Final test 453 Flashcards
(118 cards)
1
Q
patho of aneurysm
A
Dilation of arterial wall, thin wall blister
Rupture at Dome
Rupture During Activity
2
Q
aneurysm results from
A
Developmental defects in Media and Elastica of Artery Wall
3
Q
classification of arteries
A
saccular (berry), fusiform (giant), and mycotic
4
Q
Saccular (Berry)
A
Most Common
85% Involve Circle of Willis
Leak—>WARNING “Worst headache of my life”
5
Q
Fusiform (Giant)
A
Large - 3cm or more in diameter
Rarely Rupture
6
Q
Mycotic
A
Arterial Wall Weakens
Usually on distal branch
rare
7
Q
Clinical Presentation of aneurysm
A
close to aseptic meningitis - change in LOC, severe headache, fever, EKG changes
8
Q
how would you diagnose aseptic meningitis
A
lumbar puncture (LP) but cannot do it if their ICP is elevated
9
Q
what type of EKG changes would you see with an aneurysm
A
a tachy/brady arrhythmia
10
Q
clinical grading of an aneurysm is most important
A
on day of OR and the higher the grade the worse the prognosis
11
Q
Aneurysm PrecautionsNursing Care
A
Patient Positioning Seizures Monitor S/S Increasing ICP VS Respiratory Temperature
12
Q
Treatment Options for aneurysm
A
Choice
Clipping – a surgery to clip the aneurysm to prevent bleeding
Coiling - when surgery is not an option
13
Q
mortality rate with No Surgery with aneurysm
A
70% mortality
14
Q
how much blood can be fatal during an aneurysm
A
30-50 cc of Blood
15
Q
patients who get their aneurysm fixed are at risk for
A
Potential for Rebleed 7-10 days - Plts regenerate q 7-10 days
It takes 7-10 days for Fibrin to be removed
16
Q
Vasospasm
A
Abnormal narrowing of the cerebral arteries. Constriction of the artery or branch in comparison to corresponding vessel on the other side of the aneurysm vessel.
Frequently occurs in the vessel adjacent to the ruptured aneurysm
17
Q
Highest morbidity and mortality complication of aneurysm
A
vasospasm??
18
Q
highest risk for vasospasm
A
3-14 day from the initial leak with Peak @ 5 days following initial rupture
19
Q
what causes vasospasm
A
Etiology Unclear:
By-products of Blood-Breakdown
Release of serotonin, prostaglandin and histamine–spasmogenic substances
Increased influx of calcium into vasc smooth musc—altered cell contraction
20
Q
Dx of vasospasm
A
Made using angiography Transcranial Doppler (TCDs) – higher rate of flow on the side with the aneurism
21
Q
first signs of vasospasm
A
global or focal neuro defects
22
Q
other signs of vasospasm
A
Worsening H/A, Seizures, Increase B/P
Onset of confusion
23
Q
most common drug prescription for vasospasm
A
Nimodipine
24
Q
nimodipine
A
Calcium Channel Blocker
Lipid sol. Readily crosses BBB
Prevents influx of Ca into smooth muscle
25
nimodipine may be _______ if hypotension is not controled
dose divided and given more frequently if can’t control for hypotension
26
triple H therapy with vasospasm
Hypervolemia
Arterial Hypertension
Hemodilution
Hemodynamic Monitoring!!!!!
27
what can be seen given to create hypervolemia in vasospasm
Crystalloids (Lactated Ringers, NS)
| Colloids (Albumin)
28
goal for hypertension during vasospasm
SBP 160-200mmhg if clipped
| SBP 120-150mmHg not clipped
29
Vasopressor Agents to create hypertension in vasospasm
Dopamine (Intropin)
Dobutamine (Dobutrex)
Neosynepherine
30
why hemodilution for vasospasm
Thought to decrease viscosity-->improved cerebral blood flow (CBF) but May reduce oxygen-carrying capacity with lowered Hct
31
Complications of “Triple H” for vasospasm
```
Increased ICP
Hemorrhage into an area of infarction from the vasospasm
Increased ischemic edema
Rupture of and unclipped aneurysm
Pulmonary edema, CHF, MI
Dilutional Hyponatremia
```
32
Craniotomy nursing care
```
Skin/Positioning (bone flap?)
