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174 Cards in this Set

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akinetic mutism
unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens the eyes
altered LOC level of consciousness
may exhibit:
-not oriented
-does not follow commands
-needs persistent stimuli to achieve a state of alertness
autoregulation
ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure
brain death
irreversible loss of all functions of the entire brain
1. coma
2. absence of brain stem reflexes
3. apnea
coma
a clinical state of unarousable unresponsiveness in which ther are no purposeful responses to internal or external stimuli, although nonpurposeful responses to painful stimuli and brain stem reflexes may be present
craniotomy
a surgical procedure that involves entry into the cranial vault
craniectomy
a surgical procedure that involves removal of a portion of the skull
Cushing's response
brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure
Cushing's triad
three classic signs - bradycardia, hypertension, and bradypnea - seen with pressure on the medulla as a result of brain stem herniation
decerebration
an abnormal body posture associated with a sever brain injury, characterized by extreme extension of the upper and lower extremities
decortication
an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities
epidural monitor
a sensor placed between the skull and the dura to monitor intracranial pressure
epilepsy
a group of syndromes characterized by paroxysmal transient disturbances of brain function
fiberoptic monitor
a system that uses light refraction to determine intracranial pressure
herniation
abnormal protrusion of tissue through a defect or natural opening
intracranial pressure aka ICP
pressure exerted by the volume of the intracranial contents within the cranial vault
locked-in syndrome
condition resulting from a lesion in the pons in which the patient lacks all distal motor activity (tetraplegia) but cognition is intact. pt is unable to speak
microdialysis
procedure in which an intracranial catheter is inserted near an injured area of brain to measure lactate, pyruvate, glutamate, and glucose levels
migraine headache
a sever, unrelenting headache often accompanied by symptomes such as nausea, vomiting, and visual disturbances
Monro-Kellie hypothesis
theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents - brain tissue, blood, or CSF - causes a change in the volume of the others
persistant vegetative state
condition in which the unresponsive patient resumes sleep wake cycles after coma, but is devoid of cognitive or affective mental function
primary headache
a headache for which no specific organic cause can be found
seizures
paroxysmal transient disturbance of the brain resulting from a discharge of abnormal electrical activity
status epilepticus
episode in which the patient experiences multiple seizure bursts with no revoery time in between
secondary headache
headache identified as a symptom of another organic disorder (eg brain tumor, HTN)
subarachnoid screw or bolt
device placed into the subarachnoid space to measure ICP
transsphenoidal
surgical approach to the pituitary via the sphenoid sinuses
ventriculostomy
a catheter placed in one of the lateral ventricles of the brain to measure ICP and allow for drainage of fluid
What is the first priority for a patient with altered LOC
obtain and maintain a patent airway
duration of coma
usually limited to 2-4 weeks
initial clinical manifestations of altered LOC may include...
subtle behavioral changes, such as restlessness or increased anxiety
pupils become sluggish
as the patient's LOC decrease, changes will ultimately include...
decreased pupillary response
decreased eye opening response
decreased verbal responses
decreased motor responses
eventually coma
What 3 things does the Glascow Coma Scale measure?`
1. eye opening
2. verbal response
3. motor response
Scale 3-15.
a 3 on the Glascow Coma Scale may indicate...
severe impairment of neurologic function
brain death
pharmacological inhibition of the neurologic response
What does a 15 on the Glascow Coma Scale indicate?
that the patient is fully responsive
If a patient is comatose and has localized signs such as abnormal pupillary and motor responses, what is assumed?
that neurologic disease is present, until proven otherwise
If a patient is comatose but pupillary light reflexes are preserved, what is suspected?
a toxic or metabolic disorder
What are the top three most common diagnostic procedures to identify the cause of unconsciousness?
CT
MRI
EEG
What are the less common procedures to detect the cause of unconciousness, after CT MRI AND EEG?
PET
SPECT
potential complications for the patient with alterd LOC
respiratory failure
pneumonia
pressure ulcers
aspiration
DVT
contractures
complications associated with immobility
What is the first priority for a patient with altered LOC?
obtain and maintain a patent airway
Why should BP and HR be monitored in a patient with altered LOC?
to ensure adequate perfusion to the body and brain
pupillometer
a portable automated device with a screen and digital video camera that measures pupil size and reactivity
How serious is flaccidity?
results from the most severe neurologic impairment
equal, normally reactive pupils in an unconscious patient, suggests..
that coma is toxic or metabolic in origin
progressive dilation of pupils in an unconscious patient suggests...
increasing ICP
fixed dilated pupils in an unconscious patient suggests...
injury at level of midbrain
the corneal reflex examination tests which cranial nerves?
