Neurologic Dysfunction

Front 1

What two factors are the most important to measure a patient's condition?

Back 1

Level of responsiveness and consciousness

Front 2

Coma

Back 2

Unconsciousness, unresponsiveness, and inability to arouse

Front 3

Akinetic mutism

Back 3

Unresponsiveness to the environment

Patient makes no movement or sound, but may open and blink eyes

Front 4

Persistent vegetative state

Back 4

Patient lacks cognitive function but has sleep-wake cycles

Front 5

Locked-in syndrome

Back 5

Patient unable to move or respond but has eye movements (indicates lesion of the pons)

Front 6

Assessment:

Doll's eyes

Back 6

Eyes stay straight when they turn their head

(They would usually follow the turn)

Front 7

Assessment:

Babinski's reflex

Back 7

Positive Babinski's Reflex occurs when patient's toes spread

Front 8

What are decorticate and decerebrate posturing?

Back 8

Postures that patients assume with neurological damage

Front 9

What is the earliest sign of increased ICP?

Back 9

A change in level of consciousness

Front 10

Describe the Glasgow Coma Scale (range, what the ranges mean, what three categories are there)

Back 10

Eye opening

Verbal response

Motor response

3 (severe neurological damage) - 15 (full responsiveness)

Front 11

Where do we measure ICP?

Back 11

Lateral ventricles

Front 12

What is the main priority/concern/diagnosis for a patient with impaired LOC?

Back 12

Their airway

Deficient fluid volume, skin integrity, thermoregulation are also important

Front 13

How can we help maintain the airway?

Back 13

Frequent monitoring and auscultation

Elevate bed to 30 degrees

Lateral or semi prone position

Suctioning, hygiene

Front 14

How can we help maintain fluid status?

Back 14

Assess turgor, mucosa, lab values, I&O

IV's, tube feedings, etc.

Front 15

How can we help maintain thermoregulation?

Back 15

Adjust environment and drapery as needed

If elevated, min bedding, acetaminophen, hypothermia blanket, cool sponge bath, fan

Monitor temp frequently

Front 16

When a patient comes out of a coma (aroused), and becomes agitated, what should the nurse do?

Back 16

Minimize stimulation

(limit visitors, clutter, sounds)

Front 17

What is the Monroe-Kellie hypothesis?

Back 17

Due to limited space in the skull, an increase in any skull component will cause a change in the volume of the other components

Front 18

What are the 3 skull components?

Back 18

Brain tissue, blood, CSF

Front 19

What is the normal range of ICP?

Back 19

10 - 20 mmHg

Front 20

How can we compensate to maintain a normal ICP?

Back 20

Shift or displace the CSF

*ICP may increase with disease or injury

Front 21

What effects does increased ICP have?

Back 21

Decreased cerebral perfusion, ischemia, cell death, and further edema

Brain tissues may protrude through the dura and cause a herniation (coning)

Front 22

What symptoms (vitals) will someone with increased ICP have?

Back 22

Slow, bounding pulse

Respiratory irregularities

Increased PaCO2

Front 23

Autoregulation

Back 23

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

Front 24

What vessel effect does PaCO2 have?

Back 24

Decreased CO2 = vasoconstriction then (to keep CO2)

Increased CO2 = vasodilation (to get rid of CO2)

Increased CO2 = increased ICP

Front 25

What is CPP?

Back 25

Cerebral perfusion pressure

Normal: 70-100 mmHg

Front 26

How do you determine CPP?

Back 26

CPP = MAP - ICP

Front 27

What does a CPP of less than 50 mmHg mean?

Back 27

Permanent neurological damage

Front 28

MAP is 110 mmHg

ICP is 16 mmHg

Determine CPP

Back 28

CPP is 94 mmHg

Front 29

What clinical manifestations someone with early increased ICP will have?

Back 29

Altered LOC

Confusion

Drowsiness

Pupillary changes

Weakness in one extremity/side

Constant headache

Front 30

What clinical manifestations someone with late increased ICP have?

Back 30

Respiratory and vasomotor changes

Increased systolic pressure

Widened pulse pressure

Slowed HR (pulse fluctuations)

Temp increase

Projectile vomiting

Hemiplegia, Stupor to coma, cheyne-stokes breathing, loss of pupil, gag, corneal, and swallowing reflexes

Front 31

What is Cushing's triad?

Back 31

Bradycardia, hypertension, bradypnea

Front 32

What are some problems or potential complications of increased ICP?

Back 32

Herniation (coning)

Diabetes insipidis

SIADH

Infection (due to probe)

Front 33

What are some nursing interventions for someone with increased ICP?

Back 33

Frequent monitoring of respiratory function, I&O, auscultation

Keep a quiet and calm environment

Position HOB at 0-60 degrees to promote venous drainage

Avoid hip flexion, Valsalva maneuver

Front 34

What is Valsalva maneuver?

Back 34

Forceful exhalation against a closed airway

It will increase the pressure on abdominal organs and stimulate Vagus nerve (increase HR)

Front 35

Craniotomy

Back 35

Opening of the skull

To remove a tumor, relieve pressure, control bleeding, remove blood clot

Front 36

Craniectomy

Back 36

Removal of a portion of the skull

Front 37

Cranioplasty

Back 37

The repair of a cranial defect using a plastic or metal plate

Front 38

Burr holes

Back 38

Circular openings that provide access to the ventricles

Front 39

What type of diuretics can help reduce cerebral edema?

Back 39

Osmotic diuretics

Mannitol

Front 40

What would diazepam be used for post-op?

Back 40

Anxiety

Front 41

What would antibiotics be used for post-op?

Back 41

Reduce potential infection

Front 42

What should we obtain from the patient post-op of neurosurgery?

Back 42

A baseline of neurological function to compare

Front 43

How can we help maintain cerebral perfusion?

Back 43

Monitor respiratory status (hypercapnia/hypoxia have big effects)

Assess VS q 15 mins - an hour

Avoid extreme head rotation

HOB flat or at 30 degrees