Seminar 11 part 1 Flashcards
1
Q
When would a nurse need to perform an advanced neurological assessment
A
Fall, A+Ox3 decline, post stroke
2
Q
What is the average pupil size
A
2-8mm but depends on light
3
Q
What size is considered a dilated pupil
A
8 mm or greater
AKA blown out
4
Q
what size is considered a constricted pupil
A
2 mm or less
AKA pinpoint, small
5
Q
What cranial nerves are both sensory and motor in function
A
trigeminal (CN V)
Facial (CN VII)
glossopharyngeal (CN IX)
Vagus (CN X)
6
Q
sensory function on the body can be assessed by testing
A
dermatomes
7
Q
What is a dermatome and what is each one associated with
A
a dermatome is a an area or zone of skin and it is associated with a single spinal nerve
8
Q
What spinal nerve does not correlate with a dermatome and how many dermatomes are there
A
C1 does not correlate, they are 30 dermatomes
9
Q
How to test dermatomes
A
have patient close eyes.
test pain sensation and light tough sensation by touching skin with either a soft or sharp object and having the pt state when and what they feel.
Test B/L
10
Q
How is sensory ataxia tested
A
with a Romberg test: get patient to stand, close eyes, watch to see if they are swaying, if this, this is positive romberg
11
Q
What is a reflex and what does normal reflex indicate
A
a instantaneous and involuntary response to stimulus.
Normal: functional pathway between
stimulus -> sensory neuron -> interneuron -> motor neuron -> the muscle
12
Q
What is a seizure
A
a sudden onset of uncontrolled electrical activity in one or more area of the brain
13
Q
What are some symptoms of a seizure
A
changes in LOC or emotion, loss of muscle control, sensory changes, loss of bladder/bowel, resp changes and staring or rapid blinking
14
Q
What are some extracranial causes of seizures
A
-Excess/deficit or glucose, lytes, triglycerides etc
OR
- Toxins which could be internal (kidney, liver, metabolic disease) or external (poison)
15
Q
What are some examples of intracranial causes of seizures
A
- secondary epilepsy: progression of brain disease (tumor), and static brain disease (scar after trauma
- primary epilepsy (idiopathic)
16
Q
What 3 key features are seizures classified by
A
- Where seizures begin in the brain (EEG)
- The level of awareness during a seizure
- Describing the other features of the seizure (movements/automatisms)
17
Q
seizure phases
What is the prodromal phase
A
- precedes seizure with signs (HA, confusion, mood/behavior change)
- can occur several days or minutes prior to seizure
18
Q
Seizure phases
What is the early ictal/aural phase
A
- sensory warnings (vision changes, smells, auditory sensations, fear, panic nausea, deja vu prior to seizure)
- an aura is a focal seizure
19
Q
seizure phases
What is the ictal phase
A
seizure activity, loss of awareness, repeated movements, convulsions, tachycardia, trouble breathing
20
Q
seizure phases
what is the postictal phase
A
rest and recovery (nausea, muscle weakness, exhaustion, fear, fatigue, decreased LOC)
21
Q
what is status elipepticus
A
- a state of constant seizure or when seizures recur in rapid succession without return to consciousness between seizures.
- can involve any type of seizure.
- brain uses more energy than is supplied.
- neurons become fatigue and cease to function
- permanent brain damage as result
neurological emergency
22
Q
what is tonic-clonic status epilepticus
A
most dangerous as it can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, systemic acidosis
23
Q
What are seizure precautions
A
padding lining the bed rails, mitigrate triggers, ensure bedside safety check has been completed (suction, oxygen)
24
Q
What should the nurse assess for during the ictal phase of a seizure
A
ab. resp rate and rhythm, sounds, apnea, airway occlusion, HTN, tachycardia, bradycardia, excessive salivation, length of phase
25
what should the nurse assess for during the post-ictal phase
precipitating factors, bitten tongue, soft tissue damage, cyanosis, bowel/urine incontinence, diaphoresis, weakness, paralysis, ataxia, neuro-vitals
26
What excitatory receptor does alcohol inhibit.
