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ALOA
| Question | Answer |
|---|---|
| Brain | Encapsulated by the skull, and surrounded by CSF (surrounds brain and spinal chord) |
| Brain and spinal chord | Are continuous and protected by bones |
| Brain | Skull |
| Spinal chord | Spine |
| Cells are unable to reproduce | Nerve ending will regenerate but cells can’t |
| Blood Brain Barrier | Limits movement of |
| Cerebrum (cerebral cortex): | Two lobes on either side so we have a right and a left side |
| Diencephalon | Relay station inside the brain, contains glands |
| Brainstem | Nerve fibers pass through, Contains the Reticular Activating System: integrates cells which allow for sleep/wake patterns…allows consciousness and unconsciousness Contain cells that control respiratory and cardiac function |
| Cerebellum | Controls coordination and keeps the body oriented in space |
| Circle of Willis | Blood is supplied by internal carotid and vertebral arteries in the brain and are joined together at the base of the brain at the |
| Circle of Willis | A circle of bloods vessels that connect the vertebral and carotid arteries allowing constant blood flow to the braino If carotid artery is blocked, there is still blood flow to the brain because there is a circle of anastomosed blood vessels |
| Blood flows back to the body from the head via the | Jugular vein (drains) |
| Systemic circulation will favor | CNS over the rest of the body; one of the last organs to shut down |
| Vessels in the brain auto regulate so they allow for | Constant pressure in the brain (head) |
| High pressure | They will slow blood flow to the brain |
| Low pressure | They will increased blood flow to the brain |
| Four fluid filled compartment in the brain called ventricles | Normally contain CSF, CSF is formed and circulates (cushioning and protecting the brain and spinal columno Helps support the weight of the brain, carries nutrients, and removes metaboliteso CSF is formed at 18 mls/hro Drains via the jugular (imp |
| Meninges | Pads the braino 3 sets of meninges cover the brain, Pia mater, Arachnoid, Dura matero Form spaces called: Subarachnoid, Subdural, Epidural |
| Causes of ALOA | Mass lesion, Disruption in blood flow, Metabolic disorders, Infectious Disorders |
| Mass lesion | Blood clot after vessels have leaked and formed a cloto Tumorso Abscesseso Edema: increase bulk in the skullo Extra CSF: increase bulk |
| Disruption in blood flow | Ischemic or hemorrhagic stroke |
| Metabolic disorders | Electrolyte imbalances, Hypoxia (decreased O2), Chemical imbalance |
| Infectious disorders | Bacterial/viral infections |
| 6 Components of Assessment | Mental status, Cranial nerves, Motor function, Reflexes, Sensory function Cerebellar function All can provide clues about progress, LOA, and whats going on with the brain |
| Alert | Person awake and responsive, follow visual cues, directions and remember dates |
| Lethargic | Asleep when not aroused, but arousable |
| Obtunded | Requires a forceful touch to respond; response is minimal; may open eyes when shook hard or yell pt name |
| Stupoeous | Generally response only to painful stimuli (may only moan; may not open eyes); arousable with difficulty |
| Comatose | No verbal or motor response to any stimuli; RAS is damaged |
| LOC | Can fluctuate or occur on a continuum |
| Bilateral dysfunction | Usually a metabolic disorder |
| Unilateral dysfunction | Usually a stroke (one area of brain is affected) |
| Glascow Coma Scale | Eyes open, Best verbal response, Best motor response, A screening tool, Helps in grafting trends does not include pupils Higher the score the better |
| Painful Stimuli | Start with soft voice, move to loud voice, move to shaking then to pain, Start with the least noxious stimuli to the most noxious, Used in pt that can’t elicit a normal response |
| Nailbed pressure | To assess non-moving extremity, Pen or pencil to pt nailbed and apply pressureo See if pt responds by withdrawing, flexing or extending arm to painful stimuli |
| Sternal Rub | Use knuckles to rub sternal areao Watch for movement of extremities or a verbal response (pt may moan) |
