Med Surge - Test 5 P.9-18

Front 1

Cranial Nerve Assessment
CN V Trigeminal-

Back 1

-chewing, assess ability to chew

Front 2

Cranial Nerve Assessment
CN IX Glossopharyngeal-

Back 2

Taste, Gag Reflex)

Front 3

Cranial Nerve Assessment
CN X Vagus-

Back 3

Taste & Stimulation of Digestive System

Front 4

Cranial Nerve Assessment
CN XI Spinal Accessory / )

Back 4

Swallowing

Front 5

Cranial Nerve Assessment
CN XII Hypoglossal -

Back 5

Tongue Movement

Front 6

Cranial Nerve Assessment
-Absent gag reflex

Back 6

(IX)

Front 7

Cranial Nerve Assessment
-Impaired tongue movement

Back 7

(XII)

Front 8

Cranial Nerve Assessment
-asses the pts ability to swallow which reflects the function of CN _ 2__

Back 8

IX and X

Front 9

Cranial Nerve Assessment
-note any facial paralysis or paresis

Back 9

(CN VII)

Front 10

What are “Aspiration Precautions?”

2

Back 10

-pt should be sitting up in bed, not flat, 30 degrees or higher
-thickener in food

Front 11

BEFORE feeding, assess the ability to swallow - NPO until swallow study

Make sure the Pt is NPO until when?

Back 11

 Make sure that the pt remains NPO until the speech language pathologist determines that the pt can tolerate liquids or foods without aspirating.

You may need to place a sign over the bed: “Aspiration Precautions!”

Front 12

Assess ability to swallow
-Observe for what?

-How should you assess the swallowing reflex?

Back 12

Observe for facial drooping, drooling & a weak, hoarse voice

-To assess swallowing reflex, place thumb & index finger on either side of the Adam’s apple, & ask patient to swallow – you should feel the larynx elevate

Front 13

Assess ability to swallow
-how should you position the patient?

Back 13

Patient should be sitting UP in bed 30 degrees or higher, NOT flat! They can aspirate their own secretions

Front 14

Assess ability to swallow

what foods are easier to swallow?

Back 14

Often times, these patients can swallow soft or semi-soft foods (custard, scrambled eggs) & fluids (mechanical soft diet), better than thin liquids (water, juice, or milk).

Front 15

Arteriovenous Malformation (AVM)
-what is it?

Back 15

-A developmental abnormality that occurs during embryonic development.
-It is a tangled, spaghetti-like mass of malformed, thin-walled, dilated vessels.

Front 16

Arteriovenous Malformation (AVM)
-there is a problem where?

Back 16

There’s an abnormal communication between the arterial and venous system.

The vessels may rupture, causing bleeding into the subarachnoid space or intracerebral tissue.

Front 17

Arteriovenous Malformation (AVM)
-what tells you that it is likely to rupture?

Back 17

Elevated BP leads to changes within the arterial wall that suggest it is likely to rupture

Front 18

Complications of the patient with an aneurysm or AVM
-monitor for what 2 things?

Back 18

Monitor for s/s of hydrocephalus and vasospasm

 Hydrocephalus (increased CSF within the ventricular and subarachnoid spaces) may occur as a result of blood in the CSF.

Front 19

Complications of the patient with an aneurysm or AVM
-Hydrocephalus if left untreated, results in ICP. Observe for s/s of hydrocephalus which are

Back 19

change in LOC, headache, pupil changes, seizures, poor coordination, gait, and behavior changes

Front 20

Complications of the patient with an aneurysm or AVM
-s/s of vasospasm may include?

Back 20

decreased LOC, motor and reflex changes, and increased neurologic deficits (ex: cranial nerve dysfunction, motor weakness, and aphasia)

Front 21

Expressive Aphasia is also known as:

Back 21

(Motor Aphasia)

Front 22

Expressive Aphasia

Back 22

-inability to speak remembered words;
-patient knows what to say but cannot articulate the words.
-Also called (Broca’s Speech area, in the frontal lobe is affected)
- Pt may have difficulty writing, but may be able to write.
-Difficulty speaking and writing

Front 23

What is Aphasia?

