question

Normal ICP

answer

0-15mm/hg

question

Increased ICP

answer

20mm/hg or greater, persisting for 5 minutes or longer

question

Monroe-Kellie Hypothesis

answer

Calls for a balance between blood, csf, and brain tissue; cranial cavity is a closed cavity (no place for expansion), so this says if one of these three components increases, the others are going to have to decrease to maintain cerebral perfusion

question

Risk Factors for Increased ICP

answer

1. Increased Brain Volume 2. Increased Cerebral Blood Flow 3. Increased Cerebrospinal Fluid

question

Increased Brain Volume typical causes

answer

tumors, edema (swelling from trauma)

question

Increased Cerebral Blood Flow typical causes

answer

trauma (rupture of vessel), stroke (ruptured aneurysm)

question

Increased Cerebrospinal Fluid typical causes

answer

hydrocephalus

question

What are factors that can temporarily increase ICP

answer

Anything that increases intrathoracic pressure increases intracranial pressure; therefore sneezing, valsalva maneuver (straining), suctioning, pain, physical activity, excessive stimulation can all temporarily increase ICP

question

What are nursing interventions to avoid things that temporarily increase ICP

answer

stool softeners, adequate rest, low lights, suction intermittently

question

S/S of IICP

answer

Earliest: subtle change in LOC / confusion Others: HA, blurred vision, pupil changes, motor/sensory changes Cushing's Triad: bradycardia, change in respiratory pattern, wide pulse pressure (170/40) --> not good!

question

Glascow Coma Scale

answer

Rates the eyes 1-4, motor 1-6, verbal 1-5

question

How to perform hourly "neuro checks"

answer

Don't test pain response unless decreasing LOC Appropriate: sternal rub, squeeze shoulders, press on nail beds

question

What is a late sign of IICP

answer

Posturing

question

Decorticate posturing

answer

Flexion = 3 under motor response

question

Decerebrate posturing

answer

Extension = 2 under motor response

question

What should a full neuro assessment include

answer

s/s, glascow coma, dtr, babinski reflex, posturing, hourly neuro checks

question

Indications for ICP Monitoring

answer

1. Glascow Coma Scale of 3-8 2. To treat IICP: use a system that treats both monitors and treats ICP 3. Patients with risk of IICP 4. To assess response to therapy

question

Cerebral perfusion pressure

answer

The pressure it takes to perfuse the brain

question

Cerebral perfusion pressure formula and normal values

answer

MAP-ICP; 60-100mm/hg

question

When does cerebral perfusion stop

answer

When MAP (drops) and ICP (rises), because it makes them begin to equalize

question

Nursing Interventions for patients at risk for CPP problems

answer

Patient with high ICP may be able to tolerate a blood pressure higher than normal --> we may not be as aggressive with HTN treatment

question

ICP monitoring insertion procedure

answer

Explain/consent Sterile: in OR Head shaved Local anesthetic; sedatives if indicated Scalp incised Placed through a burr hole (hole is skull) Device inserted Connect equipment Note waveform/pressures Suture, dress Most devices have direct contact with CSF, so sterile/aseptic technique is critical!

question

Methods to Invasively Measure ICP

answer

1. Intraventricular 2. Subarachnoid Screw 3. Epidural 4. Fiberoptic Catheter' *All of these will be set up to a saline solution that is pressurized (same as pulmonary artery catheter monitoring) and a transducer (gives us waveforms/numbers)

question

Intraventricular insertion

answer

Catheter is introduced via burr hole, and placed into the ventricle of the brain

question

Advantages of intraventricular insertion

answer

1. May be placed with a ventriculostomy, which allows us to drain CSF to decrease the ICP 2. We can monitor and treat IICP

question

Disadvantages of intraventricular insertion

answer

1. Possibility of causing brain damage due to difficulty of placement 2. Risk of infection

question

Subarachnoid screw insertion

answer

Screw is introduced via burr hole, and the tip rests in the subarachnoid space

question

Advantages of subarachnoid screw

answer

1. Insertion is easier 2. Lower risk of infection

question

Disadvantages of subarachonid screw

answer

1. Able to become occluded with tissue/clots 2. Not possible to drain CSF

question

Fiberoptic catheter insertion

answer

Catheter with light that can be placed anywhere (subdural, subarachnoid, or intraparenchymal), and the monitor gives a second to second read-out of brain activity

question

Advantages of fiberoptic catheter

answer

Accurate/reliable

question

Disadvantages of fiberoptic catheter

answer

1. CSF drainage is not possible 2. Expensive 3. Fragile

question

Epidural insertion

answer

Place catheter (sensor) between the dura and skull via burr hole

question

Advantages of epidural insertion

answer

1. Least invasive procedure 2. Low risk of infection

question

Disadvantages of epidural insertion

answer

1. Least accurate/reliable

question

ICP waveforms

answer

A, B, and C waves

question

A waves

answer

AKA plateau waves; the most clinically significant of the three types (concerning) that generally occur in situations where ICP is already increased Sharp increase of about 30 - 70 mmHg (more) that remains for about 2 - 20 minutes

question

B waves

answer

Sharp, rhythmic, saw-tooth appearance that can indicate problems, or can just be physiologic Occur every 30 seconds - 2 minutes and raise ICP 5-70 mmHg

