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64 Cards in this Set

  • Front
  • Back
What are aspects of a focused neurological assessment?
2. Pupillary response
3. Motor function
4. VS
5. Reflexes
6. Brainstem function (if appropriate)
What are the three categories of the Glasgow Coma Scale?
Eye Opening (4), Verbal response (5), Motor Response (6)
What are the points for Eye opening?
Spontaneously - 4
To speech- 3
To pain- 2
None- 1
What are the GCS points for verbal response?
Oriented- 5
Confused- 4
Inappropriate- 3
Incomprehensible- 2
None- 1
What are the GCS points for motor response?
Obeys Commands- 6
Localizes to pain- 5
withdraws from pain- 4
flexion to pain- 3
extension to pain- 2
none- 1
What is decorticate posturing?
hands up to chest in fists
What is decerebrate posturing?
hands at sides and fists facing out
what are protective reflexes?
They indicate brainstem function.
1. corneal/blink
2. gag reflex
3. swallow reflex
4. cough reflex

other reflexes:
oculocephalic reflex - dolls eyes
oculovestibular reflex- when the head moves to the right, the eyes move to the left etc.
What is the most common neurological side effect of a frontal lobe brain injury?
personailty inhibitions
What are some fundamentals of metabolic activity in the brain?
oxygen and glucose, blood supply and drainage, cerebrospinal fluid.
What is autoregulation?
the ability of cerebral blood vessels to adjust their diameter to arterial pressure changes within the brain. if a rapid increase in MAP occurs, the cerebral vessels constrict to prevent excessive distention of the cerebral arteries. If the MAP drops, the cerebral blood vessels dilate to maintain normal CBF and to prevent cerebral ischemia
When does autoregulation fail?
the cerebral vessels are sensitive to chemical regulators to maintain CBF, the partial pressure of carbon dioxide or oxygen and the hydrogen ion concentration.

carbon dioxide is the most poten agent that influences CBF. when PaCO2 is greater than 45, cerebral blood vessels vasodilate to increase CBF.

cerebral arteries are less sensitive to changes in PaO2, and CBF is not affected until PaO2 is 50 or less. this can cause cerebral hypoxia, vasodiilation of crebral vessels.
What is the Monro-Kellie Hypothesis?
The pressure volume relationship between ICP, volume of CSF, blood, brain tissue, and Cerebral Perfusion Pressure.

it states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. The cranidum and its constituents create a state of volume equilibrium, such that any increase in volume of one of the cranial consituents must be compensated by a decrease in the volume of another.
Example: an increase in lesion volume (epidural hematoma), will be compensated for by a downward displacement of CSF nd venous blood.
Monro-Kellie Hypothesis
Skull contents
Brain- 80%
Cerebral Blood- 10%
CSF- 10%
What is intracranial pressure?
A combination of the 3 compartment volumes. It is measured via the CSF- pressure exterted by the CSF within the ventricles of the brain.

normally, it is 5-15mmHg, but it is dynamic and fluctuates!
What is cerebral perfusion pressure (CPP)?
It depends on the cerebral blood flow and ICP. It is the pressure gradient necessary to supply adequate amounts of blood to the brain.

normal is 80-100mmHg
What is increased intracranial Pressure (ICP)?
intracranial pressure above the norm. sustained increases in icp can lead to herniation syndromes. herniation occurs through shifting of brain tissue from an area of high pressure to one of lower pressure.
Primary causes of increased ICP.
lesion, trauma, cerebral hemmorrhage, ischemic stroke, hydrocephalus, post-op cerebral edema, meningitis
Secondary causes of increased ICP.
airway obstruction, hypoxia/hypercarbia, hyper/hypotension, position, hyperthermia, seizures, metabolic disorders
What are indications for placement of ICP monitoring?
severe head injury, subarachnoid hemorrhage, brain tumors, stroke, meningitis
What are the intracranial monitoring sites?
subarachnoid, intraventricular, intraparenchymal, epidural
What are nursing measures in increased ICP?
1. VS/temp
2. neurological assessments
3. monitor drainage/ICP/CPP/waveforms/system&tubing, insertion site
4. sedation/analgesia
5. drain CSF as ordered
6. use strict aseptic technique
7. level/zero machines
8. notify physician when apropriate
What are the priority nursing care measures of pts recieving ICP monitoring?
-prevent complications
-maintain integrity of system
-drain CSF appropriately (open vs closed system)
-gather, document, report accurate data
What is intracranial hypertension?
ntracranial hypertension literally means that the pressure of cerebrospinal fluid (CSF) within the skull is too high.

