Question | Answer |
An altered level of consciousness(LOC) is a patient who is not | oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness |
If patient becomes unable to arouse and unresponsive to internal/ext stimuli. Responses to pain and brain stem reflex may be present is called | coma |
A _______is a condition of sleep-wake cycle after coma devoid of dognitive/affective mental fx | Persistent vegetative state |
What two things are the most important indicators of a pt condition? | Level of responsiveness and consciousness |
This test measures eye opening, verbal response, and motor response on a scale of 3 - 15 | Glasgow Coma scale |
A score of _____ or less indicates coma. A score of _______is the most. | 15, 7 |
Eye Opening response:
Spontaneous
To voice
To pain
None | 4
3
2
1 |
Best Verbal response
oriented
confused
inappropriate words
incomprehensible sounds
None | 5
4
3
2
1 |
Best Motor response
obeys commands
localizes pain
withdraws
flexion
extension
None | 6
5
4
3
2
1 |
What is meant by orientation x 4 | person, place, time, situation |
An unconscious patient responds to painful stimuli, this is referred to as | purposeful/appropriate and is seen in pt who crosses the midline of the body in response to pain |
Name the three types of posturing that are assessed | decorticate, decerebrate, flaccid |
Pt presents with flexion of upper extremities, internal rotation of lower extremities, and plantar flexion of feet, what posturing is this? Seen in damage above brain stem/stroke | decorticate (arms make "c" shape), adducted |
Pt has extended and outward rotation of extremities and plantar flexion. Seen in damage at brain stem and is most ominous | decerebrate (arms make "e" shape |
Damage below brain stem can reveal what kind of posturing? | Flaccid |
What is the most important intervention in managing pt with altered LOC? | patent airway and ventilation |
Aspiration is a serious complication, what is nsg intv? | Elevate HOB 30 deg, position pt in lateral/semi-prone position, suctioning(oxygenate b4/after(hyperventilated on vent)) |
T/F: Raising three side rails is considered a restraint? | False, raising all 4 is restraint. |
Cheyne-Stokes respiration can indicate what type of brain damage? | lesions deep in both hemispheres, basal ganglia, upper brain stem |
Hyperventilation can indicate what in an unconscous pt? | metabolic problem (incr O2/decr CO2) or brain stem damage |
In checking eyes in pt with altered LOC, what does PERRLA stand for? | pupils equal round, reactive to light and accomodation |
An increase in cranial pressure ICP, would show pupils in what state? | Progressive or in dilation |
This is absent in coma pt and tests corneal reflex, what cranial nerves is it testing? | V and VII |
What is an abnormal sign with the Babinski reflex in an adult? | big toe and other toes fan out |
How is temperature taken in unconscious pt? | rectal/tympanic only, not oral/axillary |
How is an increase in temp for unconscious pt dangerous? | increases metabolic demands of brain which can exceed cerebral circulation and O2 delivery. Edema can form which incr ICP. |
Every 8 hours, a nurse to provide sensory stimulation does what? | orients pt to time and place |
The Monro-Kellie hypothesis is? | volume/pressure of brain tissue/blood/CSF are in state of equilibrium and produce ICP, so an incr in one affects the others |
What is Cushing's triad? | bradycardia, hypertension, and bradypnea - three responses that occur when autoregulatory system fails |
An incr in paCO2 does what to ICP? | vasodilation - incr cerebral blood flow. Best to maintain >30mmHg |
What is earliest sign of ICP?
What are other ealy signs? | altered LOC, slowed speech and delayed response to verbal commands |
When ICP begins, what autoregulating mechanisms occurs? | change vessel diameter to maintain constant blood flow in brain |
Fixed and dilated pupils are signs of what in unconscious pt? | resp distress and even death is close |
What is best diuretic for decr ICP?
What type of diurectic is it? How does it work? | Mannitol, osmotic diuretic that pulls fluid out of the ICF to the intravasculature and CSF, decr ICP. Fluid restriction works too. |
What drugs would help incr cardiac output to decr ICP?
