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96 Cards in this Set
- Front
- Back
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What are Burr Holes used for?
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Determine presence of cerebral swelling
Relieve ICP |
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What are Craniotomy's used for?
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Remove tumors
Relieve ICP Evacuate Blood Clots & Bleeds |
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What are Craniectomy's used for?
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When you need to have more access than a craniotomy would provide
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What is a transphenoidal approach used for?
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When access to the pituitary gland is needed.
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What is a Cranioplasty used for?
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When there has been a cranium defect that needs fixed. Simply wires pieces back together.
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What antiseizure meds might be given preoperatively to intracranial surgery & why?
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**Dilantin - drug of choice for seizure. High seizure risk anytime manipulating brain tissue. P.O. form.
Cerebyx - IV form of Dilantin |
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What diuretic drugs are given preoperatively to intracranial surgery & why?
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**Mannitol is the drug of choice. it is an osmotic diuretic meaning it won't affect F&E balance. Diuretics are given to decrease fluid volume and help reduce ICP/edema.
Also Lasix may be given in combo w/ Mannitol. |
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What anxiolytics are given preoperatively to intracranial surgery & why?
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Valium &/or Diazepam
The patient will be under conscious sedation and will be able to hear everything. Need to reduce anxiety related to this. |
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What is the MOST important Preoperative Nursing performed prior to Intracranial Surgery?
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LOC / Thorough Neurological Assessment. We need a good baseline to compare to post surgery. So...
* Paralysis * Neuro Deficits * Visual Dysfunction * Personality Changes * Speech * Bowel/Bladder Control * Strength * Glascow Coma Scale |
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What is our responsibility as nurses to assess with the patient/family prior to intracranial surgery?
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Only their understanding of the information provided.
It is NOT our responsibility to discuss complications, risk vs. benefits, etc. If more teaching is needed - call surgeon. |
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What is the #1 postoperative care provided post intracranial surgery?
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#1 - ICP monitoring & responding to it. This is the most common post-op complication & most important nursing duty.
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What methods can we use to monitor ICP?
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Intracranial Bolt will measure ICP
Cushings Triad (Isolated Systolic HTN, Bradycardia, Alterations in Resp's (usually slowed)) |
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What common complications might you see especially with Pituitary Gland Surgery (Transphenoidal Approach) or any cranial surgery that might increase pressure on the Pituitary Gland?
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DI
SIADH |
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Most common NANDA for Intracranial Surgery?
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Ineffective Cerebral Tissue Perfusion r/t Cerebral Edema
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What are common interventions r/t intracranial surgery?
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* Electrolyte Fluid Monitoring - shifts are common
* Monitor for Impaired Gas Exchange * Monitor for SIADH & DI * Fluid Restrictions? |
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What complications might occur with intracranial surgery?
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> ICP
Hypovolemic Shock F&E Disturbances Seizures |
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What is the most common S&S of Cerebral Aneurysm?
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**Sudden, unusual severe headache
Also... Pain & Rigidity in neck & spine Visual & Auditory Disturbance Mental Confusion Tinnitus, Dizziness, Hemiparesis, Paralysis |
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What is the most common causative factor for Cerebral Aneurysm?
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Hypertension
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What is the number one sign that there could be an oncological problem in the brain?
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Change in personality
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What is a primary brain tumor vs. a secondary brain tumor?
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Primary - A tumor that originated in the brain
Secondary - A tumor that is a met from another cancer from within the body ie. lung, breast, lower GI, pancreatic, kidney, skin. |
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Does brain cancer typically metastasize to other locations?
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No. There is no lymph system in the brain which is the primary route for metastasizing.
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What are the 5 common types of brain tumors?
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Gliomas
Meningiomas Neuromas (most are Acoustic) Pituitary Adenomas Angiomas |
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Define Meningioma.
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A tumor arising from the covering of the brain.
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Define Neuroma.
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A tumor arising on the cranial nerves.
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Define Glioma.
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A tumor arising within the brain tissue.
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What are some common types of gliomas from best to worst?
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Oligodendrocytoma - b/c it responds well to chemo/radiation
Astrocytoma - Grade 1 or 2 of a glioma, might be able to remove tumor but not all of the infiltration. Glioblastoma - Grade 3 or 4 of a glioma. Worst case scenario, inoperable & terminal w/ ~ 6 mo's. to live. |
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What is the most common type of Glioma?
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Astrocytoma
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What type of brain cancer tumor is the most common?
