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Sensory 212

nursing 212 sensory 2.3.9

most head injuries are major or minor minor
what is the most common cause of trauma deaths; ex of trauma injuries major head injuries; falling, gunshot wounds, baseball bat,
what is number one intvervention if you suspect injury to cervical spine sabalize the neck
mechanisms of injury: what is the most common cause of subdural hematomas; what sport has a lot of head injuries; what cause of head trauma is common in the eldery; MVAs; football; falls;
mechanisms of injury: why is it dangerous for elderly to fall; falls associated with ___ hematomos; they are on Coumadin and they have cerebral atrophy; subdural
Cranial nerves: 1- name; sensory or motor; what is sense; where are receptors located; olfactory; sensory; smell; nasal mucosa
Cranial nerves: 2- name; sensory; what is sense; receptors originate where; optic; sensory; vision; in retina;
Cranial nerves: 3-name; sensory or motr; what is function; how to assess; oculomotor; motor; movement of eyeball; have pt follow pen;
Cranial nerves: 4- name; sensory or motor; wht does it do; where does it originate in the brain; trochlear; motor; eye movement, eye rotating; dorsal aspect of the brain;
Cranial nerves: 5- name; sensory or motor; what does it do; located where; how do we assess this trigeminal; sensory and motor; facial sensations, helps with chewing; lateral pons; with cotton ball and finger
Cranial nerves: 6- name; sensory or motor; what does it move; how does it move the eye; where is it located in the eye abducens; motor; eye movement; abduces it; caudal border of the pons
Cranial nerves: 7- name; sensory or motor; what does it do; located where; responsible for taste on what portion of the tongue; facial; motor and sensory; sense of taste, smiles, frowns, purses lips; pons; anterior 2/3 of it;
Cranial nerves: 8- name; sensory or motor; what does it do; located where acoustic; sensory; hearing; pons
Cranial nerves: 9 - name; sensory or motor; what does it do; in medulla; glossopharyngeal; motor and sensory; throat muscle, taste;
with damage to what cranial nerve may we see swallowing issues CN #9
Cranial nerves: 10- name; sensory or motor; what does it do; located where; Vagus; sensory and motor; part of pns drops bp, baring down; back of brain towards the medulla;
Cranial nerves: 11- name; sensory or motor; what does it do; located where; spinal accessory; motor; shoulder shrug, symmetrical movements; medulla;
Cranial nerves: 12- name; sensory or motor; what does it do; located where in the brain; hypoglossal; motor; tongue movement; medulla
golden hour for head injury: when does this start; we have an hour to do what; when the head injury occurs; get pt to emergency, control bp, surgery if needed,
assessment of the cranial nerves can tell us where ___ may be located head injury
Cranial nerves: what one responsible for pupil size; def hippus; oculomotor; rhythmic pupil dilation and contraction
def ptosis drooping eyelide;
ptosis is sign of pressure on what Cranial nerves 3rd
Cranial nerves: what 3 are responsible for EOMs; what does EOM stand for; 3,4, 6; extra ocular movments;
Cranial nerves: def diconjugate gaze; what cranial nerve responsible for this gaze one eye lazy and points a diff direction; 4 and 6
Cranial nerves: def absence of corneal reflex; if there is no corneal reflex this indicates issue with what CN no reflex means pt does not blink when we come at them with finger or object; 5
specific head/brain injuries: what is the most minor head injury; scalp lacerations;
after ___ mo the head is a fixed structure; since the head is a fixed structure there is no place for ___ to expand; where is the only place that the brain can expand; what are the 3 components in the skull; 18mo; the brain; the foramen magnum; brain, blood, CSF;
a change in one of the 3 components in the brain changes the other 2 why; b/c there is no placed for expansion;
list the anotomoy of the skull from skin to pia mater; what is located right on top of brain and very vascular; where is the CSF located; skin, periosteum, bone, dura mater, arachnoid, pia mater; the pia mater; right below the arachnoid space
nursing assessment for emergent brain injury: what should we obtain; what in hx are we looking for; what else assessed; assessment of __ very important Hx; determine the past and present health status of the individual, if they had strokes, ms, uncontrolled DM; vitals, mental status, motor system, sensory system, cranial nerves; LOC
CMs of head injuries: what is the 1st thing we see with head injuries; what is second change we see with head injuries; what are we assessing with motor functions; what other change would we see change in LOC; ocular signs; can they talk to you and get words out right; change in VS
Glascow coma scale: best motor response-what is a 6; what is a 5; obeys and follows commands, walk in room and they are awake alert and respond appropriately, may not be able to move butthumbs up,squeeze and release; localizes but clearly pushes away from pain