question

C waves

answer

Small and related to normal fluctuations in respirations and blood pressure

question

What is the first thing a nurse does if there is any alteration in waveform

answer

Assess the patient

question

Location of waveform transducer

answer

The foramen of monroe --> estimated to be at eyebrow level

question

IICP medical interventions

answer

1. Adequate oxygenation: PaO2 > 80 2. Controlled hyperventilation: put patient on a ventilator, sedate, and hyperventilate (causing resp. alkalosis), because resp. alkalosis causes vasoconstriction and therefore decreased ICP --> BUT we also decrease the perfusion, so this is not used much anymore 3. Stable H&H 4. Barbituate coma/ Neuromuscular Blockade: induced, and decreases brain activity to conserve energy / O2 5. Hypothermia: induced (usually around 88 degrees); fever and shivering take up too much O2 (keep pt. normothermic), so use coma to make sure they don't shiver 6. Drainage of CSF 7. Surgical procedures: remove clots, aneurysms, tumors, etc.

question

IICP medications

answer

1. Diuretics: Osmotic (Mannitol) 2. Steroid therapy: anti-inflammatory to help with swelling 3. Anticonvulsants: Dilantin; prophylactaly 4. Histamine antagonists: to prevent stress ulcers / peptic ulcers 5. Fluid management : isotonic solutions, NOT hypotonic so they don't overload (hypotonic causes cerebral edema); outcomes are better if the patient is not fluid overloaded 6. Antihypertensives: generally for a systolic > 160

question

Nursing interventions for IICP

answer

1. ICP monitor: sterile, look for leaks 2. Neuro assessments 3. Positioning: need to be aligned to ensure adequate blood flow; HOB elevated 30 degrees 4. Environment: cool, calm, quiet, darkened (does not mean isolation from the family) 5. Activities to avoid: prevent constipation (stool softeners)

question

Perinatal Hypoxic-Ischemic Brain Injury

answer

Asphyxia before, during, or after delivery

question

Hypoxic-Ischemic Reperfusion Injury

answer

Due to the decrease in cerebral blood flow and therefore O2 (brain becomes hypoxic)

question

Result of injuries

answer

Hypoxic-ischemic encephalopathy (HIE) Mild: very few repercussions Moderate Severe: doesn't survive

question

Clinical Manifestations of Perinatal Hypoxic-Ischemic Brain Injury at birth

answer

Infant may be stuporous or comatose

question

Clinical Manifestations of Perinatal Hypoxic-Ischemic Brain Injury at 6 - 12 hours

answer

Seizures occur in 50% of infants and are more frequent and severe by 12 to 24 hours

question

Clinical Manifestations of Perinatal Hypoxic-Ischemic Brain Injury at 24 - 72 horus

answer

Decreased LOC

question

Clinical Manifestations of Perinatal Hypoxic-Ischemic Brain Injury at 72+ hours

answer

1. Persistent stupor 2. Abnormal tone 3. Muscular weakness 4. Apneic episodes

question

Clinical Manifestations of Perinatal Hypoxic-Ischemic Brain Injury long-term

answer

1. Cognitive impairment 2. Seizures 3. Cerebral Palsy

question

Therapeutic Management of Perinatal Hypoxic-Ischemic Brain Injury

answer

1. Prevention: recognize high-risk pregnancies and monitor fetus 2. At birth: induce hypothermia and manage seizures

question

Nursing Care of Perinatal Hypoxic-Ischemic Brain Injury

answer

1. Neurological: for S & S of cerebral hypoxia or ischemia, seizure precautions 2. Respiratory: apnea monitor, oxygen saturation 3. Temperature: hypothermic protocol 4. Supporting and assisting parents and family

question

Peds. Intraventricular Hemorrhage

answer

Involves the germinal matrix (highly cellular/vascular region of brain from which cells migrate during fetal brain development); may result in cerebral palsy and seizures; 95% of all IVHs occur in first three postnatal days of life

question

Highest risk for IVH

answer

Less than 32 weeks of gestation (premature), difficult birth

question

Grade extent of hemorrhage

answer

1. Germinal matrix hemorrhage with minimum to no IVH; 50% of ventricle 4. IVH and periventricular hemorrhage

question

Three types of IVH

answer

1. Catastrophic deterioration 2. Saltatory deterioration 3. Clinically silent deterioration

question

Catastrophic deterioration S/S

answer

Coma Apnea Fixed pupils Cardiac arrhythmias Posturing Generalized seizures Bulging fontanels

question

Saltatory deterioration S/S

answer

Altered LOC Abnormal eye position Hypotonia: abnormal muscle tone May occur over several hours (slow onset)

question

Clinically silent deterioration S/S

answer

Decreased H & H Unobvious S/S

question

Diagnosis of IVH

answer

1. Ultrasonography 2. Computed tomography (CT) 3. Magnetic resonance imaging (MRI)

question

Prevention of IVH

answer

1. Premature birth 2. Delivery complications 3. Maintenance of adequate oxygenation 4. Provide medications to prevent IVH: anti-inflammatory, phenobarbital, antenatal betamethasone

