MedSurg – Neuro – Flashcards
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Which would be worse to see coming out of the skull, white or gray matter?
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Neither are great. Gray is WAY bad
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What are the three essential components of the brain that make up the monro-kellie hypothesis?
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Blood CSF Brain matter *a change in one affects the others
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What are 5 factors that influence ICP?
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-Arterial/Venous pressure -Intraabdominal/thoracic pressure -Posture -Temp -Blood gases (CO2)
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What is the hydrostatic force measured in the brain CSF compartment?
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intracranial pressure
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When does intracranial volume change?
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Never, what changes is the pressure. That's the monro-kellie hypothesis
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What is decompression of the brain?
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Compression and ischemia of the brain stem
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What is normal ICP?
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5-15 mmHg
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ICP can be measured in which places?
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-ventricles (most common) -Subarachnoid space -Subdural space -Epidural space -Brain parenchymal tissue
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Which part of the brain consumes more, gray or white matter?
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gray matter - gets much higher blood flow
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What is autoregulation of the CBF?
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the automatic adjustment in the diameter of the cerebral vessels by the brain to maintain constant blood flow during changes in arterial blood pressure
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What is the ideal mean arterial pressure (MAP) to maintain good perfusion of all organs?
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65 mmHg *can be as low as 50
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What are two common symptoms of decreased CBF and cerebral ischemia?
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Syncope Blurred vision
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How are cerebral perfusion pressure and cerebral blood flow related?
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as CPP decreases, autoregulation fails and CBF decreases
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What is normal CPP?
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70-100 mmHg
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What CPP is not compatible with life?
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<30mmHg
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What pressure of CPP is associated with ischemia and neuronal death?
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<50mmHg
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What is the clinical significance of ICP?
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-decreases CPP -Increases risk of ischemia and infarct -associated with poor prognosis
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What is the first clinical sign of ICP?
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Change in LOC - defined by both the behavior and the pattern of brain activity recorded by an EEG
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Which scores of the glasgow coma scales are important to know?
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If it's 8 you intubate
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What score would dead be on the GCS?
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3
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What is a normal GCS?
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15 - AOx3
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What are the three parts of the GCS and what do they measure?
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4 eyes Jackson 5 - verbal V6 - motor
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Pressure on the thalamus, hypothalamus, pons, and medulla would all cause what?
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Change in vital signs
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What is cushing's triad?
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-Widened pulse pressure -Bradycardia -Bradypnea
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When does Cushing's triad appear?
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Not until ICP is increased for a long time, or if there is a SUDDEN increase in ICP
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What other vital sign may be affected by ICP?
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change in temperature due to pressure on hypothalamus
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What are 4 ocular signs of ICP?
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-Ipsilateral dilation on the side of the lesion -Sluggish/absent response to light -Inability to look up -ptosis of the eyelid
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What are changes in motor function in someone with ICP?
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Hemiparesis and hemiplegia on body side contralateral to lesion.
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What are the two postures that happen with severe ICP?
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decorticate (hands makes an O, toes down) decerebrate (Hands flip out, toes point inward)
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Which is worse decorticate or decerebrate?
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decerebrate (lower brainstem involvement)
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What is vomiting like in patients with ICP?
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NOT preceded by nausea Sometimes projectile
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What is the order of action if your patient has a blown pupil?
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-CALL FOR HELP! -Then assess vitals -Get them ready to go to CT
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What is never performed on a patient with ICP?
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Lumbar puncture - there is a possibility of herniation from the sudden release of pressure in the skull
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What is the best way to monitor ICP?
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Ventriculostomy - catheter in the ventricles of the brain, can also be used to drain CSF
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What are the risks associated with a ventriculostomy?
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Abscess Meningitis Encephalitis RISK FOR INFECTION!
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When someone has a ventricular catheter in place, where is the transducer placed?
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Normally it should be at the same level as the ventricular reference point so as not to affect the pressure when you are draining CSF? However, the physician can order another placement.