why do we want to be sure they can release too b/c it could just be a reflex
Glascow coma scale: best motor response- what is a 4; what is a 3; what is a 2 ; what is 1; withdraws only from painful stimuli; abnormal flexion or decorticate postering; abnormal extension or decerebrate posturing; flaccid no response to painful stimuli
def decorticate posturing; def decerebrate posturing; with decorticate posturing there is a problem where in the brain; with decerebrate posturing there is a problem where in the brain flexion of arms and extension of legs to stimuli; extension of all extremities to painful stimuli; cervical spinal tract or cerebral hemisphere; problem with midbrain or pons
Glascow coma scale: from all areas a score of ___ or less = comatose; even if pt is comatose they will for sure have a score of __ 7 or less ; 3
Glascow coma scale: eye opening response- what is 4; 3; 2; 1; spontaneous; to voice; to pain; none;
Glascow coma scale: best verbal response- what is a 5; 4; 3; 2; 1; converses oriented; converses disoriented; inappropriate words; incomprehensible words; no verbalization
Glascow coma scale: what are the 3 components; best motor response, eye opening response, best verbal response
skull fx: what are the 2 types; what one is worse and why; def linear; def depressed; open or closed; open worse b/c increased risk for infection; break in continuity of bone; identation of skull
skull fx: def comminuted; def compound; where on brain can there be a lot of bleeding; what sign will you see with basilar fx multi linear fx with fragments in many pieces; depressed fx with laceration, leaves open path to intracranial cavity; basilar fx; battle sign
skull fx: why is leakage of clear fluid a bad sign; how can it be distinguished from snot; def halo sign; possibly CSF; use glucometer and if it is CSF it will have sugar in it; white paper towel touch it to CSF and rings will form;
CSF: what does it have in it; a leak increases the risk for what protein and glucose; RBCs or WBCs; infection
concussion: there is a disruption of what; why is there a disruption; what is usual tx; what s/s indicate pt should come back; neuronal activity; due to josseling of the brain; be sent home with instructions and when to come back; inc tiredness, increased confusion, irratibility, n/v
concussion: do they always lose consciousness; for how long is LOC change; pt may experience what; is there visable damage to brain no; 5 min or less; amnesia; no
post concussion syndrome: how long after concussion is it seen; s/s; what unit do they end up in at times from 2 weeks to 2 months after concussion; HA, lethargy, behavioral changes, ADD, change in intellectual ability; psych
def contusion bruising of brain tissue
contusion: cerebral- this can lead to swelling where; what else can it lead to; brain; edema, IICP, herniation;
contusion: brain stem contusion- there is always an altered __; what other changes are evident LOC; resp, pupil, eye movement, and motor changes;
def coup; def contrecoup; injury on affected side; secondary impact as brain bounces to other side of the cranium (ex- MVA, shaken baby, baseball bat
hematomas: epidural- located between where; arterial or venous bleed; what initially happens; the dura and inner surface of the skull; arterial; concussion, person recovers and then deteriorates fast;
what hemotoma is an emergency epidural
hematomas: subdural-bleeding: bleed is where; venous or arterial; do we have more or less time then epidural between dura and arachnoid layer; venous; more time
hematomas: intracerebral- where is the bleeding; what pt is a big risk; inside the parenchyma- inner cerebral stroke bleeding; anticoagulant pt
hematomas: epidural- where is blood; what artery bleeds often; this bleeding increases __; body tries to compensate by doing what; between skull and dura mater; middle meningeal artery; ICP; diplaces fluids- can only do this for so long;
hematomas: epidural- IICP causes what; what happens 1stafter trauma; after unconsciousness what happens to pt; after lucidness what happens herniation; unconscious at first; they are awake and lucid; rapid deterioration in LOC;
hematomas: epidural- when LOC decreases what happens to pupils; as hematoma increases what happens on side of hematoma; eventually client will lapse into ___; surgery is for what; why is cranium left off they dilate; paralysis; coma; to evacuate clot and repair the bleed; to accomidate swelling
hematomas: subdural- located where; most common cause; what veins cause the bleeding; does ICP increase; what happens to pupils; why may we not notice IICP with older adults; between dura mater and arachnoid; injury and fall; bridging veins between cortex and dura; yes; on same side of pressure they are dilated; brains are atrophying;
hematomas: subdural - what pt have worse outcomes younger;
hematomas: chronic subdural- who does this happen to; what happens to brain; the bridging veins do what; the stretched veins can easily what; how long to develop elderly or alcoholics; atrophies; stretch; rupture; weeks to months