question

IVH treatment

answer

1. Detection: ultrasonography 2. Manage hydrocephalus, shunting

question

IVH long-term outcomes

answer

1. May recover fully 2. May have cognitive impairment, seizures, etc. long-term

question

Nursing Interventions for IVH

answer

1. Measures to decrease intracranial pressure: keep pain and stimulation to a minimum 2. Monitor Labs: ABG, H&H, GLUCOSE 3. Vital signs: may induce hypothermia, maintain normothermia if not inducing hypothermia 4. Support family: skin to skin contact, emotional support

question

Stroke

answer

Sudden loss of functioning resulting from disruption of blood supply to part of the brain

question

Causes of stroke

answer

ischemia due to thrombi or emboli, hemorrhage

question

Risk factors for stroke

answer

HTN, atrial fibrillation, hyperlipidemia, diabetes, smoking, carotid stenosis, obesity, excessive ETOH intake, atherosclerosis

question

Two types of strokes

answer

Ischemic, Hemorrhagic

question

Ischemic Stroke

answer

1. Large artery atherosclerosis (carotid artery) 2. Cardioembolic Stroke (A. Fib) 3. Lacunar Stroke

question

Lacunar Stroke

answer

Small vessel occlusive disease associated with HTN, hyperlipidemia, diabetes, obesity

question

Hemorrhagic Stroke

answer

15% of strokes 1. Intraparenchymal Hemorrhage: bleeding into brain tissues; can be from uncontrolled HTN 2. Ruptured Cerebral Aneurysm with Subarachnoid Hemorrage 3. Arterio-venous malformation

question

Assessment of stroke

answer

1. Weakness/ numbness 2. Slurred speech 3. Inability to comprehend speech 4. Visual disturbances 5. Dizziness, vertigo, uncoordination 6. Nausea/vomiting 7. Severe headache

question

Transient Ischemic Attack

answer

Tiny Stroke, 5-30 minutes, symptoms last less than 24 hours

question

Reversible Ischemic Neurologic Deficit

answer

Little Stroke, symptoms last 24 hours to 1 week

question

What to do in both a transiet ischemic attack and reversible ischemic neurologic deficit

answer

Treat cause and address risk factors

question

Prevention/ Early Intervention of CVA

answer

1. Antihypertensives 2. Antiplatelet Aggregates 3. Anticoagulants 4. Thrombolytics 5. Calcium Channel Blockers 6. Endarterectomy 7. Carotid Artery Angioplasty with Stenting

question

Calcium Channel Blockers and CVA

answer

Antihypertensives --> reduce BP variability, which reduces the chance of stroke

question

Endarterectomy and CVA

answer

For large vessels (obvious atherosclerosis of carotid artery) --> open up carotid artery, get plaque out

question

Carotid Artery Angioplasty with Stenting

answer

Mash plaque with balloon tipped catheter and use stent to hold artery open

question

CVA diagnositc tests

answer

1. Rely on S/S 2. CT Scan w/o contrast until we have ruled of hemorrhagic stroke; may have to do more than 1 CT because it takes 24 hours for hemorrhagic stroke to show up

question

CVA treatment

answer

1. Thrombolytic Candidates - Get them to a facility that can bust clots; only about 5% receive tx; administer within 3 hours of symptom onset - Check PTT/INR, H&H, start IV 2. Non Thrombolytic Candidates - Treat symptoms, treat ICP, and supportive care - Usually if beyond 3 hours of symptom onset

question

CVA acute phase NI

answer

1. CV/Resp. support 2. Treat cause: thrombolytics, craniotomy

question

CVA post acute phase NI

answer

1. Survived stroke, move to more generalized unit 2. Orient frequently, bring family into care

question

CVA rehabilitative phase NI

answer

Will last until they reach the highest level of functioning possible; can last weeks to months

question

Primary Injuries of the head

answer

Skull, brain and scalp injuries

question

Secondary Injuries of the head

answer

IICP, cerebral edema, systemic hypotension

question

Head injuries are often associated with what other types of injuries

answer

Spinal cord injuries

question

Causes of head injuries

answer

Trauma, catastrophic event, gunshot wounds, violence

question

Linear skull fracture

answer

Single crack, bedrest, monitoring

question

Depressed skull fracture

answer

Indentation, surgery required

question

Comminuted skull fracture

answer

Many fragments, craniotomy to repair

question

Compound skull fracture

answer

Depressed with added problems of scalp lacerations an debris, which must be surgically removed and repaired

question

Complications of Skull Fractures

answer

1. Hemorrhage: epidural, subdural 2. Infection 3. Cerebral edema 4. Herniation (late signs evident: posturing, cushing's)

question

Special peds. considerations for skull injuries

answer

1. Bicycle Safety (helmets, EDUCATE) 2. Falls most common cause (can occur from falls from height of 3 ft.)

question

Basilar Skull Fracture S/S

answer

1. Battle's sign: bruising of the temple bone 2. Raccoon eyes: bruising underneath the eyes 3. CSF from nose and ears

question

Treatment of basilar skull fracture

answer

Bed rest with HOB elevated Neuro checks No blowing of the nose or nasal suctioning Antibiotics Test for glucose in mucous/snot (normal will be absent) Can't operate or do anything else Self-healing

question

What is the big issue associated with basilar skull fracture

answer

Risk for meningitis

question

Concussion

answer

Temporary diffuse brain injury (mild) characterized by a very brief period of loss of consciousness (could be seconds); often amnesia about events before/after injury

