T4 - Care of Critically Ill Patients with Neuro Probs (Josh) Flashcards Preview

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Flashcards in T4 - Care of Critically Ill Patients with Neuro Probs (Josh) Deck (93):
1

--- and --- have stroke-like symptoms and serves as a 'warning sign' of a possible stroke.

TIA (Transient Ischemic Attack)

Reversible Ischemic Neurologic Deficit (RIND)

2

TIA and RIND:

TIA lasts --- to ---

RIND lasts --- to ---

minutes to less than 24 hours

less than 24 hours to less than a week

3

With a TIA and RIND, what is happening?

brief interruption in cerebral blood flow

4

TIA and RIND:

What is the treatment plan?

Complete neuro assessment

CT Scan, lab, ECG

Possible admission

Anticoagulant therapy (clopidogrel)

5

TIA and RIND:

What anticoagulant would we give to treat?

Clopidogrel

6

With --- you recover.

With --- you have permanent change.

TIA and RIND

CVA

7

Which heart arrhythmia is a concern for CVAs?

Afib

8

A stroke is a change in -- -- -- to the brain.

normal blood supply

9

Stroke (Brain Attack):

What are he causative agents?

HTN

Arteriovenous Malformation (AVM)
***Can be congenital

10

What are the types of Strokes?

Ischemic (lack of blood flow)

Hemorrhagic (bleeding in brain)

11

Stroke:

Thrombus and Emboli are examples of which type of Stroke?

Ischemic (lack of blood flow)

12

Which type of Strokes have SUDDEN onset?

Which type have GRADUAL onset?

Sudden:
- Embolic (ischemic)
- Hemorrhagic

Gradual:
- Thrombotic (ischemic)

13

Causes of Hemorrhagic Strokes:

Aneurysm

HTN

Arteriovenous Malformation

14

What is an Arteriovenous Malformation?

tight cluster of arteries and veins bundled together

blood passes quickly from artery to vein without going through normal capillary network

15

Risk factors for Stroke

Smoking

Substance abuse

Obesity

Sedantary Lifestyle

Oral contraceptive use

Heavy ETOH use

Use of Phenylpropanolamine (PPA)
***no longer made in US

16

Stroke in Left Hemisphere will have which symptoms?

Aphasia, Alexia, Dyslexia

Acalculia

Right Visual Field Deficit

Anxiety, Anger, Frustration

Intellectual Impairment

17

Stroke in Right Hemisphere will have which symptoms?

Disorientation (left sided motor weakness)

Loss of depth perception

Unilateral body neglect syndrome

Denial of illness

Impulsiveness

18

Stroke:

What is the eligibility criteria for Thrombolytic Therapy?

Last seen normal (LSN) less than 3 hrs- 4.5 hrs

Less than 80 yo

No anticoagulant use (INR less than or equal to 1.7)

NIH scale less than or equal to 25

No history of both STROKE and DIABETES

19

Stroke:

What is the time goal for ED door to treatment?

less than 60 mins

20

Stroke:

How often are neuro exams given?

q 15 mins first 2 hrs

21

Stroke:

What are the Endovascular Interventions?

Embolectomy
**mechanical clot removal
**NOT common

Intra-arterial Thrombolsis

22

Stroke:

When can an Intra-arterial Thrombolysis be done?

with 6 hrs LSN (last seen normal)

23

Medication classes for Strokes

Thrombolytics

Anticoagulants (ASA, Clopidogrel)

Lorazepam (other antiepileptics)

CCBs

Stool softeners

Analgesics

Antianxiety drugs

24

Stroke:

Which CCB is likely to be given?

Nicardipine

25

Stroke:

Which surgeries are used to treat?

Carotid Artery Angioplasty with Stenting

Endarterectcomy

Extracranial-Intracranial Bypass

26

Stroke:

Nursing interventions

Neuro Assessments

Monitor ICP

Safety

Emotional Support

Education

27

Brain Tumors:

Where do primary tumors originate?

Where do secondary tumors originate?

within CNS

metastasis from other parts of body

28

Brain Tumors:

What are the classifications?

Benign or Malignant

Location

Cellular Origin

Anatomic Location

29

Brain Tumors:

What is non-surgical management?

Radiation

Chemo

Analgesics

Dexamethasone

Phenytoin

Pantoprazole

Steriotactic Radiosurgery

30

Brain Tumors:

Why is Dexamethasone given?

to decrease size of brain tumors

31

Brain Tumors:

Nursing interventions post-Craniotomy.

