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Nsg 210 Ch. 61
Mgmt of Pt w/ Neurologic Dysfunction
| Question | Answer |
|---|---|
| An altered level of consciousness(LOC) is a patient who is not | oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness |
| If patient becomes unable to arouse and unresponsive to internal/ext stimuli. Responses to pain and brain stem reflex may be present is called | coma |
| A _______is a condition of sleep-wake cycle after coma devoid of dognitive/affective mental fx | Persistent vegetative state |
| What two things are the most important indicators of a pt condition? | Level of responsiveness and consciousness |
| This test measures eye opening, verbal response, and motor response on a scale of 3 - 15 | Glasgow Coma scale |
| A score of _____ or less indicates coma. A score of _______is the most. | 15, 7 |
| Eye Opening response: Spontaneous To voice To pain None | 4 3 2 1 |
| Best Verbal response oriented confused inappropriate words incomprehensible sounds None | 5 4 3 2 1 |
| Best Motor response obeys commands localizes pain withdraws flexion extension None | 6 5 4 3 2 1 |
| What is meant by orientation x 4 | person, place, time, situation |
| An unconscious patient responds to painful stimuli, this is referred to as | purposeful/appropriate and is seen in pt who crosses the midline of the body in response to pain |
| Name the three types of posturing that are assessed | decorticate, decerebrate, flaccid |
| Pt presents with flexion of upper extremities, internal rotation of lower extremities, and plantar flexion of feet, what posturing is this? Seen in damage above brain stem/stroke | decorticate (arms make "c" shape), adducted |
| Pt has extended and outward rotation of extremities and plantar flexion. Seen in damage at brain stem and is most ominous | decerebrate (arms make "e" shape |
| Damage below brain stem can reveal what kind of posturing? | Flaccid |
| What is the most important intervention in managing pt with altered LOC? | patent airway and ventilation |
| Aspiration is a serious complication, what is nsg intv? | Elevate HOB 30 deg, position pt in lateral/semi-prone position, suctioning(oxygenate b4/after(hyperventilated on vent)) |
| T/F: Raising three side rails is considered a restraint? | False, raising all 4 is restraint. |
| Cheyne-Stokes respiration can indicate what type of brain damage? | lesions deep in both hemispheres, basal ganglia, upper brain stem |
| Hyperventilation can indicate what in an unconscous pt? | metabolic problem (incr O2/decr CO2) or brain stem damage |
| In checking eyes in pt with altered LOC, what does PERRLA stand for? | pupils equal round, reactive to light and accomodation |
| An increase in cranial pressure ICP, would show pupils in what state? | Progressive or in dilation |
| This is absent in coma pt and tests corneal reflex, what cranial nerves is it testing? | V and VII |
| What is an abnormal sign with the Babinski reflex in an adult? | big toe and other toes fan out |
| How is temperature taken in unconscious pt? | rectal/tympanic only, not oral/axillary |
| How is an increase in temp for unconscious pt dangerous? | increases metabolic demands of brain which can exceed cerebral circulation and O2 delivery. Edema can form which incr ICP. |
| Every 8 hours, a nurse to provide sensory stimulation does what? | orients pt to time and place |
| The Monro-Kellie hypothesis is? | volume/pressure of brain tissue/blood/CSF are in state of equilibrium and produce ICP, so an incr in one affects the others |
| What is Cushing's triad? | bradycardia, hypertension, and bradypnea - three responses that occur when autoregulatory system fails |
| An incr in paCO2 does what to ICP? | vasodilation - incr cerebral blood flow. Best to maintain >30mmHg |
| What is earliest sign of ICP? What are other ealy signs? | altered LOC, slowed speech and delayed response to verbal commands |
| When ICP begins, what autoregulating mechanisms occurs? | change vessel diameter to maintain constant blood flow in brain |
| Fixed and dilated pupils are signs of what in unconscious pt? | resp distress and even death is close |
| What is best diuretic for decr ICP? What type of diurectic is it? How does it work? | Mannitol, osmotic diuretic that pulls fluid out of the ICF to the intravasculature and CSF, decr ICP. Fluid restriction works too. |