hematomas: chronic subdural- s/s; what is tx; what should HOB be when draining and why; HA, N/V, hemiparesis, gait disturbances; surgical draining; flat postop to fill up evacuation in brain;
hematomas: chronic subdural- what meds should we have on hand just in case; vit K and FFP to reverse anticoags
hematomas: subarachnoid- bleeding where; bleed caused by rupture of what; what happens to the ventricles; how long are they in the hospital cerebralspinal fluid filled space; cerebral aneurysm on circle of willis; they fill with blood; a long time
hematomas: intracerebral- where is bleeding; associated with other __; neuro deficits depend on ___; what happens to ICP; what is cause; cerebral substance; injuries; region involed and size; it increases; high BP, trauma
conditions the predispose to IICP: as pressure rises what happens to CBF; if there is decreases cerebral blood flow what happens to perfusion; too much decreased perfusion can cause what it decreases; it decreases; stroke;
conditions the predispose to IICP: decreased perfusion causes what to rise; decreased perfusion causes what to decrease; increased PC02 causes what to veins; vasodilation does what to brain; pCO2; Po2 and pH; vasodilation; cerebral edema;
conditions the predispose to IICP: increased cerebral edema causes what; IICP causes displacement of what; IICP; displacement or the 3 elements of the cranium tissue, CSF, blood
intracranial dynamics: def compliance; shunting of CSF into ___ does what; with compliance what happens to CSF production; the ability of the brai to adapt to increasing pressure without increasing ICP; in the spinal subarachnoid space increases CSF absorption; it decreases
intracranial dynamics: where is blood shunted with compliance; def herniation out of the skull; when swollen tissue goes out of the foramen magnum
CPP: aka; def; calculation; how is MAP calculated; what is goal of CCP to adequately perfuse brain cerebral perfusion pressure; the amount of systemic blood flow required to provide adequate oxygen and glucose for brain metabolism; MAP - ICP ; MAP = 1/3 (SBP-DBP); 70-100
ICP: aka; def; how is it measured; what is norm; pressure > ___ = IICP; increased pressure effects what; intercranial pressure; pressure excerted in the cranium by its contents (brain, blood, CSF); via monitors In the ventricle or subarachnoid space; 5-15 mm HG 20; cerebral perfusion;
what is the leading cause of death in head injuries IICP
IICP: what is a late sign of IICP; what is cushing's triad cushings triad; altered breathing, slow pulse, increased BP
ICP monitoring: indications- when there is an increased volume of what 3 things; what other regions brain, blood, CSF; legions -they can go into the subdural space or ventricles
intracranial monitoring: this helps clinician see what; helps monitor brain response to what IICP before clinical signs and destruction to brain tissue; other tx
intracranial monitoring: monitor waves- how many types of waves are there; def C wave; def B waves; how often to B waves occur; def A waves; 3 types; normal low pressure waves; IICP to 50; 30 sec- 2 min; brain not compensating, IICP worse then B;
A waves aka plateau waves
intracranial monitoring: ventriculostomy- can this type drain fluid; where is it placed; purpose; advantages; disadvantages yes; small tube placed into the lateral ventricle on non dominant hemisphere; monitor ICP, drain CSF and decrease ICP; accurate pressures and drainages; high risk for infection
intracranial monitoring: subarachnoid screw- where is it placed; is it more or less invasive; can it drain fluid in subarachnoid space; less; no
intracranial monitoring: epidural- where is this catheter placed b/t skull and dura
intracranial monitoring: nursing care for ventriculostomy- what should be sterile and why; prevent what; what system should be leveled to physician parameters; transducer is usually leveled to where; tubing and drainage system- huge risk for infection; tubing kinks; transducers; in line from tragus to get accurate reading
ventriculoperitoneal shunt: this redirects CSF to where; the CSF is reabsorded where; fluid should be what color; if there is a bleed slowly we expect fluid to be what color; to peritoneum through one way valve and catheter; in the peritoneum and pressure is relieved in brain thus decreases IICP; clear; back to clear
increased ICP r/t cerebral edema- we want to monitor for s/s or what; what should HOB be and why; what else do we need to manage; IICp with neurochecks; at 30 degrees to not impact venous return; sedation, agitation and hyperactivity;
ventriculoperitoneal shunt: nursing care- no pressure where; monitor for what; monitor for ___ occlusion; s/s of decreased ICP; how do you alleviate HA; teach what on incision; IICP, wound infection, HA, seizures; shunt; HA; place pt in recumbent position; to report fever, HA, irritability and signs of increased or decreased ICP;