What should CPP be maintained at? | dobutamine(Dobutrex) & norepinephrine(Levophed)
CPP >70 |
How does O2 therapy help lower ICP? | More O2 means more saturation so autoreg will shut blood flow by constricting vessels. Clotting happens faster too. Propofol, paralyzing agent, help. |
What is CPP? What is normal?
How is it calculated? | cerebral perfusion pressure=70-100, <50 means irreversible neurologic damage
CPP = MAP - ICP |
What is normal ICP | 5-15mm HG. If ICP = MAP then cerebral circulation ceases |
How do you determine MAP and what is normal? | (MAP = [2(diastolic)+ systolic]/3 Normal = 70-110, never <60 |
What is the phenomenon of Cushing's reflex? | when cerebral blood flow decr significantly, ischemia causes vasomotor center to trigger incr in arterial pressure to overcome incr in ICP. |
A widening in pulse pressure, increase in systolic BP, and decr in HR are a late sign of what? | Cushing's reflex(syndrome)requiring immediate intervention. It can lead to Cushing's triad. |
Herniation can occur as a result of Cushing's triad, and causes brain tissue to shift how? | area of high pressure to low press causing decr in blood flow and possibly brain death |
As a pt deteriorates in consciousness, what s/s may appear? | restlessness(w/o cause), confusion, drowsiness, stupor, react only to loud/painful stimuli, coma |
Diabetes insipidus, SIADH, and herniation are all complications of what? | incr ICP |
Decr secretion of ADH with excessive urine output, decr using osmolality and serum hyperosmolality is the result of what? | diabetes insipidus(DI) |
What is nsg mgmt of DI? | IV fluids, electrolyte replacement, vasopressin(desmopressin, DDAVP) |
Syndrome of inappropriate ADH(SIADH) presents itself how? | increased secretion of ADH, FVE, serum sodium is diluted(hyponatremia) |
Treatment for SIADH includes? | fluid restriction(800ml/day), no free water, severe: 3% hypertonic saline solution |
intraventricular catheter(ventriculostomy), subarachnoid bolt, fiberoptic transducer are more used for what? | ICP monitoring |
What is #1 cause of onset of seizures in adult? | brain tumor |
Compression of jugular vv, hip flexion are avoided so as to not incr ICP how? | Keep head in midline position with C-collar to promote venous drainage avoid hip flexion to decr intra-abd/thoracic press |
What tell pt to avoid Valsava manuever? | exhale(opens glottis) |
What are possible complications of Mannitol? | CSF, pulmonary edema bc shift of fluid from ICF to vascular |
Why is a catheter necessary with Mannitol and what level is monitored to avoid diabetes insipidus? | To monitor urine output and >200ml/hr for 2 consecutive hours means DI |
What are signs of infection with ICP? | stiff neck, menningitis, fever, chills, persistent HA |
Early s/s of ICP are? | restless, disoriented, incr resp, impaired eye mvmt, weakness on one side of body, constant HA |
Late s/s of ICP? | coma, decr/erratic pulse/resp rate, incr BP/temp, altered resp patterns, projectile vomit, (D) posturing, loss of gag, corneal, swallowing reflexes |
How can you test if fluid is CSF or not? | CSF has yellowish ring and test with glucose stick, will have glucose |
What are three approaches to a craniotomy | supratentorial: above tentorium
infratentorial: brainstem
transsphenoidal: thru sphenoid |
what are two types of seizures | partial(part of brain) and generalized(whole brain) also known as grand mal |
how should pt be positioned during seizure? | side-lying position with suctioning available |
What is status epilepticus? | continuous seizure activity lasting at least 30m, emergency |
what is 1st line medical mgmt for status epilepticus | (Adivan)lorazepam, valium, phosphenytoin |
What are side effects to watch for with Dilantin? | gingival hyperplasia(dental care), severe skin reaction, peripheral neuropathy, ataxia, drowsy |
What are seizure medicines | Depakote, Dilantin, Tegretol, Keppra, Topamax, Gabitrol, Mysoline |
What are four phases of migraine headache? | prodrome, aura, headache, recovery |
A medicine for cluster heachaches?
Other migraine meds? | Indocin, ergotamine
triptans, beta blockers, no tyramine in diet |