| What drugs would help incr cardiac output to decr ICP? What should CPP be maintained at? | dobutamine(Dobutrex) & norepinephrine(Levophed) CPP >70 |
| How does O2 therapy help lower ICP? | More O2 means more saturation so autoreg will shut blood flow by constricting vessels. Clotting happens faster too. Propofol, paralyzing agent, help. |
| What is CPP? What is normal? How is it calculated? | cerebral perfusion pressure=70-100, <50 means irreversible neurologic damage CPP = MAP - ICP |
| What is normal ICP | 5-15mm HG. If ICP = MAP then cerebral circulation ceases |
| How do you determine MAP and what is normal? | (MAP = [2(diastolic)+ systolic]/3 Normal = 70-110, never <60 |
| What is the phenomenon of Cushing's reflex? | when cerebral blood flow decr significantly, ischemia causes vasomotor center to trigger incr in arterial pressure to overcome incr in ICP. |
| A widening in pulse pressure, increase in systolic BP, and decr in HR are a late sign of what? | Cushing's reflex(syndrome)requiring immediate intervention. It can lead to Cushing's triad. |
| Herniation can occur as a result of Cushing's triad, and causes brain tissue to shift how? | area of high pressure to low press causing decr in blood flow and possibly brain death |
| As a pt deteriorates in consciousness, what s/s may appear? | restlessness(w/o cause), confusion, drowsiness, stupor, react only to loud/painful stimuli, coma |
| Diabetes insipidus, SIADH, and herniation are all complications of what? | incr ICP |
| Decr secretion of ADH with excessive urine output, decr using osmolality and serum hyperosmolality is the result of what? | diabetes insipidus(DI) |
| What is nsg mgmt of DI? | IV fluids, electrolyte replacement, vasopressin(desmopressin, DDAVP) |
| Syndrome of inappropriate ADH(SIADH) presents itself how? | increased secretion of ADH, FVE, serum sodium is diluted(hyponatremia) |
| Treatment for SIADH includes? | fluid restriction(800ml/day), no free water, severe: 3% hypertonic saline solution |
| intraventricular catheter(ventriculostomy), subarachnoid bolt, fiberoptic transducer are more used for what? | ICP monitoring |
| What is #1 cause of onset of seizures in adult? | brain tumor |
| Compression of jugular vv, hip flexion are avoided so as to not incr ICP how? | Keep head in midline position with C-collar to promote venous drainage avoid hip flexion to decr intra-abd/thoracic press |
| What tell pt to avoid Valsava manuever? | exhale(opens glottis) |
| What are possible complications of Mannitol? | CSF, pulmonary edema bc shift of fluid from ICF to vascular |
| Why is a catheter necessary with Mannitol and what level is monitored to avoid diabetes insipidus? | To monitor urine output and >200ml/hr for 2 consecutive hours means DI |
| What are signs of infection with ICP? | stiff neck, menningitis, fever, chills, persistent HA |
| Early s/s of ICP are? | restless, disoriented, incr resp, impaired eye mvmt, weakness on one side of body, constant HA |
| Late s/s of ICP? | coma, decr/erratic pulse/resp rate, incr BP/temp, altered resp patterns, projectile vomit, (D) posturing, loss of gag, corneal, swallowing reflexes |
| How can you test if fluid is CSF or not? | CSF has yellowish ring and test with glucose stick, will have glucose |
| What are three approaches to a craniotomy | supratentorial: above tentorium infratentorial: brainstem transsphenoidal: thru sphenoid |
| what are two types of seizures | partial(part of brain) and generalized(whole brain) also known as grand mal |
| how should pt be positioned during seizure? | side-lying position with suctioning available |
| What is status epilepticus? | continuous seizure activity lasting at least 30m, emergency |
| what is 1st line medical mgmt for status epilepticus | (Adivan)lorazepam, valium, phosphenytoin |
| What are side effects to watch for with Dilantin? | gingival hyperplasia(dental care), severe skin reaction, peripheral neuropathy, ataxia, drowsy |
| What are seizure medicines | Depakote, Dilantin, Tegretol, Keppra, Topamax, Gabitrol, Mysoline |
| What are four phases of migraine headache? | prodrome, aura, headache, recovery |
| A medicine for cluster heachaches? Other migraine meds? | Indocin, ergotamine triptans, beta blockers, no tyramine in diet |
Created by:
palmerag
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