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NURS 3000 > Week 5 > Flashcards

Week 5 Flashcards

(59 cards)

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1
Q

What are some nursing diagnoses for Head Injury?

A

Risk for Ineffective cerebral tissue perfusion
Hyperthermia
Impaired physical mobility
Anxiety

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2
Q

What are the nursing goals for someone with acute head injury?

A

a) Maintain adequate cerebral perfusion
b) Remain normothermic
c) No pain/discomfort
d) Attain max cognitive, motor, and sensory function

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3
Q

What are some potential eye problems that may occur in pts with TBIs?

A

Loss of corneal reflex, periorbital ecchymosis, edema, diplopia.

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4
Q

What are the 3 essential components of the skull/brain?

A

Brain tissue, blood, cerebro-spinal fluid

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5
Q

What are factors that influence ICP?

A

a) BP
b) Cardiac function
c) Intra-abdominal and intrathoracic pressure
d) Body position
e) temp
f) blood gases

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6
Q

What is primary injury?

A

Occurs at the initial time of an injury (ie MVA) that results in displacement, bruising, and damage.

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7
Q

What is a secondary injury?

A

Results of hypoxia, ischemia, hypotension, edema, and increased ICP.

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8
Q

What is ICP?

A

Increased intracranial pressure, pressure exerted b/c of the combined total volume of the skull components.

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9
Q

What is the Monro-Kellie doctrine for ICP?

A

Explains dynamic equilibrium in the skull. If the volume of one of the 3 components increases, and the volume of another is displaced, the total volume will not change. If the volume of 1/3 increases w/o a corresponding decrease, then the ICP will increase.

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10
Q

Where can ICP be measured?

A

Ventricles, subarachnoid space, subdural space, epidural space or brain tissue.

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11
Q

What are the normal ICP ranges?

A

5 to 15 mmHg. Over 20 mmHg is considered abnormal.

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12
Q

What is cerebral blood flow and how is it measured?

A

Amount of blood (mL) passing through 100 g of brain tissue. Brain uses 20% of O2 and 25% of glucose.

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13
Q

What mechanism ensures adequate cerebral perfusion?

A

Autoregulation regulates the brains metabolic needs and blood flow. If MAP is less than 50 not good. If MAP is above 150 also not good.

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14
Q

What are other factors affecting CBF?

A

CO2, O2, H+ concentration affect cerebral vessel tone. Cardiac/respiratory arrest, systematic hemorrhage, stroke.

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15
Q

What is CPP?

A

Cerebral perfusion pressure. Used to ensure adequate brain tissue perfusion. Equal to MAP-ICP.

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16
Q

What are some important CPP measurements?

A

Normal: 70 to 100
Minimum: 50-60
Cerebral Ischemia: Less than 50
Death: Less than 30.

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17
Q

What things can increase the brain tissue component of ICP?

A

Cerebral neoplasm, contrusion, abscess, or cerebral edema.

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18
Q

What are conditions that increase cerebral blood volume?

A

Intracranial hematomas, metabolic/physiological factors, vascular anomalies.

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19
Q

What factors can increase CSF?

A

CSF secreting tumours, hydrocephalus.

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20
Q

What is cerebral edema?

A

Increased accumulation of fluid in the extravascular spaces of brain tissue.

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21
Q

What are some causes of cerebral edema?

A

Mass lesions (brain abscess, brain tumour, hematoma, hemorrhage), head injuries (confusion, diffuse axonal injury, post-traumatic brain swelling), brain surgery, cerebral infections (meningitis, encephalitis), vascular insult (anoxic and ischemic episodes, cerebral infarction, venous sinus thrombosis), toxic/metabolic encephalopathic conditions (hepatic encephalopathy, lead/ arsenic intoxication, uremia).

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22
Q

What are the 3 types of cerebral edema?

A

Vasogenic, cytotixic and interstitial.

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23
Q

What is vasogenic cerebral edema?

A

Most common type. Occurs in white matter. Attributed to changes in endothelial lining of cerebral capillaries. This allows leakage of macromolecules from the capillaries into the extracellular space, leading to edema.

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24
Q

What factors affect the speed and extent of edema?

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A

Systemic BP, site of brain injury, extent of blood-brain barrier defect.

