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Neuro Flashcards

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1
Q

Monro-Kellie Doctrine

A

Skull = barrier

  1. CSF absorption/production/displacement to the spinal cord
  2. Cerebral Vessels
    Vasoconstriction/dilation
  3. Brain Tissue
    expansion into dura/compression of the tissue

ICP increases related to the displacement of lesions (head injury, cerebral edema, tumor, encephalitis), herniation, ischemia, brain death

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2
Q

Cerebral Perfusion Pressure

A

CPP = 60-100
<60 = ischemia/neuron death
>100 = increased and breakthrough hypoperfusion

CPP = MAP-ICP
MAP is the only thing you can control

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3
Q

Causes of Increased ICP

A

MASS hematoma, contusion, abscess, tumor

CEREBRAL EDEMA (increased fluid in extravascular space) tumor, hydrocephalus, head injury, inflammation, meningitis, encephalopathies, vascular insult (stroke, anoxic episodes, cardiac arrest)

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4
Q

Clinical Manifestations of Increased ICP

A

CHANGES IN LOC impaired cerebral flow (GCS <8 intubate)

CHANGES IN VS
temperature (hypothalamus)
Cushing’s Triad

OCULAR SIGNS Unilateral, fixed, dilated pupil = medical emergency
Sluggish pupils, no response to light, does not move up/laterally, ptosis

DECREASE MOTOR FUNCTION Hemiparesis/hemiplegia (1-sided weakness/paralysis)
Cannot withdraw from painful stimuli
Posturing = decorticate/decerebrate

H/A

VOMITING - projectile and unexpected
Sometimes can be accompanied by nausea

SEIZURES

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5
Q

Cerebral Perfusion Pressure (CPP)

A

Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)

Normal CPP = 60-100 mmHg
Normal MAP = 70-90 mmHg
Can control the pressures
Normal ICP = 5 -15 mmHg

ICP > MAP brain cannot be perfused

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6
Q

Complications of Increased ICP

A

HERNIATION related to displacement which can lead to brainstem death

Pressure on the medulla (controls breathing)
Sudden changes of neurological status and VS, pupillary changes

Cushing’s Triad

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7
Q

Cushing’s Triad

A

Widen pulse pressure (increased BP)
Low HR
Irregular Respirations (Cheyne-Stokes)

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8
Q

DX Studies

A

LABS
ABG - PaO2/PaCO2
CBC - H/H, plts
Coag Profile
Chem panel - Na+
Serum and Urine Osmoalality
Drug/Tox Screen

IMAGING
CT and MRI for any presence of lesions
EEG
Transcranial Doppler - blood flow of the brain

PROCEDURES
ICP measurements

NO LUMBSR PUNCTURES Suddenly release P leading to brain herniation

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9
Q

Ventriculostomy/External Ventricular Drain (EVD) Functions

A

Measure ICP - Stroke, hemorrhage, tumors, infection, TBIs

CSF Drainage - dx/intervention
sample, monitor, and can give meds

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10
Q

Leveling the Transducer

A

Tragus of the ear
Foramen of Monro

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11
Q

EVD Complication

A

Risk of Infection with prolonged use

Routine assessment (insertion site), aseptic technique, monitor CSF for color/clarity (cloudy = infection)

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12
Q

Drug Therapy

A

Mannitol = Osmotic Diuretic
Decreased ICP and decreased fluid total volume and moving it from tissues into vasculature
Monitor F&E

Hypertonic Saline = Higher sodium pulls water out of tissue

Corticosteroids = Lower cerebral edema

Prophylactic Anti-Seizure Meds (dantrolene, levetiracetam) - prevent seizures that increase ICP

Antipyretics - Tx fever and pain
Shivering increases ICP

Sedatives/Pain Management NO strong opioids (fentanyl/morphine) because it alters neuro assessment
Paralytics decrease metabolic demands

BP MANAGEMENT
Vasoactive drugs (epi/norepi/vasopressin/dopamine)
IVF to increase blood volume
MAP > 90 CPP >70

