Exam 1 Flashcards
(42 cards)
Normal ICP range
5-15 mmHg
Describe the nursing care for a patient with IICP
drug therapy: Mannitol (decr. swelling in the brain), anti-seizure meds (Dilantin), stool softeners, hypertonic saline
- nutritional therapy: increase glucose
keep pt normovolemic w/ 0.9% NaCl
Correlate the abnormal respiration patterns with the part of the brain that is affected.
Cheyne Stokes= metabolic dysfunction in the cerebral hemisphere
Neurogenic hypovent.= dysfunction in low mid brain and middle pons
apneustic= middle or caudal pons
ataxic= in medulla
cluster= medulla or pons
What is included in the neurological assessment?
Risk factors, CN, LOC, motor function, VS, Respirations, incr. in temp., pupils, posturing
List the diagnostic tests for the nervous system.
- CSF analysis 2. Lumbar puncture 3. Cerebral angiography 4. EEG 5. CT scan 6. MRI 7. PET scan
What is the most common way to obtain CSF? And who is this test contraindicated in?
LP and it’s contraindicated in a pt with increased ICP or infection at the puncture site.
What are some important things to remember while performing a lumbar puncture?
obtain informed consent, have pt empty their bladder, maintain strict asepsis, force fluids to replace CSF removed and to prevent spinal headache
Pre-procedure guidelines for an angiogram.
obtain informed consent, assess allergies to iodine, shellfish, and contrast dye
- must have documented evidence of WNL creatinine
- assess for meds that may react with dye such as anti epileptic drugs, antidepressants or Glucophage
- NPO after midnight
- empty bladder prior
Describe a cerebral angiogram.
femoral puncture, insert contrast to light up vessels
- check pedal pulses before and after procedure
- if creatinine is elevated, kidneys aren’t functioning properly and therefore wouldn’t be excreting the dye
Post-angiogram procedure care.
- keep leg immobilized and on bed-rest w/ bed flat for 4-6 hrs
- assess peripheral pulse in procedure leg
- assess femoral groin site for bleeding
- apply sandbags and pressure dressing to puncture site as ordered
- force fluids to eliminate dye from kidneys
What are the components that maintain ICP under normal conditions?
brain tissue= 78% volume
bloood= 12%
10% CSF
Describe the purpose, significance of results and nursing responsibilities related to a lumbar puncture.
to test for CSF; pressure can be measured and fluids obtained
nursing responsibility= watch site, check pedal pulses before and after, assist with collection of specimen and label them in sequence, force fluids to replace CSF
Describe the purpose, significance of results and nursing responsibilities related to a cerebral angiography
femoral puncture; insert contrast to light up vessels
nursing responsibility= informed consent, assess allergies to iodine, shellfish, and contrast, maintain asepsis, keep flat, force fluids
post-procedure- keep led immobilized and flat bed for 4-6 hours, assess peripheral pulses, assess for bleeding, apply sandbags and pressure dressing to site
Identify factors that influence ICP.
arterial pressure, venous prssure, intra-abdominal and intrathoracic pressure, posture (laying flat increases), temperature, blood gases (Co2= vasoactive agent)
Identify possible causes of IICP.
causes- mass or lesion, cerebral edema, head trauma, stroke, brain inflammation, hydrocephalus, metabolic insult
What are the clinical manifestations of IICP?
manifestations- change in LOC (early sign)
- change in VS (if BP is low 3x check diastolic) - Cushing’s triad: 1. systolic hypertension/ widening pulse pressure 2. bradycardia w/ full bounding pulse 3. irregular respirations - ocular signs- CN II, III, IV, VI— doll’s eyes - decreased motor function- posturing - headache- often continuous and worse in morning - vomiting- not preceded by nausea, projectile
What is the treatment and nursing care for a pt with IICP?