Fluid Balance

Incision site

Monitor ICP changes

Avoid activities that decrease ICP

DVT prophylaxis

Stress ulcers

Pneumonia

Proper positioning
***HOB 30 degrees or more

Eye care

32

Brain Tumors:

Post-craniotomy, what activities can be done to avoid increase in ICP?

Stool softeners to avoid valsalva

Antiemetics for N/V

Antipyretics/cooling blankets for fever

33

Brain Tumors:

Which procedure goes through the nose?

Which tumor is it used specifically for?

Transphenoidal Hypophysectomy (TPH)

Pituitary Tumor

34

Brain Tumors:

What are complications from surgery?

Air embolism

CSF Leak (meningitis)

Diabetes Insipidus (messing with hypothalamus)

Visual Disturbances

35

Brain Tumors:

Post op care

HOB increase to 35-40 degrees

Hourly UOP

Monitor electrolytes

Avoid straining

Monitor for visual disturbances

36

Brain Tumors:

We are concerned about Diabetes Insipidus. What UOP will this have?

400 mL/hr

***normal is 0.5-1 mL/kg/hr

37

Brain Tumors:

Post-op, why do we want them to avoid blowing their nose?

avoid any straining to prevent rise in ICP

38

Cerebral Aneurysms:

Which type is behind the eye?

Which type is in the Circle of Willis?

Fusiform

Berry

39

Subarachnoid Hemorrage (SAH) from Cerebral Aneurysm:

What are physical assessments of SAH?

Severe, sudden Headache

Brief loss of consciousness

N/V

Kernig's Sign, Brudzinskis Sign, Photophobia

40

Cerebral Aneurysm:

What do we suspect if client presents and says, 'I'm having the worst headache of my life.'

Subarachnoid Hemorrhage (SAH)

41

Cerebral Aneurysm:

Why have positive Kernig's and Brudzinskis with a SAH?

blood in meninges irritates them, giving meningitis symptoms

42

Cerebral Aneurysm:

What will a Lumbar Puncture reveal with SAH?

blood inCSF

43

Cerebral Aneurysm:

What is gold standard for diagnosing SAH?

Cerebral Angiogram

44

Cerebral Aneuysm:

What is treatment plan for SAH?

craniotomy with aneurysm clipping within 48 hours post bleed


***SAH is an emergency

45

Cerebral Aneurysm:

What is treatment after clipping the SAH?

HHH

- Hypertensive (increase BP and CO)

- Hypervolemic (volume expanders -- albumin)

- Hemodilution (fluids)

46

Cerebral Aneurysm:

Post op from SAH clipping, what is our concern?

not bleeding, since they're stable

our biggest concern is VASOSPASM, so we keep BP HIGH

47

Cerebral Aneurysm:

What is Endovascular Coiling?

filling the aneurysm with thin coil that will close it off

48

Brain Abscess:

What causes a BA?

Which areas of brain are most common?

purulent infection of brain

frontal and temporal most common

49

Stroke:

S/S of Left Hemisphere Stroke

Inability to discriminate words and letters

Intellectual Impairment

Deficits in right visual field

50

Stroke:

S/S of Right Hemisphere Stroke

Disorientation

Constant smiling

Deficits in left visual field

51

What is earliest indicator of increased ICP?

agitation and confusion

52

ICP:

What is the Monroe-Kellie Hypothesis?

due to the fact that the brain is closed system with tissue (brain) and fluids (blood and CSF)...

...an increase in any one MUST be compensated with a decrease in one or more of the other components

53

ICP:

Bran takes up --- us space

Blood takes up --- of space

CSF takes up --- of space

80 percent

10 percent

10 percent


***any change in one must be compensated by changes in others

54

ICP:

What is normal ICP?

5-15 mmHg

55

ICP:

When would you treat increases in ICP?

ICP greater than 20 mmHg that is sustained for 5 mins

56

ICP:

What does an ICP of 10-20 mmHg indicate?

borderline.. it is compensating

over 20mmHg you start treating it

57

ICP:

What is severely high ICP?

greater than 40 mmHg

58

Cerebral Blood Flow (CBF):

What is the name of the pressure gradient that drives CBF?

CPP (Cerebral Perfusion Pressure)

59

CBF:

What is Autoregulation?

the ability of cerebral blood vessels to contract of dilate to deliver just the right amount of blood flow to the brain tissues

60

CBF:

What four factors can we controle to improve autoregulation?

Hypoxia

Hypercapia (CO2 is a vasodilator)

Hypotension

Hypovolemia

61

CBF:

What factors influence Autoregulation of blood flow?

Acidosis (dilates)

Alkalosis (constricts)

Metabolic Rate

62

CBF:

If Metabolic rate increases, what happens to CBF?

