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NRSG 421 > Week 5 - Altered LOC & Multisystem > Flashcards

Week 5 - Altered LOC & Multisystem Flashcards

1
Q

what is the most common type of stroke?

A

ischemic

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2
Q

what is the most common type of stroke?

A

ischemic

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3
Q

what are 3 compartments that impact ICP?

A
  • brain
  • blood
  • CSF
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4
Q

if ICP is increased how can it affect the brain/ what can it cause?

A
  • meningitis
  • tumor
  • inflammation
  • trauma
  • glioma
  • surgery
  • abcess
  • TBI
  • encephalitis
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5
Q

if ICP is increased how can it affect the CSF/ what can it cause?

A
  • meningitis
  • infection
  • hydrocephalus
  • choroid plexus tumor
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6
Q

what does meningitis affect?

A

proper drainage

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7
Q

describe a choroid plexus tumor

A

tumor in ventricles of brain that affect CSF

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8
Q

if ICP is increased how can it affect the blood/ what can it cause?

A
  • hemorrhagic stroke
  • increased CO2
  • HTN
  • aneurysm
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9
Q

describe a hemorrhagic stroke

A
  • weakened/ diseased blood vessels rupture
  • blood leaks into brain tissue
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10
Q

describe an ischemic stroke

A
  • blood clots stop flow of blood to an area of the brain
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11
Q

what are indications of a head wound?

A
  • scalp wound
  • fracture
  • swelling
  • bruising
  • loss of consciousness
  • nasal discharge
  • stiff neck
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12
Q

explain the process of ICP

A
  • SNS activation do to decreased perfusion
  • brain stem pressure
  • baroreceptors activated
  • PNS activation
  • death
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13
Q

what does CPP stand for?

A

cerebral perfusion pressure

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14
Q

explain cerebral perfusion pressure (CPP)

A
  • cerebral blood flow decreases
  • leads to cerebral ischemia
  • pressure then put on vasculature
  • once pressure stronger than MAP artery compressed
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15
Q

what are early warning signs of ICP?

A
  • papilledema
  • headache
  • N/V
  • blurred vision
  • restlessness
  • irritability
  • confusion
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16
Q

what is papilledema?

A

swelling of both optic discs in eyes

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17
Q

how do you assess for papilledema?

A
  • MRI
  • CT
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18
Q

if someone has ICP what can make their headaches worse?

A
  • cough
  • sneezing
  • exertion
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19
Q

what are late signs of increased ICP?

A
  • pupil dilation
  • hemiplegia
  • impaired oculophalic movements
  • increased motor tone
  • flexion or extension to pain
  • reps containing sighs, deep yawns or pauses
  • Cushing’s triad
  • decreased GCS
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20
Q

what is the Cushing’s triad reflex?

A

nervous system response

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21
Q

once ICP is increased what are the different stages of Cushing’s triad ?

A

stage 1
- SNS
- HTN (widening pulse pressure)
- tachycardia

stage 2
- PNS (due to HTN)
- bradycardia

Stage 3
- HTN and increased ICP makes pressure on ponds and irregular resps

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22
Q

describe a 6th cranial nerve palsy

A
  • hearing loss
  • facial weakness
  • decreased facial sensation
  • droopy eyelid
  • fever
  • headache
  • N/V
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23
Q

what are some signs and symptoms of a sub arrachnoid hemorrhage (SAH)?

A
  • worst headache EVER
  • N/V
  • change in LOC
  • nuchal rigidity
  • photophobia
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24
Q

what is nuchal rigidity?

A

stiff neck

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25
Q

what causes a sub arrachnoid hemorrhage (SAH)?

A
  • aneurysm
  • trauma
  • bleeding disorder
  • medications
  • arteriovenous malformations (avm)
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26
Q

A TBI is more severe if LOC is lost for what?

A

more than 30 minutes

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27
Q

what are different types of TBI’s?

A
  • concussion
  • subarachnoid hemorrhage
  • subdural hematoma
  • epidural hematoma
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28
Q

what type of TBI can impair consciousness?

A

epidural hematoma

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29
Q

what do you use to identify and assess changes in LOC?

A
  • AEIOUTIPS
  • head CT
  • lumbar puncture
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30
Q

what does AEIOUTIPS stand for?

