Bonnie's Set - Care Of Adults - Test 4

Front 1

What are the factors that affect intracranial pressure (ICP)?

Back 1

* Arterial Pressure

* Venous Pressure

* Intra-abdominal and intra-thoracic pressures

* Posture

* temperature - high temp increases ICP as well as shivering

* Blood gases (high CO2 levels dilates cerebral arteries)

* valsalva maneuver (straining as on the toilet)

Front 2

What are the three components of the brain?

Back 2

* Cerebrospinal fluid (CSF) - 10%

* Intravascular blood - 12%

* Brain tissue - 78%

Front 3

What is the Monro-Kellie Doctrine?

Back 3

If one of the components of the brain increases, then another must decrease to maintain ICP, which is normally 5 - 15mm Hg. This is assuming that the skull is closed.

Front 4

What is ICP?

Back 4

Intracranial pressure is pressure sustained about 20 mm Hg with a skull closed.

Front 5

What are the three different ways that the body can compensate with ICP?

Back 5

* Changes in CSF volume (absorption, production or displaced to the subarachnoid space)

* Changes in intracranial blood volume (collapse of the cerebral veins and dural sinuses, regional cerebral vasoconstriction or dilation, changes in venous outflow)

* Changes in tissue brain volume (distention of the dura or compression of the brain tissue)

Front 6

What is autoregulation?

Back 6

When the brain auto-regulates the intracranial pressure by adjusting diameter of the blood vessels ensuring consistent cerebral blood flow (CBF). It only works if the MAP is 70 - 150 mm Hg. If below 70, CBF decreases and cerebral ischemia occur as syncope and blurred vision. If above 150, the vessels are maximally restricted and the ability to compensate is lost causing decompensation.

Front 7

What is MAP and how is it calculated?

Back 7

Mean arterial blood pressure is calculated as a math equation with systolic blood pressure and diastolic blood pressure as SBP and DBP.

MAP = [SBP + 2(DBP)]/3

Front 8

What are the stages of ICP?

Back 8

* Stage 1: total compensation

* Stage 2: decreased compensation, risk for Increased ICP

* Stage 3: failing compensation, clinical manifestations of inc. ICP (Cushing's triad)

* Stage 4: Herniation imminent (death)

Front 9

What is Cushing's Triad?

Back 9

* Systolic Hypertension with a widening pulse pressure

* Bradycardia with a full bounding pulse

* Altered respirations

Front 10

What affects cerebral blood vessel tone?

Back 10

* Oxygen (too little tension, <50 mm Hg, dilates vessels)

* Carbon Dioxide (too much partial pressure, vessels dilate, too little, vessels constrict)

* Hydrogen Ion concentration (if O2 tension is not increased, anaerobic metabolism begins resulting in lactic acid, increasing H+ further dilating vessels potentially causing loss of auto-regulation and compensation)

Front 11

What are the 3 types of cerebral edema?

Back 11

* Vasogenic - most common type (intravascular to extravascular shift)

* Cytotoxic - Cell membrane disrupted (fluid shift from extravascular to intravascular)

* interstitial - blockage of flow, cannot reabsorb fluid - usually caused by hydrocephalus

Front 12

What are the causes of cerebral edema?

Back 12

* Brain lesions

* Head injuries

* Cerebral infection

* Vascular insult

* Toxic or metabolic encephalopathy

Front 13

Describe decorticate posture.

Back 13

Arms curled into chest, lets straight out with toes pointed.

Front 14

Describe decerebrate posturing.

Back 14

Arms straight down with fists curled out, legs straight with toes pointed. This is the more dangerous sign of ICP, indicating damage to the brain stem.

Front 15

What is a ventriculostomy?

Back 15

An intraventricular catheter to drain CSF in cases of ICP. A "brain drain".

Front 16

What is important in managing a ventriculostomy?

Back 16

* Need to turn the drain off while repositioning the patient

* The drain reservoir needs to be leveled to the ear to regulate the internal pressure and rate of drainage

* septic technique w/masks, shields, etc.

* monitor for s/s of infection

Front 17

When discussing risk factors for stroke with a patient, which factors should be discussed?

Back 17

Only the modifiable ones to give the patient an opportunity to adjust habits and reduce the risk.

Front 18

What are the modifiable risk factors for stroke?

