Med Surg Chapter 61 Management Of Neuro

Front 1

Altered Level of Consciousness is a patient who is:

Back 1

not oriented, does not follow commands or needs persistant stimuli to achieve state of alertness

Front 2

What is the most important indicator of a patient's condition? (1st sign of neuro problem)

Back 2

LOC
LOC is also earlist sign of increasing ICP

Front 3

Define Coma

Back 3

unarousable, unresponsiveness to purposeful internal or external stimuli (nonpurposeful responses may be present, but not significant)
lasting 2-4 weeks

Front 4

Define akinetic mutism

Back 4

state of unresponsiveness to the envirnoment with no voluntary movement. Sometimes eyes open

Front 5

Define Persistant Vegetative State

Back 5

Patient is devoid of cognitive function but has sleep-wake cycles (usually after coma)

Front 6

Define Locked-in Syndrome

Back 6

patient is unable to move except for eye movements, due to lesion affecting the pons

Front 7

Clinical manifestations of altered LOC

Back 7

restlessness, agitation, decreased alertness, unresponsiveness, pupils become sluggish or fixed, etc

Front 8

Assessment of altered LOC

Back 8

Orientation x3, motor response, respiration pattern, pupillary reaction, eye movement, reflexes, posture, glasgow coma scale

Front 9

Decorticate posturing

Back 9

adduction and flexion of the upper ext., internal rotation of lower ext, plantar flexion
lesion in internal capsule or cerebral hemisphere

Front 10

Decerebrate posturing

Back 10

extension and outward rotation of upper ext., plantar flexion of feet
lesion at the midbrain
MORE SEVERE DYSFUNCTION

Front 11

Flaccidity

Back 11

result of lower brain stem dysfx, severe neuro impairment, probably brain dead

Front 12

If patient is comatose but has pupillary light reflexes what can be suspected?

Back 12

the cause is a toxic or metabolic disorder

Front 13

Glasgow Coma Scale

Back 13

eyes, verbal and motor response 3-15, 3 is brain death, <8 intubate

Front 14

Complications of altered LOC

Back 14

resp failure, pneumonia, pressure ulcers, aspiration, DVT, contractures

Front 15

Nursing Diagnosis For Alterned LOC

Back 15

ineffective airway clearance, risk of injury, ineffective thermoregulation, risk for impaired skin integrity

Front 16

Goals for alterned LOC

Back 16

clear airway (suction, 30°), protection from injury, fluid balance, skin integrity, thermoregulation (only rectal or tempanic), oral care, corneal protecion, sensory stimulation, ROM

Front 17

What is normal ICP pressure and where is is measured?

Back 17

10-20 mm Hg, lateral ventricles

Front 18

What is the Monro-kellie hypothesis?

Back 18

An increase in brain tissue, blood or CSF causes a change in the volume of the others. Shifting must occur because there is a limited amount of space

Front 19

What can cause elevated ICP?

Back 19

head injury, brain tumors, subarachnoid hemorrhage, toxic or viral encephalopathies

Front 20

What does ICP do to cerebral perfusion? What are the signs?

Back 20

reduces cerebral perfusion, resulting in ischemia and cell death.
SLOW BOUNDING PULSE, RESP IRREG., INC SYS BP

Front 21

What is the effect of CO2 on ICP?

Back 21

Increase in CO2 causes cerebral vasodilation leading to increased cerebral blood flow and increased ICP

Front 22

What will severe edema in the brain cause?

Back 22

brain tissue to shift through opennings in rigid dura resulting in herniation

Front 23

What does autoregulation refer to in ICP?

Back 23

the brain's ability to change the diameter of blood vessels to maintain cerebral blood flow.

Front 24

Cerebral perfusion pressure

Back 24

CCP= MAP (mean arterial pressure) - ICP
Normal CCP is 70-100 mmHg (must be maintained at 70-80, <50 irrev damage)

Front 25

What is Cushing's response?

Back 25

cerebral blood flow decreases (ICP increases) causes increase in BP to increase MAP, HR then decreases

Front 26

What is Cushing's triad?

Back 26

bradycardia, hypertension, bradypnea that eventually leads to brain stem herniation

Front 27

Early signs of ICP

Back 27

changes in LOC, restlessness, confusion, increase resp, pupillary changes, headache, weakness

Front 28

Late signs of ICP

Back 28

Cushing's Triad (inc sys BP, dec HR, bradypnea), projectile vomiting, coma, flaccidy, decort/decer posturing, cheyne-stokes breathing

Front 29

What are the diagnosis techniques used for ICP?

