[Exam 5] Chapter 65/66 - Mx of PAtients with Neurologic Dysfunction Flashcards
(165 cards)
1
Q
Neurologic Function: Nervous system 2 major parts?
A
CNS and Peripheral Nervous System
2
Q
Neurologic Function: Whats including in CNS?
A
Brain and Spinal Cord
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Q
Neurologic Function: Whats included in Peripheral Nervous System?
A
Cranial Nerves
Spinal Nerves
Autonomic Nervous System
4
Q
Neurologic Function: What are the cranial nerves?
A
Facial nerves, smelling, moving, ocular motor movements .
5
Q
Neurologic Function: What are the spinal nerves?
A
They carry the motor and sensory signals
6
Q
Neurologic Function: What is the autonomic nervous system?
A
Carries signals to and from the internal organs. Made of sympathetic nervous system and parasympathetic system.
7
Q
CNS - The Brain: What is included here?
A
Cerebrum
Brain stem
Cerebellum
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Q
CNS - The Brain: What is included in the cerebrum?
A
Frontal, Temporal, Occipital Lobe, Parietal Lobe
9
Q
CNS - The Brain: Where is the occiptal lobe located?
A
On the very back of the head
10
Q
CNS - The Brain: Where is the parietal lobe located?
A
Between the frontal lobe (front) and occipital lobe (back)
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Q
CNS - The Brain: Where is the temporal lobe located?
A
On the side of the head
12
Q
CNS - The Brain: What does the frontal lobe do?
A
Problem solving, emotions, reasoning, speaking, and voluntary motor activity
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Q
CNS - The Brain: what does the parietal lobe do?
A
Knowing right from left. Sensation, reading, body orientation
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Q
CNS - The Brain: What does the occipital lobe do?
A
vision, color perception
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Q
CNS - The Brain: What does the temporal lobe do?
A
Understand language, behavior, memory, hearing
16
Q
CNS - The Brain: Purpose of brain stem?
A
Breathing Body Temp Digestion Alertness/Sleep Swallowing
17
Q
CNS - The Brain: Function of Cerebellum?
A
Balance
Coordination and Control of Body Movement
Fine Muscle Control
18
Q
CNS - The Brain: If patient has issue with cerebellum, they may have what?
A
Ataxia , loss of full body controls of bodily movement
19
Q
CNS - The Brain: If patient has brain stem injury, what happens
A
They have loss the ability to perform the basic bodily functions needed to survive
20
Q
Structure Protecting Brain: What is included here?
A
The Meninges .
21
Q
Structure Protecting Brain: What is the meninges?
A
The protective layer of the brain and the spinal cord
22
Q
Structure Protecting Brain: What is included in the meninges?
A
Dura mater, Arachnoid mater, pia mater
23
Q
Structure Protecting Brain: What is the Dura Mater?
A
The outermost layer of meninges. Its a thick, fibrious protective layer
24
Q
Structure Protecting Brain: What is the Arachnoid Mater?
A
Is the middle layer. Middle membrane. Fairly thin. It gets that name because of the arachnoid spider web look.
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Structure Protecting Brain: What is included in the Arachnoid Mater?
CSF, for protection
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Structure Protecting Brain: What is the Pia mater?
This is the innermost layer. Hugs the brain and covers the entire brain surface for extra protection.
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Structure Protecting Brain: Order of meninges layer?
Dura Mater (Outer) -> Arachnoid Mater -> Pia Mater (Inner)
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Structures of Brain: why is CSF important?
This should always be clear and colorless. Important to maintain immune and metabolic functions in the brain as well as protecting the brain and spinal cord
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Structures of Brain: Cerebral circulation, why is this needed?
Brain doesn't store nutrients. Needs a constant supply of oxygen. Without this oxygen supply due to a clot, patient is unable to get oxygen they need which is harmful to the patient.
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Structures of Brain: What is the blood-brain barrier?
This helps protect the brain and blood components. Part of CNS. Is inaccessible due to this barrier unless there is a break from severe trauma that causes cerebral edema.
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Structures of Brain: What is the function of the spinal cord?
The connection between brain and periphery. Comes off of brainstem where the butterfly shape is.