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Gliomas - develop in the brain tissue itself.
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Describe Meningiomas.
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An encapsulated tumor of the arachnoid cells of the meninges.
* No metastasizing * Benign * Excise via craniotomy |
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Describe Neuromas. Which is the most common nerve impacted?
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It is a tumor of a cranial nerve. #8 Vestibulococlear/Accoustic. This nerve is responsible for hearing & balance.
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What usually brings a patient to seek treatment when they have an acoustic neuroma?
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Pain on the side of the face once the growth on the 8th nerve starts to compress the 5th cranial nerve.
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What are common S&S of Acoustic Neuromas?
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Tinnitus
Loss of Hearing Episodes of Vertigo Staggering Gait or Loss of Balance |
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What is the most common symptom of pituitary adenomas?
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Vision problems b/c the growth on the pituitary gland causes pressure on the Optic Nerve.
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What are common S&S of a pituitary adenoma?
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Pressure Effects
* Headache (esp. frontal) * Visual Dysfunction * > ICP * Hypothalamus D/Os (sleep, appetite, temp, labile emotions) Hormonal Effects * Female - prolactin hormone * Both - growth hormone, ACTH (Cushing's disease), ADH (DI & SIADH) |
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What is an angioma?
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An abnormally large tangle of blood vessels that typically occur in the cerebellum. Increased risk for a hemorrhagic CVA.
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If you have a patient < 40 y.o. who has suffered a cerebral hemorrhage, what might you think?
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Cerebellar Angioma.
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What is the most common S&S of a brain tumor?
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#1 - Change in Personality
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Common S&S of > ICP. Where do tumors (based on the location) typically manifest their headaches. Ie. Frontal Tumors, Pituitary Tumors, Cerebellar Tumors.
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Headache - most common in the morning & made worse by coughing, straining & sudden movement.
Frontal - Bilateral Frontal Headache Pituitary - Pain behind the forehead between temples Cerebellar - Sub-occipital headache |
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Common S&S of > ICP.
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Headache - esp. frontal
Vomiting Visual Disturbances Cushing's Triad |
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What localized symptoms would you see with a brain tumor based on location of the tumor?
Motor Cortex Tumor Occipital Tumor Cerebellar Tumor Frontal Tumor Acoustic Tumor |
Motor cortex - Jacksonian seizures (seizure movements on one side of the body)
Occipital - Visual disturbance Cerebellar - Balance, Dizziness, Ataxia, Staggering Gait Frontal - Personality Disorders & Emotional Lability Acoustic - Tinnitus & Vertigo |
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What is the most useful diagnostic tool for brain tumors?
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MRI
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What type of medical management is performed for brain tumors?
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Chemo/Radiation - to shrink tumor size pre-surgery
Brachytherapy - radioactive seeds via burr hole Bone Marrow Transplant - Autologous transplant Corticosteroids - to decrease inflammation/edema |
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What is the most important nursing management for brain tumors?
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Neuro Assessment
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What treatment is given once you have developed cerebral metastases?
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Palliative care
Surgical resection to reduce pressure but comes back Radiation/chemo/surgery is for therapeutic pressure reduction only. It is not a cure. |
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What is the most common NANDA after brain tumors?
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Self Care Deficits
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What is the most important aspect of head injuries?
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The secondary injury which may not develop for hours or days which will include > ICP in the brain due to bleeding or swelling.
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What S&S might you see with the secondary brain injury that occurs hours or days after the initial injury?
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Hyper-somnolent
Projectile Vomiting > ICP S&S |
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What are the classifications of skull fractures?
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Linear - line fracture
Comminuted - multiple fragments Depressed - Section of skull is displaced inwardly Basilar - around the ear |
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What is the difference between open & closed head injuries?
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Open - an open laceration or a tear in the dura mater
Closed - no laceration & dura is in tact |
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What is Battle's Sign?
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Bruising over the Mastoid Process right behind the ear.
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What are the S&S associated with head injuries?
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Hemorrhage - either inside or outside
Battle's Sign CSF Otorrhea - CSF drainage from ears CSF Rhinorrhea - CSF draining from nose Halo Sign (staining in circular fashion on pillowcase from CSF Otorrhea drainage) Altered LOC/Confusion Pupillary Abnormalities - one bigger than other Altered/Absent Gag Reflex Sudden Neuro Deficits V/S's change Vision/Hearing Impairment Sensory Dysfunction Headache Seizures |
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What tests might be run for head injuries?
