med surg 3 exam

Cushing’s Triad

Medical emergency, sign of brainstem compression and impending death, Release pressure in brain, May happen slowly, usually do not notice until we get to irregular resp

cushing’s triad findings

HTN with widening pulse pressure (BP numbers widening but systolic increasing and diastolic dropping), bradycardia with full bounding pulse, irregular respirations

purpose of administration of Mannitol

Pulls fluid out to help reduce cerebral pressure

intracranial pressure

ICP, pressure within skull, normal ICP 5-15

interprofessional management of ICP

reduce it with mannitol or 3% hypertonic saline, craniotomy to relieve pressure, surgery to remove mass or lesion, early feeding, adequate oxygenation, corticosteroids (improve neurogenic function, vasogenic edema)

acute care of ICP

resp function, pain and anxiety management, monitor fluid and electrolytes, monitor and minimize increases in ICP, keep HOB elevated 30 degrees, interventions to optimize ICP and CPP, minimize complications of immobility, protection from self injury, psychologic considerations

resp function for acute care of ICP

maintain patent airway, monitor ABGs, elevate HOB 30, suction PRN, prevent abd distention, maintain effective ventilation

monitor fluid and electrolytes for acute care of ICP

daily weights, monitor IV fluids, serum electrolytes, monitor for DI or SIADH

monitor and minimize increases in ICP for acute care of ICP

Do not change the blood pressure too fast, keep BP a little elevated,

interventions to optimize ICP and CPP for acute care in ICP

HOB elevated, neck midline, avoid extreme neck flexion, turn slowly, prevent pain or discomfort, avoid hip flexion

protection from self injury for acute care of ICP

restraints, sedatives, seizure precautions, quiet, non-stimulating environment

manifestations of ICP

decreased O2 and blood flow, altered LOC, sluggish/dilated pupils, pupils have no response to light, any part of abnormal neuro assessment can be indicator of ICP, Cushing’s triad, hemiparesis, hemiplegia, nocturnal headache, unexpected vomiting

vital sign manifestations for ICP

systolic HTN with widening pulse pressure, bradycardia, bradypnea or tachypnea

complications of ICP

pressure on brain causing injury or herniation, compression of brainstem, resp center, and eventually stop breathing, life threatening, infection, hemorrhage, stroke, ischemia, immobility

interventions to avoid with ICP

extreme neck and hip flexion, no straining during bowel movements, coughing, sneezing, hyperthermia, excessive PEEP/airway obstruction

pt teaching for ICP

avoid straining, use stool softeners, rest, report early symptoms, keep HOB elevated, avoid abrupt physical manipulation or head turning

prevention of ICP

treat underlying causes early, enforce strict bowel regimens to prevent straining, implement seizure prophylaxis in high risk pts

how to test for CSF with head injury

Check for halo sign, anything coming out of nose or ear put on white gauze, put a drop of water on it and if blood in the middle and yellow halo on outside that is indicator of CSF leak

head injury

Most commonly from facial fractures but frontal skull fractures in general

prioritizing patient care for head injury

CT, may or may not have surgery

complications of head injury

infections, hematoma, tissue damage

head trauma: concussion discharge teaching

Do not return to activity until cleared, watch for changes in LOC, headaches, light sensitivity, low stimuli environment, avoid screens

diagnosis of head injury

CT and MRI, both can come back normal and still have a head injury

post-concussion syndrome symptoms

HA, changes in HA, worried about vomiting when they do not have nausea too, when it happens more than once, or uncontrolled, lethargy, personality changes, shortened attention span, decreased short term memory

assessment findings for bacterial meningitis

fever, severe HA, N/V, nuchal rigidity (stiff neck)

late symptoms for bacterial meningitis

photophobia, decreased LOC, signs of increased ICP: seizures occur in 1/3 cases, headache worsens, vomiting and irritability

bacterial meningitis

life threatening inflammation of the meninges surrounding brain and spinal cord, Always do head CT before lumbar puncture, initiate precautions (contact, airborne)

how to know if meningitis is bacterial or viral

gram stain, takes days to get back, assume bacterial until proven otherwise so getting antibiotics, will not heal viral but use it as precaution, antivirals if viral (acyclovir) usually self limiting though