What does it inhibit
glutamate
GABA
27
what results in symptoms of withdrawal
When someone stops using ETOH, neurotransmitters must readjust to regain sensitivity needed to function correctly.
The brain has an excitatory overload, which results in the symptoms of withdrawal.
| alcohol quiets brain, when gone, brain rebounds
28
is wernickes encephalopathy reversible
| confusion, ataxia, oculomotor dysfunction
yes but it is a medical emergency and if not treated can lead to permanent damage
| wernickes "walk it off"
29
Is Korsakoffs syndrome reversible
| memory
no, permanent damage is done
| korasakoffs "keep it"
30
mild to moderate symptoms of AWS
tremor, **anxiety, N/V, HA,** tachycardia, diaphoresis, **irritability, confusion, insomnia, nightmares,** HTN
31
Severe AWS
**profound confusion, agitation, fever, agg., seizures, tactile disturbances, auditory/ visual hallucinations,** excessive diaphoresis, tachycardia and pnea, tremors, HTN
32
What tool is used to assess alcohol intake (misuse or dependancy)
The CAGE tool
C: cut down
A: annoyed
G: guilty
E: eye-opener
33
What does CIWA assess for
used to assess and monitor symtoms caused by alcohol withdrawal
34
When is CIWA not helpful
- language barrier
- cognitive impairment
- delirum
- decreased LOC
35
10 most common symptoms of AWS
1) N/V
2) tremor
3) tactile disturbance
4) auditory disturbances
5) paroxysmal sweats
6) visual disturbances
7) anxiety
8) HA
9) agg
10) orientation/clouding or sensorium
36
what medication can be given if a patient scores a 0-9 on the CIWA-Ar score?
no medication! reassess and do vitals Q4H
37
What medications can the nurse give if the patient scores 10-19 on the CIWA scoring
Diazepam (10mg PO/IV)
Lorazepam (1mg SL/IM/IV)
Lorazepam (2mg SL/IM/IV)
38
What medications can the nurse give if the patient scores 20+ on the CIWA scoring
Diazepam (20mg PO/IV)
Lorazepam (2mg SL/IM/IV)
Lorazepam (4mg SL/IM/IV)
39
If a patient has a CIWA score greater than 10, how often should the nurse re assess
Q1H until score is less than 10
40
What is the max dose of Lorazepam and Diazepam
Diazepam: 120 mg/ 24 hrs
Lorazepam: 12 mg/ 12 hrs
41
What is the treatment goal for the CIWA protocol
mild sedation (rouses easily) and to score less than 10
42
For what reasons would the nurse choice to give lorazepam over diazepam
for age over 70 or resp distress, or if the patient has underlying liver disease or is unable to take PO or IV med
43
How soon after alcohol cessation do withdrawal symptoms begin to display
6-12 hours with mild symptoms
44
how many hours after ETOH cessation has the greatest risk for withdrawal seizures
**24-48**
45
what withdrawal symptoms mark the 12-24 hour period with ETOH
alcoholic hallucinosis: visual, auditory, tactile hallucinations
46
What symptoms are displayed at the 48-72 hour mark post ETOH cessation
ETOH withdrawal delirum, hallunications (visual mostly), disorientation, agitation, diaphoresis
47
What is the kindling phenomenon
with each epsiode of ETOH use and ETOH withdrawal, (even mild), the brain becomes more
- excitable
- sensitive to effects of ETOH withdrawal
48
With each episode of ETOH withdrawal, what happens
- clinical manifestations become more severe.
- people become increasinly likely to experience seizures and delirum tremens
49
What are the other challenges during ETOH withdrawal
- Hypovolemia/dehydration
- malnutrition/electrolyte imbalances
50
What is common in people who drink excessive amounts of ETOH
Thiamine deficiency (vitamin B1)
51
what is thiamine essential for
energy metabolism!!! it converts carbs into glucose
52
What does dry beriberi effect
effects the CNS and PNS and can lead to wernickes or korsakoff
53
What does wet beriberi effect
effects the heart and circulatory system
54
characteristics of Korsakoffs syndrome
- irreversible, significant short-term mem impairment.