Back 18

* Hypertension

* Heart Disease

* High Serum cholesterol

* Smoking

* Excessive alcohol consumption

* Obesity

* Sleep apnea

* Metabolic syndrome (DM, HTN, Obesity, High Cholesterol)

* Sedentary Lifestyle

* Poor Diet

* Drug abuse

Front 19

What are the types of stroke and differences between them?

Back 19

* Thrombotic Stroke - a blood clot gets caught in an artery that is narrowed by plaque

* Embolic Stroke - a blood clot gets caught in an artery that is just too narrow

* Hemorrhagic Stroke - a burst blood vessel causes bleeding in the brain until clotting can control the bleeding

Front 20

What is tPA and when is it used?

Back 20

tPA is a clot buster that is used in patients with thrombotic or embolic strokes. There is a narrow time frame that it can be used (3 - 4.5 hours after symptoms have set in) or it is ineffective.

Front 21

What happens when a stroke happens on the right side of the brain?

Back 21

* Left sided hemiplegia

* Spatial-perceptual deficits

* Deny or minimize problems

* Rapid performance, short attention span

* Impulsive, safety problems

* Impaired judgement

* Impaired time concepts

Front 22

What happens when a stroke happens on the left side of the brain?

Back 22

* Right sided hemiplegia

* Impaired speech (dysphasia)

* Impaired right/left discrimination

* Slow performance, caution

* Aware of deficits, depressed, anxiety

* Impaired comprehension related language, math

Front 23

What happens to the pupil of the eye of a stroke patient?

Back 23

There is dilation of the eye on the ipsilateral side (same side) as the damage in the brain.

Front 24

What is the order of events that need to take place when a person is suspected of having a stroke?

Back 24

1. Find out when the person was last 'normal'

2. Monitor mental status

3. Quick neuro assessment

4. Trigger patient for 'code stroke'

5. VS, EKG and finger stick (be sure it's not DKA)

6. Obtain other tests after CT scan - timing is important!!

Front 25

What causes a hemorrhagic stroke?

Back 25

* cerebral aneurism

* trauma

* drug abuse

Front 26

What are the clinical manifestations of a hemorrhagic stroke?

Back 26

* neurologic deficits

* headache

* N/V

* decreased levels of consciousness

* HTN

Front 27

In the Glasgow Coma Scale Eye opening section, what are the levels to choose from?

Back 27

4. Spontaneous eye opening

3. Eye opening to voice

2. Eye opening to pain

1. none

Front 28

In the Glasgow Coma Scale Verbal response section, what are the levels to choose from?

Back 28

5. Normal conversation

4. Disoriented conversation

3. Words, but not coherent

2. No words, only sounds

1. None

Front 29

In the Glasgow Coma Scale Motor response section, what are the levels to choose from?

Back 29

6. Normal

5. Vocalizes to pain

4. Withdraws from pain

3. Decorticate posturing

2. Decerebrate posturing

1. None

Front 30

What is a coup-contrecoup injury?

Back 30

After the head strikes an object, an injury occurs as the brain strikes the skull (coup), when the head falls back, the brain strikes the skull on the opposite side (contrecoup).

Front 31

What is a halo sign and what kind of situation would you find this?

Back 31

When fluid from rhinorrhea or otorrhea is placed on a tissue or gauze pad and a clear fluid ring appears around the blood. It is positive for Cerebral Spinal Fluid (CSF). Most often appears in basilar skull fractures.

Front 32

What is a battle sign?

Back 32

A bruise that appears behind the ear of a head injury victim.

Front 33

What is the main difference between bacterial meningitis and viral meningitis?

Back 33

Bacterial meningitis involves brain tissue, viral meningitis does not. Bacterial meningitis can kill, viral meningitis is self-limiting and full recovery is expected.

Front 34

Describe bacterial meningitis.

Back 34

* Affects brain matter

* 100% mortality if not caught emergently

* Highly contagious

* CSF is cloudy, high in protein, low in glucose

* Need antibiotics ASAP

* Treat for ICP issues

* for first 24 hours: droplet precautions, patient should be in a negative pressure room with staff wearing masks & PPE

Front 35

What are the clinical manifestations of bacterial meningitis?

Back 35

* fever

* severe headache

* N/V

* Nuchal rigidity (neck)

* photo & phonophobia

* if meningococcal infection, petechia of the trunk

* decreased LOC

* signs of increased ICP

Front 36

What is the nursing care for bacterial meningitis?

Back 36

* blood culture

* CT scan

* lumbar puncture and analysis of CSF

* antibiotic therapy after collection of specimens, but before diagnosis confirmed

* rapid diagnosis crucial

Front 37

What is encephalitis?