Back 23

The inability to use or comprehend language.

Front 24

Receptive Aphasia (Sensory Aphasia):
-damage to what area?
-impaired comprehension of?

Back 24

-damage to the temporoparietal area.

-Impaired comprehension of language; patient hears what’s being said but cant understand it

Front 25

Receptive Aphasia (Sensory Aphasia):

what does this involve

Back 25

-The pt cant understand the written word. Although he or she may be able to talk, the language is often meaningless.
- Neologism (made up words) are common parts of speech.
-Also called (Wernicke’s Aphasia)

Front 26

Receptive Aphasia (Sensory Aphasia):

difficulty..

Back 26

-Difficulty understanding spoken words
-Difficulty understanding written words
-Speech often meaningless
-Made up words

Front 27

hemiplegia means:

Back 27

(paralysis on right side of the body)

Front 28

hemiparesis means:

Back 28

(weakness on right side of the body)

Front 29

Right Hemiplegic or Right Hemiparesis indicates a stroke where?

Back 29

indicates a stroke on the LEFT side of the body.*** because the motor nerve fibers cross in het medulla before entering the spinal cord and periphery.

Front 30

Left hemiplegia or left hemiparesis
indicates a stroke where?

Back 30

in the RIGHT cerebral hemisphere.

Front 31

For what types of stroke are thrombolytic agents given?



what are they also called?

Back 31

-used for acute ischemic strokes
-dissolves the cerebral artery occlusion to re-establish blood flow and prevent cerebral infarction
-thrombolytic agents are also called fibrinolytic therapy


-thrombolytics activate plasminogen, which degrades the thrombus by breaking down fibrin

Front 32

What thrombolytic drugs can be given and what precautions does the nurse need to take when the pt receives these medication?

Back 32

-recombinant tissue plasminogen activator (rtPA [Retavase] - only approved drug at this time

-must meet strict eligibility criteria: give grive within 3 hours after the first stroke symptoms

Front 33

thrombolytic drug rTPA
-how is the dosage based?
-while this is infusing, what do you have to monitor? how often?

Back 33

-the dosage is based on the pts actual weight


-perform neurologic assessments, including VS every 15 minutes during infusion and every 30 minutes after for at least 6 hrs. monitor 24 hrs after treatment

Front 34

thrombolytic drug rTPA
-what about their BP?

Back 34

-if systolic BP is 180 or greater or diastolic is 105 or greater, give antihypertensive drugs

Front 35

thrombolytic drug rTPA
-do not place what into the patient?


-discontinue the infusion if the pt reports what?

Back 35

-do not place invasive tubes, such as NG or urinary catheters until pt is stable and prevent bleeding


-discontinue infusion if pt reports severe headache or severe hypertension, n/v

Front 36

rtPA
-after therapy, what should you make sure you obtain?

Back 36

-obtain a follow up CT scan after 24 hrs of treatment before starting on antiplatelet or anticoagulant drugs

Front 37

Thrombolytic Therapy – TPA (Tissue Plasminogen Activator)
---is what?

Back 37

enzyme that dissolves clots

Front 38

Thrombolytic Therapy – TPA

must be at the OR in how long?

Back 38

*Must be at the OR within 3 hours of the onset of symptoms otherwise you can’t have TPA

Front 39

Thrombolytic Therapy – TPA
Eligibility Requirements:

Back 39

- No stroke/head injury in last 3 months (intracerebral bleed)
- No pregnancy
- No MI
- No increased PTT or on anti-coagulant therapy
- Stroke must be verified by CT (if you give TPA and it’s a hemorrhagic stroke, u kill the pt because you take away clotting and they hemorrhage into their brain

Front 40

Hypertonia - AKA:

Back 40

spastic paralysis (spasms into a weird position and stays there)

Front 41

Hypertonia
-tends to cause:

Back 41

-tends to cause fixed positions or contractures of the involved extremities

Front 42

Hypertonia
-what does it to do ROM

Back 42

-ROM of the joint is restricted and should subluxation may easily occur from either spaciticity or flaccidity.

