Critical exam 5

what is the assessment for Neuro patients?

-Need to know if taking meds to suppress neurological status

-Diabetes can mask neurological symptoms

-Encephalopathy

-Hypothermia can too -> warm them up to confirm they are dead

-Labs >> electrolytes, ammonia, BUN, Cr

what is conversion disorder?

a condition where patients experience real, involuntary physical symptoms—such as paralysis, blindness, or seizures—that cannot be explained by a conventional neurological disease

what to do for a lumber puncture?

arch back to spread vertebrae 

-Think about: can have leak of CSF -> complain about headache  

-Help relived by reduce stimuli, lay them flat (evens out the fluid, gives brain to rest and relive headache) 

what is confusion?

impaired judgement and decision making

what is disorientation?

disorientation to time, place, self

what is lethargy?

limited spontaneous movement or speech

What is obtundation?

mild to moderate reduction in arousal with limited response to environment

what is stupor?

condition of deep sleep or unresponsive from which the person may be aroused only by vigorous and repeated stimulation

what is a coma?

unconsciousness, unarousable unresponsiveness

what is localized arousal?

moving your hand with their hand, purposeful movements

what is withdrawal arousal?

reflexes, moves shoulder away

what is persistent vegetative state?

complete unawareness of self or surrounding environment and complete loss of cognitive function

what is akinetic mutism?

severe disturbance in behavioral drive, limited to eye opening and visual tracking

what Is minimally conscious state?

demonstrates minimal defined behavioral evidence of self or environmental awareness, can follow simple commands

what is locked in syndrome?

complete loss of spontaneous movement; expect eye movements (has cognitive function but cannot move)

what is dolls eyes?

When the eyes go the opposite direction of head movement

What is the oculovestibular reflex?

Cold calorics: ice water is injected into the ear. The normal response is that the eyes deviate toward the ear and there is nystagmus. No eye movement is pathological. This tests cranial nerves 3,6, and 8 and the cerebral hemispheres.

what is ICP?

pressure inside the skull

- Brain tissue

- Blood

-CSF

what is early signs of ICP?

- change in LOC

- restlessness/agitation

- headache

- N/V

-blurred vision

what is late signs of ICP?

-Cushing triad

- increase BP (widened pulse pressure)

- decreased HR

- Irregular respirations

What is the normal range of ICP?

0-15 mm Hg

what is Monroe Kelli hypothesis?

the skull is a fixed space, so if brain tissue, blood, or CSF Increases, one of the others must decrease or ICP will rise

what is the causes of High ICP?

-hemorrhage

- cerebral edema

- tumors

-abscess

what is the causes of low ICP?

- they have a drain trying to get CSF off

- EVD

- over draining

- lumbar puncture

what is the nursing management of ICP?

Maintain level at ventricles (tragus-noted part of the ear)

Maintain proper alignment in bed

Mannitol to reduce ICP (not reduce CSF)

Hypertonic saline (not reduce CSF)

Temp

Vitals Q1H

ABGs

Appearance of CSF

what does cerebral perfusion pressure mean?

- CPP = how much blood is getting to the brain

- the brain needs constant blood flow -> oxygen + glucose

-If CPP drops -> brain ischemia -> brain damage

what is CPP = MAP - ICP?

MAP (pressure pushing blood to the brain)

ICP (pressure inside the skull pushing back)

** CPP = "push in" - "pressure against it" ***

what is low CPP?

Not enough blood to brain

-> ischemia, hypoxia, brain injury

Causes

Decrease MAP (shock, bleeding)

Increase ICP (edema, hemorrhage)

what is High CPP?

Can increase risk of brain swelling or bleeding

Usually less emphasized than low CPP

what is mannitol?

osmotic diuretic

what is the mechanism of action of mannitol?

Increases osmotic pressure in the brain stream

Pulls fluid out of the cells -> into the vascular system

Then excreted by kidneys -> diuresis

Decrease intracranial pressure and decrease intraocular pressure

what is nursing consideration for mannitol?

Can lead to dehydration

Assess lung sounds

Monitor electrolytes

Check serum osmolality (risk >320 -> toxicity)

CAN CAUSE FLASH FLUID SHIFT

What is hypertonic saline?

crystalloid solution to shrink the cells and pull water out of the brain cells and decrease swelling

what is the mechanism of action for hypertonic saline?

Creates high osmotic gradient in blood

Pulls water from the cells -> into bloodstream

Expands intravascular volume

Used to decrease ICP and treat severe hyponatremia

what is the nursing considerations for hypertonic saline?

