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Test Four

Cardiac Structure, Neuro, Intracranial

What is paraplegia? Paralysis of the lower portion of the body, sometimes involving the lower trunk. It occurs when the thoracic, lumbar, and sacral portions of the spinal cord are injured.
What is quadriplegia? Also called tetraplegia, it occurs when cervical segments of the cord are injured, impairing function of the arms, trunk, legs, and pelvic organs
What is spinal shock? Temporary loss of reflex function below the level of injury
What are spinal shock manifestations? Flaccid paralysis of skeletal muscles, loss of all spinal reflexes, loss of sensations, and loss of ability to perspire all below level of injury. Bowel & bladder dysfunction. Shock develops in 30-60 minutes after injury & can last for minutes to months
What is autonomic dysreflexia? (also called autonomic hyperreflexia) An exaggerated sympathetic response that occurs in clients with SCIs at or above the T6 level
When is the only time autonomic dysreflexia is seen? Is only seen after recovery from spinal shock and occurs as a result of a lack of control of the autonomic nervous system by higher centers
What are signs and symptoms of autonomic dysreflexia? Pounding headache, hypertension, sweating, goose flesh, nasal congestion, severe bradycardia
What triggers autonomic dysreflexia? Distended bowel, distended bladder, stimulation of skin. A full bladder/blocked urinary catheters are the most common causes.
What are the treatments for autonomic dysreflexia? Elevated HOB, drain bladder, remove impaction/tactile stimuli, B/P meds (apresoline, hyperstat), muscle relaxants
How do they diagnose spinal cord tumors? Xray, CT Scan, MRI, myelogram, lumbar puncture
What are medications and treatments for spinal cord tumors? Narcotic analgesics via epidural catheter, steroids (e.g. decadron) to control edema, surgical removal, radiation therapy
What are the appropriate nursing diagnoses for spinal cord tumor clients? Anxiety, risk for constipation, impaired physical mobility, acute pain, sexual dysfunction, urinary retention
What is the most common cardiac valve dysfunction? Aortic Stenosis
Where is the blood flow obstructed with aortic stenosis? It obstructs forward blood flow from the left ventricle during systole
What are the causes of aortic stenosis? Age related degenerative calcification and rheumatic disease
What are complications of aortic stenosis? Risk for CHF, dilated cardiomyopathy, ineffective endocarditis, and sudden death
What are the cardinal symptoms of aortic stenosis? Angina, syncope, exertional dyspnea; if severe, reduced ejection fraction and A Fib, S3 & S4
What is the most common early sign of aortic stenosis? A systolic heart murmur (heard best in a forward-leaning, sitting position)
How do they diagnose aortic stenosis? ECG (tall R waves, ST depression, inverted T wave), Chest xray, transthoracic echocardiography, cardiac catheterization
What are treatments for aortic stenosis? HMG-CoA reductase inhibitors (statins), surgical valve replacement for severe symptomatic patients, prophylactic antibiotics before invasive procedures, avoidance of vasodilators
What is aortic regurgitation? Valve doesn’t close fully during diastolic; blood flows back into left ventricle
What are complications of aortic regurgitation? Leads to left ventricular hypertrophy and reduced volume, ejection fraction
What are causes of acute aortic regurgitation? Aortic dissection, trauma (requires immediate surgical repair)
What are causes of chronic aortic regurgitation? Hypertension, collagen vascular disease, congenital bicuspid valve
What are signs and symptoms of aortic regurgitation? Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, angina, patient aware of heartbeat
How do they diagnose aortic regurgitation? Transthoracic echocardiography, cardiac catheterization, ECG
What are treatments for aortic regurgitation? Vasodilator therapy, surgery in chronic regurgitation if ejection fraction falls below 55% or trauma or aortic dissection
How does mitral stenosis affect the flow of blood? It impedes blood flow from left atrium to left ventricle during diastole, increasing left atrial pressure
What is the most common cause of mitral stenosis? Rheumatic fever (other causes include congenital conditions, and manifested with stress of pregnancy)
