complex #2 - neuro

Morno-kellie doctrine

the 3 components of the brain must stay at a relatively constant volume within the closed skull; if the volume of one increases then the volume of another will decrease

the skull is closed

what idea does the Monro-Kellie doctrine rely on?

5 to 15 mm Hg

what is normal ICP?

stage one of increased ICP

ICP is completely compensated; an increase in one component does not affect ICP

stage 2 of increased ICP

compensation starts to decline; there is an increased risk for increased ICP

stage 3 of increased ICP

failing compensation; small increases in volume cause big increases in ICP; clinical manifestations increased ICP (i.e. Cushing’s triad)

stage 4 of increased ICP

herniation imminent → leads to death

cerebral blood flow

amount of blood in mL passing through 100g of brain tissue in 1 minute

50mL/min/100g

what is the normal cerebral blood flow

when MAP is between 70 to 150 mmHg

when is autoregulation effective?

autoregulation

automatic adjustment in diameter of cerebral blood vessels

MAP minus ICP

cerebral perfusion pressure =

60 to 100 mmHg

what is normal CPP?

less than 50

what CPP is associated with ischemia and neuronal death?

less than 30 mm Hg

what CPP is incompatible with life

CO2, O2, and hydrogen ion concentration

what factors affect cerebral blood vessel tone?

vasogenic cerebral edema

extracellular accumulation of fluid resulting from disruption of the blood-brain barrier (BBB) and extravasations of serum proteins

cytotoxic cerebral edema

extracellular water passes into cells resulting in swelling

interstitial cerebral edema

outflow of cerebrospinal fluid from the intraventricular space to the interstitial areas of the brain

change in LOC

what is a hallmark sign of increased ICP?

(systolic hypertension) widened pulse pressure, bradycardia, irregular respirations

what are the three s/s associated with Cushing’s triad?

decerebrate posturing

what posturing indicates more serious damage?

compression of cranial nerve III

patient begins to have ipsilateral pupil dilation, eyelid ptosis, and is unable to move their eyelid upwards - what do you suspect is happening?

brain hermination

your patient suddenly has a fixed, unilateral, dilated pupil - what neurologic emergency do you suspect?

continuous, worse in the morning

what kind of headache would you associated with increased ICP?

not preceded by nausea

how is vomiting with increased ICP unique?

tentorial herniation

occurs when mass lesion forces brain to herniate downward

uncal herniation

lateral and downward herniation

cingulate herniation

lateral displacement of brain tissue beneath falx cerebri

lumbar puncture

what diagnostic study would you not perform on someone you suspect has increased ICP?

ventriculostomy

what is the preferred way of monitoring ICP?

ventriculostomy

directly measures pressure within the ventricles; facilitates removal and/or sampling of CSF; allows for intraventricular drug administration

fiberoptic catheter

catheter containing a sensor transducer is placed within the ventricle

air pouch/pneumatic technology

air-filled pouch at catheter tip; senses pressure changes within the cranium

CSF

what can you remove from the brain to treat increased ICP?

jugular venous bulb catheter

measures jugular venous oxygen saturation (SjvO2)

glucose (patient is hypermetabolic and hypercatabolic)

what does an patient with increase ICP need an increase of nutritionally?

immediately after, within 2 hours, or within 3 weeks

when are the 3 points following a head injury when death is most likely to happen?

minor head injury

GCS of 13 to 15 following a head injury would indicate?

moderate head injury

GCS of 9 to 12 following a head injury would indicate?

severe head injury

a GCS of 3 to 8 would most likely indicate?

epidural hematoma

bleeding between the dura and inner surface of the skull

slowly

a venous epidural hematoma would develop -

rapidly

an arterial epidural hematoma will develop -

subdural hematoma

bleeding between the dura mater and arachnoid

subarachnoid hemorrhage

bleeding below the arachnoid membrane into the subarachnoid space

aneurysm and head injury

what are the most common causes of a subarachnoid hemorrhage?

intracranial hematoma

bleeding within brain tissue; usually in the temporal and frontal lobes

size and location

what are the two factors that determine a patients outcome with an intracranial hematoma?

CT scan (rapid diagnosis and treatment)

what is the best way to evaluate for head trauma?