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Peripheral Nervous System: What is included here?
Cranial Nerves
Spinal Nerves
Autonomic Nervous Sysem
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Peripheral Nervous System - Cranial Nerves: How many pairs of nerves are there?
12
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Peripheral Nervous System - Cranial Nerves: functions?
Sensory, facial movements, vision.
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Peripheral Nervous System - Spinal Nerves: How many pairs are there?
There are 31 pairs of spinal nerves that send signal back and forth
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Peripheral Nervous System - Autonomic Nervous system: This is split into what?
Sympathetic Nervous System and Parasympathetic Nervous system
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Peripheral Nervous System - Autonomic Nervous system: What is the main purpose of this ??
It regulated the activities of the internal organs and acts independently of the bodies consciousness. Always works in the background.
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Peripheral Nervous System - Autonomic Nervous system: Sympathetic Nervous systems tend to affect how much of the body?
They tend to be more widespread.
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Peripheral Nervous System - Autonomic Nervous system: Parasympathetic nervous system produces what type of response?
More of a specific localized response.
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Autonomic Nervous System: Breaks down into what?
SNS and PSNS
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Autonomic Nervous System: Activation of SNS leads to what?
Flight or Fight . Situations that require alertness.
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Autonomic Nervous System: Activation of PSNS leads to what?
Rest and Digest
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Autonomic Nervous System: Signs of SNS activation?
Increased HR, BP, RR, Vasoconstriction, Release Glucose (Energy).
This is due to being in a situation that requires alertness.
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Autonomic Nervous System: Signs of PSNS activation?
Decreased BP, RR, Store Glucose, Vasodilation, and Increased Gastric Motility
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Altered Level of Consciousness (LOC): What is this important
Level of responsiveness and consciousness , which is the most important indicator of the patient's condition
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Altered Level of Consciousness (LOC): What is this
A continuum from normal alertness and full cognition (consciousness) to coma
The patient can be anywhere between these full cognition to coma.
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Altered Level of Consciousness (LOC): Altered LOC is a result of what?
Not the disorder, but the result of a pathology.
May be caused by another medical condition like DKA, Liver Failure (High ammonia level).
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Altered Level of Consciousness (LOC): What is a coma?
When patient is unconsciousness, unarousable, and unresponsive
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Altered Level of Consciousness (LOC): What is Akinetic mutism?
Unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
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Altered Level of Consciousness (LOC): What is a persistent vegative state?
Devoid of cognitive function but has sleep wake cycles
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Altered Level of Consciousness (LOC): What is a minimally conscious state?
Reproducible signs of awareness
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Altered Level of Consciousness (LOC): What is locked-in syndrome?
Inability to move or respond except for eye movement due to a lesion affecting the pons
They are aware of everything.
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Altered Level of Consciousness (LOC): What can cause this?
Head injury, drug overdose, DKA, , Renal Failure, Liver Failure
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Altered Level of Consciousness (LOC): Assessments include what?
Looking at pupils. If change here, it is a indicator.
Initial sudden changes like restlessness.
Glasgow Coma Scale (GCS)
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Altered LOC: Glasgow Coma Scale based on what?
```
Eye Opening Response (1-4)
Verbal Response (1-5)
Motor Response (1-6)
```
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Altered LOC - Glasgow Coma Scale: Example of Eye Opening Response Rating?
4. Spontaneous
3. to Speech
2. To Pain
1. No repsonse
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Altered LOC - Glasgow Coma Scale: Example of Verbal Response rating?
5. Oriented x3
4. Confused
3. Inappropaite words
2. Incomprehensible sounds
1. No sounds
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Altered LOC - Glasgow Coma Scale: Example of Motor repsonse rating?
6. Obeys commands
5. Moves to localized pain (Go to where pain comes form)
4. Flex to withdraw from pain (Pull away)
3. Abnormal flexion (Pull arms toward chest)
2. Abnormal extension (Extending arms away)
1. No response
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Altered LOC - Glasgow Coma Scale: Best score?
15
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Altered LOC - Glasgow Coma Scale: Compatose score?/
Less than 8. Patients now have a severe score. They are not able to respond fully. May be intubated and on ventilator because they cannot protect their ventilator.