Back 37

An acute inflammation of the brain. Is serious and sometimes fatal and caused by viruses. Ticks and mosquitos sometimes carry these viruses. Anticipate for ICP.

Front 38

What is a brain abscess?

Back 38

* Pus filled swelling in the brain caused by an infection

* May need craniotomy/craniectomy if IV antibiotics do not cross-blood brain barrier

* Causes- dental care, sinus infection, trauma, systemic endocarditis

* Nursing care same as for patient with increased ICP d/t infection and compression of brain matter

Front 39

What is Bell's Palsy?

Back 39

An inflammation of cranial nerve VII. It is a hemiplegia affecting only the face. It is viral in origin, possibly caused by Herpes Simplex, Lyme Disease, flu or infection. It has a good prognosis - full recovery in 3 to 6 months if treatment started soon.

Front 40

What is Botulism?

Back 40

*Most serious type of food poisoning.

* It is a GI absorption of a neurotoxin found in soil. Improper home canning is most common cause in US.

* Involves descending paralysis and can lead to respiratory or cardiac arrest.

* Nursing care: rest, maintaining respiratory function, adequate nutrition, prevention of muscle mass loss

Front 41

What is tetanus?

Back 41

* a severe nervous system infection affecting spinal/ cranial nerves

* The potent neurotoxin spores are found in the garden soil and manure

* Enters the blood stream through open wounds or frostbite

* The initial symptoms are trismus (lockjaw), nuchal rigidity and fever

* muscles become progressively rigid

* Eventually opisthotonos (arching of back and retraction of head)

* 100% mortality in severe form

Front 42

How is tetanus prevented?

Back 42

* TDap vaccine Q10 years

* Immediate cleaning of wound

* With open wounds, if vaccine status is unknown or given longer than 5 years, TDap vaccine is given

* Tdap and Tetanus immune globulin are given in different sites to neutralize toxins

Front 43

How is tetanus treated?

Back 43

* Spasm control with barbiturates

* Neuromuscular blocking agents

* Pain control

* Antibiotics (10-14 days)

* Tracheostomy w/ sedatives, analgesics and paralytics

Front 44

Describe spinal cord injuries.

Back 44

* Damage to the spinal cord

* Highest risk is for males between 16 and 30 years of age

* 81% of people with SCI are male

* There is a trend toward older adults with SCI

* 90% are non-institutionalized

* Usually caused from trauma with 42% from motor vehicle collisions

Front 45

How is the spinal cord damaged?

Back 45

* Compression by bone displacement

* Interruption of blood supply to the cord

* traction from pulling on the cord

* penetrating trauma, suchas gunshot and stab wounds, can result in tearing and transection.

Front 46

What is the etiology of SCIs?

Back 46

The initial injury can be broken up into the

* Primary injury (initial mechanism disruption of axons as a result of stretch or laceration) and

* Secondary injury (the ongoing, progressive damage that occurs after initialinjury).

Front 47

What causes ongoing damage after the initial injury?

Back 47

* Free radical formation

* Uncontrolled calcium influx

* Ischemia

* Lipid peroxidation (related to free radical formation)

* happens in the form of apoptosis, ischemia, hypoxia, hemorrhage and edema

Front 48

What is CCP? How is it calculated and what is the normal pressure?

Back 48

* Cerebral Perfusion Pressure

* CPP = MAP - ICP

* Normal is 60 - 100 mm Hg (<50 mmHg is associated with ischemia and neuronal death and <30 is death)

Front 49

With a SCI, when is prognosis finally determined?

Back 49

After 72 hours

Front 50

What is spinal shock?

Back 50

* About 50% of people with acute spinal cord injuryexperience this temporary neurologic syndrome

* is characterized by decreased reflexes, loss of sensation, and flaccidparalysis below the level of the injury.

* This syndrome lasts days to months and may mask post-injury neurologic function.

Front 51

What are the clinical manifestations of neurogenic shock?

Back 51

* Hypotension

* Bradycardia

* Peripheral vasodilation

* venous pooling

* decreased cardiac output

* Happens at T6 injury or higher

Front 52

What are the clinical manifestations of spinal shock?

Back 52

TEMPORARY

* Loss of reflexes

* Loss of sensation

* Flaccid paralysis below level of injury

Front 53

What's the difference between spinal and neurogenic shock?