V and VII
asymmetry in the face of an unconscious patient is a sign of...
paralysis
drooling vs. spontaneous swallowing (swallowing reflex) in an unconscious patient, tests CN...
X and XII
a stiff neck in an unconscious patient suggests...
subarachnoid hemorrhage or meningitis
absence of spontaneous neck movement in an unconscious patient suggests...
fracture or dislocation of cervical spine
goals for patients with r/t altered LOC
maintenance of a clear airway
(major goal is to compensate for the absence of the protective reflexes - coughing, blinking, swallowing)
protection from injury
attainment of fluid volume balance
achievement of intact oral mucous membranes
maintenance of normal skin integrity
absence of corneal irritation
attainment of effective thermoregulation
effective urinary elimination
bowel continence
accurate perception of environmental stimuli
maintenance of intact family or support system
absence of complications
possible interventions to maintain airway in an unconscious patient
most important*
HOB 30 degreses
lateral or semiprone position
suctioning and oral hygiene
chests physiotherapy and postural drainage
auscultate chest q8h
intubation and mechanical ventilation
What should be done before suctioning and why?
hyperoxygenation to prevent hypoxia
possible interventions to protect an unconscious patient
2 siderails during the day
3 siderails at night
prevent injury from lines, tubes, restraints, damp bedding, dressings, etc
protect the patient's dignity
possible interventions to maintain fluid balance and manage nutritional needs
assess hydration status
administer required IV fluids
possible interventions to provide mouth care in an unconscious patient
inspect for dryness, inflammation, and crusting
clean and rinse carefully
thin coating of petrolatum
move ET tube to opposite side of the mouth daily to prevent ulcerations
if the mouth of an unconscious patient is not kept clean,
they are at risk for parotitis
kinesthetic mean...
sensation of movement
vestibular means...
sensation of equilibrium
interventions to maintain skin and joint integrity
turning and repositioning schedule
avoid shearing force and friction
maintain correct body position
passive exercise to prevent contractures
splints or foam boots
specialty beds
preserving corneal integrity in an unconscious patient
cleanse with cotton balls moistened with sterile normal saline
artificial tears q2h as prescribed
eye patches used cautiously b/c of potential for corneal abrasion
when is periorbital edema normal?
after cranial surgery
interventions to maintain body temperature in an unconscious patient
remove all bedding except for sheet
room cooled to 65 deg F, unless elderly
administer acetaminophen as prescribed
cool sponge baths
electric fan for surface cooling
hypothermia blanket
frequent temp monitoring to prevent excessive temp decrease
How do you take the temperature of an unconscious patient?
never NPO
rectal or tympanic preferred to axillary
slight temperature elevation may be caused by...
dehydration
very high temperatures can be caused by...
damage to the temp center in the brain or severe intracranial infection
interventions to prevent urinary retention in an unconscious patient
palpate or scan bladder at intervals
catheterization
monitor for skin breakdown
monitor for infection
interventions to promote bowel function in an unconscious patient
listen for bowel sounds
measure girth of the abdomen
monitor number and consistency of BM
rectal exam for signs of fecal impaction
interventions to provide sensory stimulation to the unconscious patient (if ICP is not an issue)
maintain usualy day and night patterns for activity and sleep
touch and talk to patient, encourage family to do so also
orient the pt to time and place <q8h
sounds from usual environment
favorite TV programs
when arousing from coma, what may happen and what should the nurse do
many patients experience a period of agitation when arousing from coma, which is actually a positive sign. at this time, reduce stimulation and only have one person talk to the patient at a time
interventions to meet the need of an unconscious patient's family
clarifies information about patient's condition
permits family to be involved in care
listens to and encourages ventilation of feelings and concerns
supports decisionmaking about posthopitalization mangaement
support groups
what are the contents of the rigid cranial vault and how much are there of each
brain tissue - 1400 g
blood 75 mL
CSF 75 mL
normal ICP in the lateral ventricles
10 - 20 mmHg
Most common cause of increased ICP
head injury
causes of increased ICP
head injury, brain tumors, subarachnoid hemorrhage, toxic and viral encephalopathies
increase in PaCo2, leading to increased cerebral blood flow
increased ICP from any cause does what?
decreases cerebral perfusion
stimulates further swelling
herniation (which is dire and frequently fatal)
S/S early stages of cerebral ischemia
HTN
slow bounding pulse
respiratory irregularities
compensatory mechanisms for cerebral edema
autoregulation
decreased production and flow of CSF
the brain can maintain a steady perfsusion pressure if ...