Assess Neuro
Monitor CV/Renal
Alleviate H/A
Administer Meds
Head Dressings
Hemovac
Complications
O2 Treatments
```
33
Monitor for what complications after a craniotomy
Seizures
Hyponatremia
Dehydration
Be prepared for insertion on ICP or Ventriculostomy
34
brain tumors etiology
Based on Tumor growth, increased ICP and cerebral edema
Direct pressure on Brain Tissue
Fld. Accumulation, hemorrhage, or by-products
35
what to look for with brain tumors
Frontal --- Behavior, Cognitive, Intellectual
Parietal --- Think sensory
Temporal --- Understand Speech
Occipital --- Visual
4th Ventricle or Brain Stem --- Sudden Death
Drop Mets—Onset of LE Weakness
headaches - worse at night
seizures - effects 50% of brain tumor pts
36
diagnostic studies for brain tumors
```
H&P
CT
MRI
PET
Bone Scan
EEG
```
37
cranial surgery for brain tumor
Stereotactic surgery
| Craniotomy
38
goals of craniotomy
Goals: Identify Tumor, remove or debulk mass, prevent or manage ICP issues.
39
Treatment Options for brain tumor
Seeding
High Concentrated Radiation Dose
Radiosurgery
Chemotherapy (limited due to BBB)
40
Monro-Kellie
The principle of homeostatic intracerebral volume regulation.
41
Autoregulation
Ability of the brain to regulate the diameter of the arterioles
42
Increased B/P or Decrease PaCO2
CONSTRICTION
43
Decreased B/P or Increased PaCO2
DILATION
44
Coupling
Cerebral Blood flow meets Metabolic Needs
45
Hyperemia
Cerebral Blood Flow > Needs i.e.... Edema
46
Subflow
Cerebral Blood Flow < Needs i.e..... Ischemia, infarction
47
Cranio-Cerebral Trauma
Vehicular Accidents (leading cause)
Falls
Violence
48
Leading cause of death ages 1-44
cerebral trauma
49
response to uncontrolled ICP- Within seconds
Injured cells spill their contents into extracellular fluids and extracellular ions enter the cells
- all the neural activity stops
50
response to uncontrolled ICP- Within minutes
Tissue begins to swell
| Large changes in tissue sodium, potassium, calcium and water concentration.
51
response to uncontrolled ICP- Within hours
BBB breaks down, blood flow fails, hemorrhage may occur
52
response to uncontrolled ICP- Within days
Inflammatory cells infiltrate the lesion site
53
response to uncontrolled ICP- Within weeks
debris carried of and digested by microphages
54
response to uncontrolled ICP and macrophages
Macrophages release various cytokines
Induces microvascular injury, vasodilation & increased endothelial permeability
Promotes ion and H2O shifts, leading to vasogenic edema
Ultimately, cerebral ischemia and impaired autoregulation.
55
Diffuse
concussion - generalized, wide spread
56
focal
localized - contusion
57
Post-Concussive Syndrome(PCS)
S/S emotionally labile, H/A, fatigue, sleep disturbances, changes in cognition.
58
Diffuse Axonal Injury (DAI)
Not just a blow to the head
Result of brain moving back and forth.
Tissue slides over tissue
59
Hematoma- epidural
Bleeding Between Skull and Dura
*****Arterial Bleed*****
SURGICAL EMERGENCY
85% Accompanying Skull Fracture
60
subdural hematoma
```
Bleeding Between the Dura and arachnoid layer
Causes immediate pressure to brain
******Venous Blood*****
Acute Within 24 hours
Subacute 2-10 days
Chronic 2 weeks - months
```
61
Basilar Skull Fracture- anterior
Fx Parasinuses, “Raccoon Eyes”, CNI, Rhinorrhea –Never stick NG tube in because they will likely have a crack in bone and the tube can go into their brain
62
Basilar Skull Fracture- middle
Fx Temporal Bone, Middle ear, Otorrhea, Tinnitus, Deafness, N/V, Vertigo, Nystagmus
63
Basilar Skull Fracture- posterior
Epidural Bleed---Proximity of Internal Carotid, “Battle Signs” - bruising behind the ears
64
Coma mnemonic
```
AEIOU TIPPS
A – alcohol
E - epilepsy (heat stroke, hypothermia)
I - insulin (diabetic emergency)
O - overdose or oxygen deficiency
U - uremia (toxins due to kidney failure)
T - trauma (shock or head injury)
I - infection
P - psychosis
P - poisoning
S - stroke
```
65
Glasgow Coma Scale
Three Essential Components
Eye Opening
Verbal Responsiveness
Motor Response
66
Glasgow Coma Scale - numerical score
15 Normal
13-14 Mild Head Injury
9-12 Moderate Head Injury
8 or < Severe Head Injury
67
Intracranial Pressure Monitoring
Monitor ICP levels to guide medical therapy and nursing care.
