Exam 3 - neuro trauma shock spinal

Question 1

Why is mannitol given

Answer 1

For ICP that has exceeded 15-20 mmHg for at least 10 min

Question 2

How does mannitol work to decrease ICP?

Answer 2

(osmotic diuretic) draws fluid out of brain cells by increasing the osmolality of the blood

Question 3

Repeated use of mannitol can lead to what

Answer 3

risk of seizure, risk of fluid and electrolyte imbalance, cautious in pts with renal disease (continual elevations in osmolality)

Question 4

Nursing responsibilities for Mannitol

Answer 4

Monitor vitals, urinary output, CVP, pulmonary pressure, assess for dehydration, assess for muscle weakness, tingling, paresthesia, confusion, and excessive thirst, assess for pulmonary edema, monitor near and ICP, monitor renal function and electrolytes

Question 5

When do you not admin Mannitol

Answer 5

Do not admin if crystals are present in solution and do not admin with blood products

Question 6

How to admin mannitol

Answer 6

IV bolus or infusion with a inline filter and observe infusion site for infiltration

Question 7

Assessment for a patient with ALOC

Answer 7

assess LOC (confusion, restlessness, lethargy, progressive disorientation time then place then person, mental processing first then pressure increases more primitive function is lost, pupils (sluggish response to light, fixed pupils), papilledema, abnormal motor responses (hemiparesis early then hemiplegia decorticate/decerebrate), vitals (increase in MAP and systolic, decrease pulse, hyperthermia, altered respirations, N/projectile V

Question 8

Nursing care for ALOC

Answer 8

Airway maintenance = gag

Airway clearance = cough

Question 9

Diagnostic labs for ALOC

Answer 9

Blood glucose, serum electrolytes, ABGs, liver function tests, toxicology

Question 10

Decorticate posturing

Answer 10

upper arms are close to the sides the elbows, wrists, and fingers are flexed and the legs are extended with internal rotation and the feet are plantar flexed

Question 11

Decerebrate posturing

Answer 11

neck is extended with jaw clenched, arms pronated extended and close to the sides legs are extended straight out and the feet are facing outward

Question 12

Cheyenne-Stokes Respirations

Answer 12

alternating periods of deep and rapid breathing followed by periods of apnea

Question 13

what part of the brain is damaged in Cheyne-stokes respirations

Answer 13

diencephalon

Question 14

Neurogenic hyperventilation

Answer 14

may exceed 40 BPM the result of uninhibited stimulation of the respiratory centers

Question 15

what part of the brain is damaged in neurogenic respirations

Answer 15

midbrain damage

Question 16

Apneustic respirations

Answer 16

characterized by sighingon mid-inspiration or prolonged inhalation and exhalation; results from excessive stimulation of the respiratory centers

Question 17

what part of the brain is damaged in Apenustic respirations

Answer 17

Pons

Question 18

Ataxic/Apneic Respirations

Answer 18

(totally uncoordinated and irregular) probably as a result of the loss of responsiveness to CO2

Question 19

What part of the brain is damaged in ataxic/apenic respirations

Answer 19

medulla

Question 20

Doll eye movement

Answer 20

reflexvice movement of the eyes in the opposite direction of head rotation. Positive doll eye response is head turned to side but eyes still facing forward (brainstem function)

Question 21

Glasgow coma scale

Answer 21

Eyes open (4-1) best motor response (6-1) best verbal response (5-1)

Question 22

lowest possible GCS

Answer 22

3 = coma

Question 23

what does a GCS of 8 mean

Answer 23

pt is unresponsive and cannot protect airway so airway management is necessary

Question 24

manifestations of an acute stroke

Answer 24

• Internal carotid artery: contralateral paralysis/deficits of the arm, leg, and face, aphasia (if dominant hemi is involved), apraxia, agnosia and unilateral neglect (if nondominant hemi is involved)
• Middle cerebral artery: drowsiness, stupor, coma, contralateral hemiplegia/sensory deficits of the arm and face, global aphasia (if dominant hemi is involved)
• Anterior cerebral artery: contralateral hemiplegia/sensory deficits of the toes, foot, and leg, loss of ability to make decisions or act voluntarily, urinary incontinence
• Vertebral artery: pain in the face, nose, or eye, numbness/weakness of the face on involved side, problems with gait, dysphagia

Question 25

FAST (stroke)

Answer 25

Face - drop Arm- weakness Speech- slurred or none Time- time of onset

Question 26

treatment of acute stroke

Answer 26

antithrombotic/anticoag, start CT scan to rule out bleed, if time of symptoms is less than 3 hours give tPA in ER to dissolve clot, stroke team will take patient for cerebral angiogram to attempt to remove clot, rehab

Question 27

nursing care of acute stroke

Answer 27

* Holistic, individualized nursing care is essential in all settings and focus on promoting the achievement of maximum potential and quality of life. Family often faced with many changes the nurse should assess and identify the needs and provide info/referrals * Collaborating with interprofessional team to ensure adequate treatment of the underlying process while providing care that supports the physical and psychologic responses

Question 28

subarachnoid bleed cause and manifestations

Answer 28

ruptured intracranial aneurysm Sudden, explosive headache and neck pain, N/V, a stiff neck and photophobia (due to meningeal irritation), cranial nerve defects, stroke syndrome, cerebral edema, DI, and hyponatremia (from the pituitary

Question 29

Treatment of subarachnoid bleed

Answer 29

Interventions using radiology, angiography, and a variety of procedures may be used to prevent aneurysm rupture or to stop the bleeding. Surgery is the treatment of choice to repair the bleeding artery. Calcium channel blockers are used to improve neuro deficits due to vasospasm following subarachnoid hemorrhage

Question 30

Nursing care for subarachnoid bleed

Answer 30

prevent rebleeding as well as meet the needs resulting from neuro deficits. priority is to treat ineffective cerebral tissue perfusion

Question 31

Subdural hematoma causes

Answer 31

Closed head injury, acceleration-deceleration injury, cerebral atrophy, chronic ETOH abuse, use of anicoags, contusion

Question 32

manifestations od subdural hematoma

Answer 32

* Acute/Subacute: headache, drowsiness, agitation, slowed thinking, confusion *subacute may develop more slowly * Chronic: may not appear until weeks to months after injury. Confusion, slowed thinking, drowsiness

Question 33

Nursing care for subdural hematoma

Answer 33

Maintaining an effective airway and breathing pattern, continuous assessment, monitoring neuro function as well as other body systems. Monitor ICP and symptoms like vomiting/headache/lethargy/restlessness/purposeless movements/changes in mentation

Question 34

Epidural hematoma causes

Answer 34

skull fractures contusion

Question 35

Epidural hematoma manifestations

Answer 35

Momentary loss of consciousness followed by a lucid period (few hours – ½ days) then rapid deterioration in LOC (drowsiness to confusion to coma), seizures headache, hemiparesis, fixed pupil, rise in BP with decrease in pulse and respirations

Question 36

Treatment of epidural hematoma

Answer 36

Managing IICP, airway management, hyperventilation, fluid resuscitation, positioning, temperature regulation, medications, surgery Surgical evacuation of the clot = burr holes

Question 37

Nursing care of epidural hematoma

Answer 37

Maintaining airway and breathing, continuous assessment and monitoring of neuro function, monitor ICP,

Question 38

Treatment of epidural hematoma

Answer 38

Managing IICP, airway management, hyperventilation, fluid resuscitation, positioning, temperature regulation, medications, surgery Surgical evacuation of the clot = burr holes