question

Post-concussive syndrome

answer

Limit activity from last headache to two weeks after

question

Cerebral Contusion

answer

Bruising of the brain, more severe than concussion (moderate vs. mild)

question

Severe head injury indications

answer

Glascow coma scale of 3-8, loss of consciousness of 6 hours or more

question

Cerebral Contusion treatment

answer

1. Treat IICP, symptoms 2. Support --> long-term cognitive impairment, physical limitations, long-term care

question

Coup injury

answer

Caused when the head is stopped suddenly and the brain rushes forward; It not only gets injured by hitting in the side of the skull but it is also damaged as it rubs against all the inner ridges

question

Contrecoup injury

answer

Caused when the brain bounces off the primary surface and impacts against the opposing side of the skull; Again, addional injury occurs as the brain again rubs against all the inner ridges

question

Epidural Hemorrhage

answer

Bleeding into the potential space between the periosteum of the skull the dura matter

question

Intracranial Hemorrhage

answer

Bleeding into the brain tissue

question

Subarachnoid Hemorrhage

answer

Bleeding under arachnoid matter which covers the brain

question

All the hemorrhages are what

answer

Mmedical emergencies with poor outcomes; stabilize patient, treat IICP, surgery if indicated

question

Epidural (extradural) Hemorrhage

answer

1. 85% arterial bleed (happens quickly) 2. 15% meningeal vein 3. 90% have a skull fracture 4. Clinical manifestations of hematoma

question

Acute Subdural Hematoma

answer

Major contusion or laceration; symptoms within 2 days

question

Subacute Subdural Hematoma

answer

Less severe contusion; smptoms within 2 days to 2 weeks

question

Chronic "minor injury" Subdural Hematoma

answer

Symptoms beyond 2 weeks, sometimes months; this patient is typically an older adult, and have been brought in by caretaker due to a slowly decreasing LOC; might have been a minor injury

question

Subdural Hematoma

answer

1. Venous in origin 2. 10 times more common 3. Caused by falls, assaults, violent shaking 4. Acute (48 hours) 5. Chronic is more common

question

Intracranial Tumors

answer

1. Glioma 2. Dural meningioma 3. Acoustic 4. Angiomas 5. Pituitary adenomas

question

Glioma

answer

Orginates within the brain tissue

question

Dural meningioma

answer

Arising from the coverings of the brain

question

Acoustic

answer

Example of tumor developing on a cranial nerve

question

Angiomas

answer

Made up of blood vessels

question

Assessment of intracranial tumors

answer

Neurological problems, HA

question

Intracranial tumor diagnostic tests

answer

CT, MRI

question

Spinal Cord Tumors occur most often where

answer

In the thoracic area (pretty high up)

question

Assessment of spinal cord tumors

answer

Depends on location and speed of tumor growth; may complain of pain, sensory changes, motor loss/impairment

question

Spinal cord tumor diagnostic tests

answer

XRAY, MRI, CT

question

Spinal cord tumor management

answer

1. Nursing: VS / neuro checks q4hr 2. Surgical: removal 3. Non-surgical: radiation 4. Home care: support

question

Arteriovenous Malformations

answer

Tangled, dilated vessels that form an abnormal communication network between the arterial and venous systems; can occur anywhere in the body, but we're addressing the one's that occur in the head

question

Arteriovenous Malformations assessment

answer

1. Any kind of neurological change 2. Intracerebral steal syndrome: 3. Abnormal network also increases ICP 4. Believed that people are born with AVM's, and the onset of symptoms occurs in late childhood or early adult life

question

Number one complaint of arteriovenous malformations

answer

Unilateral headache

question

Intracerebral steal syndrome

answer

So much blood supply is devoted to this abnormal network, that the surrounding areas become ischemic

question

Arteriovenous Malformations diagnostic test

answer

Angiography

question

Arteriovenous Malformations nonpharmalogical management

answer

Embolization, irradiation, craniotomy

question

Embolization

answer

Ball released into cerebral circulation (shrivels up and dies)

question

Arteriovenous Malformations pharmacological management

answer

Beta Blockers (such as Inderal), because they decrease cerebral blood flow, once AVM issue is resolved we have too much blood flow

question

Cerebral Aneurysm

answer

Localized dilation of the cerebral artery wall

question

Cerebral Aneurysm S/S

answer

1. Assess for risk factors (about 90% born with them) 2. 50% are silent and discovered post-mortem 3. Headache, bruit, neck pain and/or other neuro s/s 4. Rupture will cause explosive headache, subarachnoid bleed

question

Role of amicar after initial bleed

answer

Promotes clotting to provide stability at the area; given IV

question

What percentage of blood loss is considered a catastrophic bleed

answer

20 - 30%

question

Pre/post-op Craniotomy Management (general)

answer

Neuro assessment, ICP monitoring, environment

question

Pre/post-op Craniotomy Management (pharmacologic treatment)

answer

Stool softeners, mild sedatives for pain (tylenol, codeine); don't want actual analgesics because it will interfere with assessments (LOC)

question

Pre/post-op Craniotomy Management (surgical intervention)

answer

Craniotomy --> monitor ICP

question

Pre/post-op Craniotomy Management (vasospasm)

answer

Triple H therapy --> induced HTN (160/80) or 20 mmHg above baseline, hypervolemia (increase PAOP to about 14), hemodilution (want to drop hematocrit by 15) *Can happen with any type of IICP