Effective diagnostic tool to measure the ICP and CPP
68
Normal ICP
Normal Wave
ICP Under 20
Rises sharply, slopes to baseline
69
CPP
Cerebral perfusion pressure - MAP – ICP
70
PP < 60mmHg
ISCHEMIA
71
CPP > 150mmHg
Hyperemia
72
what do we need to remember to look out for with brain injury
Diabetes Insipidus (DI)
73
respiratory rate comes from
the pons and medulla - see different resp. patterns when there is pressure on the pons or medulla – chart what you see in the moment
74
blood pressure during a head injury
Usually stable during initial insult
Increasing ICP activates vasomotor center of the medulla---> Increased SBP
Compensation to maintain CPP
75
pulse during head injury
```
Bradycardia:
As B/P increases, Pulse decreases, way to increase Stroke Volume (body compensating)
Tachycardia:
with Hypotension consider Volume
Decompensatory stage, Brain Death
```
76
tachy-brady rhythmia
body wants to do its normal thing but the vagus nerve says no slow down
77
temp is regulated by the
hypothalamus
78
you see hypothermia in what neuro issues
Spinal Shock, Metabolic coma, over dose (OD), Brain stem
79
you see hyperthemia in what neuro issues
(100.5 or greater): Infection - ICP cath– with these tubes we can see more infections
80
dilated pupils
compressed cranial nerve 3
81
bilateral dilated fixed pupils
ominous sign
82
pinpoint pupils
pons damage or drugs
83
Increased Intracranial Pressure s/s
***Most Sensitive Indicator*** - change in LOC!!! – red flag that something is happening
VS – increase systolic pressure and decreasing pulse
Pupils – late sign!!
84
brain injuries and younger populations
young people can compensate a lot longer than older people – they don’t show many signs until late
85
how to test for brain perfusion or brain death
Nuclear Blood Flow Test – injecting a radioactive isotope.
| Harvard Criteria
86
what to assess when thinking a pt has brain death
cephalic reflexes - oculovestibular – what's happening with ear nerves – syringe of ice water and stick in the ear and patient should look at the ear the ice is going in and have nystagmus. Oculocephalic – if patients head is moving their eyes should move too in order to keep gaze (intact) – not intact = eyes staying midline.
87
Nursing Care for Increased ICP
Positioning
Room - Have a good temp and calm quiet room Assessment
Respiratory Care
Activity/Family - can be there as long as the patient is tolerating it – watch their VS based on who is coming in the room
88
drugs to control ICP/CPP
Mannitol – common – potent osmotic diuretic – causes a pull from tissue back to vascular bed. Remember this decreases BP and cerebral perfusion
Pentobarbital- coma inducing drug
Pain Meds/Sedation
Paralytics
89
procedures to control ICP/CPP
Invasive Procedures – Ventriculostomy – drain CFS
| Surgery – Hemicraniectomy (removal of bone flap)
90
what area of the spine is hurt most often
C 5-6
91
Mechanisms of Injury with spinal injury
```
Acceleration/Deceleration
- Head-On MVA
Deformation
- Whiplash
Axial Loading
- Jump off Building or Diving
Penetrating Wounds
- Knife, GSW, etc.
```
92
symptoms of spinal shock
```
Flaccid Paralysis *
- Lower Motor Neuron Lesion
Loss of Spinal Reflex
Loss of Sensory *
Loss of Ability to Perspire below level of injury
Loss of Bowel and Bladder Function
(Neurogenic Shock)
```
93
Neurogenic Shock symptoms
Unstable VS because sympathetic Nervous system lost
Profound hypotension
HR – bradycardic
94
spinal shock duration
Immediate onset, few days - months, usually 1-6 weeks.