A

A
- alcohol
- acidosis

E
- epilepsy
- electrolyte
- endocrine (high or low blood sugar)

I
- infection
- insulin

O
- overdose
- oxygen decrease

U
- uremia
- urosepsis
- under dose

T
- trauma
- tumor
- temperature
- toxins
- timing

I
- infection
- ICP

P
- poison
- psych

S
- stroke
- seizure
- sepsis
- shock
- syncope

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31
Q

how do you identify and assess for changes in LOC?

A
  • GCS
  • neuro vitals
  • CAM PRISME
  • VS
  • NIHSS
  • SST
  • TORBSST
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32
Q

what does NIHSS assess?

A
  • if pt if getting worse or better
  • stroke scale
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33
Q

what is on the NIHSS?

A
  • LOC
  • gaze
  • visual facial palsy
  • motor arm
  • motor leg
  • limb ataxia
  • sensation
  • language
  • dysarthria
  • extinction/ inattention
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34
Q

when do you use SST?

A
  • stroke
  • tumor
  • cancer
  • ALS
  • parkinsons
  • dementia
  • delirium
  • critical illness
  • GERD
  • MS
  • intubation
  • SLE
  • TBI
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35
Q

in regards to recreational substances, what will a patient’s pupils look like if they are using opioids?

A

pinpoint

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36
Q

in regards to recreational substances, what will a patient’s pupils look like if they are using cocaine, MDMA?

A

dilated

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37
Q

What is assessed in a GSC? what do we want pt to score?

A
  • eyes opening response
  • verbal response
  • motor response

want pt to score high, if low means altered LOC

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38
Q

what’s included in a focused neuro assessment?

A
  • how are they presenting
  • mobility
  • concentration
  • speech
  • swallow
  • eye contact/ movement
  • decision-making
  • impulsiveness
  • VS
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39
Q

what do you to diagnose a change in LOC?

A
  • head CT
  • MRI
  • lumbar puncutre
  • X-ray
  • EEG
  • labs
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40
Q

what specific labs are you looking at when diagnosing a change in LOC?

A
  • ECG
  • INR
  • CBC
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41
Q

what are you trying to asses for with a lumbar puncture for a change in LOC?

A
  • meningitis
  • cancers
  • bleeding
  • GBS
  • MS
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42
Q

what complications can result from a head injury?

A
  • re-bleed
  • neuro deficits
  • seizure
  • epidural tear
  • CSF leak
  • post confusion syndrome
  • acute intracranial hypertension (AIH)
  • autonomic dysreflexia
  • neurogenic shock
  • death
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43
Q

describe post concussion syndrome

A
  • > 90 days or lasts longer than expected
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44
Q

what are the signs and symptoms of post concussion syndrome?

A
  • headaches
  • dizziness
  • fatigue
  • irritability
  • anxiety
  • trouble falling asleep or sleeping to much
  • loss of concentration/ memory
  • ringing in ears
  • blurry vision
  • noise/ light sensitivity
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45
Q

what is autonomic dysreflexia?

A
  • injury T6or above
  • SNS response to noxious stimuli
  • bladder
  • bowel
  • break down of skin
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46
Q

what do you need to monitor for a pt with altered level of consciousness ?

A
  • external ventricular drain
  • lumbar drain
  • urinary output
  • cranial nerves
  • vitals
  • MSKL system
  • bladder
  • bowels
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47
Q

If someone has a drain in their brain what are they at risk of?

A

high risk of infection

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48
Q

What do we want someones ICP to be? when is it abnormal? When is it concerning?

A

normal < 15mmHg

abnormal 15-20mmHg

concerning >20 mmHg

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49
Q

when monitoring a pt with a stroke what we want their systolic BP to be? why?

A

< 160 or risk for re-bleed

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50
Q

what are some nursing interventions and precautions we should take for clients with a changed level of consciousness?

A
  • decrease stimuli
  • educate family and pt
  • HOB 30-45 degrees
  • safe mobility
  • stool softeners
  • antiemetics
  • hyperventilating
  • align head and neck
  • no flexion, blowing nose, sneezing, coughing
  • fluid interventions
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51
Q

what are some treatments patients with a change in LOC could have?

A
  • lumbar puncture
  • tPA
  • EVT
  • coiling
  • clipping
  • craniotomy
  • burr holes
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52
Q

what does EVT stand for? what does it treat? When is it done? What does it put the pt at risk for?

A
  • endovascular treatment
  • thrombectomy
  • normally within 6 hours
  • puts pt at risk for intraccerebral bleed
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53
Q

describe coiling, what is the purpose of it?