question

Spinal cord injury typical patient

answer

Male, young adult, white (summer, weekend, alcohol, drugs)

question

Spinal cord injury

answer

Cars, crahses, violence, stabbing, falls, cliff diving

question

Complete spinal cord injury

answer

The spinal column is completely severed

question

Quadriplegia (tetraplegia)

answer

Loss of motor and sensory function below the level of the injury

question

Paraplegia

answer

Lumbar or thoracic area

question

Level of bone injury

answer

Where the vertebrae is broken

question

Level of functional injury

answer

Where the spinal cord is actually damaged

question

Brown-Sequard Syndrome

answer

Incomplete injury to one side of the spinal cord; functionally, the side with the best motor control has little or no sensation and the side with sensation has little or no motor control

question

Anterior Cord Syndrome

answer

Incomplete injury associated with injury to the anterior gray horn cells (motor), spinothalamic tracts (pain) and corticospinal tracts (temp); caused by flexion injuries or acute disk herniation

question

Central Cord Syndrome

answer

Incomplete injury associated with cervical hyperextension/flexion injury; also can result from contusion, compression, or hemorrhage into the gray matter; motor and sensory deficits are more pronounced in the upper extremities than the lower

question

Assessment and Early Management of the SCI patient

answer

ABC's, neurological assessment, and diagnostic tests

question

Airway

answer

1. Stabilization of the spinal cord (cervicla) = FIRST PRIORITY! 2. Do not take patient off board until you have c-spine injury cleared 3. NG tube protects the airway

question

Breathing

answer

Effects of SCI on Ventilatory Functions 1. C1-C3: ventilator 2. C4-C5: phrenic nerve impairment, may need phrenic nerve pacemaker 3. Below C5: can breath without a ventilator, poor respiratory reserve

question

Neurological assessment

answer

Cranial nerve assessment *Some function may return once stabilized and edema goes down

question

Diagnostic Procedures

answer

1. CT, MRI 2. Clear c-spine with chest x-ray

question

Medical management of spinal cord injury

answer

High dose of methylprednisolone within 8 hours of injury; IV push followed by a drip

question

Surgical management of spinal cord injury

answer

Provides stability: laminectomy, spinal fusion, rodding

question

Laminectomy

answer

1. Remove lamina of vertebral rings 2. Allows for decompression and reduces edema 3. Cleans up debris/fragments

question

Spinal fusion

answer

Use bones from areas of body to fuse 2-6 vertebrae together Rodding

question

Rodding

answer

Use commercial rods to fuse 2-6 vertebrae together

question

Non-surgical Managementof spinal cord injury

answer

Cervical Injury: cervical tongs (halo), halo vest

question

Complications of Spinal Cord Injury

answer

1. Spinal Shock 2. Neurogenic Shock 3. Autonomic Dysreflexia

question

Spinal shock

answer

1. Occurs immediately (30 min- 1 hr) after injury 2. Refers to loss of all neurologic activity below level on injury and is short term (6 weeks) 3. Is signified by return of reflexes 4. After patient recovers, it is over, there are not long-term complications/impairments

question

Shock (general principles)

answer

Clinical syndrome with inadequate tissue perfusion, that results in cellular, metabolic, and hemodynamic derangement; results from ineffective cardiac function, inadequate blood volume, or inadequate vascular tone

question

Neurogenic shock

answer

A type of distributive shock that results from the loss of sympathetic tone which leads to decreased tissue perfusion and the shock response; it is a disruption of sympathetic nervous system and is the rarest form of shock

question

Causes of neurogenic shock

answer

Most common is a spinal cord injury above the level of T6 and onset is within minutes, and lasts for days-weeks Other causes: spinal anesthesia, drugs, emotional stress

question

Assessment of neurogenic shock

answer

Hypotension, bradycardia, hypothermia, warm dry skin

question

Medical management of neurogenic shock

answer

Fluids & vasopressors

question

Nursing interventions for neurogenic shock

answer

1. Prevention, early detection 2. Respiratory support 3. Maintain normothermia 4. DVT prophylaxis

question

Autonomic Dysreflexia

answer

A life threatening complication in SCI above T6

question

Causes of autonomic dysreflexia

answer

Massive sympathetic response to a noxious stimulus Could be a full bladder, bowel issue, or developing bed sore (anything really)

question

Assessment of autonomic dysreflexia

answer

Headache, flushing, bradycardia, hypertension, diaphoresis

question

Nursing interventions for autonomic dysreflexia

answer

Remove the cause, treat the HTN (Apresaline), medi-alert bracelet

question

SCI acute phase nursing concerns

answer

Respiratory and CV deficits; preventing secondary damage to spinal cord; monitoring for spinal shock, preventing/managing neurogenic shock

question

SCI Acute Phase and later nursing concerns

answer

Nutrition, elimination, skin integrity, mobility, psychosocial, maintain function

question

Nutritional status of SCI patients

answer

Men tend to lose weight, women do not (especially with higher level injuries that may hinder swallowing/chewing *Bring in speech pathologist

question

Elimination in SCI patients

answer

After a complete SCI, flaccid paralysis; need indwelling foley and will probably be incontinent of stool; once spinal shock resolves, it is possible to regain some bowel control