95
spinal shock resolution
Return of minimal reflex , spasm activity
96
spinal shock Treatment
Vasopressors, Poikilothermia
97
what do we give for inflammation during spinal shock
Methylprednisolone- - Swelling above the injury is what we are worried about – this helps to decrease swelling/inflammatory response
98
Methylprednisolone side effects
compromise the immune system (infection), cortisol issues, glucose goes up
99
Immobilization during spinal injury
Halo Traction – maintains head in neutral position
Pin Care
- important to think about positioning with these contraptions
100
surgical indication in spinal surgery
```
If patient is experiencing any of these the patient should go into the OR unless excessive swelling is occurring:
Cord compression
Progressive neuro deficit
Compound fx of the vertebrae
Bone Fragment in the spinal canal
Inability to Reduce sublux with Tx
```
101
type of procedures for spinal injury
Decompression with Fusion
| Internal Fixation, Wiring, Plates, Rods
102
Spinal Cord Syndromes - Central Cord
Highest % of Incomplete Lesions
Bladder Dysfunction
Varying degrees of sensory loss below the level of injury
103
Spinal Cord Syndromes - Central Cord recovery
Return of Lower extremities, bladder function, Upper extremities, Fingers last
104
Anterior Spinal Cord Syndrome
Immediate Complete Motor Paralysis
Hyperesthesia and Hypoalgesia
Preservation of Touch, Motion, Position
Assoc. with Flexion Injuries
105
Hyperesthesia
(senses a lot of pain)
106
Hypoalgesia
(not sensing pain)
107
Anterior Spinal Cord Syndrome recovery
NO Ambulation or Hand Function, NO Bladder or Bowel, + Sensory
108
Brown-Sequard Syndrome
incomplete cord- usually from penetrating
109
Brown-Sequard Syndrome s/s
Loss of Sensory on ones side and Loss of Movement on the opposite side
Positioning VERY Important
Ambulation likely
Hand function usually returns
Bowel and Bladder Function usually not affected
110
Brown-Sequard Syndrome is usually from
Open Wounds i.e. GSW, Knife
111
Posterior Cord Syndrome
```
Least Frequent and Least Known
Preservation of Anterior Cord (Motor)
Loss of Sensation
Ambulation usually preserved
Hand Function minimally impaired
Bowel and Bladder usually unimpaired
```
112
Autonomic Dysreflexia
Uninhibited SNS response to Noxious Stimuli
T 6 and above
More common in 1st year post injury, but can occur any time
MEDICAL EMERGENCY
113
S/S of Autonomic Dysreflexia
```
Elevated B/P (20 mmHg above baseline)
Bradycardia, Bronchospasm
H/A (may be severe and pounding)
Flushing & Diaphoresis (above level of level of injury), Anxiety, Apprehension
Chills without fever, Nasal Congestion
Visual Changes (blurred, tunnel)
```
114
respiratory Nursing Assessment and Management of SCI
Establish pulmonary baseline so you know if there is any change
- Rate & Depth
- Pulmonary Toileting, Quad Coughing- taking your fist and putting it right under the diaphragm and push in and up each time they cough
- Breathing Pattern
- Mechanical Ventilation, Temporary or Permanent
- Observe for fatigue
115
CV Nursing Assessment and Management of SCI
Observe for loss of SNS Control
Monitor Extremities for Circulatory Stasis
S.S Autonomic Dysreflexia
116
GI/GU Nursing Assessment and Management of SCI
Early Bowel and Bladder Program
Monitor VS, Temperature Elevation
Monitor Daily Labs, WBC, Albumin
Anorexia, Nausea, Vomiting
117
skin/MSK Nursing Assessment and Management of SCI
Identify Level of function
Inspect Skin and Turn Q 2 or as needed
Contractures and Spasticity (Upper Motor)
Determine Caloric Intake, Dietary Consult
Monitor Labs, Calcium and Alk Phos
118
psychosocial/emotional Nursing Assessment and Management of SCI
```
Assess and Determine Support System
Encourage Independance
Address Sexuality Issues
Assess Environment (Cultural)
Assess Coping Mechanisms
Continuity of Care
Spiritual
Age Specific
```
