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N4117

Exam III Neuro

QuestionAnswer
Pts with seizure has what injury to what part of the brain? Temporal
interventions with pts with increased ICP? Elevate HOB. Put head in neutra position. Hyperventilate with PaCo2 low end or 35.
Pts eye remain in a fixed position after 10mls of ice water is instilled into left the ear. The nurse interpretes this reflex as? Abnormal oculvestibular reflex
Glascow of 11, unconscious for 1hr, and no memory of event for the past 2 days after the car accident. this indicates...? moderate traumatic brain injury
Post ruptured subarachnoid hemorrhage (SAH)... drowisiness with occassional inability to state place and time and nuchal rigidity. Which grade is this SAH according to Hunt and Hess? Grade III
Calculate CPP? MAP - ICP = CPP
Pt with ICP of 28...nurse doea what intervention to optimize cerebral perfusion pressure? Administer dopamine to increase MAP
Pt with a head injury had an imediate loss of consciousness, followed by regain consciousness, then loss of consciousness again... Pt has? Epidural hematoma
Purpose of HHH after aneurism clipping is to prevent Vasospasm
Pt recovering from head injury has excess thirst and increase UOP...Which endocrine gland was affected? Pituitary gland
Pt post-ops for transsphenoidal hypophysectomy (TPH)... nursing intervention? Educate on mouth breathing
Pt with post-op craniotomy has blurred vision...nursing intervention? Monitor for alteration in cranial nerve II (Optic nerve)
Pt with brain tissue coming out of the skull has? Transcaverical herniation
Pt with inability to drink through a straw has alteration of which cranial nerve? Facial (VII)
Pt diagonosed with brain death is getting an EEG test. The nurse makes sure? CORE TEMPERATURE IS > 32 DEGREES CELCIUS (89.6F)
What drives cerebral blood flow? Cerebral perfusion pressure (CPP)
Which part of the brain controls life essentials such as breathing, heartbeat and articulate speech Brainstem
the Brainstem consists of what? – Midbrain – Pons – medulla Oblangata
cerebellum is responsible for? Maintaining overall balance, motor coordination, learning repetitive asks, muscle tone and sens of equilibrum
Damage to the cerebellum will result in what? Atxic gait
CSF is secreted by what structure of the brain? Cortex plexus
CSF serves as what? Shock absorbers to the brain
Blockade of the CSF @ any pathway will lead to what? Hydrocephalus
Non-convolution/smotthness of the brain indicates what? ICP
CFS is produced @? 20ml/hr
Circulating volume of CSF at anytime should be? 135 - 150ml
Volume of CSF produced in a 24 hr window is? 500cc/24hrs
Smokey colored CFS indicates what? RBC present
Cloudy colored CFS indicates what? Infection
Yellow colored CSF indicates what? Increased protien present
What is pathological reflex A return of reflexes that one had when a baby such as sucking, babinski etc)
Name the five components of neuro assessments? LOC (first & foremost in neuro checks), Motor functions, pupilliary/eye movement, respiratory patterns, vital signs.
What causes a pt to have partholigical reflex? Brain damage. Baby reflex may returns when there is a brain damage
An oval eye shape indicates? Pressure in the brain
Define localizing pain? Application of cubital pressure on the rt hand, the lt habd reaches over to stop the pain
Define generalizing pain? Trying to get away from the painful stimuli by moving arm away from the stimuli
No motor response to pain 1
extensor posturing to pain 2
flexor posturing to pain 3
Generlaized withdrawal to pain 4
Localizing response to pain 5
obeys command 6
No speech 1
Incomprhensible speech 2
inapropriate conversation 3
Confused conversation 4
oriented 5
no eye opening 1
eye open to pain 2
eye open to speech 3
spontaneous eye opening 4
If pt has noting in GCS, the score will be 3
if the pt is oriented and good, the GCS score will be 15
What drives cerebral blood flow? CPP
What are The four factors we try to control to improve autoregulation? Hypoxia, Hypercapnia, Hypotension, Hypovolemia.