If Metabolic rate decreases, what happens to CBF?

increases

decreases

63

CBF:

Since Acidosis dilates vessels, what doe it do to cerebral blood volume?

increases


***in same manner, Alkalosis decreases cerebral blood vol

64

CBF:

How is Cerebral Perfusion Pressure (CPP) calculated?

CPP = MAP - ICP

65

CBF:

What CPP levels are we looking for?

Normal = 70-95 mmHg

***CPP less than 60 = hypoperfusion of brain

***CPP less than 40 = brain ischemia

66

ICP:

Why does increased CO2 cause an increase in ICP?

it's a vasodilator

67

What is mortality rate for someone with both Hypoxia and Hypotension?

greater than 75%

68

What is treatment for Hypoxia and Hypotension?

Early resuscitation using 100% FiO2

69

MAP:

What is target MAP?

greater than 90

70

Optimize MAP:

How do you treat hypotension?

DA or Dobutamine

***target MAP is 90 or more

71

Optimize MAP:

How do you prevent HTN?

Nicardipine 25 mg in 250 mL

**CCB

72

Fluid Balance:

What do we want to keep the serum osmalirity level at?

less than 315

73

Mannitol:

How much can be given in 24 hrs?

do not exceed 200 G in 24 hrs

***hold if serum osmolarity is greater than 315

74

Increased ICP:

What is first s/s of increased ICP?

decreased LOC

75

Increased ICP:

What is Herniation?

complication of increased ICP where tissue from one compartment of brain shifts to another

***leads to coma, loss of reflexes, posturing, loss of brainstem function, and death

76

ICP:

Nursing interventions

Monitor serum electrolytes

Monitor serum Dilantin/Phenobarbitol levels

CVP monitoring

Diuretics

Keep SBP 140-160

Hyperventilation

Antiseizure meds

Antipyretics/Cooling blanket

HOB 30-45 degrees

Avoid activities that increase ICP

77

Traumatic Brain Injury (TBI):

Contact, Accel-Deceleration, or Rotational injuries are examples of --- TBI

Cerebral Ischemia is an example of --- TBI

Primary

Secondary

78

TBI:

What is Mild TBI?

Altered or Loss of Consciousness less than 30 mins with normal CT or MRI

GCS of 13-15

Post Traumatic Amnesia less than 24 hrs

79

TBI:

What is Moderate TBI?

Altered or Loss of Consciousness less than 6 hrs with abnormal CT or MRI

GCS of 9-12

Post Traumatic Amnesia less than 7 days

80

TBI:

What is Severe TBI?

Altered or Loss of Consciousness greater than 6 hrs with normal CT or MRI

GCS of less than 9

Post Traumatic Amnesia greater than 7 days

81

Skull Fracture:

Racoon Eyes are a sign of a fracture of which area?

Frontal or Orbital Fracture

82

Skull Fracture:

Battle Sign (bruising behind ears) are a sign of fracture where?

Basilar Skull Fracture

83

Contusions:

What are clinical manifestations of Contusion?

Focal findings

Disturbance in LOC

Seizures common

84

Lacerations:

With a brain laceration, which will we see on opposite side of body as lesion?

What will we see on same side of body lesion?

Hemiplegia (paralysis on side of body)

Dilated pupil

85

Subdural Hematoma time-frame:

Acute SDH is ---

Subacute SDH is ---

Chronic SDH is ---

first 48 hrs

2 days to 2 wks

2 wks to several months

86

Subdural Hematoma:

Which type of vessel is ruptured/torn?

venous

87

Epidural Hematoma:

Which type of vessel is ruptured/torn?

artery

***middle meningeal artery

88

Epidural Hematoma:

Why might they not seek help?

LOC changes quickly, then they recover lucidity so they think they're ok

Afterwards, there is rapid deterioration

***Epidural Hematoma is arterial bleeding!!

89

Epidiural Hematoma:

What will eyes look like?

dilated, fixed pupil on same side of injury

90

Which hemorrhage is often associated with Cerebral Contusions?

Subarachnoid Hemorrhage

91

Which hemorrhage results from a brain laceration?

Intracerebral Hemorrhage

***most often in Frontal and Temporal areas

92

Diffuse Axonal Injury (DAI):

What is DAI?

brain injury in which damage in the form of extensive lesions in white matter tracts occurs over a widespread area.

93

Diffuse Axonal Injury:

What is Mild?

Moderate?

Severe?

Mild = coma 6-24 hrs (follows commands by 24 hrs)

Moderate = coma greater than 24 hours with NO brainstem signs

Severe = prolonged coma with prominent brainstem signs