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Altered LOC - Glasgow Coma Scale: Unresponsive score?
3
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Altered LOC - Glasgow Coma Scale: Score meanings?
13-15 : Altered GCS symptoms
9-12 - Moderate alered GCS symptoms
3-8 - Severe altered GCS symptoms
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Altered LOC - Diagnostic Findings: What will be done?
CT , MRI
| EEG - Best indicator of brain death. Shows brain wave forms.
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Altered LOC - Medical Mx: First treatment is always what?
The airway. Making sure they have a airway.
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Altered LOC - Medical Mx: What else is done?
Look at circulatory status for adequate perfusion to brain
IV for medication and nutritional support
Also looking at causes of LOC to identify it and treat it.
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Altered LOC - Nursing Process: Assessment incldues what?
Getting GCS, getting orientation to see if they know where they are at, time, and what is going on. A and O x4.
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Altered LOC - Nursing Process: After Assessment of neurological, what else will be assessed?
You will look at the circulatory or respiratory status. Look for posturing such as abnormal flexion or extension
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Altered LOC - Nursing Diagnosis: Most important one?
Airway so Ineffective Airway Clearance. May also have RF Injury or Deficient Fluid Volume.
With AMS, may have impaired skin integrity or impaired mobility
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Altered LOC - Nursing Diagnosis: If brainstem involved, may have what?
Ineffective thermoregulation, impaired urinary elimination
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Altered LOC - Nursing Diagnosis: Goals focus on what?
The nursing diagnosis.
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Altered LOC - Nursing Interventions: More broadly, if they have ineffective airway clearance, what will we do?
Goal is to keep their airway patent and clear. Maintain airway by HOB being up, suctioning, listening to lung sounds, venting, mouth care.
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Altered LOC - Nursing Interventions: What other interventions may we do?
Maintaining a body temperature.
Impaired Urinary Elimination, monitoring bladder and output.
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Altered LOC: What is Decorticate Posturing?
Elbow flexed and hands are on chest, and wrist flexing inward.
Thighs internally rotated
Feet plantar flexed down toward the ground
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Altered LOC: What is Decebrate Posturing?
Elbows extended, with the arm pronated and wrist flexed.
Feet will be plantar flexed down toward the ground.
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Altered LOC: When you hear decorticate posturing, think what?
Core. The arms and hands are toward the core of the chest.
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Altered LOC: What to know for decebrate?
This is more severe than decorticate. That means that there is more brain damage.
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Altered LOC - Monitoring and Mxing Potential Complications: This includes what?
```
Respiratory Distress
Pneumonia
Aspiration
Pressure Ulcer
Venous Thrombembolism
Contrctions
```
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Altered LOC - Monitoring and Mxing Potential Complications: What to know for the respiratory complications?
Do a lot of respiratory assessments by seeing CBCs and listening to lungs.
Aspiration leads to pneumonia leading to respiratory distress.
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Altered LOC - Monitoring and Mxing Potential Complications: VTE may be seen why and monitor for what?
Monitor for signs and also start Prophylaxis protocols. . Low dose heparin or lovenox and also SCDs.
This is due to immobility.
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Increased Intracranial Pressure: What is this?
When the pressure within the cranium gets above 15. The normal pressure within the cranium is 0-15.
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Increased Intracranial Pressure: Whats inside the cranium?
Brain, blood, and CSF.
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Increased Intracranial Pressure: What is the Monro-Kellie Hypothesis?
If there is a increase of volume in one area (Brain, blood, CSF), there will be a decrease of volume in another area.
The body is staying in equilibrium.
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Increased Intracranial Pressure: Why will you usually see this?
If the brain starts to swell, if there is decreased cerebral blood flow, or cerebral edema.
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Increased Intracranial Pressure: SO what happens in the body when we sneeze?
ICP will increase causing a small drop of CSF. After sneeze, it will regulate itself again.
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Increased Intracranial Pressure: What type of things would cause a increased intracranial pressure that would be harder to compensate for?
Head injuries or a brain tumor.
Hemorrhagic stroke with brain bleed
Encephalopathies.