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How often do you drain CSF out of the ventricular catheter?
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That will be ordered by the physician
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What is the collaborative care for a patient with ICP?
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-identify and treat underlying cause -support brain function
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What is the DOC for treating ICP?
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Mannitol (osmotic diuretic)
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Other than mannitol, which 3 other drugs would probably be given to an ICP patient?
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-Corticosteroid (decrease inflammation) -Barbiturate (induce a coma if needed) -Anticonvulsant (you don't want them seizing)
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Corticosteroids are contraindicated in which patients?
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Head injury. Steroids are good to use to control vasogenic edema surrounding tumors or abscesses.
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Which three nursing assessments are most important for ICP patients?
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-Glasgow coma scale -Neurological assessment -Respiratory assessment
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Pinpoint pupils might indicate what?
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Drug use
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What is your priority assessment with someone with ICP?
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AIRWAY! BREATHING! CIRCULATION!
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What are good diagnoses for someone with ICP?
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-Ineffective airway clearance related to diminished protective reflexes (cough, gag) -Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement) -Ineffective cerebral tissue perfusion related to the effects of increased ICP -Deficient fluid volume related to fluid restriction -Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter)
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What is probably the most common type of pain felt by humans?
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headache
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What are the three classifications of headaches?
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tension migraine cluster
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Which HA presents with unilateral or bilateral THROBBING pain?
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migraine - described as steady, throbbing pain that coincides with pulse
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What type of HA is characterized by repeated HA that occur for weeks or months as a time, followed by periods of remission?
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cluster HA
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Which headache presents as a bilateral, band-like feeling of pressure around the head, with constant squeezing tightness?
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tension-type headache
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What symptoms accompany a tension HA?
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-no nausea vomiting -May have light/sound sensitivity -Intermittent
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Triggers are associated with which type of HA?
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Migraine
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What are clinical manifestations of migraines?
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-Generalized edema -Irritability -Pallor -N/V -Sweating
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How are migraines diagnosed?
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usually from history
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What does a cluster HA feel like?
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-throbbing in the eye radiating to temple, forehead, cheek, nose, or gums -sharp/stabbing
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How are cluster HA diagnosed?
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-Usually based on Hx -Scans would be used to r/o aneurysm, tumor, or infection -HA diaries are helpful
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What is collaborative care for HA?
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-Identify if there is underlying physiological cause -Pain relief -Symptom relief -Prophylaxis
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What type of therapies are used for symptomatic relief of prophylaxis of HA?
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-drugs -yoga -biofeedback -CBT -relaxation
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For moderate to severe migraines what is DOC?
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Triptans are first line of therapy
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What are the three methods of actions of triptans?
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-Affect serotonin -Reduce neurogenic inflammation -Vasocontrict
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Why do people with migraines feel HA more severely?
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because the migraine lowers the pain threshold.
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What drugs are used for prophylaxis of migraines?
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-Topamax -Depakote -Beta blockers -SSRI -Ca-Chan blockers -Some antipsychotics -Botox has been effective
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Cluster HA are not as receptive to drug therapy, but what drugs might be tried to prophylaxis?
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-Verapamil -Lithium -Ergotamine -Divalproex -NSAIDs
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What are common nursing diagnosis for HA?
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-Acute pain -Anxiety -Hopelessness
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What are good nursing interventions for HA?
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-Educate! -Encourage exercise -Yoga -Meditation -Relax -Self hypnosis -Massage and heat packs (tension) -Make written note of meds to prevent accidental overdose -Dietary counseling for food triggers -Avoid smoking -Teach about prophylactic treatment
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Seizures can be caused by what illnesses?
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-Tumor -Meningitis -Fever -ICP
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What is epilepsy?
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spontaneously recurring seizures caused by an underlying chronic condition.
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What is not considered epilepsy?
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If the seizures stop when the underlying cause or condition is treated.
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What is a generalized seizure?
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When the whole brain is involved at the onset of the seizure
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What is a partial seizure?