| Supraorbital Pressure | Thumb to eye orbital bone (not socket) |
| Pinch trapezius muscle | May see bruising |
| Signs that Indicate Deterioration | First signs may be: Headache, Restlessness: in a normally relaxed pt, Irritability:Quietness: from a normally loud pt, Orientation: going from being alert to not knowing where they are; hallucinations, Speech:slurred, When you see these signs evalu |
| Cranial Nerves | Provide important information about the brain stem and its pathways, Generally test Cranial Nerves 3-7 III Oculomotor: constriction of pupils; look at equalness and briskness IV Trochlear V Trigeminal VI Abducenso VII Facial |
| Pupillary Reaction | CN III (Oculomotor) |
| Direct Response | Shining light |
| Consensual Response | Both react the same; when light is shined in one eye the other reacts the same |
| Accommodation | Pupils move as things are close and far |
| Eye Movement: Conjugate movement | They track together; follow finger and eyes move together |
| Eye Movement: Disconjugate movement | (roving eyes, bobbing, nystagmus): one eye moves one way but the other does not follow |
| Eye Movement: Doll’s Eyes | Oculocephalic Response Used in unconscious pto Open eyes, move head side to side- if eyes stay forward or if eyes rove (move around) it is a bad response |
| Eye Movement: Cold Calorics | Oculovestibular Response Tests CN III, VI, VIII (ear, balance, auditory nerve) Bulb syringe with ice water injected in to the earo Eyes should deviate (opposite) to side of ice water Warm water can be used too |
| Motor Response: Drift | Close eyes, arms out, see if one arm driftso In unconscious pt: equal hand grasping |
| Motor Response: Posturing | Decorticate: flexion, move arms up (better than extension), Decerebrate: extension, move arm down |
| Motor Response: Flaccicidy | No response to pain no matter how much pain appliedo Worst of all |
| CN IX: Gag Reflex | Swab the back of the pt throat, pt should gag or cougho If don’t have gag reflex, may have brain stem injury |
| CN V, VII: Corneal Reflex | Stroke eyelashes, pt should blink No blinking indicates nerve damage and deeper brain stem dysfunction |
| Babinski | Heel to toe, and across ball of footo Normal sign in adults is flexion (toes curl under) Positive sign is toes fanning out (pathological reflex) |
| Snout | Tap above or below lips and pt will purse lips |
| Chewing | Pt will chew if something is put in their mouth, Pt will try to chew an oral airway, Severs diffuse brain injury |
| Grasp | Pt will grasp when something is put in their hand and not let go when asked |
| Sucking | Touch lips with blunt object, pt will suck |
| Pathological Reflexes | These indicate more diffuse brain injury, May give false hope to pt families |
| Vital Signs | Auto regulation is often impaired with craniocerebral trauma, HR, BP, RR have control in the brain stem area. Look at VS changes |
| Respiratory Patterns | Helps to indicate where lesion is located in CNS, The more central it is located in the brain, the more ominous, Cheyne-Stokes Respirations indicate a bilateral/metabolic injury to the braino Hard, fast respiration followed by apnea (end-of-life resp) |
| Nursing Focus on Assessment | Information gathering, Know what has been observed previously (know labs), Serial evaluations of neuro status of pt has brain trauma, Management of pt is often adjusted in response to changes noted by the nurse |
| Nursing Management of ALOA | P:Disturbed thought process, E:Incont bowel/urinary, R:Risk injury r/t ineffect thermoreg (temp can go high up to 106- cooling lanket), corneal reflex (eye drops, tape eyes closed), S: Ineffect tissue perf (brain will begin to swell), O: Risk aspiration ( |
| *Whenever the pt is unable to act as a self advocate | The nurse is required (go with the pt to radiology) |
| Skull x-rays | Ids fractures |
| CT scan | Distinguishes bone, soft tissue, vascular, and ventricular system, With/Wo contrast, Horizontal slices of the brain, Things to know: Remove metal objects, Remain still (may have to sedate if restless or seizures, It takes time so void before or provide a |