- inability to learn new things or retain new info.
- some long-term memory loss
- aphasia
- lack of insight
- confabulation (filling in the mem gaps with false stories)
55
Wernickes encephalopathy characteristics
- acute/sudeen syndrome requiring urgent tmt.
- swelling causes damages to nerves and blood vessels in brain.
- ataxia, confusion, nystagmus
- can lead to korsakoff's syndrome
56
Nursing role in managing alcohol withdrawal
1) early/accurate assessment
2) recognition and management of signs/symptoms
3) supportive nursing care
57
how are SCI classified
1. mechanism of injury
2. level of injury
3. degree of injury (partial or not)
58
Mechanism of injury for a SCI can be either?
traumatic or non-traumatic
59
# define
flexion:
hyperextension:
compression fracture:
flexion-rotation injury:
**flexion:** when your neck (or spine) bends too far forward (head banging)
**hyperextension:** when your neck (or spine) bends too far backward, like when you get whipped back (think whiplash).
**compression fracture:** when pressure is put directly down on the spine,
**flexion-rotation:** This injury combines bending forward and twisting (or rotating) the spine at the same time
60
What is meant by neurological level of injury in regards to SCI
Lowest spinal segment with normal sensation and movement (bilateral)
| function
61
What is meant by skeletal level of injury in regards to SCI
- Where the spine is physically broken, vertebrae and ligament damage.
- The higher the injury the more body parts affected. (cervical, thoracic, lumbar)
62
# degree of injury
What is the difference between complete and incomplete spinal cord injury
Complete: SC is completely severed. Complete loss of mobility and sensation below the injury.
Incomplete: incomplete or partial cord severance. Some movement and or sensation below the level of injury.
63
what is important to do to prevent damage from the secondary injury stage
eliminate invading pathogens
remove debris
promote wound healing
| extend of damage is not immediately clear primary injury
64
CT scans can be useful for SCI in assessing
stability of injury, location, and degree or vertebrae injury
65
What is the Gold standard for SCI dx testing
MRI, as it allows imaging of neurological tissues including the spinal cord
66
what are the immediate goals when a patient comes to the hospital with a SCI
1. patent airway
2. adequate ventilation
3. adequate circulating blood volume
4. treat systemic and neurogenic shock to maintain BP
67
What aspects make thoracic and lumbar injuries less severe as cervical injuries
- less intense
- resp compromise is not as severe
- bradycardia is not a problem
- specific problems treated symptomatically
68
what things should the nurse be sure to assess for in pt with SCI
- motor and sensory exam
- note spontaneous movements
- possibility of brain injury (unconcious, concussion, incr. ICP)
- musculoskeletal injury
- trauma to interal organs
69
after stabilization of a patient with a SCI, what are the next steps
obtain history and learn how the injury occured, and the extend of injury perceived by patient
70
what level of SCI injury may experience autonomic dysreflexia
level T6 or higher
71
what is the most common precipitatiin factor for autonomic dysreflexia
distended bladder or rectum
72
what is autonomic dysreflexia
- Massive uncompensated cardiovascular reaction mediated by the SNS.
- Irritant below site of injury causes a CVS response as the injury blocks the signal to the brain
| massive raise in BP and drop in HR
73
What can happen if issue causing autonomic dysreflexia is not resolved
status epilepticus, stroke, MI, death
74
Autonomic dysreflexia manifestations
HTN,blurred vision, dilated pupils, throbbing HA, diaphoresis, bradycardia, piloerection, flushing of skin, spots in visual field, nasal congestion, anxiety, nausea
75
nursing interventions to resolve autonomic dysreflexia
- elevate HOB to 45 degrees, or sit patient upright.
- assess cause.
- remove stimulus.
- notify MRP if symptoms don't resolve.