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CT/MRI
Cerebral Angiography |
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What medical management occurs with head injuries?
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Observation
* S&S of > ICP * Changes in LOC Surgery Sterile Cotton/Cotton Pad? |
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How is a closed brain (blunt) injury defined?
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Head accelerates & decelerates OR hits object
& brain tissue is damaged w/o opening through skull or dura mater **These pts frequently have a double injury (point of impact & then rebound to the other side) |
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How is an open brain injury defined?
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Object penetrates the skull, enters the brain, and damages soft brain tissue (penetrating injury)
OR Blunt trauma to the head is so severe that it opens scalp, skull and dura to expose the brain. |
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What are the four types of brain injuries?
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Concussion
Contusion Diffuse Axonal Injury Intracranial Hemorrhage * Epidural, Subdural (Acute/Subacute & Chronic), Intracerebral |
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What is a brain concussion?
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A temporary loss of neurological function with no apparent structural damage.
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What Clinical Manifestations might go with a brain concussion?
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Temporary loss of neuro function
No apparent structural damage Unconsciousness - few seconds to few minutes Pt. reports "seeing stars" Monitor for secondary injury (dizziness, neuro deficits, unilateral vision deficits, N/V, hyper-somnolent, VOMITING) |
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What is a brain contusion?
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The brain is bruised w/ possible surface hemorrhage.
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What Clinical Manifestations might go with a contusion?
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Loss of Consciousness for more than a few minutes
Person lays motionless Pulse is weak/rapid Shallow respirations Cool/pale skin May involuntarily evacuate bowel/bladder Pt. may be aroused with effort but slips back into unconsciousness BP & Temp subnormal Vomiting - go to ER if this occurs |
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What is a Diffuse Axonal Injury?
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A type of brain injury where there is widespread damage to axons in the cerebral hemisphere & brain stem. This injury can occur with mild, moderate & severe brain traumas.
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What Clinical Manifestations might go with a Diffuse Axonal Injury?
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Lucid intervals
Immediate coma Decorticate/Decerebrate posturing Dx is made by clinical signs & CT/MRI EEG can declare brain death |
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What is an intracranial hemorrhage?
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A hematoma that develops within the brain vault & are the most serious brain injuries. Can occur epidural, subdural, or intracerebral.
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What Clinical Manifestations might go with an Intracranial Hemorrhage?
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Major S&S are delayed until hematoma causes > ICP.
The S&S of cerebral ischemia are variable depending on the location of the hematoma and what areas are being compressed. |
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What S&S are caused by expanding hematomas?
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C/O headache
Sees stars Few seconds of unconsciousness followed by recovery or lucid intervals. No neuro deficits @ this time During lucid intervals brief compensation of expanding hematoma is occurring. Rapid onset of > ICP symptoms Then neuro deficits such as: *Dilated & Fixated pupil *Paralysis *Rapid Deterioration |
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What S&S occur with subdural hematomas?
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S&S develop over 24-48 h
Changes in LOC Pupillary Changes Hemiparesis Chronic may take 3 wks to 1 month to appear Severe - neurological deficits & changes |
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What group of people are most at risk of chronic subdural hematomas?
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Elderly.
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What S&S might occur with intracerebral hematomas?
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Symptoms delayed until hematoma causes > ICP
Frequently occurs when impact is over small area such as stab wounds or bullets Onset is incidious (can be hard to even recognize) Onset of neuro deficits followed by a headache Ensuing S&S of > ICP |
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What is the most common cause of secondary brain injury?
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**> ICP/Edema
Hypotension Respiratory Failure Electrolyte Imbalance |
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What nursing management occurs with Brain Injuries?
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Neuro Assessments
Diagnostic Tests - CT & MRI Monitor ICP & CPP Vent Support - to > O2 & < CO2 & < ICP Seizure Prevention - Dilantin & Padded Siderails F&E Maintenance - Negative Fluid Balance Nutrition Pain & Anxiety Mgmt NG Tube Bowel & Bladder Mgmt Reduce metabolic requirements - Vent/Sedation/Paralysis |
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What is the first assessment to be done for the patient with a brain injury?
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GCS & then serial GCS's
V/S's LOC Determine direction of head impact/blow |
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What is the most common NANDA r/t brain injury?
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Ineffective Airway Clearance
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What group is at greatest risk for spinal cord injuries?
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Young males
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What is a spinal cord transection?
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A complete break in the cord.
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What are the classes of spinal cord injuries?
