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Nsg 210 Ch. 61

Mgmt of Pt w/ Neurologic Dysfunction

QuestionAnswer
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