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When the onset of the seizure is localized to one part of the brain
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Auras are most commonly associated with which type of seizure?
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partial or focal seizure
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What is status epilepticus?
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state of constant seizure or condition when seizures recur in rapid succession without return to consciousness between seizures *permanent brain damage can result due to increased brain energy consumption
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What are diagnostic studies of seizures?
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-complete seizure and medical history -EEG -They may admit the patient and have them go off of meds to induce a seizure, then they would draw labs and look at the brain immediately following the induced seizure.
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What is important with patients on anticonvulsants?
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Monitor drug serum levels
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What are good nursing diagnoses for seizures?
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-Ineffective breathing pattern -Risk for injury related to seizure activity -Fear related to the possibility of seizures -Ineffective individual coping related to stresses imposed by epilepsy -Deficient knowledge related to epilepsy and its control -ineffective self-health management
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What are the two most common drugs used for seizure therapy?
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-carbamazepine (Tegretol) -divalproex (Depakote)
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What are other drugs used for seizure disorders?
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-gabapentin (Neurontin) -Lamictal -Gabitril -Topamax -Keppra -Zonegran
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What is important teaching for the patient on anticonvulsants?
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do NOT discontinue meds abruptly, because that can precipitate a seizure
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Which drug would be contraindicated for seizures in older adults with liver impairment?
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phenytoin (Dilantin)
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What is the NUMBER ONE diagnosis for seizure?
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Risk for injury
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What are goals for seizure patients?
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-Be free from injury during seizure -Optimal mental/physical health while on meds -Satisfactory psychosocial functioning
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What are good nursing interventions for seizures?
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-Have patient wear helmet if risk for head injury -Seizure diaries -Work to improve general health habits -Assist to identify triggers -Instruct to avoid alcohol, fatigue, and loss of sleep (college kids at risk)
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What is the acute intervention for someone having a seizure?
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-Ensure clear airway -Support head -Turn them on their side -Loosen tight clothes (around neck) -ease to floor -may require suctioning or oxygen after seizure
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What is the most important piece of education for someone with seizures?
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DO NOT ADJUST YOUR MEDS OR STOP TAKING THEM
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What is a chronic, progressive, degenerative disorder of the CNS characterized by the demyelination of nerve fibers of the brain and spinal cord?
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Multiple sclerosis
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How are nerve impulses affected from the demyelination?
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they are slowed
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What are common S&S of MS?
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Motor problems Sensory problems Cerebellar problems Emotional problems
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What are some motor problems associated with MS?
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-Weakness or paralysis of limbs, trunk, head -Diplopia -Slurring speech -Muscle spasticity
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What are some sensory problems associated with MS?
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-Numbness and tingling -Blurred vision -Vertigo -Tinnitus -Decrease hearing -Chronic neuro pain
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What are some cerebellar problems associated with MS?
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-Nystagmus (erratic eye movement) -Ataxia (lack of voluntary muscle movement) -Dysarthria (lack of speech) -Dysphagia
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How might bowel and bladder function be impaired by MS?
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-Constipation -Spastic bladder -Flaccid bladder
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What is a spastic bladder?
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Small capacity for urine leads to incontinence, there is no control over when the bladder will empty
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What is a flaccid bladder?
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Large capacity for urine and no sensation to urinate
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What are some cognitive problems associated with MS?
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-Short term memory -Information processing -Planning -Visual perception -Word finding
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What are some emotional problems associated with MS?
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-Anger -depression -euphoria
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What is the DOC used to treat MS?
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Corticosteroids - treat acute exacerbations but do not ultimately affect the progression of the disease
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How is MS diagnosed?
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MRI - lesions on spine or brain
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What are other drugs used with MS?
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-Muscle relaxants -CNS stimulants -Anticholinergics -Acetylcholinesterase inhibitors -Tricyclics -Anticonvulsants
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What nutritional therapy would a patient with MS want to adhere to?