Will originally try to compensate using Monro-Kellie Hypothesis.
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Increased Intracranial Pressure: What happens to blood flow as ICP goes up?
It will decrease. Because there is no nutrients in the brain stored there, there will be cell death. This is why you will see a slow, more bounding pulse with irregular respiration's.
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Increased Intracranial Pressure: What changes occur due to a decrease blood pressure?
Increase in PaCO2 which will cause vasodilation. Also decrease venous outflow which plays a role increasing cerebral blood volume to get more oxygen in the brain
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Increased Intracranial Pressure: What happens to the brain however with all of the extra oxygen in their brain?
That increases the ICP which can be very dangerous.
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Increased Intracranial Pressure: What changes does cerebral edema cause in the brain?
You have swelling which causes decreased cererbal spinal fluid production and flow and causes the body to have a increased cerebral response
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Increased Intracranial Pressure: What is the normal cerebral perfusion pressure?
70-100 mmHg. As ICP continues to increase in the body, the body is unable to compensate.
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Increased Intracranial Pressure: What happens if cerebral perfusion pressure gets below 70?
You will see decreased blood flow, decreased cerebral blood flow to the brain and that can cause some tissue and cell death.
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Increased Intracranial Pressure: What sign may we see when this is increased?
Cushing's Triad
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Increased Intracranial Pressure: What changes occur in the body with Cushings Triad?
Increased in Systolic BP
Decrease in Pulse and Respiration
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Increased Intracranial Pressure - Cushings Triad: This is caused by what?
The brains ability to autoregulate becomes ineffective, so the brain is not able to compensate through the Monro Kelley Hypothesis with the change in volume of another component within cranium.
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Increased Intracranial Pressure - Cushings Triad: When is this activated?
When they have decompensated.
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Increased Intracranial Pressure - Cushings Triad: The signs of this are the opposite of what?
Shock.
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Increased Intracranial Pressure - Cushings Triad: What changes occur with shock?
Decreased BP
Increase in Pulse/Respirations
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Increased Intracranial Pressure - Cushings Triad: When this happens, it can result in what
Ischemia (Infarction in Brain) leading to brain death.
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Increased Intracranial Pressure - Cushings Triad: Why do you see a decreased heart rate?
Because of vagus nerve stimulation.
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Increased Intracranial Pressure - Cushings Triad: Important to separate this from what?
Shock.
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Increased Intracranial Pressure - CMs: Biggest indicator of this?
Change in LOC.
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Increased Intracranial Pressure - CMs: Earliest sign of this?
Headache, Agitation, slowing in speech, change in LOC. Any change in the patient's condition.
May also have vomiting.
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Increased Intracranial Pressure - CMs: Changes in eyes?
Papilledema,
Pupillary Changes (One pupil may be bigger than other)
Impaired Eye Movement
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Increased Intracranial Pressure - CMs: Changes in postruing?
May be flaccid, decerebrate, or decorticate
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Increased Intracranial Pressure - CMs: Changes in motor function?
Changes in motor ability and posturing
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Increased Intracranial Pressure - CMs: What may happen to vital signs?
Will result in Cushings Triad.
Increased BP
Decreased Pulse, Respiration
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Increased Intracranial Pressure - CMs: What changes will be seen in an infant?
Bulging Fontanels
Cranial Suture Separation
Increase Head Circumference
High Pitched Cry
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Increased ICP - Assessment: This will include what?
Neuroexam for pupils, GCS, reflexes, VS, and can put monitor within brain to monitor ICP.
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Increased ICP - Nursing Diagnosis: This incldues what?
Ineffective Airway Clearance
Ineffective Breathing Pattern
Ineffective Cerebral Tissue Perfusion
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Increased ICP - Nursing Diagnosis:
| Goal for airway clearance?
Maintain patent airway
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Increased ICP - Nursing Diagnosis: How to maintain patent airway?
Suction for no more than 15 seconds (discourage coughing because it increases pressure in brain)
HOB > 30
Listening to lung sound
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Increased ICP - Nursing Diagnosis: What will you do for ineffective breathing patterns?
You want to maintain breathing.
| If hyperventilating, may be placed on vent.