the arterial SBP is 50 - 100 mmHg
AND
ICP < 40 mm Hg
CPP =
CPP = mean arterial pressure - ICP
normal is 70-100 mmHg
normal CPP
70-100 mm Hg
if CPP <50
irreversible brain damage
if CPP = 0
cerebral circulation ceases
When ischemia occurs in the brain, what center does what?
the vasomotor center triggers an increase in arterial pressure in an effort to overcome the increased ICP
late sign of decreased cerebral blood flow
Cushing's response
-increase SBP
-widening of pulse pressure
-decreased HR
grave sign of decreased cerebral blood flow, usually followed by herniation
Cushing's triad
-decreased HR
-HTN
-decreased Respiration
earliest signs of increasing ICP
change in LOC
slowing of speech
delay in response to verbal suggestions
late signs of increased ICP
coma
abnormal motor responses (decortication, decerebration, flaccidity)
3 complications of increased ICP
brain stem herniation
diabetes insipidus
SIADH
S/S diabetes insipidus
decreased secretion of ADH
-excessive urine output
-decrease urine osmolality
-serum hyperosmolarity
therapy for DI
administration of fluids
electrolyte replacement
vasopressin (desmopressin, DDAVP) therapy
S/S SIADH
increased secretion of ADH
-volume-overload
-decreased urine output
-serum sodium concentration becomes dilute
therapy for SIADH
fluid restriction <800 cc /day
no free water
in severe cases - 3% hypertonic saline solution - but change in serum sodium should not exceed a correction rate of 1.3 mEq/L/hour
Rapid correction of sodium imbalance greater than 1.3 mEq/L./hour may result in...
central pontine myelinolysis, resulting in tetraplegia with CN deficits
medical management of increased ICP
-administer osmotic diuretics
-restrict fluids
-drain CSF
-control fever
-maintain systemic BP and oxygenation
-reduce cellular metabolic demands
-no corticosteroids if TBI
-possible judicious use of hyperventilation , only for a short duration, only if ICP is refractory to other measures
are corticocosteroids give if TBI leading to increased ICP
no
equipment to monitor ICP
ventriculostomy
subarachnoid bolt
epidural or subdural catheter
fiberoptic transducer-tipped catheter in subdural space or ventricle
ventriculostomy aka ventricular catheter monitoring
used for continuous monitoring ICP
transducer records the pressure in the form of an electrical impulse
allows CSF to drain during acute increases in pressure
to drain blood from ventricle
access for intraventricular admin of meds and instillationof air or a contrast agent
complications of ventriculostomy
infection
meningitis
ventricular collapse
occlusion by brain tissue or blood
interpreting incracranial pressure waveforms on an oscilloscope
A waves (plateau waves) - transient, paroxysmal, recurring elevation of ICP that may last 5-20 min and range in implitude from 50 -100 - have clinical significance - indicate changes in vascular volumewithin the intracranial compartment that are beginning to compromise cerebral perfusion. reflects ischemia before overt S/S of raised ICP are seen clinically
B waves - less clinically significant but if seen in a series in a pt with depressed consciousness may precede appearance of A waves - may be seen in patient with intracranial HTN and decreased intracranial compliance
C waves - significance unknown - appear to be r/t rhythmic variations of the systemic arterial BP and respirations
if increased ICP when are corticosteroids (ie dexamethasone) used vs not used
used - if brain tumor is the cause
not used - if TBI is the cause
methods to decrease cerebral edema
osmotic diuretics
if brain tumor - dexamethasone
fluid restriction
methods to maintain cerebral perfusion
improvements in CO made using fluid volume and inotropic agents such as Dobutrex (dobutamine hydrochlorideand Levophed (norepinephrine bitartrate)
how is the effectiveness of CO to maintain cerebral perfusion reflected?
by a CPP > 70 mm Hg
hyperventilation r/t ICP
hyperventilation leads to a decrease in PaCo2 and vasocontriction of cerebral vessels, decreasing ICP
-may not be so beneficial
-use only is other therapies refractory
PaCo2 should be maintained at
30-35 mm Hg
controlling CSF volume r/t ICP
can drain with a ventriculostomy but caution b/c excessive drainage may result in collapse of the ventricles and herniation
why is controlling fever important to control ICP
fever increases cerbral metabolism and the rate at which cerebral edema forms
why should shivering be avoided when reducing fever?
