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128 Cards in this Set
- Front
- Back
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level of consciousness (what are the top 3)
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alert: best
confused: awake, talking lethargic: arouse and get vebal response and follow commands obtunded stuperous comatose |
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glasgow coma scale : eye opening
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4 = spontaneous
3 = to voice: requier more stimulus 2 = to pain 1 = none |
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glasgow coma scale : motor response
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6 = obeys commands
5 = localizes to pain 4 = withdrawals to pain: pinching and withdraw extremity 3 = abnormal flexion (decorcate) 2 = abnormal extension (decerebrate) 1 = no response |
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decorticate posturing
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slowly pulling arms to body
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decerebrate posturing
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pulling arms away from the body
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glasgow coma scale : verbal response
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5 = oriented
4 = confused: responding but no appropriately responding to questions 3 = inappropriate words: words don't make sense 2 = incomprehensible sounds: not formulating words 1 = no response |
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glasgow coma scale : muscle strength
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5 = full strength
4 = active movement against resistance 3 = active movement against gravity 2 = active movement without gravity 1 = trace (muscle contraction only) 0 = no movement |
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what to remember when measuring muscle strength
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do bilaterally and indicate difference R vs. L
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assessing pupils
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- size
- reaction - shape |
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what to remember with cataracts
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pupils are not normally round. need to check Hx
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blown
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d/t head injury, increased ICP, will have fixed dilated pupils > 4 mm, no constriction w/light. indicates brain injury
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what other medications can constrict and dilate pupils
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narcotics - constrict
eye drops - constrict & dilate |
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nursing management for pupils
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1. contact the physician if any minute change in size
2. medical bracelets need to be worn if pupil sizes are normally unequal |
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corneal reflex cranial nerve
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V and VII
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cough/gag reflex cranial nerve
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IX and X
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extraocular eye movements cranial nerves
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III, IV, VI
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how do you test the corneal reflex
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with eye drop, cotton tip applicator, touch the eye lashes or cornea to see a blinking reaction
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how do you test the cough/gag reflex
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stick yankur or during suction to initiate a gag/cough response
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how do you test extraocular eye movements
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with a pen
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CN II
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visual fields & acuity
- if pituitary tumor remember to check visual fields. fingers side, below, above |
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CN V
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facial sensation. touch face.
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CN VII
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facial muscles. facial motions -> raise eyebrows.
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CN VIII
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Hearing.
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CN XI
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sternocleidomastoid/trapezius muscle strength. move head from side to side, may use resistance.
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CN XII
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tongue movement.
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3 components of intracranial space
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1. brain tissue/matter
2. CSF 3. blood |
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craniotomy
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bone flap to allow edema to occur
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monro-kellie hypothesis
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proposes that an incrase in one component results in a derease of the other components so that the total voume is constant 100%
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the brain requires
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15-20% resting CO
15% of the body's oxygen demand |
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what is autoregulation?
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brain regulating blood flow to the brain.
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how does the brain autoregulate if BP goes up
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vasoconstriction
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how does the brain autoregulate if the BP does down
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vasodilate to allow more blood to get to the brain
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how do you use lose autoregulation. ICP increase or decrease?
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brain injury or trauma. will have problems w/increased ICP
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hypocapnia
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paCO2 < 35
alkalosis |
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hypercapnia
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paCO2 > 45
acidosis |
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what happens to ICP in hypercapnia. what will you have to do?
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increases. have to regulate CO2 the pt. has in the system
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increase in CBF (> ICP)
(4) |
1. cerebral vasodilation
2. acidosis 3. hypoxemia 4. increase in metabolic rate -> hyperthermia |
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decrease in CBF (< ICP)
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alkalosis
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purpose of CSF
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cushion for the brain
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production of CSF
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choroid plexus
500 mL/day |
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absorption of CSF
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arachnoid villi
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overproduction of CSF =
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increased ICP
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2 disorders of CSF that increases ICP
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overproduction:
communicating hydrocephalus -> no obstruction, overflow non communicating hydrocephalus -> obstruction causing accidents. i.e. tumor, cerebral bleed |
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how does increase blood volume increase ICP
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obstructed venous outflow.
