pain (sternal rub).

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26
Q

What are some examples of noxious stimulus? (central/peripheral stimulation)

A

Central: Trapezius pinch, sternal rub, superaorbital pressure. To the extremities, nail bed pressure.

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27
Q

What does decorticate posturing mean? Demonstrate for me plz. Flexion or extension?

A

Cerebral hemisphere dysfunction

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28
Q

What does decerebrate posturing mean? Demonstrate for me plz. Flexion or extension?

A

Brain stem dysfunction, VERY BAD.

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29
Q

What are manifestations of content (awareness) dysfunction?

A

Memory impairment, disorientation, impaired problem solving abilities, and attention deficits.

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30
Q

What conditions may impair cerebral hemispheres?

A

Anoxia, ischemia, metabolic alternations, poisons, drugs and psychiatric disturbances.

31
Q

Define receptive aphasia.

A

Cannot interpret language, can speak clearly.

32
Q

Define expressive aphasia.

A

Can interpret language, cannot speak clearly.

33
Q

Define global aphasia.

A

Cannot interpret language or speak clearly.

34
Q

If both pupils are nonreactive/fixed (don’t constrict to light) & are mid position, what does this mean?

A

Damage to midbrain

35
Q

If both pupils are dilated and fixed, what does this mean?

A

THIS IS AN EMERGENCY. It indicates severe anoxia or ischemia.

36
Q

If both pupils are constricted (pinpoint & nonreactive), what does this mean?

A

There is a lesion in the pons or opiate drug overdose.

37
Q

If one pupil is dilated and the other is fixed what does this mean?

A

Compression of oculomotor nerve (CN III)

38
Q

What are normal and abnormal responses to the doll’s eye test?

A

Normal: Eyes conjugate opposite to side of head turned. Abnormal: Eyes fixed in midline position as head is turned.

39
Q

What are normal and abnormal responses to the caloric (oculovestibular) test? What outside factors can cause absent reflexes?

A

Normal: If warm water, eyes turn to side that water was injected. If cold water, eyes turn to opposite side that water was injected. Abnormal: Eyes do not respond to either warm or cold water. Outside factors: ototoxic drugs, neuromuscular blockers, ethyl ETOH

40
Q

What are cheyne-stokes respirations? What causes this?

A

A regular crescendo-decrescendo pattern with increasing then decreasing rate and depth of respirations followed by a period of apnea. This is caused by a bilateral lesion in the cerebral hemispheres, cerebellum, midbrain, or upper pons (in rare cases). Lesion may be caused by cerebral infarction or metabolic diseases.

41
Q

What are central neurogena hyperventilation respirations? What causes this?

A

A sustained pattern of rapid, regular, deep respirations (hyperpnea). Aka breathing really deep. This is caused by infarction or ischemia of the midbrain or pons, anoxia, or tumors of the midbrain.

42
Q

What is apneustic breathing? What causes this?

A

Prolonged inspiration with a pause at full inspiration followed by expiration and a possible pause following expiration. This is caused by a lesion in the mid or low pons that may be caused by infarction or severe meningitis.

43
Q

What is cluster breathing? What causes this?

A

Clusters of several breaths with irregular periods of apnea between clusters. This is caused by a lesion in the low pons or upper medulla that may be caused by a tumor or infarction of the medulla.

44
Q

What is ataxic respirations? What causes this?

A

Respirations that are completely irregular in pattern and depth with irregular periods of apnea. This is caused by a lesion in the medulla that may be caused by cerebellar or pons bleed, tumors of the cerebrum, or severe meningitis.

45
Q

What does a increased pulse mean?

A

Poor cerebral oxygenation

46
Q

What does decreased pulse mean?

A

Late stages of increased ICP

47
Q

What is a classic sign of increased ICP? What are the components of this?

A

Cushings triad: increased systolic BP, decreased diastolic BP (widening pulse pressure), and bradycardia. Bradypnea/Tachypnea?

48
Q

What are the components of the glasgow coma scale?

A

Eye opening, verbal response, best motor response

49
Q

When should the nurse be alert for impending brain herniation?

A

When ICP starts to near MAP

50
Q

How does hypothermia occur?

A

As a result of spinal shock, metabolic coma, drug overdose (depressants), and lesions of brainstem or hypothalamus.

51
Q

How does hyperthermia occur?

A

As a result of CNS infection, subarachnoid hemorrhage, hypothalamic lesion, or hemorhhage of hypothalamus or brainstem.

52
Q

What is the nursing care of someone with increased ICP?

A

Keep the HOB >30 degrees, make sure the head and neck are straight and midline, decrease stimulation, keep the temperature as normal as possible, monitor glucose levels, make sure fluid volume is as balanced as possible, use normal saline if you must infuse fluids, patient doesn’t need to be on seizure precautions unless indicated, provide adequate pain control, make sure patient is on prescribed bowel regimen (colace/senna)

53
Q

What are some medications you can give to someone with increased ICP? Nursing considerations?

A

Mannitol, 23% sodium chloride, 3% hypertonic saline bolus/drip. Monitor Na & serum osmmolality q6h. Na should be between 145-155 mEg/L. Serum osmolality

54
Q

What is the purpose of a barbiturate coma? What is normal and abnormal when monitoring?