people at highest risk for bacterial meningitis

college students around diff people, bad diets, sleep deprived, get sick a lot

diagnostics for bacterial meningitis

blood/LP culture, CT/MRI, xrays of skull, diagnostics verified: lumbar puncture (neutrophils are predominant WBC in CSF), analysis of CSF with MRI, specimens of secretions are cultured to identify causative organism (swab NG mucosa), gram-stain to detect bacteria

prevention of bacterial meningitis

vaccinations for pneumonia and influenza, meningococcal vaccines, early, vigorous tx of resp tract and ear infections, prophylactic antibiotics for anyone exposed to bacterial meningitis, vaccinate adolescents and college freshman

nursing actions for bacterial meningitis

relieve head and neck pain, minimize environmental stimuli, monitor seizures and provide safety, close observation and assessment, position for comfort, antibiotics, vigorously manage HA, fever, and nuchal rigidity, dexamethasone before or with first dose of antibiotics, IV fluids, rest, mannitol if ICP

nursing care for bacterial meningitis

allow family to keep patient calm and less anxious as they might be disoriented

encephalitis

Acute inflammation of the brain caused by a virus, ticks or mosquitos transmit epidemic encephalitis, due to west Nile, bugs

prevention of encephalitis

stay inside, stay away/avoid ticks and mosquitos, clean rain gutters, drain puddles of water, repellent

manifestations of encephalitis

Flu like symptoms that progress to confusion, seizures, and personality changes over 48 hrs

cerebral edema interventions

HOB elevated 30-45, treat fevers aggressively with antipyretics, controlled hyperventilation, ventriculostomy to drain CSF

cerebral edema treatment

Mannitol, hypertonic saline 3%, corticosteroids (dexamethasone), craniectomy, lesion or hematoma evacuation

cerebral perfusion pressure (CPP) calculation

CPP= MAP-ICP

CPP normal levels

60-100

abnormal cerebral perfusion pressure meaning

less than 50 is ischemia, neuronal death, less than 30 is ischemia and incompatible with life

basilar skull fracture assessment findings

Racoon eyes: bruising around eyes or battle sign: bruising behind the ear, from facial or basilar skull fractures

what to avoid with basilar skull fracture

avoid NG tubes, only use orogastric tubes, do not let them blow their nose

basilar skull fracture complications

meningitis, CSF leak, cranial nerve damage, death, TBI, vascular injury, hematoma, infections, tissue damage

risk factors for brain injury

Sports, any high risk or high velocity activities, being male, older than 65 due to brain atrophy so more space in the head, being on blood thinners, falls

seizure precautions

Abnormal brain activity, Padding, decrease stimulation, Keppra prophylactic or Ativan if any concerns because more likely to have abnormal activity with head injury

craniotomy

Take part of skull out to decrease pressure and allow head to swell, Decreases ICP

craniotomy nursing management

Protect head, eventually put it back hopefully, will have helmet or padding in meantime, fall precautions

decerebrate posturing

outwards, worse everything is an extension, indicator of increased brain damage, all 4 extremities in rigid extension

decorticate posturing

everything going in, decorticate go in towards core, flexion of arms, wrists, and fingers with adduction in upper extremities

patient/family education for traumatic injuries

ambulatory care, home safety to prevent falls, prevent car and motorcycle accidents: wear safety helmets, use seat belts and child car seats, do not drive under the influence or text and drive

factors to take into consideration for traumatic injuries

how did it happen, is there a concern for safety, do they have residual things that put them at risk, change in personality, can they be at home, can they not be at home, how do we prevent more injuries

intracranial hemorrhage

Bleeding in the head, anything that increases risk of stroke also increases risk of intracranial hemorrhage

nonmodifiable risk factors for intracranial hemorrhage

age (after 55), men, blacks, heredity/family history

modifiable risk factors for intracranial hemorrhage

blood thinners, HTN, obesity, heart disease, diabetes, serum cholesterol, smoking, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, drug and alc use