What are common signs and symptoms of mitral stenosis? Dyspnea, fatigue, hemopysis, orthopnea, paroxysmal nocturnal dyspnea, palpitations, resting tachycardia, irregularly irregular pulse, enlarged left atrium, lung congestion, increased pulmonary pressure
What are treatments for mitral stenosis? Severe stenosis requires surgical repair, diuretics and digoxin for heart failure, beta blockers, calcium channel blockers and anticoagulants for A Fib, prophylactic antibiotics before invasive procedures
How does mitral regurgitation affect the flow of blood? The blood is ejected back into the left atrium during contraction
What is hallmark cause of mitral regurgitation? Chronic volume overload
How do they diagnose mitral regurgitation? Echocardiography
What are signs and symptoms of mitral regurgitation? SOB, orthopnea, paroxysmal nocturnal dyspnea, fatigue, and decreased exercise tolerance, atrial irritation, pulmonary congestion
What are treatments for chronic mitral regurgitation? Reduce afterload with angiotensin-converting enzyme (ACE) inhibitors
What are treatment options for acute mitral regurgitation? Surgery if ejection fraction below 60% or acute symptomatic mitral regurgitation. Surgery options: repair or replacement—repair preferred because it reduces need for long-term anticoagulants and replacement raises the risk of endocarditis
Who is at greatest risk for mitral valve regurgitation? Young men, older women
Where is the obstruction of blood flow with tricuspid stenosis? Blood flow is obstructed from right atrium to right ventricle
What is the primary cause of tricuspid stenosis? Rheumatic heart disease
Where is the obstruction of blood flow with bicuspid (pulmonic) stenosis? Blood flow is obstructed from right ventricle to the pulmonary system
What is the acute cause of heart failure? Myocardial infarction
What are the chronic causes of heart failure? Cardiomyopathy, valvular disease, coronary heart disease
What are the four heart valves? Mitral, aortic, tricuspid, pulmonic (aka bicuspid)
What is a mitral valve prolapse? When the mitral valve cusps fall into the left atrium. It is usually asymptomatic. Those at biggest risk are women age 14-30.
What is rheumatic fever? Inflammation of the endocardium, myocardium, and pericardium
What are signs and symptoms of rheumatic fever? Rash, chest discomfort, pericardial effusions, rubs, murmurs
What is the treatment for rheumatic fever? Antibiotics, PCN, steroids
What is myocarditis? Inflammatory disorder of the myocardium
What is myocarditis caused by? Infection (usually viral), burns, poison exposure, autoimmune response
What is the treatment for myocarditis? Steroids, antibiotics, rest
What is pericarditis? Inflammation of the pericardium
What are causes of pericardium? Idiopathic, MI, trauma, post op infection
What are the signs and symptoms of pericarditis? Cough, chest pain, hemoptysis, dyspnea, friction rub, signs and symptoms of tamponade
What are the treatments for pericarditis? Steroids, antibiotics, pericardiectomy or window, pericardiocentesis or tap
What is preload? Volume of blood in the ventricles at end-diastole (stretch)
What is afterload? Amount of force the ventricle must develop to eject the blood into circulation
Which is more common: Left-sided or Right-sided heart failure? Left-sided
What are signs and symptoms of left-sided heart failure? Signs & symptoms of decreased CO, pulmonary congestion, SOB, S3, cyanosis, orthopnea
What are causes of left-sided heart failure? Atherosclerotic heart disease, MI, myocarditis, valvular disease, hypertension, overloading
What are causes of right-sided heart failure? Pulmonary hypertension, COPD, right ventricular MI, PE, left ventricular failure (number one cause)
What are signs and symptoms of right-sided heart failure? Edema, increased venous pressures, hepatic congestion, JVD, ascites, oliguria, anorexia/nausea
What is hemodynamic monitoring? Invasive monitoring to evaluate cardiac function in critical patient. Measures the pressures within the vessel by use of a transducer
What is an arterial line used for? Direct, continuous monitoring of systolic, diastolic, and mean pressures
What is a Swan-Ganz catheter? Balloon tipped catheter threaded through right atria to right ventricle into the pulmonary artery. Assesses left ventricular function, right atrial pressures, pulmonary capillary wedge pressure (PCWP)
What is the pulmonary capillary wedge pressure? It reflects the left ventricular diastolic pressure and is measured with the Swan-Ganz catheter balloon inflated.