i.e. kinked neck, peep > 5, tight trach ties, coughing, n/v, suctioning, vasalval, intraabdominal pressure |
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3 intracranial blood disorders that increases ICP
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1. hematoma/hemorrhage
2. vasodilation 3. increasing cerebral blood volume |
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3 brain tissue disorders that can increase ICP
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1. lesion
2. ischemic brain injury causing edema -> lack of O2 to brain cells 3. increased metabolic rate increaseing cerebral blood flow and ICP |
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2 examples of increased metabolic rate increasing cerebral blood flow and ICP
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seizures and hyperthermia
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2 types of cerebral edema that causes increased ICP
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vasogenic: vessel permeability, fluid leak to intravascular space
cytotoxic: cellular edema, cell components leak |
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concussion and contusion
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brain bruising
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concussion
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combined effect if more than one. can't do much to fix. multiple, in the long run will lose a lot of function
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coup contrecoup injury
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velocity of brain gets shifted and end up with multiple contusions/concussions
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epidural hematoma
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- outside of dura mater space
- caused by arterial bleed - rapid - blood accumulation and shift occurs to accomodate for excessive blood |
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subdural hematoma
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- venous bleed
- slow - underneath duramater space |
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diffuse axonal injury (6)
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1. widespread axonal damage of white matter
2. traumatic injury 3. axonal swelling. twisted and damaged 4. need to rule out everything else 5. can not be seen in CT/MRI 6. pt in vegetative state |
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diffuse axonal injury s/s (4)
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1. decreased LOC
2. increased ICP 3. posturing 4. cerebral edema |
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increase ICP s/s (7)
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1. LOC - early sign
2. cushings triad 3. pupils rxn to light 4. brainstem reflexes 5. decerebrate or decorticate posturing 6. HA 7. N/V |
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what are early signs of ICP
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LOC, agitation, mentation, anxiety. possible lack of O2 or hypoxemic state
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cushings triad and what does it indicate?
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slow HR, rising systolic BP, lowering diastolic BP.
indicates loss of regulation |
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what should you do if there is any change in pupils
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notify the physician
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example of diminished brainstem reflexes
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varying patterns of breathing
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example of HA and what can it indicate?
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new onset, light bothering pt, no Hx of migranes, can be s/s of possible head bleed
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intraventricular monitoring site
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sits in the ventricle, can also use to drain excess CSF
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intraparenchymal
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w/in the brain tissue
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subarachnoid/volt monitoring site
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monitor pressure
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what does CPP figure out
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how much of the brain is being perfused.
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normal ICP
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<= 15 mmHG
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when do you treat ICP
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>= 20
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how do you decrease ICP (5)
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1. take away tissue
2. bone flap to allow brain to expand 3. diminish blood 4. control CSF by manipulating O2 levels 5. drain excess CSF |
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CPP formula
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CPP = MAP - ICP
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CPP norms, goal and range
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normal 80-100
goal >= 80 range 80-150 |
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nursing actions to decrease ICP (8)
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1. HOB
2. neck alignment 3. diminish hip flexion 4. reduce coughing 5. suction 6. loosen trach ties 7. minimize valsalva maneuver 8. diminish stimuli |
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what can you use while suctioning
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lidocaine to reduce cough if the carina is stimulated
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what can you do to reduce stimuli
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cluster nursing activities and have family there
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4 collaborative modalities to maintain normal ICP
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1. ABG goals
2. normothermic 3. blood pressure goals 4. control seizures |
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ABG goal to maintain normal ICP. what are you decreasing and why?
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CO2 < 35 +- 2
institute slight resp. alkalosis decrease cerebral blood flow b/c vessels vasoconstrict |
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normothermic goal to maintain normal ICP
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- tylenol
- ice in groin regions - increase room temp - warm blankets do not use cooling blankets. will also increase metabolic need |
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blood pressure goals to maintain normal ICP (medication)
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dopamine, levafed, epi
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control seizure to maintain normal ICP
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dilantin or anti-seizure
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collaborative modalities to maintain normal ICP (5)
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1. blunt coughing
2. external drains to manage CSF 3. maintain euvolemic state: keep I/O as close to normal as possible 4. lower levels of PEEP 5. nutritional goals |
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what to remember when there is a device in the brain
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STERILE! drape, gloves, mask.
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responsibilities of a nurse for draining
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- documenting fluid (should be clear, little blood after surgery)
- change connection (MD does insertion) |
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pharmacology: sedation
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propofol, phenobarb drip to enduce phenobarb coma (last resort)
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pharmacology: pain control
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use assessment skills b/c pt. may not be able to respond.
fentinil, delodid |
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pharmacology: neuromuscular blockade
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paralyze pt to control ICP
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pharmacology: osmotic diuretics (4)
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manitol.