question

Skin integrity in SCI patients

answer

Lower motor neuron injury that occurs when the nerves between the SC and muscle are severed; unlikely to have urinary control (indwelling foley, diaper); if upper motor neuron injury, the nerves between the brain and spinal cord are severed, and can regain some control of bladder (straight cath, won't leak or be incontinent); educate patient to drink cranberry juice, vitamin C (acidify urine to prevent UTI, stones, etc.), good skin care (weight shifting by repositioning, stay clean/dry, sit on smooth surfaces)

question

Psychosocial events in SCI patients

answer

Young, white males; main concerns are survival and quality of life (lifestyle alterations: occupational, recreational, losses (spouses, homes, cars, sexual functioning)

question

Number one killer of SCI patients

answer

Pneumonia; susceptible to many types of infections

question

General seizure disorder

answer

Involve both cerebral hemispheres, alter consciousness, and have motor manifestations bilaterally

question

Partial seizure disorder

answer

Begin in one cerebral hemisphere and motor activity is localized

question

Simple partial seizure

answer

Consciousness remains intact

question

Complex partial seizure

answer

Consciousness is impaired

question

Status Epilepticus

answer

A medical emergency characterized by a series of seizures without recovery of baseline neurological status between the seizures; can occur with any type of seizure; brain does not return to normal functioning between seizures Lasts longer than 5 minutes or repeated seizures over the course of 30 minutes

question

Big issue with SE

answer

Worried patient is going to stop breathing 1. Resp. assessment is very important (RR, pulse ox., suction equipment at bedside 2. CV assessment is very important because SE can precipitate various dysrythmias

question

SE diagnostic tests

answer

Complete workup (CBC, complete electrolye count, trace minerals, toxins), EEG, CT, MRI

question

SE nursing diagnosis

answer

1. Airway 2. Safety 3. Cerebral Perfusion

question

SE nursing management

answer

1. Patent airway, oxygen 2. Vascular access: IMPORTANT NI --> make sure saline lock is intact and patent to always have IV access 3. Seizure Precautions: protect head, turn on side, rails up, give meds. IV (not in mouth)

question

SE medical management

answer

Must be started STAT 1. Ativan (Lorazepam) 2. Valium (Diazepam) 3. Dilantin 4. Phenobarbital 5. Diprivan

question

Ativan (Lorazepam)

answer

.05 mg/kg q 10-15mg to total of 4 mg Longer duration of action without depressing resp. system like Valium does

question

Valium (Diazepam)

answer

5-20 mg at rate of 5mg/min or less

question

Diazepam and pediatrics

answer

Rectally for home or pre-hospital treatment

question

Dilantin

answer

12-18 mg/kg at 50 mg/min (no faster than this); should be given with NS, IV push Takes a while to work, but with SE we don't have a lot of time to wait

question

Phenobarbitol

answer

5-8 mg/kg at 50 mg/min; IV, long duration of action

question

Diprivan

answer

Given when other measures aren't working

question

Encephalitis

answer

Infection of the brain parenchyma most commonly caused by Herpes Simplex Virus, Arthropod borne viruses (West Nile), Fungal causes Treatment is symptomatic

question

Who is more likely prone to getting encephalitis

answer

Occurs in the immunosuppressed/immunocompromised 1. AIDS, chemotherapy, steroids 2. Steroids: asthma, COPD, rheumatory arthritis 3. Avoid mosquito bites

question

Brain Abscesses

answer

Rare in immunocompetent people; hard to reach with IV antibiotics; incisision and drainage of abscess is necessary; treat symptoms of IICP

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Guillian-Barre

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Acute onset of symptoms involving the peripheral and cranial nerves due to degeneration of the myelin sheath; usually following an acute illness of viral event Thought to be an autoimmune component because patient can usually tell you they've had a sickness about 2 weeks - 1 month ago; involved a fever and sick enough to remember it

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Guillian-Barre S/S

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Patient has a flaccid, symmetrical, ascending paralysis; 10 days of symptom progression, 10 days of dysfunction, 2 - 48 weeks resolution

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Guillian-Barre dx tests

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No specific test to confirm, so rule out other things and assess history/clinical progression of symptoms

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Guillan-Barre medical management

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1. Plasmaphersis 2. Immunoglobulins (IV) 3. Corticosteroids

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Plasmaphersis

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Rinse out blood of offending antibodies (earlier in course of disease)

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Corticosteroids

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Controversial, but maybe to help with autoimmune process

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Guillan-Barre nursing management

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1. CV/Resp. support 2. Pain management, promoting nutrition and sleep 3. Involves unusual pain sensations especially at night 4. May not be able to maintain oral feedings 5. Sleep deprivation due to pain

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Myasthenia Gravis

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Neuromuscular transmission disorder; an autoimmune response where acetylcholine (need this for muscles to work) is destroyed at the neuromuscular receptor sites

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Myasthenia Gravis S/S

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History of muscle weakness after activity that gets better with rest (more than normal) S/S: drooping eyelid, intermittent diplopia (blurred vision that comes and goes), dysarthric speech

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Myasthenia Gravis life threatening S/S

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dyspnea, dysphagia

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Myasthenia Gravis dx test

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Tensilon test Tensilon is a short acting anticholinesterase that inhibits destruction of ACH; given IV push; ifatient has more energy, test is positive

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Myasthenia Gravis medical management

