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2.0 Adult Nursing Exam 3 > Neuro Assessment & Interventions part 2 > Flashcards

Neuro Assessment & Interventions part 2 Flashcards

(112 cards)

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1
Q

What is a motor assessment generally?

A

When you assess movement, strength, and tone of the arm and legs.

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2
Q

What is the most important thing to look for when doing the motor function assessment?

A

The most important part is symmetry.

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3
Q

If the movements are asymmetrical, where are is the damage in the brain?

A

The damage will be on the opposite side of the brain that the deficit is of the limbs.

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4
Q

What does Decerebrate posture look like?

A

Arms are at the side and extended with the wrists pronated.

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5
Q

What does Decorticate posturing look like?

A

Arms are tucked into the core.

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6
Q

What does Decerebrate posture indicate?

A

Brain stem damage

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7
Q

What does Decorticate posture indicate?

A

Overstimulation or pain is causing muscles to contract

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8
Q

You see your patient with a tucked in posture to the core. The family is in the room. What do you as the nurse do?

A

Ask the family to step outside because the patient is being overstimulated.

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9
Q

What is the most important part of the neuro assessment?

A

LOC changes

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10
Q

T/F

A decrease in LOC is a disorder

A

False. LOC is a continuum from normal to coma. If this changes, it is a result of a pathology.

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11
Q

What are some pathologies that cause LOC changes?

A

Septic

UTI

dehydration

(just for an example - don’t memorize).

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12
Q

What are the characteristics of a coma?

A

Unconscious

Unresponsive

Inability to arouse

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13
Q

What are the characteristics of the Persistent Vegetative state?

A

No cognitive function but has sleep wake cycles still

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14
Q

Your walk in. You ask your patient a question but they cannot respond or move their body. The only thing moving is their eyes.

What condition could this be?

A

Locked-in Syndrome

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15
Q

What is the cause of Locked-in Syndrome?

A

A lesion affecting the pons of the brain

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16
Q

What medication can mimic Locked-in Syndrome?

A

Giving a paralytic without giving a sedative.

  • socs or rocs
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17
Q

You aren’t sure about the patient heart sounds. And you doubt what you are hearing. What can you do?

A

Move the patient around, tap with it on the monitor.

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18
Q

What to assess when feeling the pulse?

A

Rate, rhythm, and quality of the pulse

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19
Q

How do we assess tissue perfusion?

A

Cap refill and temperature

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20
Q

When checking temperature, what are we assessing for?

A

Hypothermia or Hyperthermia && also if we induced it or if it was caused by an underlying cause

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21
Q

CPP equaltion

A

MAP - ICP

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22
Q

What does increased ICP related to fluid result in?

A

Increases odds of brain herniation into the brain stem (brain drop) and death.

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23
Q

How does the brain Autoregulation when there is increased ICP?

A

Autoregulation: The brain is able to change the diameter of the vessels to maintain the blood flow

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24
Q

What does decreased CO2 cause?