25
What is cytotoxic cerebral edema?
Results from local disruption of the funtctional/morphological integrity of cell membranes. Happens in grey matter.
26
What is cytotoxic cerebral edema caused by?
Destructive lesions, trauma to brain tissue. Leads to cerebral hypoxia, anoxia, sodium depletion and syndrome of inappropriate antidiuretic hormone. Edema results from a protein and fluid shift.
27
What is interstitial cerebral edema?
Result of periventricular diffusion of ventricular CSF in pt w/ uncontrolled hydrocephalus.
28
What are early signs of cerebral edema?
Altered LOC, unilateral pupil change, altered respiratory change, unilateral hemiparesis. Variable: Focal findings, vomiting, headache, seizures, papilledema.
29
What are the late signs of cerebral edema?
Decreased LOC, unilateral/bilateral pupillary changes, ineffective breathing pattern, abnormal motor response. Variable: hypertension, bradycardia, hyperthermia.
30
What are the terminal CM of cerebral edema?
Bilat fixed dilated pupils, respiratory arrest, absence of motor response. Variable: hypertension, bradycardia, hyperthermia
31
Why do changes in vital signs occur in pts w/ cerebral edema?
Caused by increasing pressure on the thalamus, hypothalamus, pons and medulla.
32
What is cushing's triad?
Increased systolic pressure, bradycardia w/ full bounding pulse, irregular respiratory pattern.
33
what causes ocular changes in pts with cerebral edema?
Compression of the oculomotor nerve (CN 3), causes dilation of pupil ipsilateral to the mass or lesion, sluggish or no response to light, inability to move eye upward, ptosis of eyelid. CN 2,4,6 may also be affected.
34
What causes a decrease in motor function in pts w/ cerebral edema?
Depending on the location of the swelling, it may cause contralateral hemiparesis, or hemiplegia. Decorticate posture (internal rotation/abduction of arms, voluntary movement)
35
What causes headache in pts w/ cerebral edema?
Compression of intracranial structures. Straining, agitation, movement may worsen pain.
36
What causes vomiting in pts with an increased ICP?
Pressure on the vomiting centre. Often projectile.
37
What are the major complications of increased ICP?
Cerebral perfusion, and cerebral herniation.
38
What are the 2 types of herniation?
``` Cingulate herniation (occurs when there is lateral displacement of brain tissue beneath the falx cerebri). Tentorial herniation (when mass lesion in the cerebrum forces the brain to herniate downward) ```
39
What diagnostic studies are used to diagnose increased ICP?
MRI, CT, MRA (magnetic resonance angiography), CTA (computed tomographic angiography). EEG, ICP measurements, transcranial doppler studies, PET scan.
40
What type of drugs would you administer for increased ICP?
``` Anticonvulsants Antipyretics Corticosteroids Histamine H2-receptor antagonists Hypertonic saline Nutritional support Osmotic diuretics Stool Softeners. ```
41
Why is hypertonic saline administered?
B/c it pulls water out of the brain. Must closely monitor bp, serum Na.
42
Why are corticosteroids used to treat vasogenic edema?
Used to treat vasogenic edema surrounding tumors, abscesses. They stabilize the cell membrane and inhibit the synthesis of prostaglandins.
43
What is the Glasgow coma scale?
Standardized test to assess for consciousness. Evaluates eye opening, best verbal response, and best motor response. Higher the score, higher the level of brain functioning. Highest possible score is 15, lowest is 3. 8 or less is a coma.
44
What are some potential nursing diagnosis for increased intracranial pressure?
- Decreased intracranial adaptive capacity - Risk for ineffective cerebral tissue perfusion - Risk for disuse syndrome
45
What are your nursing priorities in pts w/ increased intracranial pressure?
AIRWAY, fluid and electrolyte balances, monitoring intracranial pressure, body positioning, protection from injury.
46
What is head injury?
Any trauma to scalp, skull or brain. Signifies cranio-cerebral trauma, includes an alteration in consciousness no matter how brief.
47
What are the types of head injuries?
Scalp lacerations, skull fractures, head trauma,
48
How can you describe skull fractures?
a) linear or depressed b) simple, comminuted/compound c) closed/open
49
How can you test for a CSF leak from the nose/ear?
Dextrosix/TEs-Tape strip to determine if glucose is present in the fluid. Look for halo or ring sign. Collect the drip on a piece of white pad, if there is a yellow ring that forms, its CSF.
50
What is a diffuse injury?
Damage to the brain that cannot be localized to one area. Eg. A concussion (sudden, transient mechanical head injury with disruption of neural activity and change in LOC).
51
What is post concussion syndrome?
2 weeks to 2 months post incident. CM: headache, lethargy, personality/behaviour changes, shortened attention span, decreased short term memory, changes in intelectual ability.
52
What is diffuse axonal injury (DAI)?
Widespread axonal damage occuring after a TBI. Damage occurs around axons in subcortical white matter of cerebral hemispheres, basal ganglia, thalamus and brain stem.
53
What are the CM of DAI?
Decreased LOC, increased ICP, decerebration or decortication, global cerebral edema. 90% stay in vegetative state.
54
What is focal injury?
Mild to severe, localized to an area of injury. Consists of lacerations, contusions, hematomas, cranial nerve injuries.
55
What is a contusion?
Brusing of brain tissue within a focal area. Develops in areas of hemorrhage, infarction, necrosis, and edema.
56
What is an epidural hematoma?
Collection of blood that results from bleeding b/w dura and inner surface of skull, compresses dura mater and brain.
57
What is a subdural hematoma?
Collectuon of blood resulting from bleeding between the dura mater and arachnoid layer of the menigeal covering of the brain. Venous in origin. Develops slower than epidural hematomas.
58
What are the types of subdural hematomas?
Acute (up to 48. hrs post trauma) Subacute (48 hrs to 2 wks post trauma) Chronic (Weeks to mths post trauma)
59
What is intraparenchymal or intracerebral hematoma?
Collection of blood within the parenchyma that results from bleeding within the brain tissue itself. Occurs in 16% of head injuries.

NURS 3000 (6 decks)

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