ICP greater than 15.
What are the early symptoms of intracranial hypertension?
Decreased LOC (earliest)
What are some late signs of intracranial hypertension?
changes in pupil reaction to light and size
Cushing's Triad (herniation)
diminished brainstem reflexes
abnormal extension (decorticate)
abnormal flexion (decerebrate)
changes in respiratory patterns
What is cushings triad?
a sign of increased intracranial pressure
1. systolic hypertension
2. change in respiratory pattern
3. bradycardia
**widening pulse pressure
What are nursing measures aimed at decreasing/managing ICP?
1. sedation - propofol
2. osmotherapy
3. CSF drainage- open vs closed
4. hyperventilation
5. barbituate therapy
6. maintain CPP
What are some collaborative mgmt aims of ICP?
therapy aimed at reducing the volume of one or more of the components. The head elevation positioning- now it is individualized to minimize ICP and maximize MAP. Avoid positions that decrease venous return from the brain!!

1. Keep the PEEP less than 20cm H2O.
2. Coughing/suctioning- allow adequate rest time.
3. Do not tie the trach ties too tight!
4. Hyperventilation- keep CO2 low, normal now.
5. Temp control- cerebral metabolic rate.
6. BP control
7. Sedatives and/or beta blockers
8. Hypotension- give fluids or inotropes
9. Seizure Control
10. Cerebral spinal fluid drainage
11. Maximize CPP
How does the nurse maintain BP control in collaborative MGMT of ICP?
- maintain in the high normal for adequate perfusion. Not too high or we have increased CBV (cerebral blood volume), which may increase ICP.
How does the nurse maintain seizure control in collaborative MGMT of ICP?
give anticonvulsants prophylactically. Seizures increase metabolic requirements- may have ischemia. Dilantin (phenytoin) and ativan.
How does the health care worker perform cerebral spinal fluid drainage in collaborative MGMT of ICP?
-ventriculostomy- pliable catheter is placed into the anterior horn of the lateral ventricle
-CSF drainage
-monitoring devise for ICP
-treatment to lower ICP
-aseptic technique
How does the health care worker maximize CPP in collaborative MGMT of ICP?
-diuretics and volume maintenance
Osmotic diuretics- mannitol
Non-osmotic diuretics- furosemide (lasix)
-serum osmolality 300 to 320 mOsm/L
-fluid volume maintenance
How do you control the metabolic demand?
Maximize CPP and perform sedation and pain control.

Maximize CPP- reduce noxious stimuli/pain/pressure. reduce metabolic demand. assist with patient care activities.

Sedation and pain control- use benzodiazepines, propofol, narcotics, neuromuscular blockades, and barbituates
What are herniation syndromes?
the goal of neurologic evaluation, ICP monitoring, and treatment of ICP is to prevent herniation syndromes!

the herniation of intracerebral contents results in:
-shifting of tissue from one compartment of the brain to another
-places pressure on cerebral vessels and vital centers of the brain

herniation rapidly causes death as a result of cessation of blood flow.
Deterioration in brain function results in changes in:
LOC, decreased GCS, pupillary/oculomotor responses, VS, and protective reflexes.