shivering is associated with increased oxygen consumption, increased level of circulating catecholamines, and increased vasocontriction
methods to maintain oxygenation
monitor arterial blood gas and pulse oximetry
HgB saturation can be optimized to provide oxygen more efficiently at the cellular level
methods to reduce metabolic demands
if pt unresponsive to conventional treatment - high does of barbituates
paralyzing agents such as propofol (Diprivan)
goals for a patient with increased ICP
maintain a patent airway
normalization of respiration
adequate cerebral tissue perfusion through reduction in ICP
restoration of fluid balance
absence of infection
absence of complications
Cheyne-Stokes respirations may result from
increased pressure on the frontal lobes or deep midline structure
hyperventilation may result from...
pressure in the midbrain
irregular respirations that eventually cease result from
pressure on the pons and medulla
PaCo2 should be maintained at or above
> 60 mm Hg
to decrease intraabdominal or intrathoracic pressure
no coughing or sneezing
no Vasalva maneuver
-stool softeners (but not enemas or cathartics)
-when moving, instruct pt to exhale
During nursing interventions, ICP should not increase more than
ICP should not increase more than 25 mm Hg and should return to baseline within 5 minutes
-if so pt may need sedation and a paralytic agent before
for the patient receiving mannitol, the nurse observes for complications such as
heart failure and pulmonary edema
what urine output may indicate the development of diabetes insipidus
greater than 250 mL/hr for 2 consecutive hours
S/S meningitis
fever
chills
nuchal rigidity
increasing or persistent headache
what is the primary complication of increased ICP
brain herniation
Order in which S/S of increased ICP can be seen, early to late
1. Disorientation, restlessness, increased respiratory effort, purposeless movements, mental confustion
2. Pupillary change, impaired extraocular movement
3. Weakness in one extremity or on one side of the body
4. Headache that is constant, increasing in intensity, and aggravated by movement or straining
LATER
5. LOC deteriorates until pt is comatose
6. Pulse and respiratory rate decrease or become erratic, BP increases, temp increases, pulse pressure widens, fluctuating pulse
7. alterd respiratory patterns (ie Cheyne-Stoke and ataxic breathing)
8. Projective vomiting
9. Hemiplegia, decordticate, decerebrate, or bilateral flaccidity
10. Loss of brain stem reflexes, incl. pupillary, corneal, gag, and swallowing reflexes (ominous sign of approaching death)
Medications that may be prescribed before supratentorial and infratentorial intracranial surgery
-antiseizure meds - phenytoin (Dilantin) or phenytoin metabolite (Cerbyx) before to reduce the risk of post-op seizures
-corticosteroids - dexamethasone (Decadron) - if brain tumor to reduce cerebral edema
-fluids restricted
-hyperosmotic agent - mannitol
-diuretic agent - furosemide (Lasix) - IV before and sometimes during
-antibiotics if a chance of contamination
-to reduce anxiety - diazepam (Valium)
ongoing postop management for cranial surgery
reducing cerebral edema
relieving pain
preventing seizures
monitoring ICP
mannitol
used to reduce cerebral edema, works by increasing serum osmolality and drawing free water from areas of the brain. the fluid is then excreted by osmotic diuresis
dexamethasone (Decadron)
corticosteroid to reduce cerebral edema. if post cranial surgery.. IV q6h for 24-72h, route changed to oral asap, dosage tapered over 5-7 days
acetaminophen
usually prescribed post cranial surgery for temp exceeding 99.6 and for pain
meds to decrease pain post cranial surgery
codeine IV
morphine sulfate
what should be given to patients after supratentorial neurosurgical procedures?
antiseizure meds such as phenytoin or diazepam b/c of the high risk for seizures
potential complications of intracranial surgery
increased ICP
bleeding and hypovolemic shock
fluid and electrolyte disturbances
infection
seizures
when does cerebral edema peak after brain surgery
24-36 hours after surgery, producing decreased responsiveness the second post-op day
After cranial surgery, when might a clot be suspected?
If the patient does not awaken as expected or whose condition deteriorates
After cranial surgery, what is suspected if the patient has any new neurologic deficits, especially a dilated pupil on the operative side?
an intracranial hematoma
Patients undergoing surgery for brain tumor often receive large doses of corticosteroids and therefore tend to develop hyperglycemia. Serum glucose levels are measured...
every 4-6 hours. These patients are also prone to gastric ulcers, so H2 blockers are prescribed to suppress the secretion of gastric acid. The patient also is monitored for bleeding and assessed for gastric pain.
what should be monitored if DI develops post op
serum potassium levels
intake and output
urine specific gravity q1h
is SIADH usually self limited?
yes
If the patient complains of a salty taste or post nasal drip...
this can be caused by CSF trickling down the throat
Before and after cranial surgery, what is a very important med to administer...
anti-seizure meds may prevent the development of seizures in subsequent months or years
on to seizures...