Back 53

* Spinal - sudden loss of power, sensations and reflexes below level of injury

* Neurogenic - sudden loss of sympathetic nervous system signals

* Spinal - has absent 'anal wink' (bulbocaverno sus reflex), with neurogenic it's variable

* Spinal - motor has flaccid paralysis, neurogenic is variable

* Spinal - peripheral neurons become temporarily unresponsive to brain stimuli

* neurogenic - disruption of autonomic pathways (loss of sympathetic tone and vasodilation)

Front 54

What are the classifications of SCI?

Back 54

* Mechanism (how the injury occurred)

* Level of injury (which vertebrae)

* Degree of injury

Front 55

What are the major mechanisms of SCIs?

Back 55

* Flexion (flying forward in car accident)

* Hyperextension (hitting chin on table during fall)

* Flexion-rotation (as from a horse - most unstable)

* Extension-rotation

* Compression (diving into shallow pool)

Front 56

What levels are there for SCIs?

Back 56

C3 - and above means ventilator

C4 - may be able to feed self with powered devices

C5 - Powered wheelchair

C6 - may self propel lightweight wheelchair, can write

C7-C8 - can drive a car with hand controls

T1-T4 - iron leg braces for standing

T5-L2 - still requires wheelchair, limited ambulation with crutches and leg braces

L3-L5 - crutches or can

L5-S3 - ambulation

Front 57

What is the collaborative care, nursing management of a patient with SCI?

Back 57

* Ensure airway patency

* Stabilize cervical spine

* O2

* IV

* Assess for other injuries

* Control external bleeding

* Monitor VS, cardiac rhythm, I&O

* keep warm

* Monitor for urinary retention, HTN

* Anticipate need for intubation (if no gag reflex)

Front 58

What is the acute collaborate care of a patient with a SCI?

Back 58

* Obtain a history of the accident

* Thorough assessment of the muscle groups, sensory exam (starting at toes), associated brain injury, other injuries (like internal injuries)
* Logroll

* Continuous monitoring

Front 59

What is the initial care once in the ER of a patient with a SCI?

Back 59

* obtain imaging (X-ray, CT, MRI)

* Prepare for stabilizing with tongs and traction

Front 60

What is important to remember when a patient is in traction or wearing a brace of some sort?

Back 60

That meticulous skin care is critical.

Front 61

When a patient with a SCI is in an automatic bed that rotates, which three systems does this address?

Back 61

* Cardiovascular

* Integumentary

* Respiratory

Front 62

What are the clinical manifestations of the respiratory system of a patient with a cervical or thoracic SCI?

Back 62

* Paralysis of the abdominal and intercostal muscles causing any cough to be ineffective increasing the risk of atelectasis, pneumonia, infection or neurogenic pulmonary edema. This makes bronchial hygiene and chest physiotherapy imperative for these patients.

Front 63

What is neurogenic pulmonary edema?

Back 63

An increase in pulmonary interstitial and alveolar fluid that is due to an acute central nervous system injury and usually develops rapidly after the injury.

Front 64

What is an unopposed vagal response?

Back 64

A SCI above T6 decreases the influence of the sympathetic nervous system, causing vasodilation, bradycardia and hypotension, also causing relative hypovolemia because the increased venous capacity with dilated veins.

Front 65

What could it mean for a patient with a SCI to have an unopposed vagal response?

Back 65

Any vagal stimulation could cause cardiac arrest, possibly causing the need for a pacemaker.

Front 66

What are the needs of a patient with a SCI and unopposed vagal response?

Back 66

* VS need to be frequently assessed

* If bradycardia is symptomatic, give atropine

* pacemaker (temporary or permanent)

* Hypotension managed with vasopressors

* Pneumoboots or compression stockings

* ROM exercises or stretching

* Assess thighs and calves every shift for DVT

Front 67

What is the leading cause of death in patients with SCI?

Back 67

Pulmonary embolism

Front 68

What are the clinical manifestations of the GI tract of a SCI patient above T5?

Back 68

Hypomotility, causing paralytic ileus and gastric distention, causing the need for an NG tube and Reglan. Stress ulcers often develop due to the hydrochloric acid in the stomach, causing a need for H2 blockers and PPIs. If there is GI bleeding, often difficult to tell due to lack of pain. Checking hemoglobin and hematocrit will help.

Front 69

What imbalances can be caused in a SCI patient?

Back 69

Gastric suctioning can cause metabolic alkalosis and decreased tissue perfusion can cause metabolic acidosis. Electrolytes needs to be monitored

Front 70

What is neurogenic bowel?