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Increased ICP - Nursing Diagnosis: Why would a patient be placed on a vent?
To decrease CO2, which would cause cerebral vasoconstriction
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Increased ICP - Nursing Diagnosis: What to do for ineffective cerebral tissue perfusion?
Position patient with HOB at 30-45 degrees (promotes venous drainage and decreases ICP)
Avoid hip flexion, hip flexion, and rotation of neck (can cause blockage of blood flow)
No vagal maneuvers.
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Increased ICP - Nursing Diagnosis: What to do for RF Infection?
Maintain aseptic technique
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Increased ICP - Nursing Diagnosis: What to do for deficient fluid volume?
Want to restore fluid balance.
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Increased ICP - Nursing Diagnosis: How do you restore fluid balance?
By giving Mannitol. This is a diuretic that pulls the fluid from the brain. Want to monitor urine output.
Monitoring mucuous membranes and skin tugor show where they are at.
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Increased ICP - Nursing Diagnosis: What will you monitor for a patient on Mannitol?
Urine output.
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Increased ICP - Nursing Diagnosis: ICP shouldn't exceed what?
25, because this is too much pressure on the brain.
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Increased ICP - Med Txs: What can be given?
Mannitol
Barbiturates (Produces a coma-like appearance, and rests the brain quite a bit)
Antiseizure to prevent seizures
Corticosteroids to help with inflammation. Watch for SEs.
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Increased ICP - Complications: What can occur?
Brain Stem Herniation
Diabetes Insipidus
SIADH
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Increased ICP - Complications: What is Brain Stem Herniation?
You have part of the brain stem herniating out of the normal opening. This is brain death. Worst possible complication
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Increased ICP - Complications: Why may you see Diabetes Insipidus?
You may see a decreased of ADH. This is going to cause excessive urine output.
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Increased ICP - Complications: How to treat Diabetes Insipidus.
You will give major fluid and electrolyte replacement. Can also give vasopressin which is ADH and can reverse excess fluid output.
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Increased ICP - Complications: What to do if patient has brain injury, increased ICP. and starting to have increased urine output (>200 x 2 hours)?
You will want to check to see if they have diabetes insipidus
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Increased ICP - Complications: What is SIADH?
Syndrome of Inappropriate ADH. Increased secretion of this causing patient to have fluid volume overload and decreased urine output
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Increased ICP - Complications: How to treat SIADH?
Fluid restriction.
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Increased ICP - Complications: What happens to serum sodium concentration with SIADH?
It becomes very diluted. You will see lower sodium levels because of this.
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Med Mx of Increased ICP: What all can be done?
Monitor ICP and Cerebral Oxygenation
DEcrease Cerebral Edema
Maintain Cerebral Perfusion
Reducing CSF and Intracranial Blood Volume
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Med Mx of Increased ICP: How to decrease cererbal edema?
By giving Mannitol that dehydrates brain tissue to reduce the cerebral edema
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Med Mx of Increased ICP: If this is because of brain tumor, what is given?
Corticocsteroid given like decadron. Will be given to try to decrease the inflammation and edema in the brain.
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Med Mx of Increased ICP: Barbiturates given why?
Sedatives decrease the brain activity and puts them in coma-like state to decrease ICP
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Med Mx of Increased ICP: How to maintain cerebral perfusion?
Increased CO from fluids or pressors potentially because we cant to keep cerebral perfusion pressure about 70. Will try to increase CO to make sure brain is being perfused.
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Med Mx of Increased ICP: How to reduce CSF of intracranial blood volume?
Can put different drains in. Some can go into ventricle.
May also see them try to keep CO2 levels at 30-35 to cause some vasoconstriction. Be careful to not cause hypoxia
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Med Mx of Increased ICP: Patients may also have feveers, so what can be done?
Control fever. Increased temperatue causes increased O2 demand . DOn't want to starve brain of more oxygen than necessary.
Can also barbiturates to result in comatose state to reduce oxygen needed from brain.
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Med Mx of Increased ICP: Why is a Hypothermic Protocol done sometimes?
To lower the body temperature to decrease needs and o2 demand on brain
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ICP Monitoring - Pressure Waves: This consists of what?