Where are the AV valves found and what are their purpose? The AV valves are found between the atria and the ventricles. These valves open and shut to keep blood flowing forward through the heart.
What is the purpose of the semilunar valves? These valves keep blood flowing out to the lungs and the body
What is stroke volume? How much blood the heart pumps out every time it beats (strokes)
What is cardiac output? The amount of blood that the heart pumps out in one minute
How is cardiac output calculated? Stroke volume multiplied by heart rate
What is cardiac index? calculation that uses the CO & body surface area. Much more reflective than cardiac output of whether or not the amount of blood being pumped out of the heart is enough for the client because it takes into consideration the size of the client.
What are the four classifications of heart failure? Systolic or diastolic failure, left ventricular or right ventricular, low-output or high-output, and acute or chronic failure
What is systolic heart failure? When the ventricle fails to contract adequately to eject a sufficient blood volume into the arterial system
What is diastolic failure? When the heart cannot completely relax in diastole, disrupting normal filling.
What are common causes of left ventricular (left-sided) heart failure? Coronary heart diseases and hypertension
What are the common causes of right ventricular (right-sided) heart failure? Conditions that restrict blood flow to the lungs, such as acute or chronic pulmonary disease
Clients with which conditions develop low-ouput heart failure? Heart failure due to coronary heart disease, hypertension, cardiomyopathy, and other primary cardiac disorders
Clients with which conditions develop high-output heart failure? Hypermetabolic states (e.g. hyperthyroidism, infection, anemia, pregnancy) which require increased cardiac output to maintain blood flow and oxygen to the tissues
What is acute heart failure? Abrupt onset of a myocardial injury (such as a massive MI) resulting in suddenly decreased cardiac function and signs of decreased cardiac output.
What is chronic heart failure? Progressive deterioration of the heart muscle due to cardiomyopathies, valvular disease, or coronary heart disease
Why is a contusion a more serious injury than a concussion? Contusions-localized & macroscopic, concussions- widespread & microscopic. Concussions involve temporary axonal disturbances, contusion is a bruise caused by bleeding in the brain & usually results in permanent damage to the injured area
How does a contra-coup injury occur? The brain nearest the point of impact bashes against the inner hard skull producing a contusion. There is a bounce back of the brain within the skull or a suddenly created vacuum that produces a 2nd contra-coup contusion on the opposite pole of the brain
How is Doll’s Eyes (oculocephalic) reflex assessed? The eyes will move opposite the direction the head is turned, thus maintaining a more-or-less steady gaze
What does the absence of the oculocephalic reflex indicate? Its absence suggests damage to the brain stem. It carries a very poor prognosis, possibly indicating brain death
What is the advantage of the MRI over the CT scan? MRI gives much higher detail in the soft tissues and can produce images in any plane
How does Mannitol work to reduce ICP? osmotic diuretic that increases the osmolarity of the blood, thereby drawing water out of the edematous brain tissue and into the vascular system for elimination via the kidneys
How do steroids decrease ICP? They restore cell wall integrity and help in recovery and reduces edema
What is the maximum dose of dilantin? 20 mg/kg max
What is the max rate of dilantin? 50 mg/min
What is Nimotop and how does it work? It is a lipophilic calcium channel blocker that effectively crosses the blood brain barrier. It reduces the incidence and severity of neurological deficits resulting from vasospasm
How do you calculate Mean Arterial Pressure (MAP)? MAP = systolic + (2 x diastolic)/ 3
How do you calculate Cerebral Perfusion Pressure (CPP)? CPP = MAP –ICP
What is normal range for CPP? 70 to 95 mmHg
What doctor’s orders should the nurse expect to help lower ICP? Sedation, bedrest, IV fluids, antipyretics, antiulcers, antihypertensives, vasopressors, stool softeners, HOB elevated at least 30 degrees, knees flat, keep neck neutral
Why does a brain herniation occur? When pressure inside the skull increases and displaces brain tissues
What are the primary nursing diagnoses for the neurological client? Ineffective airway clearance, High risk for fluid volume deficit, altered oral mucous membranes, high risk for impaired skin integrity, ineffective thermoregulation
What are nursing interventions for Ineffective airway clearance? Position in lateral or semi prone position to maintain open airway and facilitate drainage of secretions, suction as necessary to prevent aspiration, Keep HOB up 30 degrees or more, be prepared to intubate if respiratory effort diminishes
What are nursing interventions for High risk for fluid volume deficit? Monitor for side effects of dehydration, NGT placement may be required for feedings, do not give oral fluids until swallowing is assessed, administer IVF and blood slowly so as not to increase ICP
What is the difference in an open versus a closed skull fracture? In an open fracture the dura is torn. In a closed fracture the dura is not torn.