...
automatisms
involuntary motor activity, such as lip smacking or repeated swallowing
after a seizure, the patient is at risk for
hypoxia
vomiting
aspiration
what complication is associated with long term use of antiseizure meds?
bone loss, so patients should be assessed for low bone mass and osteoporosis and give instruction about other strategies to reduce their risk for osteoporosis
simple partial seizures
only a finger or hand may shake, or mouth may jerk
may talk unintelligibly, may be dizzy, may experience unusual sensations
-no loss of consciousness
two types of seizures
partial seizures - begin in one part of the brain
generalized seizures - involve electrical discharges in the whole brain
complex partial seizures
-either remains motionless
-ormoves automatically but inappropriately for time and place
-may experience excessive emotions of fear, anger, elation, or irritability
-does not remember episode when it is over
generalized seizures
involve both hemispheres, causing both sides of the body to react
-intense rigidity may occur followed by generalized tonic-clonic contraction
-characteristic epileptic cry from contractions of the diaphragm and chest muscles
-tongue often chewed
-incontinence
-after 1-2 minutes movements begin to subside, patient relaxes, lies in a deep coma, and breathes noisily, respirations abdominal, often confused and hard to arouse for hours
-many report headache, sore muscles, fatigue, and depression
special needs of women with epilepsy
-increase in seizure frequency during menses
-effectiveness of OC's decreases with antiseizure meds
-risk for congenital fetal anomaly 2-3x greater for their pregnancies
What is the leading cause of new onset epilepsy in the elderly?
cardiovascular disease
elderly patients on antiseizure meds must be monitored closely for
adverse and toxic effects
osteoporosis
major complications for patients with epilepsy
status epilepticus
medication side effects
also, osteoporosis from antiseizure meds
what should the activity level for a person with epilepsy be
moderate is therapeutic, excessive should be avoided
ketogenic diet
may be helpful for control of seizures of some patient, especially children
-high-protein, low-carb
alcohol and seizures
seizures are known to occur with alcohol intake
side effects of phenytoin (Dilantin)
gingival hyperplasia
-to prevent or control, oral hygiene after each meal, gum massage, daily flossing, regular dental care
signs of antiseizure med toxicity
drowsiness
lethargy
dizziness
difficulty walking
hyperactivity
confusion
inappropriate sleep
visual disturbances
seizure triggers include
alcohol
electrical shocks
stress
caffeine
constipation
fever
hyperventilation
hypoglycemia
lack of sleep
toxic effects of carbamazepine (Tegretol)
severe skin rash, blood dyscrasias, hepatitis
toxic effects of clonazepam (Klonopin)
hepatotoxicity, thrombocytopenia, bone marrow failure, ataxia
toxic effects of gabapentin (Neurontin)
leukopenia, hepatotoxicity
toxic effects of lamotrigine (Lamictal)
severe rash (Steven-Johnson syndrome)
toxic effects of phenytoin (Dilantin)
severe skin reaction, peripheral neuropathy, ataxia, drowsiness, blood dyscrasias
toxic effects of topiramate (Topamax)
nephrolithiasis
toxic effects of valproate (Depakote, Depakene)
hepatotoxicity, skin rash, blood dyscrasias, nephritis
what common antiseizure meds are associated with kidney problems if at toxic levels
topiramate (Topamax)
valproate (Depakote)
how long does status epilepticus last?
at least 30 minutes, even within loss of consciousness
factors that precipitate status epilepticus
withdrawal of antiseizure meds
fever
concurrent infection
cumulative effects produced by status epilepticus
-vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations-respiratory arrest at the height of each seizure produces venous congestion an hypoxia of the brain - repeated episodes of cerebral anoxia and edema can lead to irreversible and fatal brain damage
meds for status epilepticus to halt seizures
Valium, Ativan, or Cerebyx
IV injection of glucose if caused by hypoglycemia
if initial treatment unsuccessful, general anesthesia with a short acting barbituate can be used
postictal the nurse should monitor..
respiratory and cardiac function b.c. of the risk for delayed depression of respiration and BP secondary to admin of antiseizures meds and sedatives
foods that contain tyramine and can trigger a migraine
chocolate
cheese
coffee
dairy products
how does alcohol affect blood vessels
causes vasodilation