nursing care for IICP: what is fluid restriction; what fluids can be given; what med pulls volume from the brain tissue for IICP; there is strict _ and __; keep temp down with what blanket; where should HOB be; what is given to decrease brain edema; 1000-1500 ml/day; isotonic or hypertonic D5 0.9; mannitol; I and O; hypothermia blanket; 30degrees; glucocorticoids;
nursing care for IICP: who should not get glucocorticoids; prevent what with ABGs; why no suction pt with bleeds, tumor in brain; hypoxia, hypercarbia; may communicate with brain or cause pt to cough and increase pressure in he brain
altered cerebral tissue perfusion goals/ outcomes: GCS; pupils; BP; pulse; anxiey; pt at risk for DVTs why stable or improving; no change; no high SBP widening pulse pressures; no bradycardia; none, no restlessness, HA; no anticoags b/c of bleed
ventilating with ICP: this increases what ABG; this rapidly decreases what ABG; the decreasing CO2 causes what to veins; vasoconstriction reduces what; what does hyperventilation do; O2; CO2; vasoconstriction; CSF thus decreases IICP; cause neuro changes by decreasing CSF to fast;
herniations: how bad is this outcome; brain is in a closed box and pressure in the brain pushes brain where; this herniation sacrifices what; with no tx what eventually fails; the worse; down through the opening for the brain stem; upper brain and consciousness; lower brain functions (BP, resp, temp,fail)
central herniation: what is the tissue that separates the upper and lower brain; with IICP the upper brain herniates through where; def tentorial notch; this compresses what tentorium; the tentorial notch; opening in tentorium leading to lower brain; lower brain;
central herniation: what is part of lower brain; what is the 1st sign of this; what will happen to pupils diencephalon, mid-brain, pons; dec LOC; very dilated
uncal herniation: def uncus; this compresses where in brain; what nerve is affected; what artery is affected; what is 1st CMs of this; medial portion of temporal; midbrain; oculomotor nerve; cerebellar; pupil reaction sluggish then unresponsive;
uncal herniation: the sluggish pupil reaction is seen 1st on ipsilateral or contralateral side; what is 2nd CM ipsilateral side; dec LOC;
def ipsilateral same side of injury
foramen magnum or tonsillar herniation: aka; the cerebrellar tonsil herniates where; this compresses what; what are vs; what happens to body cerebellar herniation; through the foramen magnum; medulla and upper portion of spinal column; BP, P, resp Dec LOC; arched stiff neck and quadriparesis
herniation: tx- 1st; meds; tests contract surgeon; mannitol 1g/ 1kg IV push if BP stable; immediate cTscan
meds for bleeds/herniationetc: what osmotic diuretics; why are anticonvulsants given; ex of anticonvulsants; what loop diuretics are given; what steroids are given; mannitol; to prevent seizures; Dilantin, phenobarbital, valium; Lasix; decadron;
meds for bleeds/herniationetc: steroids should not be given to who; barbiturates are given for what; ex of sedatives; why are neuromuscular blocking agents given; ex or neuromusclular blocking agents; why are beta blockers given no for bleeds but tumor; sedation; phenobarbital, diprivan (propoful); when ICPs go up airway is needed and we need sedation to; norcuron; labetalol help w/ BP and a offers a bit of sedation too
osmotic diuretics: mannitol- what labs should be watched; if kidney function is not working well the excess fluid can go where; this is __ tonic; this fluid is drawn from where in the brain; side effects kidney functions; to lungs and heart; hypertonic; interstitial spaces and brain cells; altered electrolytes, hyptotension, hard on renal system
loop diuretics: why is Lasix given; this removes what from injured brain cells; this decreases the production of what; it enhances mannitol; sodium and water; CSF thus decreases swelling of brain tissues
anticonvulsants: they do what; examples; control and prevent seizures; Dilantin, phenobarbital, valium
barbituate coma: what is used if IICP is not controlled; pt needs vent?; what are side effects; what are they 3 things they do; pentobarbital; yes; hypotension, arrhythmias, F% E imbalance; cardiac depressant, reduces metabolism, stabilizes cell membrane;
barbituate coma: what should be monitored with cardiac depressant; what is goal of MAP; why is MAP important; how does it reduce metabolism; do these pt need central lines; MAP; keep >80; to decrease cerebreal blood flow; cools pt monitor temp; yes;
neuromuscular blocking agent: med; this counteracts IICP how; why do they need sedation; how is the depth of therapy monitored vercuronium; from reflex motor responses; bc pt cannot move and it is scary; with train of four
train of four: aka; ulnar peripheral nerve stimulation causes what to twitch; no twitch = ___; 2-3 twitches =___; 4 twitches =____ peripheral nerve stimulator; thumb; paralysis; adequate NMB; paralysis insufficient