A
  • prevents clots from forming
  • prevents entry of blood into weak space
  • done through artery
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54
Q

describe clipping, how is it done?

A
  • clip off broken area
  • via craniotomy
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55
Q

what are some treatments to avoid for elevated ICP?

A
  • lumbar puncture
  • HYPOtonic solution
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56
Q

why do you not want to do a lumber puncture to treat ICP?

A
  • possible risk of herniation if CSF pressure drops to low
  • mass effect caused by mass or hemorrhage
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57
Q

what medications can be used to treat Changes in LOC?

A
  • osmotics
  • diazepam
  • dilantin
  • lorazepam
  • acetazolamide
  • hydralazine
  • labetalol
  • desopressin
  • dexamethasone
  • phenobarbital
  • antihypertensives
  • antiplatelets/ anticoagulants
  • lipid lowering agents
  • antiarrhythmics
  • anti-anxiety
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58
Q

in regards to medications that can be used to treat changes in LOC what do osmotics do?

A
  • lower ICP
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59
Q

what are examples of osmotic medications that are used to treat changes in LOC?

A
  • mannitol
  • 3% hypertonic solution
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60
Q

what does mannitol do when given to a pt with a change in LOC? How is it given? when does it start to work?

A
  • decrease ICP
  • only given IV
  • works within 30-60 minutes
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61
Q

what are side effects of mannitol?

A
  • peripheral edema
  • pulmonary edema
  • works
62
Q

in regards to medications that can be used to treat changes in LOC what does diazepam or dilantin do?

A

prevents seizure

63
Q

in regards to medications that can be used to treat changes in LOC what does lorazepam do?

A

treats seizure

64
Q

in regards to medications that can be used to treat changes in LOC what does acetazolamide do?

A
  • decrease CSF
65
Q

in regards to medications that can be used to treat changes in LOC what does hydralazine and labetalol do?

A
  • lower BP due to vazodilation
66
Q

in regards to medications that can be used to treat changes in LOC what does desmopressin do?

A
  • treats diabetes for urine output over 9L/dauy
  • improves clotting
67
Q

in regards to medications that can be used to treat changes in LOC what does dexamethasone/ phenobarbital do?

A
  • prevents seizures
  • decreases brain activity
  • treats swelling
68
Q

what are examples of blood thinners?

A
  • plavix
  • warfarin
  • Xarelto
69
Q

what can be used to induce a medical coma? why?

A
  • phenobarbital
  • decreases brain activity resulting in decreased cerebral metabolism and decreased pressure
70
Q

what conditions can cause mutlisystem impacts/ failures?

A
  • COPD
  • pneumonia
  • PE
  • GI bleed
  • diarrhea
  • perforation
  • sepsis
  • TBI
  • stroke
71
Q

when someone has a TBI was does this cause to be released into the circulation?

A

inflammatory and autonomic mediators

72
Q

what releases cytokines when there is a TBI?

A
  • spleen
  • lymph
73
Q

why do the spleen and lymph release cytokines? what if they release to many?

A
  • help control inflammation
  • if to many are released cause inflammation and autoimmune
74
Q

what are signs and symptoms of high cytokine levels in the body?

A
  • high fever
  • inflammation
  • severe fatigue
  • severe nausea
75
Q

what is hypercytokinemia?

A
  • cytokine storm
  • can be severe/ life threatening
  • can lead to multiple organ failure
76
Q

what are IL in regards to WBCs? what do they do?

A
  • proteins
  • regulate inflammation
77
Q

what can increase cytokine release?

A

neuronal and glial death from injury

78
Q

IL 6, 8, 10 increases are associated with what?

A

multisystem organ dysfunction with TBI

79
Q

what are risk factors for ARDS?

A
  • pulmonary infiltrates
  • poor oxygenation
  • acute onset
  • capillary injury
  • alveolar damage
80
Q

what are S/S of ARDS?

A
  • RR >24
  • use of accessory muscles
  • increased WOB
  • MAP <65
  • decreased LOC
  • not responding to O2 and increasing O2 needs
81
Q

what does a MAP of <65 indicate?

A

hypotension

82
Q

non hydrostatic pulmonary edema is caused by what?

A

loss of normal osmotic gradient that normally opposes fluid movements in lungs due to inflammation

83
Q

what are the risks of ARDS with a TBI?

A
  • age
  • injury
  • severity
84
Q

clinical management strategies for ARDS with a TBI are aimed at what?