- used for brain edema but not good for CHF w/pulmonary edema. - reduces ICP rapidly - needs to be filtered b/c of crystallizing properties - increase urine output |
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pharmacology: corticosteroids and what to remember when administering meds
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dexamethazone, solumedrol
remember to monitor glucose levels |
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pharmacology: barbituates
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last ditch effort
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subarachnoid hemorrhage (5)
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1. associated with aneurysmsm or AVMs
2. control HTN 3. fever 4. calcium channel blocker (nimitop) 5. vasospasms common |
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what are you predisposed to with an aneurysms and what will you be experiencing
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leakage. rapid leaks will experience HA, n/v, not responsive to pain meds
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triple H therapy. what will happen to the systolic BP?
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HTN, hypervolemia, hemodilution
cause HTN to increase blood flow to the area. flood body w/excess fluid to dilute blood stream. systolic BP higher tha normal to increase perfusion to area |
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neurogenic diabetes insipidous (6)
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1. rapid dehydration
2. osmolality increase b/c blood is more viscous, hematocrit will increase 3. deficient production fo ADH 4. urine output exceeding 5-20 L/day 5. hypernatremia 6. hypovolemia |
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neurogenic diabetes insipidous Tx
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fluid replacement
vasopressin DDAVP |
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DDAVP
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stops process of diabetes insipidous
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spinal cord injury patho
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- cord compression
- deficient blood supply - pulling injuries - tearing traction |
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primary injury vs. secondary injury
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direct correlation or cause
occurs based on swelling in the area |
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what happens if the spinal cord is totally trasected
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no repair
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spinal shock (3)
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1. decreased reflexes
2. loss of sensation 3. paralysis below level of injury |
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how do you determine spinal shock (2)
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1. dermatone check with ice or pin prick
2. MRI/CT will be definitive |
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neurogenic shock
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above T6 injury
1. loss of vasomotor tone 2. hypotension 3. bradycardia 4. venous pooling 5. decreased CO |
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how do you determine neurogenic shock
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can't determine until spinal shock is alleviated, usually w/in 24 hours
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hyperflexion spinal cord injury
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rip or tearing
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hyperextension spinal cord injury
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...
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compression
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fragments
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flexion-rotation
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force & twisting
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complete cord involvement
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complete: lose motor & sensation below level of injury
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damage to C1
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death
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damage to C2
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lose HR, resp, require ventilator
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what to worry about in high level fractures
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airway and breathing
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respiratory CM. c4 above and below.
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cervical: above c4
- loss of respiratory muscle function - requires mechanical ventilation c4 or below - hypoventilation - affects intercostal and abdominal muscles - ineffective cough |
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thoracic CM
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above T6
- loss of SNS - vasodilation - bradycardia - decreased venous return |
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urinary system CM
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bladder atonicity (foley catheter)
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GI system CM
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above T5
decreased motility - paralytic ileus - gastric distension - predisposed to stress ulcers - bowel dysfunction |
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what can you use to stimulate motility
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reglin
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with gastric distension what are you predisposed to
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aspiration PNA
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what to worry about with bowel dysfunction
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autonomic dysperflexia
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thermoregulation CM
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poikilothermism: can't regulate temp
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metabolic needs CM
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high protein
positive nitrogen balance |
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peripheral vascular CM
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risk for DVT
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integumentary system CM
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risk for skin breakdown
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autonomic dysreflexia CM
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t6 or above, d/t loss of SNS
- life threatening - severe HTN - acute HA - diaphoresis above injury - bardycardia - visual deficits - nausea |
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2 main reasons for AD in the hospital
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1. make sure foley isn't kinked and urine is drained
2. digital extension for bowel impaction |
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AD Tx
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- alleviate stimulus
- antihypertensives (vasodilators) - sit pt. upright - monitor HR - pt. and family education |
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what types of meds for AD
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nipride to manage BP and atropine for bradycardia
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AD collaborative management (5)
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1. airway protection
2. immobilize/stabilize injury (log roll) 3. O2 and ventilation (mechanical) 4. maintain spinal perfusion 5. steroid therapy |
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what type of steroid therapy can you provide
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VI methyl prednisolone in the first 24 hours to alleviate edema
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more collaborative management (5)
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1. surgical reduction of fracture
2. surgical decompression of spinal cord 3. bladder and bowel interventions 4. pain management 5. manage anxiety |
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occular cephalic
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pry open eyes and move head side to side to see if eyes lag which is good. if not brain stem dysfunction
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occularvestibular reflex
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30 ml iced saline injected into ear while pt. is unconscious, want to see if eyes deviate to side of injection, if away indicates brain stem dysfunction
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