sedation: propofol- these pt need what; what does it decrease; may cause what;does it relieve pain; what happens to bp as side effect; side effects; decreases what airway; anxiety and awareness of noxious stimuli; hypotension; no; hypotension; green hair and urine; CBF, ICP, CPP
blood pressure: what is the goal of MAP; what do we use to sustain SBP; what meds are used if BP increases; why are vasodilators avoided 70-90 cm; drugs and fluids; beta blockers and labetalol, apresoline; it will increase IICP
hypothermia: what does high body temp do in IICP; hypothermia stops increased ___; damage is decreased by __% every degree that we bring the body temp down; how do we cool them; what is degree goal; how long do we cool; it accelerates brain damage; metabolic, O2 demands, and subsequent damage; 6-10%; by saline and cold blankets; 90 F and 32 C; 24 hours
nursing care with hypothermia: what is used for continuous temp monitoring; what do we want to avoid that will increase ICP; what is used to stop the shivers; why do we want to turn q1h; rectal probe; shivering response; Demerol; to prevent skin damage;
complications of hypothermia: what happens to skin; what can happen to temp; why does metabolic acidosis cause; what can happen to heart; what happens to fluid; shivering and burns when warming up; it can go too low; due to shivering; arrhythmias; it shifts
cerebral aneurysm: __% is congenital; men or women; age; what hemorrhage does it cause when it is ruptured; what type of aneurysm is commen; 90%; women; 30-50; subarachnoid hemorrhage; saccular-berry aneurysm;
cerebral aneurysm: goal in nursing care; what do we do to prevent IICP; what do we do to control BP prevent IICP and control BP; quit, low light, monitor neuros freq, HOB up 30 degrees, turn carefully, restrict visitors; CCB given to prevent vasospasms, surgery;
nursing care post-craniotomy: what assessment often; what is monitored; what to prevent; we want to maintain a normal ___; check for what drainage; frequent neuros; fluid seizures and lyte balance; infection and IICP; temp; from nose or ears for HALo effect;
nursing care post-craniotomy: why do we give a stool softener; to prevent valsalva;
Nutritional needs for Neuro pt: dec LOC increases risk for ___; what feeding is used on vent; what should tube feeding be; why low CHO; they need frequent what aspiration; tube feeding; high fat low CHO; to decrease pCO2; mouth care
nursing care for corneal transplant: why is there anxiety; why is there short notice; how is it checked in am; what needs to be assessed; what is avoided r/t short notice for OR; b/c the transplant needs to occur w/in 6 hours of death from cadaver donor and 24-48 hrs to transplant; slit lamp checked; self care ability esp with monocular vision; cough and valsalva
enucleation: what anesthesia; complications; what is put in socket; how long is pressure dressing on; when can prosthesis be used; when should it be washed local or general: hemorrhage, infection, meningitis; conformer to prevent malformation; 24-48 hours; when swelling subsides; with soap and water with insertion and reloval
IICP occurs with the increase in the size of ____ intracranial contents
autoregulation of cerebral blood flow: this is the automatic adjustment in what; what is purpose the diameter of the cerebral blood vessels by the brain to maintain a constant blood flow during changes in arterial BP; to ensure a consistent CBF to provide for the metabolic needs of brain tissue
babinskis reflex: what happens; what is wrong upgoing toes with planar stimulation; suprasegmental or upper motor neuron lesion issues
change in LOC is a result of impaired ___ cerebral blood flow
IICP: what will pupils be; at first dilated on same side (ipsilateral) to the mass then if it worsens it will remain that way and it becomes an emergency;
For CSF drainage what is ordered by the physician level of ICP pressure, amount of fluid to be drained, height of system and frequency of drainage
why is hyperventilation not used to decrease IICP increases the risk for focal cerebral ischemia and adversely effects outcomes;
contusions are usually associated with a closed or open head injury closed
what are common complications of contusions seizures
what hematoma is a neurological emergency epidurmal hematoma
s/s of what cerebral hematoma are similar to brain tissue compression IICP, decreased LOC, HA
when does ipsilateral pupil dilation become fixed when IICP is signigicant
what age is most likely to get chronic subdural hematomas; why do ppl at this age have increased risk 50-60s; due to brain atrophy
head injury: why are ppl at risk for hyperthermia; due to increased metabolism, infection and loss of cerebral integrative function secondary to possible hypothalamic
deaths from head injuries occur at what 3 time frames after injury immediately, 2 hours after, 3 weeks after
what skull fx can cause bulging of tympanic membrane caused by blood or CSF, battle's sign, tinnitus or hearing difficulty, vertigo, conjugate gaze basilar skull fx
Created by: jmkettel
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