Monitor sodium levels

Frequent neuro checks

Monitor for fluid overload

Administer via central line

Strict I&O

PREFERRED IF NOT HYMODYNAMICALLY STABLE

what is brain herniation?

A brain herniation is when brain tissue, CSF, and blood vessels are moved or pressed away from their usual position inside the skull

what causes a Brain herniation?

Cerebral edema/hydrocephalus

Increase in fluid

Brain hemorrhage

Increases ICP

Tumors

Brain malformation

What does the cerebellum control?

coordination and balance

where does a brain herniation occur?

Between areas inside the skull, such as those separated by a rigid membrane, tentorium or falx

Foramen magnum

how can they cause a herniation on purpose?

crainectomy -> remove part of the skull to allow the brain to expand

what is the s/s of brain herniation?

High BP

Irregular or slow pulse

Headache

Weakness

Cardiac arrest

Loss of consciousness

Loss of brainstem reflexes

Dilated pupils and no movement in one or both eyes

what is the diagnosis and labs for brain herniation?

X-ray of the skull and neck

CT scan

MRI scan

Blood tests if suspected abscess

* See clinical signs first

If you suspect it, you can assume they are herniating

what is the treatment for brain herniation?

- reduce ICP

- place a drain

- medication to reduce swelling

what Is barbiturates?

these are used to decrease brain activity and metabolism, which lowers cerebral blood flow and intracranial pressure

why do they intubate a patient with brain herniation?

A high RR to reduce the levels of CO2

Acidosis causes the vessels to dilate -> hyperventilate to blow off the acidosis

what is nursing management of brain herniation?

- monitor ICP

- if they have EVD drain watch for infection

- watch electrolytes

- log roll patients

what is a seizure?

Episodes of abnormal motor, sensory, psychic, or autonomic function or a combo of all. Generalized, focal, or unknown. Abnormal electrical impulses in the brain

where does a seizure occur?

may involve all or part of the brain

what causes a seizure?

Fevers

Electrolyte imbalances

Stress -> for people who have epilepsy

Hypoxia

CVA

Meningitis

Allergies

Tumors

Liver/kidney failure

what are the stages of a seizure?

-preictal (before seizure)

> may have an aura

- ictal (during the seizure)

- Postictal (after seizure)

> recovery phase, deep sleep, confusion, agitation, fatigue, headache

what is the biggest thing to do with seizures?

SAFETY

Pad the siderails

Oxygen in the room

Turn on left side

Bed in lowest position

what is status epileptics?

continuous or recurring seizure resulting in brain injury >5mins seizure

what are s/s of seizures?

Loss of consciousness

Excessive movement or loss of tone

Behavioral changes

Garbled speech

Twitching

Muscle ridgity

Incontinence

what are the seizure diagnosis and labs?

-To watch the seizure

-Record when the patient is having the seizure

EEG ** gold standard

-Determines type of seizure

-Deep or superficial

what is the nursing management of seizures?

Seizure precautions

Suction ready always

Side lying position to facilitate oral secretions to drain

what is a tonic-clonic seizure?

A generalized seizure in which the patient loses conciousness and has jerking movements of paired muscle groups.

What is a clonic seizure?

spasms only

What is a tonic seizure?

stiffening

What is atonic seizure?

loss of muscle tone

What is a myotonic seizure?

muscle jerk

what is absence seizure?

type of generalized seizure that leads to sudden temporary loss or consciousness, staring or blinking for 3-5 seconds

What is a focal seizure?

Only occurs in one area of the brain

what is ischemic stroke?

a clot blocks blood flow to an area of the brain

what causes an ischemic stroke?

blockage of a blood vessel

what is a small penetrating artery?

a tiny artery that goes deep into the brain and supplies small areas of tissue

- these arteries can get blocked, causing small, deep stroke called lacunar stroke

what is cardiogenic embolic ischemic stroke?

caused from a-fib

affects

- usually affects MCA

- circle of Willis

what is a circle of willis?

It's a ring of connection arteries that allows blood to reroute if one part of the brain's blood supply gets blocker or narrowed

what is the s/s of ischemic stroke?

- face drooping

- arm weakness

- speech difficulty

- sudden weakness

- confusion

- vision problems

- difficulty walking

what is a hemorrhagic stroke?

A stroke caused by bleeding into the brain

What are the causes of hemorrhagic stroke?

- uncontrolled HTN

- aneurysm

- AVM

- medication

What are s/s of hemorrhagic stroke?

**MAIN SYMPTOM: severe headache

-early sign: LOC changes

-vomiting

- seizure

-uchal rigidity

-death

-hypoxia

-hemiplegia

-dysarthria

-homonymous hemianopsia

what are the diagnosis and labs for hemorrhagic stroke?