Back 29

ICP monitoring (catheter drain in ventricle-ventriculostomy, subarachnoid screw, epideral monitoring, fiberoptic monitoring), intracranial pressure waves, microdialysis of metobolic function, o2 sat of jugular vein, CT, PET, MRI, etc.
LUMBAR PUNCTURE IS NOT USED, CAN CAUSE BRAIN TO HERNIATE

Front 30

Nursing Diagnosis for ICP

Back 30

ineff airway clearance, ineff breathing pattern, ineff cerebral perfusion, deficient fluid vol r/t fluid restriction, risk for infection

Front 31

Complications of ICP are:

Back 31

diabetes insipidus (dec secreation of ADH--excessive urine output >250 ml/hr), brain stem herniation, SIADH, infection

Front 32

What is SIADH?

Back 32

Syndrome of inappro ADH, increa ADH causes vol overload. Treatment is fluid restriction and maybe careful admin of 3% hypertonic sol.

Front 33

How is ICP decrease achieved?

Back 33

osmotic diuretics (MANNITOL), restricting fluids, draining CSF, controlling BP, fever and oxygenation. May use hyperventilation (causes vasocontriction), DO NOT USE CORTICOSTEROIDS unless it is a known tumor

Front 34

Interventions for ICP

Back 34

freq monitoring of resp status, lung sounds, neutral head position and elevation of 0-60°, avoid hip flexion, any rotation, monitor I/O, maintain calm environment, aseptic technique

Front 35

Define craniotomy

Back 35

opening in the skul to remove a tumor, relieve ICP, evacuate blood clot or control hemorrhage

Front 36

Define craniectomy and cranioplasty

Back 36

craniectomy-excision of a portion of the skull
cranioplasty- repair of a cranial defect

Front 37

Supratentorial surgical approach

Back 37

front side of head behind the hairline, maintaine head at 30-45° neutral, position pt on back or side

Front 38

Infratentorial surgical approach

Back 38

nape of neck, avoid flexion of neck, maintaine straight alignment, position pt on side

Front 39

Transsphenoidal surgical approach

Back 39

enter through nasal cavity, elevate head of bed, used for pituitary tumor

Front 40

Preop care for intracranal surgery

Back 40

CT, MRI, cerebral angiography, transcranial doppler, antiseizure med, corticosteroids if tumor to reduce edema, diuretics, antibiotics, antiaxiety, baseline, preparation for pt and family, education

Front 41

Postop care for intracranal surgery

Back 41

arterial and venous line and intubation monitoring, detection of cerebral edema, pain, seizure, increased ICP and neuro status

Front 42

Assessment of postop intracranal surgery

Back 42

respiratory fx, arterial blood gas, ICP, bleeding, infection, seizure, fluid status, VS

Front 43

Nursing Diagnosis of intracranial surgery

Back 43

ineff cerebral tissue perfusion, risk for imbal body temp, impaired communication

Front 44

Complications of intracranial surgery

Back 44

increased ICP, bleeding and hypovolemic shock, fluid and electrolyte dysfx, seizure

Front 45

Ways to maintain cerebral perfusion after intracranial surgery

Back 45

monitor resp closely, VS and neuro status every 15-60 mins, avoid extreme head rotation, head of bed 30°, decrease ICP and edema

Front 46

Ways to maintain temperature regulation after intracranial surgery

Back 46

cover appropriately, hypothermia blankets, acetaminophen, ice

Front 47

Ways to improve gas exchange after intracranial surgery

Back 47

turn and reposition every 2 hours, encourage deep breathing, suction as needed, use humidified O2 to help loosen secretions

Front 48

Others things to do after intracranial surgery

Back 48

avoid coughing, sneezing, blowing nose, monitor I/O, weight, blood glucose (corticosteroids), urine spec gravity, look for signs of diabetes insipidus and SIADH, lood for CSF leak, seizure, DVT, UTI, pulm embolism, oral care

Front 49

Define seizure

Back 49

abnormal episodes of motor, sensory, autonomic or psychic activity from excess discharge from cerebral neurons

Front 50

Partial seizure

Back 50

begin in one part of the brain
simple partial-consciousness remains
complex partial-impaired consciousness

Front 51

Generalized seizure

Back 51

involves the whole brain

Front 52

Causes of seizures

Back 52

CV disease, hypoxemia, fever, head injury, HTN, CNS infection, metabolic and toxic conditions, brain tumor, drug and alcohol withdrawal, allergies

Front 53

Nursing responsiblity for a patient experiencing a seizure

Back 53

observe and record sequence of events, keep patient safe and protected, side lying position, airway open, bed lowered rails up

Front 54

A headache is also known as

Back 54

cephalgia

Front 55

Define primary headache

Back 55

there is no organic cause-
migraine (periodic/recurrent/4-72hrs), tension-type, cluster (unilateral, eye/temporal, 15 mins-3 hours)

Front 56

Define cranial arteritis

Back 56

inflammation of the cranial arteries characterized by severe headache in temporal artery area

Front 57

Define secondary headache

Back 57

system with organic cause- brain tumor or aneurysm

Front 58

Assessment for headache

Back 58

history, OLDCART, medications, MRI, CT, cerebral angiography

Front 59

Nursing management for headaches

Back 59

meds asap, prevention, comfort measures, prophylactic meds, lifestyle changes