A

Vasoconstriction

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25
What does a high co2 cause?
Vasodilation
26
How can we manipulate the cerebral blood flow to the brain with the ventilator?
We can control the CO2 levels on ventilator by keeping it between 35-45 (normocapnia).
27
What orders can we use to decrease ICP?
Hypertonic fluids - 3% , mannitol
28
Why do people will increased ICP have headaches?
Complain of headache due to increased pressure in the skull
29
Why do the pupils change in size and reaction for increased ICP?
Pupils change because of compression of the 3rd Cranial nerve.
30
What type of motor loss do you expect to see in a patient with increased ICP?
Unilateral/asymmetrical
31
What changes in the respiratory pattern do you expect for increased ICP?
Slowed or changed breathing rate
32
What pulse pressure changes occur in increased ICP?
A rise in pule pressure
33
What temperature changes do you expect with someone with increased ICP?
Loss of temperature control so - shivering, hot, shivering, hot.
34
What blood pressure changes are going to occur with increased ICP?
Systolic pressure will rise + a widening pulse pressure (systolic - diastolic).
35
What behavior symptoms occur with increased ICP?
Restlessness and anxiety
36
Why might there be _seizures with increased ICP_?
Due to the vessels being compressed, the oxygen can't get to the brain.
37
What posturing changes are you looking for with increased ICP?
Decerebrate Decorticate
38
What happens to the _eyes with increased ICP_?
**Papilledema** due to the optic nerve being swollen
39
What medications can be used during seizure precautions?
Keppra Ativan
40
What _LOC_ changes occur with _increased ICP_?
Decreased LOC * use GCS to evaluate this
41
What heart rate do you expect with a patient with _late signs_ of increased ICP?
They go from being tachycardic to being bradycardic because the autoregulation isn't working anymore at this point
42
What breathing rate do you expect as a late sign of increased ICP?
Apnea due to trying regulate the Co2 levels
43
What major **cluster of signs** do we see in _late_ increased ICP?
Cushings Triad
44
What is _Cushings Triad_?
Increased systolic blood pressure + widening pulse Late onset of Bradycardia Decrease respiratory rate/bradyapnea
45
What changes can be seen in regular and late increased ICP?
Posture changes Pupil changes Seizures Papilledema
46
Symptoms of papilledema of the eye
Fleeting disturbances in vision Headache Vomiting
47
What causes cushing traid?
Increase in sympathetic outflow to the heart in order to try to compensate and increase arterial blood pressure and widening pulse
48
When will we see Cushing Triad?
Seen in **terminal stages** of acute head injury
49
How often do we do neuro checks?
Do neuro checks **every hour** or q15 if there are orders
50
T/F Increase ICP is done so evenly in the skull
False. ICP is **not** **evenly distributed**
51
Why do we need to make sure our neuro assessments are thorough?
Because you have to know the “**last known well**” if something goes wrong.
52
Why should you pay attention to speech?
Some patients have slur but if you hear an acute slur, that is indicative of neuro issues.
53
Why do we need to check trends when evaluating vital signs for cushings traid?
Sometimes patients brady down at night
54
How far does the ICP monitor measure?
It measures only the local area
55
What side is the ICP monitor inserted in the head?
Opposite side of the injury because it takes a backwards photo
56
What does Pbt02 stand for?
Brain tissue oxygenation mmhg
57
What is the pbto2 of **normal** brain tissue?
Greater than 20 mmHG
58
What will the pbtO2 be if the brain is **hypoxic**?
Less than 20
59
What is the pbto2 if you have **severe ischemia**?
Less than 10
60
What is the normal for CPP?
70 - 100
61
What happens if your CPP is _less than 50_?
Permanent neurological damage
62
Normal range for PbtO2?
20 - 40 mmhg
63
Are CPP and CBF the same thing?
NO
64
What makes CBF different than CPP?
CBF tells us how much blood the vessels in the blood have **received**. CPP is the amount of blood sent.
65
What two measurements do we need to be in agreement for brain death (when patient/family asks)?
CPP and CBF need to be in agreement
66
What can we do to decrease ICP?
Reduce CSF Preserve cerebral metabolic functioning Avoid increased ICP more
67
How can we reduce the volume of CSF?
Ventriculostomy/EVD VP shunt
68
When placing a VP shunt, where does the CSF fluid go?
Fluid is shunted to the abdomen
69
What is a Ventriculostomy?
Tube that goes into the ventricles of the brain to monitor ICP and drain out cerebral spinal fluid.
70
How can we control the amount of CSF drained with a Ventriculolstomy?
**Adjust the height** of the fluid collection device
71
What fluids can we use to decrease fluid volume for increased ICP?