-CT

-Lumbar puncture

- 12 lead EKG

- BUN/Creatinine

- PT (<15 sec)

- Platelets (>100,000)

what is the nursing management for ischemic strok

Initial airway patency 

Complete on the move to CT 

Thorough neurological assessment 

NIHSS 

Follow the directions 

Manual BP and HR 

Anticipate tPA -> TNK now  2 large Bore IV’s 

NPO until pass swallow screen 

Frequent neuro exams 

what is the nursing management of TPA in ischemic stroke?

-Last normal 3-4.5 hours ago

-SBP <180 and DBP <105

-VS Q15 minutes x 2hours

-No anticoagulants for 24 hours

-Stop TPA if you are suspecting a bleed -> may give platelets, FFP -> help them clot off

-Watch for bleeding (can convert to hemorrhagic stroke)

>Risk for intracranial bleeding ** can convert to hemorrhagic stroke

>First signs: Change LOC, complaining of headache, N/V, assess pupils

what is the nursing management of Hemorrhagic stroke?

- stop the bleeding

- respiratory assessment

- keep stimulation down

what is a subarachnoid hemorrhage?

-Vaso spasms (blood can get in there and irritate the arteries and cause them to spasms, when arteries spasms, they clamp close, the patient will look like they are having an ischemic stroke)

>Vaso spasms = ischemic stroke

>These patients can be in the hospital for a long period of time to prevent Vaso spasms

what is Nipride for?

vaso spasms

- Calcium channel blocker

-This improves their survival and outcomes

-Get it every couple hour -> never skip a dose

-Worry about = keep those vessels open (keep BP appropriate)

>BP = treat if it gets above 140

>Enough fluid volume flowing through -> keep fluid even

>Transcranial dopplers = looking at the vessels and measuring the blood velocity in those vessels

-If they are having spams -> take them to IVR and inject a calcium channel blocker or they can stent it and keep the vessel open

what is a coup head injury?

Results when brain tissue damage occurs directly beneath the site of impact

what is rational force head injury?

brain is sheared/twisted

what is contra-coup head injury?

occurs on the side opposite the area that was hit

what is a concussion?

a bruise like injury of the brain

what is a contusion brain injury?

bruising of the brain tissue within a focal area

What is a epidural hematoma?

blood between the dura and the skull

What is a subdural hematoma?

A hematoma that occurs when veins between the dura mater and the brain are broken and bleed out between the dura mater and brain

What is a basilar skull fracture?

fracture at the base of the skull

what is periorbital bruising?

"raccoon" ecchymosis -> around the eyes

what is mastoid bruising?

"battle sign" ecchymosis

what is one thing you do not due in basilar skull fracture?

NO NG TUBES

What is SIADH?

syndrome of inappropriate antidiuretic hormone

What causes SIADH?

Irritation of CNS: meningitis, encephalitis, brain tumors, brain hemorrhage, hypoxic insult, trauma, brain abscess

what is the SIADH function of ADH?

Antidiuretic hormone = vasopressin

what is the s/s of SIADH

-Decreases low urine output (specific gravity will be high, osmolality of urine will be high

-Osmolality of blood serum will be low

-Signs of hyponatremia: lethargy, apathy, disorientation, muscle cramps

what is the lab values of SIADH?

Serum NA <135

Serum osmolality low

Urine osmolality is inappropriate high

CVP is high from free water retention

what is the treatment of SIADH?

Fluid restriction

If symptomatic -> may need NaCl

Diuretics such as Lasix

Can have a salt pill

Treat underlying disorder

Sodium replacement

Can not do it quickly -> have to do it slowly

If raised to quickly

Demyelination syndrome -> can cause nerve damage

Demeclochlorotetracycline -> blocks ADH receptors in the renal collecting ducts

What is diabetes insipidus?

a disorder caused by inadequate amounts of ADH which causes excessive water loss

what is DI S/s?

-polydipsia

- polyuria

- nocturia

- dehydration

-weight loss

what is DI lab values?

Hypernatremia, Na >150-160

High serum osmolality

Urine Na <20

Low urine osmolality

what is treatment of DI?

Increased PO or IV free H20 consumption, use hypotonic saline

Volume replacement

Vasopressin

Give SubQ

what is cerebral salt wasting?

can be caused by tumors/hydrocephalus or brain trauma

unsure of mechanism but brain cannot communicate w/ kidney leading to lack of Na and water reabsoprtion

what is s/s of cerebral salt wasting?

Polyuria

Weight loss

Dehydration/ hypovolemia

Hypotension

Low CP