Management of Patients w Neurologic Dysfunction & Cerebrovascular Disorders Flashcards
(40 cards)
Akinetic mutism
a state of unresponsiveness to the environment
coma
a clinical state of unarousable unresponsiveness; no purposeful movements
Decerebration
type of posturing; extending outward
Decortication
major brain injury (if you touch them in anyway, they will pull to the core)
Locked-in syndrome
aware of what is going on; just cannot move or talk
persistent vegetative state
unresponsive but sleep wake cycle exists; no cognitive function
status epilepticus
a form of epilepsy in which the seizure lasts longer than normal; no recovery period between seizures, does not respond to normal treatment
what are possible causes of altered LOC? (3)
disruption in the cells of the NS
neurologic: nerves are damaged due to CVA, high or low blood sugars
Toxicologic: drugs (cocaine, overdose on any sedative, meth, heroin, or fentanyl)
Metabolic: lack of O2 & sugar
what tool to measure LOC?
Glasgow coma scale
what are patients patterns of respiration commonly like if they have a neurological disorder?
deep breathing w loud snoring
nursing interventions for altered LOC patients (11)
- maintaining airway (administer oxygen)
- protecting patient
- managing nutritional needs (NG tube)
- providing mouth care (suction available, monitor for s/sx of infection)
- maintaining skin & joint integrity (turning patient; proper body alignment)
- preserving corneal integrity (if patient not able to blink, admin eye drops & tape eyelids shut if needed)
- maintain body temp (if high temp, means increased ICP causing vasodilation in the brain increasing metabolic demand on the brain)
- preventing urinary retention (bladder scan; straight cath)
- promoting bowel function (manual evacuation, enemas, suppositories)
- meeting family needs
- monitor & manage complications (pressure ulcers, blood clots, aspiration, pneumonia, s/sx of respiratory failure, prevent contractures in joints, s/sx of VTE (swelling, redness, warmth))
what type of lung sounds do patients have if they are aspirating?
rhonchi
which 3 components are in the state of equalibrium?
brain tissue, blood, cerebral spinal fluid (CSF)
Monro-Kellie hypothesis
- Sum of volumes of brain, CSF, & intracranial blood is constant (if one gets off, then the other will be off)
- Limited space for expansion within the skull
- An increase in any one of the components causes a change in the volume of the others
if a patient starts to develop intracranial pressure, what will you first see a change in?
LOC
most common cause of increased ICP
head trauma
list some secondary effects of an increased ICP (6)
- brain tumors
- subarachnoid hemorrhage
- toxic or viral encephalopathies (cause a decrease in O2 to the brain, increase in CO2, changes cerebral blood flow)
- decreased cerebral perfusion
- stimulates edema
- causes herniation
cerebral edema
- definition
- S/Sx (2)
an abnormal accumulation of water or fluid in the intracellular space, extracellular space or both d/t an increase in the volume of brain tissue
S/Sx: decreased level of consciousness, seizures
autoregulation
brain’s ability to change the diameter of its blood vessels to maintain constant cerebral blood flow during alterations in SBP
Cushing’s response (reflex)
- when does it occur?
- what does it increase?
- Occurs when coronary blood flow decreases significantly
- Increases systolic BP, widening pulse pressure (130/60, 190/40), & cardiac slowing
cushing’s triad
bradycardia, hypertension, bradypnea
clinical manifestations of cushing’s response (5)
- Changes in LOC
- Abnormal respiratory & vasomotor responses
- Restlessness
- Confusion
- Increased drowsiness
clinical manifestations of IICP (3)
- Stuporous, reacting only to loud or painful stimuli
- Decortication
- Decerebration
complications of cushing’s response (3)
- Brain stem herniation: vitals all over the place
- S/Sx of diabetes insipidus
- Placidity: no muscle tone whatsoever
these first two conditions both deal w the posterior pituitary (trauma to the brain)