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13
Q

Nursing Care Increased ICP Goals

A

Maintain patent airway
Normal F&E balance
ICP w/in normal limits
Prevent complications from immobility and low LOC

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14
Q

Nursing Interventions

A

MAINTAIN RESPIRATORY FUNCTION avoid hypoxia and hypercapnia (increases ICP and lowers CPP)

SEDATION Paralytics and Analgesic
Pain, anxiety, fear, nursing care can increase ICP

F&E BALANCE, ADEQUATE NUTRITION
I&O, Fluids, Serum Electrolytes (DI and SIADH)
Intural Nutrition

MONITORING/MAINTAIN ICP Don’t scare the patient or stimulate the patient, needed straining
Control body temperature
Monitor environment, neutral body positioning, C-collar stabilization, HOB 30

PROTECTION FROM INJURY RELATED TO IMMOBILITY
VTE Prophylaxis - SCDs, lovenox (24-48 hours)
Neutral body positioning (C_Collar if needed) tQ2

PSYCHOLOGIC CONSIDERATIONS -anxious
Consult Social Work/Champlain

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15
Q

Brain Death

A

Coma, responsiveness, absence of brainstem reflexes, apnea (no air on their own)

Irreversible cessation of all brain activity
Confirmed by MRI, bedside assessments, and apnea exam
Emotional reassurance with Chaplin consult
Organ Donation

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16
Q

Head injury

A

Serious = TBI

Causes - falls, MVCs, assaults, firearms

Types = Scalp lacerations, skull fractures, head traumas

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17
Q

Skull Fractures

A

TYPES
linear, depressed
simple, comminuted, compound
Closed/open

CLINICAL MANIFESTATIONS
CN deficits
Postauricular bruising (Battle Sign)
Periorbital bruising (Raccoon Eyes)
Rhinorrhea and otorrhea (+) CSF r/t tear in dura (Halo, (+) glucose)

COMPLICATIONS
Intracranial infections, hematoma. meningeal and brain tissue damage

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18
Q

Head Trauma

A

DIFFUSE - Concussion, diffuse axonal injury (not limited to 1 area)
MVC (rapid speeding and slow down causing white matter to shear)
Nursing care = frequent assessments and pain management

FOCAL - Lacerations and Contusion
Coup Contrecoup = site and directly opposite of the brain

COMPLICATIONS
Cerebral hematomas (epidural and subdural)
Intracerebral Hematomas (inside brain tissue)

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19
Q

Assessment of Head Injury

A

Through baseline assessment - other assessments based on this

GCS/EMV - LOC/mental alertness/pupils
VS - respiratory pattern changes suggest deterioration
Monitor ICP

CSF leak, vomiting, bowel, bladder inc., battle sign, periorbital edema

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20
Q

TX of Head Injury

A

Lower ICP/Minimize interventions that cause an increase in ICP
Maintain CPP
Stabilize VS
Acetaminophen for pain control (NO NARCOTICS because it alters/impact LOC)
AVOID NGT placement (contraindicated with skull fractures) Oral insertion ok

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21
Q

Cranial Surgery

A

Increased risk of infection and high ICP
Monitor and Prevent increased ICP

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22
Q

Meningitis

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A

Bacterial = deadly
Spread via respiratory secretions

Dx = lumbar puncture (WBC, protein, glucose, gram stain, cultures), CBC, coagulation profile, electrolyte panel, plt count, blood cultures, CT, MRI

S/S = Fever, severe h/a, N/V, nuchal rigidity (neck stiff and hard to move), (+) Bradzinski’s sign (severe neck stiffness when hips and knees are flexed) photophobia, decreased LOC, signs of increased ICP, seizures, irritability, petechiae, papilloedema (swollen optic disk)

TX= IV abx, pain control, temp. control
Health promotion = Vaccines

23
Q

SCI Classification

Study These Flashcards
A

Mechanism

Level of Injury
Tetraplegia (T2- L1) - loss of motor/sensory function or extremities
Paraplegia (C1- T1) - muscle function depends on specific segments involved with impairment to arms, trunk, legs, pelvic organs