Skull fractures are either open or closed and are further classified into what four categories? Linear, comminuted, depressed, or basilar
What is a linear (simple) skull fracture? Simple, clean break in skull. Occurs with low-velocity injuries. Generally requires bed rest and observation for underlying injury to brain tissue or hematoma formation. No specific treatment is required.
What is a comminuted skull fracture? Bone is crushed into small, fragmented pieces. Usually seen with high-impact injuries.
What is a depressed skull fracture? Inward depression of bone fragments. Usually due to a powerful blow to the skull. The dura may or may not be intact. Bone fragments may penetrate into the brain tissue. Requires surgical intervention, usually within 24 hours of the injury
What is a basilar skull fracture? Occurs at the base of the skull. May be linear, comminuted, or depressed. Does not require surgery unless CSF leakage persists.
What are the purpose of Burr holes? They are used as openings to insert ventricular drains and pressure monitors. The hole may facilitate the evacuation of an extracerebral clot, or a series of holes may be made in preparation of a craniotomy
What are the three components that are found inside the rigid, non-flexible, bony structure of the skull according to the Monroe-Kellie Hypothesis? Brain 80%, cerebrospinal fluid 8%, and blood 12%
What is the Monroe-Kellie Hypothesis? A state of dynamic equilibrium exists; if the volume of any of the three components increases, the volume of the others must decrease to maintain normal pressures within the cranial cavity
What is Intracranial pressure (ICP)? It is sustained elevated pressure (10 mmHg or higher) within the cranial cavity. The normal ICP is 5 to 10 mmHg measured intracranially with a pressure transducer while the client is lying with the HOB elevated 30 degrees
What are causes of ICP? Head injury, stroke, tumor, inflammatory process, intracranial surgery, cough, mechanical ventilation
What is a brain tumor called? Glioma
What is a tumor of the brain covering called? Meningioma
What is a tumor of the cranial nerves called? Neuroma
What are terms for a tumor of the blood vessels? Angioma, hemangioblastoma
What are clinical manifestations of brain tumors? Headache (most common), vomiting, LOC changes, motor & sensory losses, seizures, autonomic & vasomotor changes, visual changes
What is an Ommaya reservoir? An intraventricular method of medication administration. The ommaya reservoir is surgically implanted into a lateral ventricle of the brain.
What is Parkinson’s disease? Progressive, degenerative neurologic disease characterized by tremor, muscle rigidity, and bradykinesia (slowness of movement)
What is the only definitive method of diagnosis Alzheimer’s disease? Postmortem examination of the brain tissue
What is the most common degenerative neurologic disorder and the most common cause of cognitive impairment in older adults? Alzheimer’s disease
What is usually the first sign of Alzheimer’s disease? Memory loss
What is the frequent cause of death with Alzheimer clients? The cause of death is often aspiration pneumonia because of the loss of the ability to swallow late in the disease. Usually live about 7 years after diagnosis.