Back 70

With a SCI of T12 or below, the bowel is initially areflexic with decreased sphincter tone. When reflexes return, sphincter tone is enhanced and reflex emptying returns.

Front 71

What is necessary for the urinary system of the SCI patient?

Back 71

Immediately post injury, there is a loss of autonomic and reflex control of the bladder and sphincter. Over distention can lead to hydronephrosis and acute kidney injury. An indwelling catheter is needed ASAP

Front 72

What is poikilothermism?

Back 72

The adjustment of the body temperature to the room temperature (as in cold blooded animals). There is a decreased ability to sweat or shiver below the level of the lesion. Cannot regulate body temperature. Monitor temp closely.

Front 73

Regarding senses of a SCI patient, what is a good nursing measure?

Back 73

* Stimulate the patient above the level of injury (conversation, interesting foods, TV, music, etc.)

* educate the patient on hyperactive reflexes, such as priapism and spacticity below LOI.

Front 74

What is autonomic dysreflexia?

Back 74

* affects patients with T6 or above SCI

* happens with return of reflexes after spinal shock

* It is a massive, uncompensated cardiovascularreaction mediated by the SNS

Front 75

What is piloerection?

Back 75

Goosebumps

Front 76

What causes autonomic dysreflexia?

Back 76

* Distended bladder

* distended rectum

* Any sensory stimulation

Front 77

What are the signs and symptoms of autonomic dysreflexia?

Back 77

* HTN (up to 300 mm Hg SBP)

* throbbing headache

* diaphoresis (above LOI)

* Bradycardia (30-40 bpm)

* flushing skin (above LOI)

* Blurred vision

* nasal congestion

* anxiety or nausea

Front 78

What happens if autonomic dysreflexia is not treated?

Back 78

* seizures

* stroke

* MI

* death

Front 79

What are the nursing measures for autonomic dysreflexia?

Back 79

* elevate head of bed 45 degrees

* call MD with assessment

* catheterize ASAP, if already in place and plugged, gently irrigate

* remove restrictive clothing & tight shoes

* Monitor BP, VS closely

* Digital rectal exam (looking for impaction)

* Give an adrenergic blocker

* educate family on signs and symptoms

Front 80

What is the difference between psychogenic and reflex erection?

Back 80

* psychogenic erection happens with sexual thoughts in the male

* reflex erection happens with physical contact of the penis and is involuntary

Front 81

What are the treatment for erectile dysfunction?

Back 81

* Drugs

* vacuum devices

* surgical procedures (such as prosthetics)

Front 82

Regarding sexuality, what can be affected by SCIs in men?

Back 82

Male fertility is affected by a SCI, causing poor sperm quality and ejaculatory dysfunction. Recent advances in methods of retrieving sperm have changed the prognosis for men with SCIs to father children from unlikely to a reasonable possibility.

Front 83

Does SCI affect fertility in women?

Back 83

SCIs do not affect the ability to become pregnant or deliver through the birth canal, however menses may cease for as long as 6 months after injury. Because uterine contractions are not felt, a precipitous delivery is always a danger (can happen quickly because labor may not be detected until delivery is imminent)

Front 84

A patient is just admitted to the hospital following aspinal cord injury at the level of T4. A priority of nursing care for thepatient is monitoring for

A. return of reflexes

B. bradycardia with hypoxemia

C. effects of sensory deprivation

D. fluctuations in body temperature

Back 84

B. Bradycardia with hypoxemia. Worried about nuerogenic shock, which is characterized by bradycardia and hypotension

Front 85

A young adult is hospitalized after an accident thatresulted in a complete transection of the spinal cord at the level of C7. Thenurse informs the patient that after rehabilitation, the level of function thatis most likely to occur is the ability to

A Breathe with respiratory support

B. drive a vehicle with hand controls

C. ambulate with long leg braces and crutches

D. use a powered device to handle eating utensils

Back 85

B. Drive a vehicle with hand controls

Front 86

During assessment of a patient with a spinal cord injuryat the level of T2 at the rehabilitation center, which finding would concernthe nurse the most?

A. A heart rate of 92

B. A reddened area of the patient's coccyx

C. Marked perspiration on the patient's face and arms

D. A light inspiratory wheeze on auscultation of the lungs.

Back 86

C. Marked perspiration on the patient's face and arms. Worried about autonomic dysreflexia.