A

induce hypertension

85
Q

what are relevant labs to assess for ARDS in someone with a TBI?

A
  • ABGs
  • D-Dimer
86
Q

What diagnostics are assessed for ARDS in a someone with a TBI?

A
  • labs
  • CXR
  • PaO2/ FiO2
87
Q

in a pt with a TBI, what early signs can the pt show us that would make us suspect they might have ARDS?

A
  • tachypnea
  • hypoxia
  • respiratory alkalosis
88
Q

what are the 5 different ranges for PaO2/ FiO2 and what do they tell us about the pt?

A

healthy 300-500 mmHg
mild 200-300mmHg
moderate 100-200mmHg
severe <100 mmHg
unhealthy <300 mmHg

89
Q

what does the lab test D-dimer indicate?

A

clots forming

90
Q

if the patient is in hypercapnia respiratory failure, how do we know this just based off of the PaCO2 and PaO2?

A

PaCO2 > 45mmHg AND PaO2 < 60mmHg

91
Q

what are nursing interventions for ARDS?

A
  • PEEP
  • prone position
  • ECMO
  • maintain fluid balance with diuretics
92
Q

what does PEEP stand for?

A

Positive
End
Expiratory
Pressure

93
Q

what is the purpose of PEEP?

A

helps to open un alveoli

94
Q

how long can we place someone in the prone position for?

A

12 hours or less

95
Q

when would we use EMCO for ARDS?

A

only in severe cases

96
Q

when using diuretics to maintain fluid balance, what we we need to watch for?

A
  • hyponatremia
  • hyperglycaemia
  • neuromuscular weakness
97
Q

what medication is contraindicated with swelling for TBI and puts the patient at an increased risk of death ? (This pt would also have ARDS)

A

corticosteroids

98
Q

how do you treat ARDS?

A
  • treat underlying issue first then based on that will determine what meds are needed
  • each case is different
99
Q

what does DIC stand for?

A

disseminated intravascular coagulation

100
Q

What are the signs and symptoms of DIC?

A
  • bleeding
  • microclots
  • sepsis
  • irregular HR
  • hypotension
  • lethargy
  • oliguria
  • tachycardia
  • pulse paradoxes
  • hypoxia
101
Q

What is the most common cause of DIC?

A

sepsis

102
Q

what are different cardiovascular problems that could arise when talking about multi system

A
  • DVT
  • PE
  • decreased cardiac output
  • CVS shock/ dysfunction
  • micro clotting
  • DIC
  • bleeding
103
Q

what is the concern about micro clots when they break down in the cardiovascular system?

A
  • fibrin degradation products are produced and have anticoagulation properties
104
Q

How do you diagnose disseminated intravascular coagulation (DIC)?

A
  • low platelet count
  • elevated D-dimer
  • decreased fibrinogen
  • prolonged clotting time (PT, PTT, INR)
  • BNP
105
Q

What is stress cardiomyopathy?

A

overworked CVS due to SNS activation

106
Q

what can stress cardiomyopathy lead to?

A
  • hypotension
  • decreased CBF
  • secondary injury
107
Q

in your nursing assessment when looking at the cardiovascular system, what in your assessment identifies concern?

A

pulses paradoxus

108
Q

describe pulses paradoxus

A

BP decreases in inhalation

109
Q

what is the best single test to look at when diagnosing DIC?

A

D-Dimer

110
Q

what does the lab test BNP tell us about?

A
  • heart failure
  • acute PE if high
111
Q

what tests can be used to diagnose DIC?

A
  • ECHO
  • ECG
  • TEE
112
Q

what does ECHO tell us about when using it to diagnose DIC?

A
  • Cardiac output
  • blood flow
  • cardiac tamponade
113
Q

what does ECG tell us about when using it to diagnose DIC?

A

rhythm

114
Q

what the diagnostic test TEE. What does it stand for?

A
  • Transesophageal Echocardiogram
  • special type of echocardiogram
115
Q

what are you focusing on if you have to resuscitate a pt?

A

C - circulation
A - airway
B - breathing

116
Q

if someone has a cardiovascular system problem what are your priorities ?

A
  • hemodynamic stability
  • maintain cardiac output
  • maintain oxygenation
  • protect lungs
  • cardiac meds
  • antiplatelets
  • anticoagulants
117
Q

what causes poor perfusion?

A
  • sepsis
  • stroke
  • hemorrhage
  • trauma
  • MAP <60 mmHg
118
Q

what are the 2 different formulas you can use to calculate MAP?