Degree
Complete
Incomplete

24
Q

Degree of SCI

Study These Flashcards
A

COMPLETE loss all voluntary motor and sensory function below level of injury

INCOMPLETE Preservation of some sensory/motor function below level of injury due to partial damage
Spastic = hyperactive neurons causing exaggerated tendon reflexes and muscle spasms
Flaccid = weakness, loss muscle tone and no reflexes
Cauda Equina

25
S/S of Cauda Equina
Urinary retention fecal incontinence unilateral/bilateral sciatica reduced straight leg raise (paresthesia) saddle anesthesia (groin numbness)
26
Clinical Manifestations
Neurogenic Bladder Thermoregulation Increased metabolic needs Peripheral Vascular Problems Motor and sensory, resp., CV, GI, skin, pain
27
Assessment
Neuro checks serially q1hr for 1st 24 hours Airway/oxygenation (c1-3 = apnea and C4 = poor cough and difficulty breathing) Bradycardia and Hypotension (above T6 = CV problems) Decreased/absent bowel sounds, constipation, fecal incontinence (flaccid = constipation spastic = diarrhea) Skin (warm, dry skin below injury - shock) Urinary retention/INC. Sensory Status Exact point where normal sensation is present Motor status Voluntary mvts./Muscle Strength Reflexes Hyperactive deep tendon reflexes = complete SCI
28
Spinal Shock
AFFECTS ONLY SPINAL CORD Bleeding, inflammation, tissue damage -- mediators + vasoconstriction -- ischemia and hypoxemia Complete Transection = Cannot regain mvt. Partial Transection = regain mvt. below injury -- relieved bleeding and inflammation via steroids Loss of sensation, DTRs, and Sphincter reflexes below the level of injury Flaccid paralysis occurs below level of injury OUT OF SHOCK -- Spastic and DTRs recovered
29
DX Spinal Shock
MRI = inflammation, infection, edema, or vascular disruptions along with injuries of spinal cord, ligaments, and disks CT Scan = Visualization of bony structures of spine and ID spinal fx Angiography = vertebral/cranial arteries w/in cervical spinal column
30
SCI Immediate Nursing Actions
Airway Management Intubate until the inflammation goes away Decompress Stomach with NGT IS, help w/ coughing Spinal Immobilization Bed Rest Log-rolling maneuvers C-Collar until spine stabilized with Sx, traction, or an external device or cleared Steroid Therapy (methylprednisolone) preventing secondary injury give w/in 3 hours for 48 hours Monitor for Autonomic Dysreflexia for SCI above T6
31
Autonomic Dysreflexia
Exaggerated SNS response for SCI above T6 below site of injury BP raises to dangerously high levels
32
Autonomic Dysreflexia Risk Factors
Bladder Distention/Spasm Bowel Impaction Stimulation of anal reflex Temperature changes Tight, irritating clothes, pressure injury UTI Decubitus Ulcer Pain Sexual activity Menstruation Broken Bones
33
Treatment
FIND and TX cause Lower BP Raise HOB Loosen binding/restrictive clothing Check for urinary occlusion/over-distention Check for impaction and facilitate defecation Pain meds (avoid opioids as impact LOC and cause constipation) Infection monitoring Personal care -- bladder and bowel program, ulcer checks
34
Symptoms
Severe hypertension due to vasoconstriction Sweating, flushing Bradycardia Piloerection = hair sticking up Sudden headache blurred vision anxiety
35
Impaired Gas Exchange/Ineffective Breathing Patterns
SCI C1-2 = Mech. Ventilation r/t loss of phrenic nerve innervation to diaphragm C3-5 = Vary degrees of diaphragm paralysis and need ventilator support BELOW C6 = impaired intercostal and abdominal muscle function causing abnormal respiratory reflexes (coughing, sneezing)
36
Impaired Gas Exchange/Ineffective Breathing Patterns Interventions
Monitor ABC, physical exam, ventilation, ability to cough and clear secretions and O2 Aggressive Resp. therapy Supp. O2 Chest PT/IS Cough and Deep Breathing Early Ambulation Assisted coughing devices Bronchodilators and Mucolytics to mobilize secretions
37
Decreased CO
Low BP (orthostatic) Dysrhythmias HR < 60 -- vagal response -- Cardiac Arrest
38
Decreased CO Interventions