Front 43

Hypotonia:

Back 43

flaccid paralysis
-cannot overcome the forces of gravity, and the extremities tend to fall to the side. the extremities fell heavy, and muscle tone is inadequate for balance, equilibrium, or protective mechanisms

Front 44

Agnosia:

Back 44

the pt is unable to use an object correctly

Front 45

Apraxia-

Back 45

the pt cannot carry out a purposeful motor activity

Front 46

Cheyne-Stokes respirations is what?

Back 46

- apnea alternating with periods of rapid breathing

-***Rhythmical respirations with periods of apnea

Front 47

Cheyne-Stokes respirations
-causes?? 2

Back 47

- central herniation of brain stem
- metabolic imbalance


-precedes death

Front 48

Traumatic Brain Injury
- Mechanisms that can cause this to occur:

Back 48

-a head injury occurs as the result of a blow or jolt to the head as a result of penetration of the head by a bullet or a foreign object. as a result, the normal functioning of the brain is disrupted.
-a direct injury: a force produced by a blow to the head.
-primary brain damage occurs at the time of injury and results from physical stress within the tissue caused by open or closed trauma
-an open head injury occurs when the skill is fractured or when it is pierced by a penetrating object
-a closed head injury is the result of blunt trauma, the integrity of the skull is not violated (more serious injury of the 2)
-indirect: a force applied to another body part with a rebound affect to the brain

Front 49

Intracranial pressure
-consists of?

Back 49

(brain, blood, and CSF)

Front 50

Intracranial pressure
-When the volume of one compartment increases, it must be compensated by a decrease in another compartment

Normal range of ICP

Back 50

-ICP is maintained at its normal level of 10-15 mm Hg despite increases in pressure that occur with straining during defecation, coughing, or sneezing.

Front 51

-As a first response to an increase in the volume of any of these components, the CSF is shunted or displaced from the cranial compartment to the spinal subarachnoid space or the rate of CSF absorption is increased. An additional response, if needed, is a decrease in cerebral blood volume by movement of cerebral venous blood into the sinuses. As long as the brain can compensate for the increase in volume and remain compliant, increases in ICP are minimal.

Back 51

-Increased ICP is the leading cause of death from head injury in pts who reach the hospital alive. It occurs when compliance no longer takes place and the brain cannot accommodate further volume changes.

Front 52

-As ICP increases, cerebral perfusion decreases, leading to tissue hypoxia, a decrease in serum pH level, and an increase in the level of carbon dioxide . This process causes

Back 52

cerebral vasodilation, edema, and a further increase in ICP

Front 53

An increased in ICP can be caused by:

Back 53

•Trauma-blunt trauma, hit head on ground
•Hemorrhage- which causes a brain hematoma (collection of blood), or clot may occur as part of the primary injury. It acts as a space occupying lesions and are surrounded by edema
•Tumors
•Edema- increase the volume of brain tissue
•Inflammation- secondary to encephalitis, meningitis
•Whenever you have trauma you have edema and inflammation

Front 54

An increase in ICP in children can be caused by:

Back 54

•Birth trauma to the head / mother in accident. Trauma to the mother can induce birth
•Hydrocephalus – too much CSF in the brain
•Head trauma
•Infection- meningitis, encephalitis, abscess, sinus infections can lead to an abscess in the brain, you develop herpes zoster (shingles) and you have surgery. There is an entry route
•Brain tumor –most common in men, ages 45-60
•Guillian-Barre Syndrome -viral

Front 55

S/S of ICP
-earliest sign is?

Back 55

Lethargy/altered LOC

Front 56

S/S of ICP
Lethargy is the earliest sign: altered LOC: followed by..

Back 56

restlessness, slowing of speech, & delayed verbal responses irritability, disorientation

Front 57

S/S of ICP
•Pupil changes –

Back 57

fixed, dilated, slowed response, inequality –come from the side dilated and nonreactive

Front 58

S/S of ICP
-what happens to your BP

Back 58

*Increasing systolic BP** with falling or stable diastolic pressure & bradycardia ex: pt has 146/60 and they have a head injury.. You watch it go 152/57, 160/50..brainstem controls BP..the pressure in your brainstem is going up

Front 59

S/S of ICP
•Hyperthermia – early or late sign?