A

To decrease refractory ICP by decreasing cerebral metabolism, CBF, ICP, and CSF production. 1/4 muscle twitch is good, if there are too many twitches give more medicine, if there are no twitches cut back on the medicine. May cause hypotension, give vasopressors.

55
Q

Describe the nursing management of someone with hypothermia.

A

Control shivering by giving demerol (opioid) or propofol (anesthetic). Shivering causes increased CO2 so monitor CO2 levels. Replace loss fluids with IV fluids. Monitor for fluid and electrolyte shifts (especially Na & K). Monitor ABGs. Skin assessments for thermal injuries. Monitor labs: at risk for infections like pneumonia, high glucose levels (insulin). Meds to lower metabolism.

56
Q

Describe the nursing management of someone in need of a decompressive hemicraniectomy.

A

The patient is going to wear a helmet for 6 months. Make sure the helmet is on whenever getting out of bed and use caution when bathing and turning.

57
Q

What is the gold standard for measuring ICP?

A

Intraventricular catheters, especially those connected to an external ventricular drainage system to drain CSF

58
Q

When are ICP catheters placed ?

A

If the patient has a GCS of than or equal to 8 either: with an abnormal CT or normal CT with hypotension, posturing, or older than 40

59
Q

What criteria needs to be met in order to classify a person as brain dead? What tests are used to measure brain activity?

A

Flaccidity, no response to stimuli (absence of reflexes), bilateral pupil dilation and fixation, no spontaneous eye movements, no spontaneous respirations. Cerebral angiography, electroencephalography, and transcranial doppler can measure brain activity.

60
Q

What does a normal ICP waveform look like? Abnormal?

A

Skiing down mountain, punch thing from GTA

61
Q

What are the differences between a CT scan and MRI?

A

CT: test of choice for acute brain injury, provides noninvasive and rapid results, 95% sensitive of hemorrhage within 48 hours, detects primary and secondary injuries (initial injury, results of initial injury), new infarcts not visualized early as strokes evolve, predict risk of vasospasm.

MRI: not sensitive to early bleeding but more sensitive to blood 4 to 7 days out. Great to detect hemorrhages > 10 days old. Sensitive to new infarct signals via Diffusion Weighted Imaging (DWI) (that star/crab looking thing that indicates bleeding)

62
Q

What are the pros and cons of CTA/MRA?

A

Pros: Minimally invasive, clear cross sectional images of blood vessels, patient friendly, cost effective.

Cons: Can diagnose but does not guide treatment.

63
Q

Describe cerebral angiography.

A

Can diagnose AV malformations, aneurysms, carotid artery disease, vasospasm, venous thrombosis. Treats: stent occluded stenotic vessels, coil aneurysm, vasospasm. Can diagnose and treat. Can eliminate need for surgery.

64
Q

Describe transcranial doppler.

A

Is a noninvasive tool, equipment is portable. Measures low and high velocity blood flow in circle of willis. Can detect cerebral vasospasm and aids in determination of brain death.

65
Q

Describe electroecephalogram.

A

Can detect abnormal voltage fluctuations such as seizures, epilepsy, space occupying lesions, cerebral infarct, and traumatic brain injuries. Continuous EEGs can detect traumatic brain injury and confirm brain death.

66
Q

Describe lumbar puncture. Complications?

A

Can provide definitive diagnosis for SAH (subarachnoid hemorrhage). Can be used as a route to deliver medications. Can be used for CSF analysis for blood or infection. 4 tubes collected, last tube should have the least amount of blood. Complications:
herniation of brainstem
(CT 1st to R/O space occupying lesion), infection, spinal headache
(allow bedrest, hydration/caffeine, blood patch: needle inserted at or around same spot
Sm. amt. patients blood injected into epidural space to seal the leak).

67
Q

What are the different categories for eye opening on the glasgow coma scale?

A

4: Spontaneous - eyes open spontaneously without stimulation
3: To speech - eyes open with verbal stimulation but not necessarily to command
2: To pain - eyes open with noxious stimuli
1: None - no eye opening regardless of stimulation

68
Q

What are the different categories for verbal response on the glasgow coma scale?

A

5: Oriented - accurate information about person, place, time, reason for hospitalization, and personal data (u good)
4: Confused - answers are not appropriate to question but correct use of language (still using english but what u sayin)
3: Inappropriate words - disorganized, random speech, no sustained conversation (gibberish)
2: Incomprehensible sounds - moans, groans, and mumbles incomprehensibly (sounds)
1: None: no verbalization despite stimulation

69
Q

What are the different categories for best motor response on the glasgow coma scale?

A

6: Obeys commands - performs simple tasks, response on command; able to repeat performance
5: Localizes to pain - organized attempt to localize and remove painful stimuli
4: Withdraws form pain - withdraws extremity form source of painful stimuli
3: Abnormal flexion - decorticate posturing spontaneously or in response to noxious stimluli
2: Extension - decerebrate posturing spontaneously or in response to noxious stimuli
1: None - no response to noxious stimuli;flaccid

70
Q

What are the three types of ICP waveforms?

A

A, B, C waves

71
Q

What do A waves mean when monitoring ICP?

A

Neurological deterioration: decreased LOC, pupillary changes, posturing.

72
Q

What do B waves mean when monitoring ICP?

A

Normal if

73
Q

What do C waves mean when monitoring ICP?

A

Normal, may fluctuate with BP & respiratory changes.

High Acuity Exam 3 (3 decks)

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