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Primary - initial insult damage & usually permanent
Secondary - results from edema of the spinal cord compartment. These are the principal cause of spinal cord degeneration at the level of the injury & is thought to be reversible if treated w/in first 4-6 h. |
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What is the #1 treatment of secondary spinal cord injury?
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Corticosteroids - massive doses
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What deficits might you see with a C-Spine Fracture or a T-Spine Fracture?
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C Spine - Respiratory
T Spine - Bowel & Bladder Control |
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What is meant by a complete spinal cord lesion? & an incomplete spinal cord lesion?
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Complete - There is a total loss of sensation & voluntary muscle control below the lesion.
Incomplete - Either sensory or motor function is lost (usually motor). Pt. may experience burning pain, numbness, tingling. |
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What is paraplegia?
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Paralysis of the lower body.
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What is quadriplegia?
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Paralysis of all 4 extremities. Depending on location may have gross motor movements of upper arms but can't do point to point or fine motor function (this is still quadriplegia). C1 or C2 would be no arm movement & vent. Lower C, pt. might be able to shrug shoulders.
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What emergency treatment is given if patient is suspected of a spinal cord injury?
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Immobilization in anatomical alignment
Log Rolling Careful Extrication Stabilization & Control of life threatening injuries Transport & Corticosteroids (within 8 hours!!!) Details neuro exam X-Ray, MRI, CT, EKG |
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Can you have damage to the spinal cord when x-ray shows there are no broken bones?
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Yes. You can still have a contusion and swelling/edema which can cause compression of the spinal cord.
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What Acute Phase Management is given for spinal cord injuries?
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Goal: Prevent further SCI
Pharm - Corticosteroids (within 8 hours) Respiratory - Patent/Rescue Breaths/Bag/Intubate/CPR/Diaphragmatic Breathing Reduction & Traction Thoracic & Lumbar Braces |
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What CPR method is used for spinal cord injuries?
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Jaw Thrust CPR
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What is spinal shock?
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A sudden depression of reflex activity in the spinal cord below the level of the injury. Areflexia
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What common S&S are seen with Spinal Shock?
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Bowel & Bladder Dysfunction (these reflexes are most commonly affected)
Bowel Distention - intest. decompression & NG tube Paralytic Ileus - intest. decompression & NG tube Bladder - Foley Cath This is common with SCI's |
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What is Neurogenic Shock?
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Develops as a result of loss of the ANS below the level of the lesion & vital organs can be impacted.
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What are the common S&S of Neurogenic Shock?
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**< BP
**< HR/Pulse **Decreased C.O. (think left Ventricular failure - adventitious lung sounds, pulmonary edema, etc.) Venous Pooling in extremities Peripheral Vasodilation Lack of perspiration - can spike fever quickly |
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What are the major complications of spinal cord injuries?
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Spinal Shock
Neurogenic Shock DVT's Respiratory Complications Autonomic Dysreflexia |
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How do we prevent DVT's in the spinal cord injury patient?
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Passive ROM regularly
SCD's, TED hose, Anti-embolism stockings Anticoagulation as prophylaxis - Hep, Lovenox, Arixtra, Coumadin |
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What is diaphragmatic pacing?
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It's like a pacemaker on the diaphragm to assist with ventilation.
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What are the S&S of autonomic dysreflexia?
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Usually occurs after spinal shock resolves.
* Pounding Headache * Bradycardia * Hypertension Profuse Sweating (above the level of the lesion) Nasal Congestion Piloerection |
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Explain the pathophysiology of autonomic dysreflexia.
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This occurs when a stimulus is introduced to the body below the level of a spinal cord lesion (frequently a full bladder). The impulse is sent up the spinal cord until it is blocked by the lesion. A reflex is activated that increases activity of the sympathetic portion of the ANS resulting in spasms & narrowing of blood vessels causing a rise in BP.
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How do you treat autonomic dysreflexia?
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#1 - empty bladder (palpate, scan, straight cath or foley)
HOB up - fowlers to high fowlers unless CI Rectal exam for constipation/impactions Check for skin rash or lesions Monitor V/S's |
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When should ROM exercises be introduced for the spinal cord injury patient?
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About 48 hours after injury unless CI.
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What interventions are used for the spinal cord injury patient?
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Promote adequate airway & breathing
Improve mobility ROM exercises Promote adaptation to sensory/perceptual alterations Maintain skin integrity Improve bowel function Maintain urinary elimination Monitor for S&S of autonomic dysreflexia |