What is ICP The combination of the pressure exerted by brain tissue, blood and CSF
Normal range of ICP 5 - 15 mmHg
We typically treat ICP when it...? > 20 mm Hg that is sustained for 5 minutes
Care of pt with ICP DOn't cluster cares @ one time. Provide adequate rest periods. Do one thing @ a time. Don't do position change & suction all the time.
Nurses will help ICP pts avoid what? Bearing down for BM, cough, vomit, blow their nose, - Valsalva maneuvers, coughing, suctioning, noxious stimuli, seizure activity,
Normal CPP range 70 - 95 mmHg
CPP < 60 mmHg indicates what? Hypoperfusion
CPP < 40 mmHg indicates what? Brain ischemia
In early rescusicitation, what do you use? 100% FiO2
Hypoxia + hypotension in ICP pts has...? 75% mortality
If pt have sudden increase in ICP... nurse knows to? hyperventilate (breath faster) to decrease CO2. This is for a short time so pt do not develop CPP problem
Etiology of Increased ICP? Disorders of brain substance. Mass lesion with local edema. Ischemic brain injury with cytotoxic edema. Increased cerebral metabolic rate.
We use tripple H therapy to prevent what in SAH? Vasospasm
CSF is produced in which part of the brain? Choroid plexus
Resorbtion of CSF is done by? Arachnoid villi
What is cushing's triad? Bradycardia, systolic HTN (widened pulse pressure) and abnormal respiration.
early sighn of ICP Decrease in LOC
late sign of ICP Cushing's triad
When pts get to cushing's response, it is close to what? Irreversible damage
Periorbital edema & scleral edema is not due to what? ICP
Periorbital edema & scleral edema is due to what? Fluid overload
Periorbital edema & scleral edema is not thesame thing as what? Papilledema.
Uncal herniation Unilaterally (one side) expanding mass of lession
Central herniation Bilaterally expanding mass of lession
singulate herniation An expanding lession of one hemisphere shifts laterally across midline an forces the singulate gyrus ubder the falx cerebri
Types of ICP monitor Intraventricular catheter. Subarachnoid bolt. Subdural or Epidural ctheter and fiber optic transducer.
Which of the following is not a determinant of brain dead? Vestibulocular reflex
TBI classification: Mild (Grade I) Altered or LOC <30 min with normal CT &/or MRI, GCS 13-15, PTA < 24 hrs. (post-traumatic amnesia)
TBI classification: Moderate (Grade II) LOC < 6 hrs with abnormal CT &/or MRI, GCS 9 - 12, PTA < 7 days.
TBI classification: Severe (Grade III) LOC > 6hrs with abnormal CT &/or MRI, GCS <9, PTS > 7 days.
Sign of Frontal or orbital fracture and Anterior fossa? Racoon eye.
Sign of Basilar skull fracture? Battle sign.
describe battle sign ecchymosis overlaying the mastoid process behind the ear
describe racoon eye? Black eye, subconjuctival and periorbital ecchymosis
Fossas of the skull can cause what during trauma? damage to the brain tissue
hallmark sign of concussion is? Retrograde amnesia
What two things does brain not store? O2 and glucose
TBI: Nursing management? Stabilization of vital signs. Prevention of secondary injury. Reduction of elevated intracranial pressure. Hemodynamic management. Fluid management. Cerebral perfusion pressure 70 mmHg or more. Aggressive pulmonary care. Reduce environmental stimul
Types of aneurysms Berry or saccular & Fusiform
describe berry or saccular aneurism Looks like berry, handgs down fron a vessel like a berry
describe fusiform aneurism an outpouching of vessel all around
define focal deficit? eyelid drooping, rt arm weaker than left side
Define Global deficit? not as awake as used to be
Differenciat between rebleeding & vasospasm? REBLEED is sudden onset of HA, increases in BP, RR, & N/V. VASOSPASM is gradual in onset, an ischemich event, U see changes over a period of hrs and days
What is embolisation used for? The securing of an aneurism that is surgically inaccessible because of size, location, type or medical instability of pt
Created by: nze