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1. Long acting anticholinesterases (Mestinon) 2. Steriods 3. Immunosuppressant's

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Myasthenia Gravis nursing interventions

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1. Improving Nutrition 2. Self Management of meds.: take meds. 45-60 minutes before eating to help them chew and swallow well 3. Teach to Avoid Precipitating and Aggravating factors

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Myasthenia Gravis other treatments

answer

1. Plasmapheresis 2. Thymectomy

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Plasmapheresis

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Washes out offending antibodies

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Thymectomy

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Taking out thymus removes a source of antigen production, therefore stopping autoimmune cascade

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Myasthenic crisis

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Symptoms are exaggerated and patient needs more of their drugs; may see symptoms like increase HR, RR, BP, incontinence of bladder/bowel

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Cholinergic crisis

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Overmedicated the patient; may see symptoms like hypotension, n/v/d Not as clear as we think --> presenting symptom is that the patient just becomes weaker (muscles) Give tensilon test, if they improve, then they have myasthenic crisis; given atropine if in cholinergic crisis, and readjust meds.

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Amyotrophic Lateral Sclerosis

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Motor neuron disease involving the degeneration of motor neurons of the spinal cord, brain, and cortex

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Amyotrophic Lateral Sclerosis clinical presentation

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Varies; insidious onset and very progressive course; muscle weakness and atropy that may start with just one limb being involved anywhere on body, have trouble writing/typing, dysoperetic speech, bilateral facial weakness *When resp. muscles become involved, death is likely to occur

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Amyotrophic Lateral Sclerosis outcomes

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Survival is rare, so help patient make end of life decisions

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Alzheimer's Disease

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Chronic progressive degenerative brain disorder with profound impact on memory, cognition and ability for self care

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Alzheimer's Disease risk factors

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Cause is unknown; age (> 65) and prevalence increases with age, gender and family history are major risk factors

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Alzheimer's Disease dx

answer

1. Autopsy shows neurofibrillary tangles and neuritic plaques 2. At least 2 cognitive deficits including memory impairment 3. Clinical picture 4. Complete work up to rule out other issues

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Alzheimer's Disease tx/nursing management

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Reminisence, validation, care giver stress

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Stage 1 Alzheimer's

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Restless, increased irritability, failure of recent memory, decrease in work performance, many time patients know something is wrong

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Stage 2 Alzheimer's

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Wander, forget about hygiene, disturbed sleep/wake cycle, communication decreases, make lists to help them remember things

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Stage 3 Alzheimer's

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Total disinterest in appearance, blank stare, emotionally/psychologically labile (mood swings), communication declines until they may not talk at all

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Alzheimer's Disease medical management

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1. Cholinesterase inhibitors (Aricept) 2. N-Methy-D aspartate receptor antagonist (Namenda) *May slow the progression of the disease, but will not alter the outcome

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Parkinson's Disease

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Chronic Progressive Disease of the basal ganglia, gradual slowing of voluntary movement, muscular rigidity and tremor; the neurotransmitter dopamine is decreased leading to inability to refine voluntary movement; unknown cause Acetylcholine remains active, leading to excessive muscular excitation

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Parkinson's Disease S/S

answer

1. Bradykinesia: slow movement 2. Postural instability: wobble when they walk, big fall risk

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Parkinson's Disease clinical findings

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Has difficulty beginning movement, may freeze during movement, faster/shorter steps, mask-like appearance

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Parkinson's Disease nursing management

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1. Allow extra time for talking and tasks 2. Give meds promptly (at times when the patient is going to be active, so that they can peak) 3. Collaborate with PT, SLP and OT 4. Assess/address insomnia, depression, anxiety, pain, med side effects 5. Respite plan for care giver

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Levodopa/Carbidopa (Sinemet)

answer

Symptom relief for about 6hours, but over time this decreases in duration

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Anticholinergic Agents (Cogentin)

answer

May be given in combination with Sinemet

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Antiviral Therapy (Symmetrel)

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Reduces tremors, rigidity, and bradykinesia

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Dopamine Agonists (Parlodel, Requip)

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Help with symptoms

question

MAO inhibitors (Eldepryl)

answer

Inhibits dopamine breakdown and are thought to slow progression of disease

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Antihistamines (Benadryl)

answer

Can sometimes help with tremors

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Parkinson's disease surgical management

answer

1. Thalamotomy or Pallidotomy 2. Deep Brain Stimulation

question

Deep Brain Stimulation

answer

Just interrupt nerve pathways to alleviate tremor and rigidity

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Huge problem with Parkinson's Disease

answer

Nutrition; slow decline (can be 15-20 years)

question

Multiple Sclerosis

answer

An immune-mediated progressive demyelinating disease of the CNS; can be acute or subacute, but more commonly chronic and episodic

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MS clinical findings

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Can vary from initial presentation; numbness/tingling in face/extremities, may complain of limbs feeling heavy yet appear normal when walking (may result in falls), bowel/bladder disorder in about 90% of patients, slurred speech, blurred vision, alter eye movement

question

MS patterns of progression

answer

Relapsing remitting, primary progressive, secondary progressive, progressive relapsing

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Relapsing remitting

answer

Classic progression; flare up of symptoms that resolve and remission may last a long time

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Primary progressive

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Steady deterioration without retention