manifestations of hemorrhagic/ischemic stroke

slurred speech, facial droop, abnormal pupils, one sided weakness, decreased sensation, movement, sensory, and vision changes, headache, swallow/speech/gag impairment, emotions/affect, impaired memory/judgement

emotions/affect manifestation for stroke

controlling emotions affected, emotions can be exaggerated or unpredictable

BEFAST for stroke

balance, eyes, face, arm, speech, time

first thing to do when you think someone is having a stroke

do FAST assessment, find out when it started (last known well), get CT

diagnosis for stroke

confirm it with a CT head non-contrast or MRI, if not bleeding then do CTA or MRA, if there is bleeding then stop, cerebral angiography, digital subtraction angiography, transcranial doppler ultrasonography, lumbar puncture, LICOX system

CT and MRI for diagnosis of stroke

shows if they have bleeding or not, will not show an acute ischemic stroke, MRI better to distinguish between ischemic or hemorrhagic stroke, show size and location of lesion, by time it shows up on CT we call it subacute

LICOX system for diagnosis of stroke

measures brain oxygenation and temperature

tPA care for ischemic stroke

recombinant tissue plasminogen activator, given to reestablish blood flow through a blocked artery to prevent cell death (IV thrombolytic or clot busting med), must be started within 3-4.5 hrs of onset, mechanical thrombectomy when you cannot use tPA

screening before tPA

make sure pt is eligible, no GI bleed, stroke, head trauma in 3 months, major surgery within 14 days, recent internal bleeding

nursing role during tPA

frequent VS, managing BP, and neuro checks to make sure pt is not deteriorating

permissive HTN for stroke care

220/120, common immediately after a stroke, may be protective response to maintain cerebral perfusion, forces blood flow through narrowed or blocked arteries to save surrounding brain tissue, contraindicated if receiving tPA

aspiration precautions for stroke care

NPO until swallow study passed, upright position, soft/thick liquid diet, small bites of food, chin tucking while swallowing, check mouth for pocketed food between bites

adapting to functional changes for stroke care

physical and occupational therapy, assistive devices, strict med adherence (antiplatelets, anticoags, statins), manage underlying risk factors

homonymous hemianopsia deficits education for stroke care

improvement within 2-6 months, some deficits may be permanent, active head scanning to spot hazards before moving, scan thoroughly when walking through crowded areas/across cross walks, driving is unsafe, rotate plate so you eat everything on it, work with OT

acute ischemic stroke care

CAB, time of onset of symptoms is critical information (LKW), baseline neuro assessment/vital signs, CT head, NIHSS, permissive HTN, recombinant tissue plasminogen activator if within 3-4.5 hrs of symptom onset (tPA, thrombolytics), stent retrievers, can also do mechanical thrombectomy where they take to neuro IR and go in and get it (up to 24hr), anticoagulants and platelet inhibitors

tPA care concerns

can cause bleedings, have to see if they do or do not meet criteria before giving thrombolytic, if pts get it they are very particular about procedures and what they can have

anticoagulants and platelet inhibitors for ischemic stroke care

24-48hrs after stroke, ASA, ticlopidine, clopidogrel, dipyridamole, use of statins is effective after ischemic stroke

acute hemorrhagic stroke care

CAB, neuro assessments/VS, CT head, NIHSS, stop blood thinners, some will just watch, some will do surgical intervention depends on how big, where it is, if they can coil it, seizure precautions, hemodilution, CCB, manage increased ICP

surgical intervention for hemorrhagic stroke

evacuation of hematomas, resection or radiosurgery, or clipping/coiling of an aneurysm

hemodilution for hemorrhagic stroke care

induced HTN with vasoconstrictors to increase MAP and cerebral perfusion

patho of intracerebral hemorrhage

bleeding in brain caused by a ruptured vessel, sudden onset, HTN most common cause

assessment findings for intracerebral hemorrhage

HA, N/V, decreased LOC, HTN, weakness, slurred speech, eye deviation

severe assessment findings for intracerebral hemorrhage

fixed pupils, abnormal body posturing, coma

difference between hemorrhagic and ischemic stroke

Hemorrhagic is bleeding into the brain from a ruptured blood vessel that results in death of brain cells, ischemic is inadequate blood flow to part of the brain