*these changes refelct an increasing ICP
What is the GCS in a mild TBI?
What is the GCS in a moderate TBI?
What is the GCS in a severe TBI?
GCS less than 8
Assessment keys of the pt with a TBI.
1. GCS
2. Pupillary response
3. motor function
4. VS
5. reflexes
6. brainstem function
7. respiratory function
Diagnostic tests for a patient with a TBI
CT, MRI/MRA, transcranial doppler, EEG, angiography, LP
What is a hyperdynamic state?
increased BP, HR and CO
What do nursing priorities in mgmt of a TBI focus on?
stabilizing VS, preventing further injury, and reducing increases in ICP and maintaining adequate CPP
MGMT of a TBI includes:
-managing secondary injuries
-brain trauma foundation protocol
What is the Brain Trauma Foundation Protocol for management of TBIs?
-early intubation
-fluid resuscitation
-CT Scan
-evacuation of lesion/mass/bleed
-management in an ICU with an ICP monitor
What is a craniotomy?
it is performed to gain access to portions of the CNS inside the cranium. It is used for tumor resection or removal, cerebral deccompression, evacuation of hematoma or abscess, clipping or removal of an aneurysm or AVM.

Patients needing critical care monitoring are usually at a greater risk for complications.
Preoperative care for a craniotomy.
Assess- document neurologic baseline
Diagnostic- blood tests, type and cross match, cxr, EKG
Teaching- avoid activities known to increase ICP, surgery specfic instructions
Postoperative medical management following a craniotomy.
care varies depending on the underlying reason for the craniotomy. management is usually directed at prevention of complications.

-intracranial hyeprtension
-surgical hemorrhage
-fluid imbalance
-CSF leak
-DVT prophylaxis
Nursing management following a craniotomy.
The primary goal of a postcraniotomy is protection of the integrity of the CNS.

-preserve adeqaute CPP
-promote arterial oxygenation
-provide comfort and emotional support
-maintain surveillance for complications
-initiate early rehabilitation
-educate patient and family
What is a stroke?
impaired blood flow. It is the third leading cause of death, and the leading cause of serious long term disability.

ischemic vs. hemorrhagic
How to assess and diagnose a stroke.
assess for a sudden onset of focal neurological signs lasting longer than 24 hrs

CT scan, EKG, CXR, echo, coags, electrolytes, glucose, renal/hepatic function, abgs, eeg, lp
Medical management of stroke:
Thrombolytic therapy- within 3 hours of onset of ischemic stroke.
airway management
BP control, temp, glucose management
What is the thrombolytic criteria indications?
acute ischemic stroke
3 hrs from symptom onset
greater than 18 years of age
What are the contraidications for thrombolytic criteria in a stroke?
intracranial hemorrhage
recent stroke
recent head trauma
uncontrolled HTN at time of tx
seizure at time of symptoms
A-V malformation, neoplasm, aneurysm
abnormal lab values
What is a subarachnoid hemorrhage?
a type of stroke, caused by a ruptured aneurysm or Arterio-Venous malformation (AVM). Accounts for 4.5-13% of all strokes, and is more common in women.
Assess and diagnose a subarachnoid hemorrhage.
"worst headache of my life"

-LOC, n/v, focal neuro defects, stiff neck
-S/s indicative of 'warning leaks' so take a good history
-CT scan
-Cerebral angiography
Medical management of a subarachnoid hemorrhage?
Medical Emergency!
-support VS
-rebleeding, cerebral vasospasm
What is rebleeding?
"Aneurysmal rebleeding" is a term that relates to the occurrence of repeated rupture in a previously ruptured aneurysm.
How do we manage rebleeding?
-BP control
-aneurysm clipping
-AVM excision
How do we manage cerebral vasospasm?
-onset is usually 4-10 days after initial hemorrhage.
Hypertensive, hypervolemic, hemodilution therapy (HHH)
-Nimodipine- a CCB also great in subarachnoid bleeds
-cerebral angioplasty
Structural/Surgical Causes of Coma
trauma, hemorrhage, hydrocephalus, ischemic stroke, tumor
metabolic/medical causes of coma
infection, metabolic conditions, encephalopathies, hyponatremia, OD, intoxication, poisoning
Medical management of coma.
Airway. Thiamin, glucose, narcotic antagonist

-monitor neuro status
-support all body functions
-provide comfort/support
-eye care

***Administration of thiamin is often recommended in patients with coma or hypothermia of unknown origin, due to the possible diagnosis of Wernicke's encephalopathy.
Collaborative mgmt measures of coma patients
-ID/treat underlying cause
-protect airway
-support circulation
-eye care
-skin integrity
-monitor for complications
-comfort/emotional support
-plan for a rehab program