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Sensory 212
nursing 212 sensory 2.3.9
| Question | Answer |
|---|---|
| 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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