What are the risk factors for Alzheimer’s disease? Older age, family history, and female gender
What are the three stages of Alzheimer’s disease? Early, Confusional, Terminal
What is the cure for Alzheimer’s disease? There is no cure, but some medications are effective in slowing the progression of the disease (Cognex, Aricept, Exelon, Reminyl)
What is Multiple sclerosis (MS)? A chronic demyelinating neurological disease of the CNS, associated with abnormal immune response to an environmental factor
What causes multiple sclerosis? It is believed to occur as a result of an autoimmune response to a prior viral infection in a genetically susceptible person, associated with a deficit in T-Lymphocytes
When is the usual onset of MS? Usually between 20 and 50 years of age, with a peak age of 30.
What is Huntington’s disease? A progressive, degenerative, inherited disease that is characterized by increasing dementia and chorea (jerky, rapid, involuntary movements)
What causes Huntington’s disease? Single gene autosomal dominant. Child has a 50/50 chance of inheriting the disease if the parent has the disease
What are the manifestations of Huntington’s disease? Usually asymptomatic until age 30 to 40, primarily affects movement and posture, swallowing and speech, cognition and personality, symptoms progress as condition deteriorates. Progression is slow, usually 15 to 20 years
What is the treatment of Huntington’s disease? Symptom driven as there is no cure, antipsychotics and antidepressants for palliative care
What is Amyotrophic Lateral Sclerosis—ALS (Lou Gerhig’s Disease)? A degenerative disease affecting upper and lower motor neurons. The cells die and the muscles atrophy. There is no sensory or cognitive changes; weakness begins as loss of fine motor in hands.
What is the etiology for ALS? Nutritional deficiency r/t problem with enzyme metabolism, vitamin E deficiency, autoimmune disorder
How do they diagnose ALS? EMG and muscle biopsy show muscle fibrillation at rest and muscle fiber loss
Is ALS fatal? Yes. They usually die within 3-5 years of diagnosis r/t aspiration pneumonia
What is Guillain-Barre? Acute infectious neuronitis where the immune system overreacts to an infection destroying the myelin sheath. Cognition and LOC not affected. Severe muscle pain. May follow upper respiratory infection or gastroenteritis
How does Guillain-Barre progress? Weakness begins in lower extremities and progresses symmetrically to upper extremities, may result in respiratory failure.
What is Myasthenia Gravis? Autoimmune disease that destroys acetylcholine receptor sites, affects skeletal muscles
What are manifestations of Myasthenia Gravis? 75% have hyperactive thymus gland, muscle weakness involving eyes (ptosis), face (difficulty smiling, closing mouth), and oropharynx (impaired speech, swallowing, chewing), respiratory paralysis and failure
How do they diagnose Myasthenia Gravis? Tensilon test results in increased muscle strength within five minutes of injection of medication.
What is Myathenic Crisis? Exacerbation of Myasthenia Gravis r/t missed dose, undermedication, infection
What is Cholinergic Crisis? Overdosage of anticholinesterase medicine. Treat with atropine
How are spinal cord tumors classified? By anatomic location
What are the two classifications of spinal tumors? Intramedullary (makes up about 10%) and extramedullary
Where are intramedullary spinal tumors located? They arise within the neural tissues of the spinal cord
Where are extramedullary spinal tumors located? They arise from tissues outside the spinal cord
What is often the first manifestation of a spinal cord tumor? Pain
What are manifestations of cervical cord tumors? Paresis of arms and legs, stiffness of neck, paraplegia, pain in the shoulders and arms, hyperactive reflexes
What are manifestations of thoracic cord tumors? Pain in the back and chest, positive babinski reflex, bowel and bladder dysfunction, sexual dysfunction
What are manifestations of lumbosacral cord tumors? Pain in the lower back radiating to the legs and perineal area, loss of sensation in the legs, bowel and bladder dysfunction, sexual dysfunction, decreased or absent ankle and knee reflexes
What tests are used to diagnose a spinal cord tumor? x-rays, CT scans, MRI, myelogram, and lumbar puncture
A lumbar puncture of the client with a spinal cord tumor will demonstrate CSF that is xanthochromic (having a yellow color), has increased protein, has few to no cells, and clots immediately. This cluster of findings is known as what? Froin’s syndrome