A

MAP = DP+1/3(SP-DP)
OR
MAP = DP+1/3(PP)

119
Q

how do you treat for pulmonale?

A
  • prevention
  • maintain lung function
  • oxygenation
120
Q

what causes for pulmonate?

A
  • pulmonary hypertension
  • any valve problem
121
Q

why can FFP cause hypocalcemia?

A

citric acid from plasma binds to calcium in blood resulting in less calcium to be available for use

122
Q

what are signs and symptoms of changes in the neuro system?

A
  • declining GCS
  • sings of increasing ICP
  • hypoxemia
123
Q

if someone has a thunderclap headache how would they describe it?

A
  • severe/ sudden headache
  • worst headache ever
124
Q

what are the main concerns with the neurological system?

A
  • neurogenic shock
  • SNS blocked below injury
125
Q

what in your nursing assessment could be used to identify concerns with the neurological system?

A
  • GCS
  • asking questions
  • watching the pt move
  • ins/ outs
  • oxygenation
  • auscultate lungs
126
Q

what are relevant labs to assess if you have concerns with the neurological system?

A
  • increased WBC
  • RBC
  • ABG imbalances and electrolytes
127
Q

what is hypercarbia?

A

increase in carbon dioxide in bloodstream

128
Q

what can hypercarbia cause?

A
  • vasodilation
  • refractory HTN > increases ICP
129
Q

what can respiratory acidosis cause in the neurological system?

A
  • altered LOC
  • confusion
  • coma (due to high potassium)
130
Q

what can respiratory alkalosis cause in the neurological system?

A
  • palpitations
  • convulsions
  • tetany
131
Q

what is tetany?

A

low potassium and calcium

132
Q

what is wernickes aphasia?

A

speaking in long complete sentences that have no meaning

133
Q

what is global aphasia?

A

can only vocalize a few words

134
Q

what is Broca aphasia?

A
  • difficulty getting words out
  • struggling to find the right words
135
Q

what is dysarthria?

A

slurring speech

136
Q

What are the main concerns with the GI/ GU system?

A
  • AKI
  • GI atrophy
  • slowed peristalsis
137
Q

what are signs and symptoms of changes in the GI/ GU system?

A
  • fluid overload
  • decreased output
  • metabolic acidosis
  • constipation
  • urinary retention
  • S/S of UTI
138
Q

what does GI atrophy increase?

A
  • permeability
  • risk for bacteria
139
Q

what in your nursing assessment could be used to identify concerns with the GI and GU?

A
  • metabolic acidosis
  • high potassium
  • altered LOC
  • confusion
  • disorientation
140
Q

what assessment findings would you see in someone who has failure or damage to liver?

A
  • juandice
  • ascities
  • more confusion from build up of ammonia
141
Q

how do you get rid of high levels of ammonia in the body?

A

administer lactulose

142
Q

what are relevant labs and diagnostics you would want to look at when assessing an issue with the GI/ GU?

A

kidneys
- GFR
- BUN
- creatinine

liver
- ALT
- AST
- GGT
- bilirubin
- ammonia

143
Q

what diagnostics would be ordered to assess an issue in the GI/GU ?

A
  • CT
  • abd x-ray
  • renal ultrasound
144
Q

if someone has a GI/GU problem, what are your priorities?

A
  • flush system
  • bowel care
  • foley care
  • monitor Ins/outs
  • nutritional support
145
Q

what are the main concerns with the integumentary and musculoskeletal systems?

A
  • pressure injury
  • muscular atrophy
146
Q

what are signs and symptoms to watch for around changes in the integumentary and musculoskeletal systems?

A
  • deconditioning
  • incontinence associated dermatitis
  • orthostatic hypotension
  • dislocation
  • drop foot
147
Q

if someone has a integumentary and musculoskeletal problems, what are your priorities?

A
  • passive and active ROM
  • turning/ positioning Q2H
  • OT and PT consults
  • hygiene
  • bowel/ bladder care
  • skin assessments
148
Q

describe rhabdomylosis

A

increased myoglobin from muscle breakdown in blood

149
Q

what does rhabdomylosis indicate?

A

tissue damage

150
Q

what can rhabdomylosis lead to? what does it make urine look like?

A
  • leads to AKI
  • urine becomes cola brown
151
Q

what does elevated CK over 5,000U/L mean?

A
  • severe muscle injury
  • risk to kidneys

NRSG 421 (6 decks)

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