Use diuretics and hypertonic fluids
72
Where does the ICP monitor need to be aligned to?
The trachus or foramen of Monro
73
How do we make sure the cerebral metabolic function is adequate?
Focus on oxygenation and perfusion of the brain Glucose levels Watch ICP/CPP
74
What interventions can increase ICP that we want to avoid?
PRN suctioning Turning or bathing
75
What positioning increases ICP?
Head flexion/extension or being off midline. Keep legs straight as well * roll up a towel for their head
76
What maneuver increases ICP?
Valsalva's Maneuver * coughing, baring down
77
Your ICP drain hasn't had any output. What do you as the nurse do?
Check for kinks and make sure the patient isn't laying on it
78
Can we change the dressing site of a ICP drain?
No
79
Where is level 0 at?
The ear canal
80
What does a nurse need to check on the Ventriculostomy/EVD? (4)
Correct **pressure settings** Make sure tubing is **open** so it can drain Monitor the **drainage** Monitor the **dressing site**
81
What can the nurse place on the door for a patient with EVD?
Sign that says not to move the patient
82
What is the difference between a lumbar puncture and a lumbar drain?
The puncture is used for testing. The drain is when it is hooked up to drain set up. They are not the same thing.
83
What is the leveling point of a Lumbar Drain?
There isn't one! Trick question. It just uses gravity.
84
How will you know how much to drain with a lumbar drainage system?
There should be orders for a specific goal. Once you reach the goal, make sure to just go in and turn the valve off.
85
Your ICP rises. What does this mean for your CPP?
CPP falls. * inverse relationship
86
If the ICP is increased, and this decreases your CPP, what will we manipulate to bring the CPP back up?
MAP - with medications
87
How can you make sure you have adequate vascular volume?
CVP readings Urine output Blood pressure MAP
88
What do we use to manipulate the MAP?
Vasopressors Fluids CSF drains
89
Why will we sedate a patient with increased ICP? List some meds
We sedate them because it decreases the workload and allows the brain to rest. Fentanyl, Propafol, Opiods, Barbituates
90
What osmotic/hypertonic fluids will we use to maintain the CPP?
Mannitol, 3%
91
You are using a hypertonic agent to help drive CPP. What do you need to watch for?
Serum sodium levels q6hrs
92
What types of meds do we use to to increase the CPP?
Paralytic - to keep patient still Pressors - to drive the MAP Sedatives - to allow healing and workload Fluids - to take off fluid to decrease ICP (which inadvertently increase CPP)
93
How does keeping a patient midline help increase CPP?
Being in the midline position decreases your ICP which will in return increase CPP.
94
What drainage system can be used to increase CPP?
Ventriculostomy/EVD since it decreases the ICP by pulling of spinal fluid and therefore increasing the CPP due to inverse relationship.
95
What system do we use as a temperature guide?
Licox catheter system
96
What is the normla brain tissue oxygenation pbto2?
20-40 mmhg
97
Associations of decrease brain pbtO2
Hypoxia Increased ICP Increased temp Decreased CPP/MAP
98
How can we increase the pbto2 if it is low?
Drain the CSF Increase CPP/MAP Decrease temp (arctic sun wrap, bubble wrap). Barbiturates
99
If a patient is intubated, why do we avoid high PIP and PEEP?
We don't want them be **dependent on vent** and we don't want the vent to interfere with **cardiac output**. * 5 to 8 hopefully peep
100
What pulse ox do we want for managing ICP?
above 94 %
101
Why will we have patients on anticonvulsant therapy?
Increase ICP causes seizures
102
Why do we want patients to be in Normothermia?
Decrease shivering and use of oxygen
103
Vasopressors we use for neuro?
Dopamine Norepinephrine Neosynephrine Vasopressin
104
What dosage of dopamine do we use?
Could use high or low dose actually.
105
Why would we use a low renal dose of dopamine?
The vasodilation that occurs can help **pull the fluid off with increased ICP** - while still having a *slight* drive.
106
What rate will Neo or levo be at?
Lower rate
107
What rate will vasopressin be?
Not something we titrate
108
Do we have patient hyperventilate to manipulate the Co2?
Its seldom used. We just want to keep the Co2 within normal. No less than 32
109
What is the danger of low Co2?
Vasoconstriction which reduces perfusion
110
What should the HOB be at?
30 degrees to avoid restriction venous return
111
Why do we do early gut feeds for ICP?
To provide the hyper-metabolic needs of the brain
112
What ph level will lead to vasodilation?
Low ph or acidosis means lots of Co2. Lots of co2 leads to vasodilatoin — which can cause hypoxia. * check abg * tbh i dont understand this

2.0 Adult Nursing Exam 3 (8 decks)

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