collaborative care= PaO2 80-100
- ABGs to guide oxygen therapy
- may need to put pt on vent
- drug therapy= Mannitol, hypertonic saline, corticosteroids, barbiturates, PPIS, stool softeners, anti-seizure meds: Dilantin
- incr. glucose in diet due to hypermetabolic state
- keep pt normovolemic w/ IV 0.9% NaCl
nursing management: neuro assess, glascow, motor strength and response, VS, maintain airway, fluid and electrolyte balance, keep HOB up, protect from injury
Differentiate between minor and major head trauma.
minor- concussion (brief disruption in LOC, amnesia, headache, short duration)
skull fractures- rhinorrhea and otorrhea indicate that a fracture has transversed the dura
major- contusion (bruising of the brain tissue in a specific area)
lacerations= tearing of brain tissue—> intracerebral hemorrhage
Differentiate between an epidural hematoma and a subdural hematoma.
- epidural hematoma- results from bleeding between the dura and the inner surface of the skull= emergency
—> can be venous or arterial in origin
—> s/s: initial period of unconsciousness, brief lucid interval followed by decrease in LOC, headache, n/v, focal findings - subdural hematoma- occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain—> most common source= the veins that drain the brain surface into the sagittal sinus
—> usually veinous origin- much slower to develop into a mass large enough to produce symptoms
Define transient ischemic attack.
temporary loss of neurologic function caused by ischemia—> lasts <15 min
warning sign of progressive cerebral vascular disease
tinnitus, vertigo, darkened or blurred vision, diplopia, ptosis, dysarthria, dysphagia, ataxia, numbness & weakness
Differentiate between a hemorrhagic and ischemic stroke.
ischemic= thrombotic- injury to a vessel wall and clot forms; 2/3 associated w/ HTN and diabetes
embolic= moving clot—> lodges in and occludes a cerebral artery resulting in infarction and edema of vessel—> commonly caused by A. fib. (can also be from fat)
hemorrhagic= bleeding into the brain due to ruptured vessel—> sudden onset, neuro deficits, headache, n/v decr. LOC
Understand the clinical manifestations, diagnostic testing, treatment (medical and surgical) and nursing interventions for patients who have suffered from a stroke.
dx: CT—> done first to rule out hemorrhage stroke (distinguishes densities), repeat 7-10 days later, MRI, cerebral angiogram, echo (clots in heart), ECG, Pet scan, carotid ultrasound—> measures velocity of blood flow through carotid, C-reactive protein lab, CBC, PT/PTT,
acute nursing care: ensure patent airway, call or activate stroke team, remove anything in pts mouth, assess pulse ox, establish IV access, seizure precautions, elevate HOB, remove clothing
pharmacological tx: tPA- within 3 hors of stroke, ASA, Heparin, Coumadin, Anti-seizure meds, platelet aggregators (Ticlid, Plavix, Persantine)
surgical tx: MERCI—> for ischemic stroke- thread wire into femoral artery and retrieve it
carotid endarterectomy
Describe the acute management of a patient with meningitis, including; etiology, clinical manifestations, diagnostic testing, collaborative management and nursing interventions.
etiology- acute inflammation of the meningeal tissues surrounding the brain and spinal cord—> bacteria typically enter CNS through upper respiratory tract or bloodstream or enter from penetrating wounds of the skull or through fractured sinuses in basal skull fractures
caused by streptococcus pneumonia or nieseria meningitis
manifestations- fever, severe headache, n/v, nuchal rigidity, photophonia, + kernig’s sign (knee bent at 90 @ hip, leg hurts on extension), decreased LOC
DX: history and physical, LP, blood cultures- figure out which bacteria is the cause, skull x-ray
TX: ampicillin, penicillin, vancomycin or cephalosporins
-dexomethasone= steroid that decreases inflammation and hearing loss
Identify deficits that may be seen in a patient who has suffered from a CVA.
- motor function- mobility, respiratory, swallowing & speech, gag reflex, self-care
- communication- when stroke involves dominant side
- affect- difficulty controlling emotions
- intellectual functioning- memory and judgement
- spacial-perceptual (usually when right sided)
- elimination