| PET Scan: Position Emission Tomography | Provides info about the function of the brain rather than the structure, In coloro Noninvasive with 3-D images, Pt injected w/ deoxyglucose tagged with a radioactive isotope, More active areas of the brain show more glucose uptake, Less radiation than c |
| SPECT Scan: Single Phonton Computed Tomography | Looks at blood flow (in color), Radionuclide is injected which emits gamma rayso Modification of PET Scan, more stable isotopeso Fast for 4 hrs, Pt must lay flat for 1-11/2 |
| Cerebral Angiography (Arteriography) | Done under fluoroscopy, Looks at arteries in brain (looking at occluded or leaking bld vessels)o Inject contrast medium into artery, sequential x-rayso Visualized carotid and vertebral circulationo Pt must remain still |
| Cerebral Angiography (Arteriography): PRE | NPO 4-6 hrs, IV access, assess for iodine allergies, baseline neuro exam |
| Cerebral Angiography (Arteriography): POST | Bed rest 12hrs, Check injection site, Continual neuro assessment, Check peripheral pulses |
| Cerebral Angiography (Arteriography) Complication | vasospasm which causes stroke or seizure |
| EEG | Electric activity of cerebral hemispheres (activity w/in brain), Determine origin of seizures, Evaluate sleep disorders, Determines neuro activity, Mechanical ventilation and electricity in room may cause false artifacts on EEG and may think pt is not bra |
| EEG: Pre | No CNS depressants for 24hrs, Artificially suppressing electrical activity and EEG will be invalid |
| Lumbar Puncture/Spinal Tap | Obtain CSF for analysiso Not with extreme ICP (will squirt out) |
| Lumbar Puncture/Spinal Tap: Pre | Pt on side w/ knees to chest (want spine curved) |
| Lumbar Puncture/Spinal Tap: Post | Flat for 4-8hrs, Increase fluid to replace CSF taken out (normally 18mls/hr produced and absorbed) May get spinal headache (not as much cushioning than before) |
| Lumbar Puncture/Spinal Tap: Complication | CSF leaks, Infection, Intervertebral disc damage (go thru disc to get to fluid) |
| CSF | Normally is clear, Pink or red: may have RBCs present (indicates bleeding in head), White: indicates infection (WBCs should not be in CSF) |
| MRI | Picture of proton energy Magnetic field images are clear for all density of tissue including vesselso See bld vesselso No radiationo With or without contrasto Not metal implants, pacemakerso Pt must lay supine |
| Duplex Studies/Scans aka: Transcranial Doppler Sonography | Ultrasound studies Provide visual representation of moving bld flow (not a clear picture)o Evaluate arterial flow in the Circle of Williso Looking for vascular abnormalities |
| Use of Contrast Agents | May use with CT, MRI, & arteriography, Tumors better seen with contrast, Bleeding/edema better seen without contrast, May irritate bld vessels, Will feel warm sensation when given, Allergic reaction: shellfish iodine allergy, Treat w/ antihistamines and |
| Intracranial Pressure (ICP) | Normal pressure 10-15mmHg, Increases in pressure normally occur w/ coughing, sneezing, straining by slight amounts because of autoregulation, Compensation normally occurs to keep pressure WNL (CSF is displaced), In brain injury pt may not be able to compe |
| Monroe-Kellie Hypothesis | An increase in volume of blood, tissue, or CSF requires decreased volume in another component, Skull cannot change w/ ICP, If tumor in brain tissue, CSF or blood has to give, Increased ICP is the leading cause of death in head trauma pts because, ccommo |
| Cerebral Perfusion Pressure | Measurement of blood flow of the brain Normal CPP about 70-100 CPP(blood flow)=MAP-ICP |
| Airway Obstruction & Aspiration are common complications of the unconscious pt | With inadequate gas exchange: Pt retains CO2 which causes: Vasodilation which can cause cerebral edema: Which then causes ICP: as pressure gets higher we have deeper coma Which causes inadequate gas exchange |
| With Elevated ICP | Cerebral blood flow is decreased: Causes tissue hypoxia: Causes pH of brain decreased (acidotic): CO2 increased Cerebral vasodilation occurs: Edema of the brain- ICP higher |
Created by:
littlemina
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