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-Megavitamins to help body repair itself -Low-fat -gluten-free -raw veg -High-protein
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What are common nursing diagnoses with MS?
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-Impaired physical mobility -Dressing/grooming self-care deficit -Risk for impaired skin integrity -Impaired urinary elimination -Sexual dysfunction -Interrupted family processes
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What are nursing interventions for MS?
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-Help patient avoid triggers -Reassure patient -Prevent major complications of immobility during exacerbations -Avoid fatigue -Avoid hot/cold extremes -Avoid exposure to infection
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What is parkinson's?
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Disease of basal ganglia and disruption of dopamine-acetylcholine balance - causes disturbed gait, tremors at rest, slowed movement, etc.
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What is the classic PD triad?
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Onset is gradual and insidious -Tremor -Rigidity -Bradykinesia
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What are S&S of beginning stages of PD?
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mild tremor slight limp decreased arm swinging
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What are S&S of late stage PD?
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-shuffling -propulsive gait with arms flexed -loss of postural reflex
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What aggravates PD tremors?
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-They are more prominent at rest -aggravated by stress -aggravated by increased concentration -Starts in hands (pill rolling)
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What types of autonomic movements are lost or diminished in bradykinesia?
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-Blinking -Swinging arms while walking -Swallowing saliva -Self-expression with facial movements
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Dysphagia puts a PD patient at risk for what two things?
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-malnutrition -Aspiration
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Why would someone with PD have orthostatic hypotension?
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Because of disabilities in their autonomic system, not due to drugs.
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What is something we can help in a patient with PD that can greatly improve their quality of life?
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Effectively help manage their sleep disturbances
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How is a diagnosis for PD made?
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Solely on history and clinical features. *Firm diagnosis when two of the three features are met
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What is the goal of PD drug therapy?
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Correct neurotransmitter imbalance
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Which is the DOC for PD?
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Levodopa/Carbidopa (Sinemet) - can cross BBB
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What is surgical therapy for PD?
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Deep brain stimulation (occasionally ablation)
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When would deep brain stimulation be indicated?
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Patients who are unresponsive to drug therapy or who have developed severe motor complications
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What is good nutritional therapy for PD patients?
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-Food that is easily chewed and swallowed (dysphagia) -Adequate roughage (constipation) *malnutrition and constipation are serious consequences of PD
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What are nursing diagnoses for PD?
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-Impaired physical mobility -Imbalance nutrition: less than body requirements -Impaired verbal communication -Deficient diversional activity
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At the beginning of PD diagnosis, what can help with the bradykinesia?
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exercise and a well balanced diet
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How do you teach someone with PD to step?
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Have them consciously thing about stepping over a line on the floor, having them lift their toes when stepping
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What are things we can do/suggest to help a patient with PD?
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-Have them get out of chair by placing the back legs on small blocks -Remove rugs/excess furniture -Simplify clothing (velcro, etc) -Use elevated toilet seat
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What are modifiable risk factors for stroke?
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-HTN -Heart disease -Smoking -ETOH -Obesity -OSA -Metabolic syndrome -Lack of exercise -Poor diet -Drug abuse
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What are three types of stroke?
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-Thrombotic -Embolic -Hemorrhagic
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What is a thrombotic stroke?
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Plaque builds up on the sides of vessel walls, narrowing the lumen and blocking the passage of blood.
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What is an embolic stroke?
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A circulating embolus gets stuck in a smaller vessel and occludes it.
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What is a hemorrhagic stroke?
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Burst blood vessel leaks into the brain
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What is an ischemic stroke?
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They result from inadequate blood flow to the brain from a partial or complete occlusion of an artery *can be thrombotic or embolic
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Which is the most common stroke?
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Thrombotic
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Which two diseases put you at highest risk for a thrombotic stroke?
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HTN DM
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Emboli from an embolic stroke most commonly arise from where?
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the heart
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What is the most important question to ask someone suspected of having a stroke?
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When did your symptoms begin?
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What drug is used to treat a stroke?
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tPA
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When must tPA be administered?