What are treatment options for spinal cord tumors? Medications (narcotics for pain, steroids for edema), surgery, radiation therapy
What is encephalitis? An acute inflammation of the parenchyma of the brain or spinal cord
Encephalitis is almost always caused by what? A virus
What is meningitis? Inflammation of the pia mater, the arachnoid, and the subarachnoid space (can be bacterial, viral, fungal or parasitic in origin)
What are manifestations of bacterial meningitis? Restlessness, agitation, irritability, severe headache, chills and high fever, confusion or altered LOC, photophobia, seizures, signs of increased ICP, petechial rash, positive brudzinski’s sign, positive kernig’s sign, nuchal rigidity
What are manifestations of viral meningitis? Similar to those of bacterial meningitis, although usually milder
What is a brain abscess? An infection with a collection of purulent material within the brain tissue. (approximately 80% are found in the cerebrum and 20% are cerebellar)
What are the nursing diagnosis for a client with bacterial meningitis? Hyperthermia r/t infection and abnormal temperature regulation by the hypothalamus, disturbed thought processes r/t intracranial infection, ineffective protection r/t progression of the illness
What age group has the highest incidence of brain tumors? Although brain tumors can occur in any age group, the highest incidence is in those ages 50 to 70
What are manifestations of frontal lobe tumors? Inappropriate behavior, personality changes, inability to concentrate, impaired judgment, recent memory loss, headache, expressive aphasia, motor dysfunctions
What are manifestations of parietal lobe tumors? Sensory deficits, paresthesia, loss of two-point discrimination, visual field deficits
What are manifestations of temporal lobe tumors? Psychomotor seizures
What are manifestations of occipital lobe tumors? Visual disturbances
What are manifestations of cerebellum tumors? Disturbances in coordination and equilibrium
What are manifestations of pituitary tumors? Endocrine dysfunction, visual deficits, headache
What are treatment options for brain tumors? Treatment may involve chemotherapy, radiation therapy, surgery, or any combination of these
What are nursing diagnoses for client with brain tumors? Anxiety, risk for infection, acute pain, disturbed body image
If a client has had intracranial surgery you must monitor for a CSF leak. If they may have a CSF leak from the nose what do you do? Keep HOB elevated 20 degrees unless contraindicated, do not suction nasally, do not clean nose, tell client not to put finger in nose, do not insert packing
What if your client has a CSF leak from the ear? Position client on side of leakage unless contraindicated, do not clean ear, tell client not to put finger in ear, do not insert packing. Place a sterile dressing over the area of drainage and change as soon as it becomes damp.
What is a migraine? A recurring vascular headache lasting from 4 to 72 hours, often initiated by triggering event and usually accompanied by a neurologic dysfunction
What are the two types of migraine headaches? Common migraine (without an aura) and classic migraine (with an aura; most often experienced as a visual disturbance prior to the pain)
Which type of migraines are more prevalent? Common migraines are most common and occur in 80% of the people who are affected by the disorder
What are the risk factors for migraine headaches? Female, family history of migraine headaches
What are cluster headaches? Extremely severe, unilateral, burning pain located behind or around the eyes. The headaches occur in “clusters” of one to eight each day for several weeks or months, followed by remission lasting months to years.
What are risk factors for cluster headaches? Male, use of alcohol or nitrates, may begin in early childhood
What is a tension headache? Characterized by bilateral pain, with a sensation of a band of tightness or pressure around the head.
What are risk factors for tension headaches? Related to tension and anxiety, no family history, often begins in adolescence
What is the primary nursing diagnosis for client with headaches? Acute pain
What is a chronic disorder of abnormal recurring, excessive, and self-terminating electrical discharge from neurons? This disorder is characterized by recurring seizures accompanied by some type of change in behavior. Epilepsy
What is a single event of abnormal electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function? Seizure
What is the most common cause of epilepsy in older adults? Arteriosclerosis of the cerebrovascular system
Created by: lhawthorne