Monitor VS, CO, CVP SBP > 90 MAP =85- 95 HOB elevated Vasopressors PRN Early detection of bradycardia (above T6) r/t unopposed vagal stimulation Atropine Pacemaker Limit vagal stimulation
39
Impaired Urinary/Bowel
URINARY Depending on level of injury Neurogenic Bladder = loss of autonomic control of the bladder (cannot sense fullness and do not know when to pee) Risk for inc., Reflux, renal stones, obstruction, UTI, overdistention BOWEL Reflexic or flaccid bowel Neurogenic Bowel = loss of autonomic control of bowel Risk for Inc., Constipation, bowel obstruction, Ileus
40
Impaired Urinary/Bowel Interventions
URINARY = Maintain infection-free GU In and Out Cath. = GOLD standard and ensures full emptying of the bladder FC Bladder scan Suprapubic Imperative cleaning Bladder spasticity BOWEL - Establish routine daily bowel care to Avoid severe constipation/inc. Bowel training via suppository/digital Stimulation (enemas), oral stool softeners (Miralax) Monitoring diet and fluid intake (increase fiber) Timing bowel routine with intake to incorporate gastrocolic and anorectal reflexes Avoid opioids
41
Ineffective Thermoregulation
Interruption of SNS (spine and hypothalamus) Poicalothermia = inability to maintain constant core temperature and assumes temperature of the environment Hyperthermia r/t loss of sympathetic control of sweat glands below the level of lesion prohibits sweating as temperature rises Hypothermia r/t unable to maintain at appropriate temperature and requires passive warming devices
42
Ineffective Thermoregulation Interventions
Set the room temperature warmer
43
Imbalanced Nutrition
HIgh metabolic state BUT get low nutrition due to bowel issues, limited ability to feed themselves, depression Risk for paralytic ileus (NGT LWS), stress ulcers (PPIs and H2 blockers)
44
Imbalanced Nutrition Interventions
Consult Nutrition Monitor I&O's, weights Initiate enternal nutrition early Swallow eval (risk aspiration) Monitor serum albumin and prealbumin (nutritional status) NGT to reduce gastric distention
45
Risk for Thromboembolism
Venous Stasis r/t lack of movement and lack of muscle tone
46
Risk for Thromboembolism Interventions
Monitor s/s of DVT/PE SCDs early and LMWH -- promote venous return PT/OT consult or ROM exercises to prevent clots
47
Risk for Infection
High thoracic/cervical injury increases risk of pneumonia, UTIs, and decubitus ulcer formations
48
Risk for Infection Interventions
S/S of infection Monitor urine ad sputum color/clarity Monitor wound beds Remove FC ASAP Strict daily perineal care (clean and dry) Cough, deep breathing, IS Chest PT/assissted coughing devices to mobilize secretions Frequent turning -- assist mobilizing secretions and prevent wounds
49
Risk for Skin Breakdown
Sensory and motor impairment -- skin subjected to prolonged periods of pressure Unable to feel discomfort/pain from pressure Unable to change positions independently Moisture exposure from sweating or bladder/bowel inc. -- pressure ulcer formation and increases risk for infection
50
Risk for Skin Breakdown Interventions
Frequently repositioning, tQ2, log roll Heel protectors Speciality beds to provide pressure reduction Physical assessments of all skin areas Evaluate for breakdown in unusual places Remove wrinkles or loose bedding Maintain body in neutral position Passive ROM
51
Self Care Deficits Interventions
Set Rehab goals Encourage independence early Ambulate Early Bowel and Bladder routines
52
Psychosocial
Suddenly experiences immobility and adjustments to social, economic, and personal roles/relationships
53
Psychosocial Interventions
Offer open communication for expression of anxieties, fears, anger, sadness, concerns Allow patient to grieve over the loss of life they expected Focus on patient's current abilities Teach patient and family self-care measures to promote independence Provide support groups Psychological support with referrals if needed

High Acuity (7 decks)

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