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within 3 hours of first symptom
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Why must a CT scan be done before you administer tPA?
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to rule out a hemorrhage. a major side effect of tPA is bleeding
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Who are people at the highest risk for a hemorrhagic stroke?
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-HTN -people on coumadin -A-fib
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What blood levels do you draw for someone on coumadin?
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INR PT
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What blood levels do you draw for someone on heparin?
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INR PTT
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What are the manifestations of an intracerebral hemorrhagic stroke?
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-Neurological deficits -HA -N/V -Decreased LOC -HTN
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What is the most common cause of a subarachnoid hemorrhage?
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bleed into CSF filled space, caused by a rupture of a cerebral aneurysm (the majority of which are in the circle of willis)
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How are subarachnoid hemorrhages described?
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"Worst headache of my life"
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How do you prevent a subarachnoid hemorrhage?
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clip the aneurysm
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What is preventative therapy for those people at risk for strokes?
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-Antiplatelet drugs (ASA) -Oral anticoagulants for those with A-Fib -Surgery for those with RIA and carotid blockages
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What are diagnostic studies for stroke?
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-CT is gold standard -MRI and CBF studies can also be done
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What is the immediate treatment goal for someone having a stroke?
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Life saving techniques Prevent extension of stroke Early treatment using a plasminogen activator (tPA within 3-4.5 hours only)
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What are a few surgical interventions for strokes?
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-Carotid endarterectomy -Transluminal angioplasty -Stenting -Extracranial-intracranial bypass
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Which stroke surgery is performed to prevent impending cerebral infartction?
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Carotid endarterectomy
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Which treatment is used to treat blockages in cerebral blood flow?
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stenting
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What is used for ischemic strokes that are more than 6 hours out or if the patient has a history of bleeding?
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mechanical embolus removal in cerebral ischemia (MERCI) -corkscrew used through a microcatheter inserted through femoral artery, and removes the plaque
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What are clinical manifestations of a stroke?
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-Motor function impairment -Communication -Affect -Intellectual impairment -Spatial perceptual alterations -Elimination problems
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What things does PT work on with the patient after a stroke?
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-Spasticity - ROM is important -Balance - they are a risk for falls -Central Pain Syndrome - generalized pain can happen
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What is affected with communicating and swallowing after a stroke?
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-Aphasia -Auditory overload -Dysarthria -Dysphagia (do a swallow study)
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What behavioral problems may occur as a result of a stroke?
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-Depression -One-side neglect -Behavioral problems (Cognitive, personality)
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What are the goals in rehab post-stroke?
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Lessen disability and attain optimal function
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What is the nursing problems the nurse should be aware of post stroke?
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-Neurological assessments (don't want the stroke extending) -Activity limitations -Psychological distress -Communication difficulties -Continence issues *Collaborative care with PT, OT, and ST
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What is aphasia?
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Affects a person's ability to comprehend, speak, read, and write Two types: fluent and nonfluent
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What is fluent aphasia?
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They speak long runs of words but the content doesn't make sense *Werkicke's aphasia
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What is nonfluent aphasia?
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They understand others but speak very slowly and use very few words
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What is dysarthria?
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It is weakness, slow movement, and a lack of coordination of the muscles associated with speech. They have to actively think to form words
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What are nursing responsibilities post stroke?
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-Enable them to interact with others to fullest extent possible -Dementia patients may still be able to answer open ended questions -Get to know patient -Make every effort to understand the patient (see if they can still write) -Need opportunities to address more than basic needs -Need opportunities for self-actualization -Have them share a meal with friends, listen to music, learn something interesting
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Which factor related to CBF most often determines the extent of cerebral damage from a stroke?
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degree of collateral circulation
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The most common behavioral response of a patient post stroke is what?
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depression
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What is the difference between a stroke and a TIA?
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TIAs resolve within 24 hours
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In older adults what things can precipitate a TIA?
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-Ortho hypo -Postural changes -Overaggressive HTN therapy