A Waves
B Waves
C Waves
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ICP Monitoring - Pressure Waves: Monitor
ICP Monitoring device placed in ventricle
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ICP Monitoring - Pressure Waves: what is a Subarachnoid Screw.
Subarachnoid Screw. Advantage here is that it doesn't require ventricle puncture.
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ICP Monitoring - Pressure Waves: What is a Intraparenchymal Sensor
into fuctional tissue of brain to monitor ICP.
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ICP Monitoring - Pressure Waves: What is a subdural bolt?
Going to work similar to subarachnoid screw. DOesn't puncture ventricle
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ICP Monitoring - Pressure Waves: What is the A wave?
This is going to show cerebral ischemia or brain damage
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ICP Monitoring - Pressure Waves: What is a B Wave?
Not as significant as A.
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ICP Monitoring - Pressure Waves: What is a C wave?
Shows us the rhythmic variations of blood pressure and respirations.
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ICP Monitoring - Licox Catheter System: What does this measure?
Cerebral oxygenation. Changes in cerebral perfusion may reflex increased ICP.
Usually will be monitored with this device and displays a temperature as well as oxygen level.
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Increased ICP - Nursing Process: Assessment will be what?
Neuro exam. looking at pupils, GCS, look at reflexes, ICP, monitoring, look for changes in neuro status
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Increased ICP - Nursing Process: Diagnostics for this?
CT / MRI
EEG
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Increased ICP - Nursing Process: Potential complications?
Brain Stem Herniation
Diabetes Insipidus
SIADH
149
Intracranial Surgery: What is a Craniotomy?
An opening in the skull surgicially to gain access to the intracranial structures.
Make an opening to gain access to brain
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Intracranial Surgery: What is a Craniectomy
To excise part of the skull and replace it with a plastic or metal part.
Actual piece of skull removed. Sometimes done to reduce cerebral edema and then skull replaed.
151
Intracranial Surgery: What is Burr Holes?
Circular Openings placed in skull. Help determine presence of cerebral swelling, evacuate a hematoma, relieve pressure. .
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Intracranial Surgery: What different types of surgeries may occur?
Craniotomy
Craniectomy
Burr Holes
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Intracranial Surgery -PreOp Mx: What diagnostic or PreOp?
Patient will be going to CT or MRI to see what is going on
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Intracranial Surgery -PreOp Mx: What meds may be given?
Seizure medications to prevent a seizure
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Intracranial Surgery -PreOp Mx: What nursing management may be done?
WIll be monitoring LOC, monitoring the overall hemodynamic status of the patient.
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Intracranial Surgery -PreOp Mx: Education for family or patient will include what?
About what is actually going on and being able to answer questions is a big nursing role
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Intracranial Surgery - PostOp Mx: The main goal will be what?
Reducing cerebral edema
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Intracranial Surgery - PostOp Mx: What will be done when trying to reduce cerebral edema?
Monitor the patients hemodynamically .
Will also receive Mannitol, Decadron, or Dexamethasone (Corticosteroid)
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Intracranial Surgery - PostOp Mx: What will have the patients have placed to monitor them hemodynamically?
Will have ART line placed, CVP, may be intubated .
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Intracranial Surgery - PostOp Mx: How to prevent seizures?
Continuing to monitor for seizure like activity.
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Intracranial Surgery - PostOp Mx: How to monitor for ICP?
May have ICP monitor or may have cerebral oxygenation monitor
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Intracranial Surgery - PostOp Mx: They've just had usrgery as well, so what will this focus on as well?
Pain control. Tylenol, morphine may be given. There is also a thing known as IV Tylenol.
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Intracranial Surgery - Nursing Process: Assessments will incldue what
Respiratory, VS, Neuro Checks, Check dressing for bleeding or CSF .
Looking at labs, ABGS, electrolytes, and I/Os
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Intracranial Surgery - Nursing Diagnosis: This includes what?
Focuses on maintaining adequate tissue perfusion, regulating temperature, improving gas exchange, self-image issue.
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Intracranial Surgery - Potential Complications: THis includes what?
They''ve just had surgery so bleeding, shock, infection, electrolyte imbalance, increased ICP or seizures.