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Secondary progressive

answer

Begins with classic, but later becomes progressive

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Progressive relapsing

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Progressive relapse with only partial recovery between flare ups

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MS dx

answer

1. History 2. MRI shows plagues in CNS and is diagnostic

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MS medications

answer

1. Disease Modifying Drugs: Interferon beta 1a (Rebif), Glatiramer acetate (Copaxone), Solumedrol (methyleprednisolone) 2. Drugs also given for symptom management: antidepressants, bladder/bowel meds., Vitamin C

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Interferon beta 1a (Rebif)

answer

SubQ x3/week to reduce frequency and duration of relapse and remove plaque

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Glatiramer acetate (Copaxone)

answer

SubQ daily to reduce frequency and duration of relapse

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Solumedrol (methyleprednisolone)

answer

Used with initial presentation; IV, large doses

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MS nursing management

answer

1. Promote mobility and manage symptoms 2. Activity and rest balance 3. Vision assessment and care 4. Bladder care 5. Medications 6. Support systems in family and National MS society

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Huntington's Disease

answer

Rare inherited disorder produced by degeneration of the basal ganglia and cerebral cortex; produces choreiform movements and progressive dementia Treatment is supportive and aimed at helping with symptoms: Genetic Counseling in childbearing age group, dilemma re pre-symptom testing

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Special Neuromuscular Pediatric Conditions

answer

1. Cerebral Palsy 2. Muscular Dystrophy

question

CP etiology

answer

Injuries or abnormalities of the brain resulting from 1. Prenatal factors in 70-80% 2. ELBW & VLBW 3. Postnatal Viruses: bacterial meningitis, viral encephalitis 4. Vehicle Accidents 5. Child Abuse

question

CP pathophysiology

answer

No single location in the brain that is associated with CP; usually happens early on, but can result later on from trauma Can be any of the following: 1. Random mutations 2. Maternal infections 3. Fetal stroke 4. Lack of oxygen 5. Infant infections 6. Traumatic head injury

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Types of CP

answer

1. Spastic 2. Dyskinetic 3. Ataxic 4. Mixed/Dystonic

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Spastic CP

answer

Classic CP (70-80%*) 1. Muscles are stiff and movements are jerky/awkard 2. Hypertonicity and poor postural/balance control

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Dyskinetic CP

answer

1. Athetoid: chorea, slow, worm like, writhing movements 2. Dystonic: drooling, abnormal posture

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Ataxic CP

answer

Rapid, repetitive movements poorly performed

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Mixed/dystonic CP

answer

Combined spastic and dyskinetic

question

CP clinical manifestations

answer

1. Delayed gross motor development 2. Abnormal motor performance 3. Alteration of muscle tone 4. Abnormal posture 5. Reflex Abnormalities 6. Associated disabilities and problems: visual or hearing problems, speech problems, seizures, balance difficulties

question

CP dx

answer

Primary: Neuro Exam 1. Neuroimaging MRI: may show abnormal lesions 2. Metabolic testing: to rule out that something else isn't going on 3. Genetic testing: moro reflex after 4 months of age Persistent primitive reflexes

question

CP mobilization

answer

Certain walkers made for children

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CP surgical interventions

answer

Tendon lengthening, orthopedic

question

CP medications

answer

1. Antispasmodic drugs, seizure medications, botox into muscle group to prevent rigidity/spasms *Symptomatic for the most part

question

CP patients quality of life

answer

With good care, can have a long, decent quality of life

question

Muscular Dystrophies (MDs)

answer

Progressive muscular dystrophies in adults-usually slow progressing, diagnose by R/O other disorders and muscle biopsy; largest group of muscular diseases in children; all have genetic origin and are mostly seen in males; all have increasing disability and deformity with loss of strength

question

Most common MD

answer

Duchenn muscular dystrophy

question

Duchenne Muscular Dystrophy (DMD)

answer

1. Most severe and most common of the MDs in childhood 2. X-linked recessive: about 30% of sisters of boys with MD are carriers, and of these carriers, about half of their male offspring will have the disease 3. A mutation of the gene that encodes dystrophin, a protein product in skeletal muscle

question

DMD clinical manifestations

answer

Appear between 3-5 years of age Slow motor development, progressive weakness, muscle wasting, sitting and standing are delayed, the child is clumsy, falls frequently, and has difficulty climbing stairs Death from respiratory or cardiac failure; survival well into 30's

question

Diagnostic Evaluation of DMD

answer

1. Confirmation by EMG, muscle biopsy, and serum enzyme measurement of CPK 2. Serum CPK is more than 10 times normal even in infancy before the onset of weakness *Levels diminish as muscle deterioration continues

question

Therapeutic Management of DMD

answer

1. No effective treatment has been established: no cure 2. Primary goal: maintain function in unaffected muscles as long as possible --> steroids help (long-term effects: weak bones, immunosuppressed) 3. Keep child as active as possible 4. ROM, bracing, performance of ADLs, surgical release of contractures prn --> sometimes need breathing assistance at night (CPAP) 5. Genetic counseling for family

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DMD Nursing Considerations

answer

1. Help child and family cope with chronic, progressive, debilitating disease 2. Help design a program to foster independence and activity as long as possible 3. Teach child self-help skills 4. Arrange for appropriate health care assistance as child's needs intensify (home health, skilled nursing facility, respite care for family, etc.)

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