Back 59

late sign of IICP

Front 60

S/S of ICP
-Focal neurologic changes:

Back 60

blurred/double vision, photophobia, muscle weakness/paralysis, positive Babinski

Front 61

S/S of ICP
-Headache
-Fever
-The pt may have photophobia (sensitivity to light) so

Back 61

keep the room lights on low

Front 62

S/S of ICP
- Pinpoint and nonresponsive pupils are indicative of

Back 62

brainstem dysfunction at the level of the pons

Front 63

S/S of ICP
-Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are treated as

Back 63

herniation of the brain from increased ICP until proven differently

Front 64

S/S of ICP
-Pupils that are fixed (nonreactive) and dilated are a poor prognostic sign, resulting from

Back 64

a marked increased in ICP. Pts with this problem are sometimes referred to as having “blown” pupils

Front 65

LATE S/S of increased ICP

Cushing’s Triad:

Back 65

a classic but late sign of increased ICP is manifested by severe hypertension with a widened pulse pressure and bradycardia. As ICP increases, the pulse becomes thready, irregular, and rapid

Front 66

LATE S/S of increased ICP

4

Back 66

*Decerebrate or decorticate posturing
*Cheyne-stokes respirations
*Papilledema: AKA choked disc, edema and hyperemia (increased blood flow) of the optic disc.

*Severe headache, nausea, vomiting, seizures

Front 67

Understand what the vital signs changes indicate about ICP

VS= autoregulatory function which is often impaired as the result of

Back 67

a TBI

The more serious the injury, the more serious the impact on auto-regulation

Front 68

Understand what the vital signs changes indicate about ICP

Respirations

Back 68

Respirations – count the number & assess the quality

Front 69

Understand what the vital signs changes indicate about ICP
Blood Pressure-
Hypertension may indicate:
Hypotension may indicate:

Back 69

hypertension may indicate increased ICP

; hypotension usually is correlational to hypovolemia, i.e., shock (due to other injuries)

Front 70

Bleeding causes the BP to be high or low

Back 70

BP will be low cuz you are in shock

Front 71

Understand what the vital signs changes indicate about ICP
Cushings triad:
-what is it result from
-what are the manifestations

Back 71

a classic but late sign of increased ICP which is manifested by severe hypertension with a widened pulse pressure and bradycardia

Front 72

Low BP and fast HR = ???(hypotension and tachycardia)

Back 72

shock syndrome

Front 73

Elevated BP and a fast HR =

Back 73

stress or anxiety

Front 74

Pulse
-how does it feel if its indicating icreased ICP

Back 74

is thready, irregular & rapid

Front 75

Temperature – an increased temperature increases the brain’s metabolic rate:

rapid rise may indicate dysfunction of

slow rise may indicate

Back 75

the hypothalmus or brainstem



infection

Front 76

most important early assessment piece related to increasing ICP is

Back 76

decreasing LOC (lethargy)

Front 77

Diagnosing
-CT assists in he diagnosis of _________

The primary purpose of the initial scan is to identify

Back 77

a stroke.


the presence of cerebral hemorrhage. Cerebral aneurysms, if lg enough, may be identified

Front 78

Diagnosing
-Tell me about the CT scan in pts with an ischemic or occlusive stroke

Back 78

the head CT is usually initially negative.

After the first 24 hrs, the CT shows progressive changes of ischemia, infarction, and cerebral edema.

Front 79

Diagnosing
-MRI:
why is it better than a CT?

Back 79

may show the presence of edema, ischemia, and tissue necrosis earlier than a CT scan.

It can tell aneurysm locations, or identify the area of vessel wall rupture and vasospasm

Front 80

Diagnosins
-what's unique about the PET scan?

Back 80

you can see blood flow and vascularity

Front 81

Most common x-ray done for an acute brain injury?