GCS of less than 8; absent gag reflex

what are indications for intubation of an individual with a hematoma?

fluids, IV access, oxygen, stabilize cervical spine

what are nursing interventions for hematomas?

maintain cerebral oxygenation and perfusion, afebrile (no infections), attain maximum function

what are some goals when treating individuals with head trauma?

headache, N/V, cognitive dysfunction

what are common clinical manifestations of brain tumors?

primary injury

initial disruption of axons due to stretch or laceration

secondary injury

ongoing, progressive damage to the spinal cord

spinal shock

patient comes to the ER after hitting there head on the bottom of the pool. they present with decreased reflexes, loss of sensation, and paralysis - what do you suspect?

neurogenic shock

what a patient has a cervical or high thoracic injury, what complication would you look out for?

neurogenic shock

loss of vasomotor tone and loss of sympathetic innervation

hypotension, bradycardia, warm/dry extremities

what are some signs of loss of vasomotor tone?

peripheral vasodilation, venous pooling, decreased cardiac output

which are some signs of a loss of sympathetic innervation?

complete SCI

total loss of sensory/motor function below the level of injury

incomplete SCI

mixed loss of motor/sensation; some tracts intact

older patients

what patient is more likely to develop a complete central cord syndrome?

central cord syndrome

loss of sensation and motor movements; worse in the upper extremities than the lower extremities; may feel some sensations of pain/tingling

anterior cord syndrome

patient has a spinal cord injury and complains of motor paralysis, loss of sensation, and loss of temperature sensation below the level of the injury - what kind of incomplete SCI is suspected?

sensations of touch, position vibration, and motion

what sensations does a patient with anterior cord syndrome still feel?

Brown-Sequard

patient presents with ipsilateral loss of motor function, position and vibratory sense, and vasomotor paralysis - what do you suspect?

loss of motor function, position and vibratory sense, and vasomotor paralysis

what symptoms would a person with a Brown-Sequard spinal injury experience on the same side of the injury?

loss of pain and temperature sensation

what symptoms would a patient with a Brown-Sequard SCI have on the opposite (contralateral) side of the injury?

mechanical ventilation

in a SCI above C-4, what in the priority intervention?

hypoventilation (decreased tidal volume) and inability to cough (risk for atelectasis/pneumonia)

in a patient with a injury below C-4, what respiratory issues are you worried about?

pulmonary edema (fluid overload or shunting of blood into the lungs)

what is a possible respiratory complication of a SCI that we should monitoring for?

atropine

how do we treat bradycardia associated with neurogenic shock?

IV fluids and vasopressors

how do we treat the decreased cardiac output associated with neurogenic shock?

quadriplegics without around the clock care

what individual will need an indwelling catheter to remain?

every 3 to 4 hours

how often should an individual self-catheterize/be catharized?

increase fluids

what patient teaching should you give to a patient with a SCI pertaining to their urinary system?

above T5

at would level would an individual have hypomobility of the GI tract?

place an NGT; administer Reglan

what are the expected interventions for an individual who develops paralytic ileus/gastric distention following a SCI?

neurogenic bowel

term to describe the lack of voluntary control over the GI tract following a SCI

reglan

medication given a day or two after a SCI in order to regain GI motility -

1-2 weeks after injury

what should you plan on beginning a bowel program for an individual with a SCI?

increase fiber intake, suppositories, digital stimulation, regular bowel schedule

what is some patient teaching to give a SCI patient about developing a bowel program?

thermoregulation (monitor room temperatures, warming/cooling blankets)

what is am important thing to remember patients with SCI loose when planning nursing care?

metabolic alkalosis

what acid/base issue are we monitoring for in a patient with continuous or intermediate NGT suctioning following a SCI?

**electrolyte imbalances**, monitor caloric intake, high protein + high fiber

what are some nursing considerations associated with eating in the acute phase of a SCI?

anorexia

what is a big issue with eating in the later stages of a SCI?

DVTs

what is a priority we want to monitor for in patients with immobility following a SCI?

Lovenox

what medication is given prophlactively to prevent DVTs in SCI patients?

doppler studies, TEDS, SCDS

what are some nursing interventions that can be done to prevent DVTs?

signs of an active bleed (recent surgery, low hematocrit)

when would a nurse need to hold a dose of Lovenox for an SCI patient?

prepare for intubation

your patient suddenly no longer has a gag reflex following a SCI - what is your priority intervention?

jaw thrust

what is the appropriate way to open the airway of an individual with a suspected SCI?

methylprednisolone

what medication do you give as soon as possible to a SCI patient to help prevent the side effect of aggressive swelling and inflammation?

hyperglycemia and stress ulcers

you just administered methylprednisolone to a patient with a SCI - what should you be monitoring for in the hours following?

H2 blockers and/or proton pump inhibitors

what medications can be given to prevent the development of stress ulcers in the first 6-14 days following a SCI?

this is normal

your patient’s spinal shock was resolved yesterday afternoon. during your morning assessment, you notice their reflexes are hyperactive and exaggerated. what do you communicate to your patient and and their family about this reaction?

baclofen

what medication do you plan on giving to a patient having hyperreflexia following spinal shock resolution?

autonomic dysreflexia

massive uncompensated cardiovascular reaction of the sympatric nervous system