clinical manifestations of right hemispheric stroke

Impulsive, inpatient, denial, difficulty in judging position, distance, and movement, respond best to directions given verbally, homonymous hemianopsia

clinical manifestations of posterior cerebral artery stroke

visual deficits

homonymous hemianopsia

Blindness in same half of the visual fields of both eyes, teach pts to turn head to scan lost visual field

prevention of subarachnoid hemorrhage

Manage BP, stop smoking, limit alcohol, prevent head trauma, monitor vascular anomalies

swallow precautions

Swallow study before you ever let them eat or drink anything, Difficulty talking, cannot sit up, drooling or unable to handle secretions- nursing does not do this swallow study, it goes to resp therapy

interventions for cerebral aneurysm/subarachnoid hemorrhage

Circulation, airway, breathing, manage BP, aneurysm securement to prevent rebleeding, oral nimodipine for vasospasms, seizure prophylaxis, DVT prevention, fever and pain management, manage secondary complications

difference between transient ischemic stroke (TIA) and stroke

TIA or mini strokes are transient so may have same symptoms as stroke but TIA resolves, higher risk of having a stroke after having a TIA

d/c teaching for TIAs

Symptoms disappear and pt returns to baseline but increases pts risk of stroke therefore they should be admitted for a stroke work up to prevent further strokes

prevention of TIAs

healthy weight and diet, regular exercise, no smoking, limit alc consumption, BP management, routine health assessments

drug therapy for TIAs

antiplatelets (aspirin), anti-coags (warfarin), statins, antihypertensives

neurogenic shock

Distributive shock, vascular below spinal cord injury, vessels dilate so all blood goes there so see hypotension

clinical manifestations of neurogenic shock

Dizziness, lightheaded, hypotension, clammy, bradycardia, peripheral vasodilation, warm/dry skin

neurogenic reflexive bladder

inability to urinate

plan of care for neurogenic reflexive bladder

anticholinergics to suppress bladder contractions, alpha adrenergic blockers, antispasmodic drugs, Botox, bladder retraining, fluid schedule, indwelling foley catheter, suprapubic catheter, self cath

spinal cord injury

Direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection (related to level and degree of injury)

sexuality and fertility for spinal cord injury

open discussion with the pt about sexual rehabilitation is essential, fertility options, tx of erectile dysfunction with drugs/surgery, affects male fertility causing poor sperm motility and ejaculation dysfunction treat with retrieving sperm by penile vibratory stimulation, rectal probe electroejaculation, or surgical removal of sperm, women usually stay fertile, alternative methods of obtaining sexual satisfaction with paraplegia

family teaching on patient care for spinal cord injury

be aware of autonomic dysreflexia and check and relieve sources immediately (kinked catheter, full bladder), skin care and pressure sores (turn q2h), bowel and bladder management, monitor for orthostatic hypotension and DVTs, safe transfer techniques, wheelchair and equipment mastery, pathways and clearance, bathroom grab bars, lower items to be accessible, slip resistant flooring, prioritize rest and respite and set boundaries on care to prevent burnout

interprofessional care for spinal cord injury

stabilize first, Immobilize C spine injuries, (traction, c-collars), then circulation (do they have pulse or uncontrolled bleeding/hemorrhage), airway, breathing, H&P, managing ABCs, neuro exam, stabilize injured spine, VTE

pulse for cervical spinal cord injuries

if no pulse with cervical injuries most likely will not get it back, usually pronounced dead on the scene with C1-2 injury

spinal cord tumor complications

Sensory loss, motor deficits, bowel and bladder dysfunction, permanent spinal cord injury or paralysis, spinal deformities, vertebral fractures and collapse, syringomyelia

manifestations of spinal cord injury

Issues with bowel and bladder, resp complications closely correspond to level of injury, injury above T6 leads to dysfunction of SNS, leads to neurogenic shock, nutritional support, increased metabolism needs and increased protein breakdown, poikilothermic, skin breakdown, VTE, nociceptive or neuropathic pain, decreased GI motor activity leading to gastric distention and development of paralytic ileus