Back 81

CT scan because MRI takes up to 5-6 days to show ischemia

Front 82

MRI (Magnetic Resonance Imaging)
-why is it better than a CT
-used to detect what? (5)

Back 82

-More detailed than CT scan

-Used to detect:
intracranial bleeding
tumor
edema
brain shifts
status of the vessels

Front 83

MRI (Magnetic Resonance Imaging)
-whats the bad thing about this?

Back 83

its not readily available

-MRI is 3000-4000 dollars more than a CT

• Patient CANNOT have any METAL, i.e., implants, pacemakers; procedure is difficult for those who are claustrophobic; also noisy (ear plugs are available)

Front 84

CT:
-whats the negative thing about this?

Back 84

can’t tell you anything small (fine edema, fine hypoxia) the CT is for a larger picture. CT can identify the presence of a lesion that requires surgical intervention, such as epidural or subdural hematoma.

Front 85

MRI (Magnetic Resonance Imaging)
Contraindicated: 3

Back 85

confused (accompanied by an RN),

pregnant (shield the baby, and you can do it),

unstable (accompanied by an RN)

Front 86

CT Scan (aka: Computed Tomography – cross-sectional slices)

Used to detect what?

Back 86

Also used to detect:

intracranial bleeding(if your bleeding now, you can see it),
tumor
edema
brain shifts

Front 87

CT Scan (aka: Computed Tomography – cross-sectional slices)

Often, a dye is used, so assess if allergic to (3)

Back 87

dyes, shellfish, or iodine

Front 88

PET Scan (Positron Emission Tomography)

Tells you about what the brain

Back 88

 Tells blood flow through brain with different colors. Tells you how extensive the brain tumor is into the cerebral tissue

Front 89

PET Scan (Positron Emission Tomography)

Why is it better than an MRI and CT?

Back 89

this test provides info about the function of the brain, i.e., glucose, oxygen metabolism, & cerebral blood flow

Front 90

PET Scan (Positron Emission Tomography)

What the negative thing about this

Back 90

 Must be NPO & no caffeine, alcohol or tobacco for 24 hours before the test

Front 91

In a patient with a brain tumor, describe how it affects the brain In relationship to ICP

regardless of the location, the tumor expands and invades, infiltrates, compresses, and displaces normal brain tissue which leads to

Back 91

the problem of increased ICP.

-cerebral edema results from changes in capillary tissue permeability that allow plasma to seep into the extracellular spaces. this leads to increased ICP.

-the cerebral blood vessels may become compressed because of edema and increased ICP. this compression leads to ischemia (decrease blood flow) of the area supplied by the vessel.

Front 92

Posturing terms:

Flaccid

Back 92

-no motor response
-aka hypotonia paralysis
-can’t overcome the forces of gravity and extremities fall to the side

Front 93

Posturing terms:

Decorticate

Back 93

- Flexing of arm(s) on chest
- Legs stiffly extended

- Indicates non-functioning CORTEX
----TOWARDS THE CORE-----

Front 94

Posturing terms:
Decerebrate

Back 94

- Stiffly extends arm(s) and leg(s)
- Indicates BRAINSTEM malfunction

Front 95

Glasgow coma scale: what is it used for

what kind of scale is it based on

Back 95

Tool used to assess neurological condition

Based on a scale from 1-15

Front 96

Glasgow coma scale:

Score below 8 =

Back 96

Coma!

Front 97

Glasgow coma scale:

•As you go (higher or lower) in your numbers, it means that you are at a greater risk of dying / brain injury

Back 97

lower

Front 98

Glasgow coma scale:

when used initially, the scale provides an estimate of severity of brain injury.

-coma scores of 3-5 indicate




Admission scores of greater than or equal to 8 correlate with

Back 98

potentially fetal damage, esp if accompanied by fixed pupils or absent oculovestibular responses.




likelihood of good recovery

Front 99

Glasgow coma scale:

do you want a high or low score

Back 99

You want a high score, the less injury to the brain

Front 100

Glasgow coma scale:

Understand how to calculate this. based on what categories?

Back 100

eye opening, verbal response, motor response

Front 101

Glasgow coma scale:
What does a score of 15 mean?
What does a score of 5 mean?

Back 101

What does a score of 15 mean? alert
What does a score of 5 mean? coma