76
If the nurse identifies that autonomic dysreflexia is being caused by bladder distention what should be done
- instill lidocaine jelly and immediate catheterization.
- if catheter in place, check for kinks or blockage.
77
if the nurse suspects stool inpaction is the cause of autonomic dysreflexia, what should be done.
a digital rectal examination should be performed only after application of an anesthetic ointment to decrease rectal stimulation and to prevent an increase in symptoms
78
What can ICP lead to
brain ischemia and infarction
79
what is ICP caused by
increasing brain tissue, blood, and CSF
80
Factors that influence ICP
BP, cardiac function, intra-abdominal and intra-thoracic pressure, body position, temperate, blood gases
81
clincial manifestations of ICP
- changes in LOC (early sign).
- ocular signs
- HA
- vomiting
Late signs: changes in vital signs (cushing's), decrease in motor function (decorticate/decerebrate)
82
what is the cushing's triad
decreased HR
Increased BP
Irregular RR
83
nursing care of a client with ICP
**monitor**
- GCS
- neuro function including (CN)
- vitals
- resp function
-ab. distention
- pain and anixety
- opioid and sedative med use
- ABG
- fluid+lytes balance
- ICP
- bpdy position
- protect from injury
- psychological considerations
84
what is normal ICP
5-15 mm Hg
85
What position should patients at risk for increased ICP be placed in and what should the nurse watch for
HOB 30 degrees and extreme neck flexion
86
what are the three types of head injuries
scalp laceration, skull fracture (closed or open), head trauma (diffuse and local)
87
what GCS indicates mild brain injury
13-15
88
what GSC indicated moderate brain injury
9-12
| often requires CT scan and admission to hospital for observation
89
What GCS indicated severe brain injury
3-8
| CT scan of brain and admission to hospital
90
what are some signs of a skull fracture
battle sign, B/L periorbital ecchymosis, CSF rhinorrhea or otorrhea
91
characteristics of a concussion
- client may or may not lose consciousness
- brief disruption of LOC
- amnesia of the event
- HA
- manifestations are of short duration
- client usually discharged home
92
characteristics of post concussion syndrome
- 2 weeks to > 2 mons
- persistent HA
- lethargy
- personality/behaviour change
- shortened attention span/ decrease ST memory
- changes to intellectual ability (can affect ADLs)
- may require CT scan
93
characteristics of a diffuse axonal injury
-12-24 hrs to develop
- decreased LOC
- increased ICP
- decerebrate or decorticate posturing
- global cerebral edema
- severe DAI remain in vegetative state
94
examples of focal injuries
laceration, cranial nerve injury, contusion
95
what is a laceration
active tearing of the brain tissue
96
what is a contusion
frequently occurs near the site of the skull fracture, bruising of the brain tissue within a focal area
97
# focal injury
coute-contrecoup injury
1. primary impact: coup, the brain strikes the skull on the side of inpact
2. Secondary impact: contrecoup, impact posterior area of skull
98
complications of a head injury
- epidural hematoma
- subdural hematoma
- intraparenchymal or intracerbral hematoma
- traumatic subarachnoid hemorrhage
99
what is a epidural hematoma
collection of blood between the dura and inner surface of the skull
100
what is subdural hematoma
collection of blood that results from bleeding between the dura mater and the arachnoid layer of the meningeal covering of the brain
101
what is a intraparenchymal or intracerebral hematoma
collection of blood within the parenchyma that results from bleeding within the brain tissue itself
102
what is a traumatic subarachnoid hemorrhage
hemorrhage that is a result of traumatic force damaging the superficial vascular structure that exist in the subarachnoid space
103
nursing interventions for head injuries
ensure patent airway
spinal stabilzation if needed
monitor VS
monitor LOC, GCS neuro status and ICP symptoms
ensure IV access and monitor fluid intake
assess for CSF rhinorrhea or otorrhea
104
factors that could increase ICP
valsalva manoeuvre, coughing, sneezing, hypoxemia, pain, fever, environmental stimuli
