Shared Flashcard Set

Details

med surg Unit 7
Neuro
141
Nursing
Undergraduate 1
12/04/2011

Additional Nursing Flashcards

 


 

Cards

Term
What is the Main Functions of the FRONTAL LOBE
Definition

"motor "strip"

speech  

Voluntary eye movement

current sensory data

past information or experience

 judgment and foresight

long-term goals

 Reasoning, concentration, abstraction

Term
What is the Main Functions of the PARIETAL LOBE
Definition

Understand sensation, texture, size, shape, 

Three-dimensional (spatial) perception

singing, playing musical instruments

processing nonverbal visual experiences 

Perception 

Term
What is the Main Functions of the TEMPORAL LOBE
Definition

Auditory center for sound interpretation

Complicated memory patterns

Wernicke's area for speech

Term
What is the Main Functions of the LIMBIC LOBE
Definition
Emotional and visceral patterns connected with survival  Learning and memory
Term
What is the Main Functions of the MEDULLA
Definition

Cardiac-slowing center

Respiratory center

Cranial nerves: IX (glossopharyngeal),

X (vagus),

XI (accessory),

XII (hypoglossal)  

VII (facial)  

VIII (acoustic)

Term
What is the Main Functions of the PONS
Definition

Cardiac acceleration and vasoconstriction centers  Pneumotaxic center helps control respiratory pattern and rate

Four cranial nerves originate from the pons: V (trigeminal), VI (abducens),VII (facial), and VIII (acoustic)

Term
What is the Main Functions of the MIDBRAIN
Definition

Contains the cerebral aqueduct or aqueduct of Sylvius  Location of periaqueductal gray, which may abolish pain when stimulated 

Cranial nerve nuclei III (oculomotor) and IV (trochlear) located here

Term
What is the lowest score on the Glasgow Coma Scale (GCS). What does it mean?
Definition

3

 

A score of 15 represents normal neurologic functioning. A score of 7 represents a comatose state.

The lower the score, the lower the patient's LOC.

Term
What is decorticate posturing a sing of?
Definition

abnormal posturing seen in the patient with lesions that interrupt the corticospinal pathways

 

arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs.

Term

What is decerebrate posturing a sing of?

Definition

associated with dysfunction in the brainstem area.

 

rigidity, extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos (body spasm in which body is bowed forward)

Term
You are preping a pt for a Cerebral angiography, what alirgy should you check for?
Definition
 iodin and shellfish
Term

How long should a pt be NPO for before a

Cerebral angiography

Definition
NPO 4 to 6 hours before the test.
Term
What instructions should the nurse give the pt reciving a Cerebral angiography, about what to do during the procedure
Definition

Your head is immobilized during the procedure 

• Do not move during the procedure

• You will feel a warm or hot sensation when the dye is injected—this is normal 

• You will be able to talk to the physician—let him or her know if you are in pain or have any concerns

Term
You pt is to have a Cerebral angiography, what assessments needed to be done before the procedure?
Definition
Assess and document neurologic signs, vital signs, and neurovascular checks.
Term
After a Cerebral angiography how should the nurse care of the injection site?
Definition

Check dressing for bleeding and swelling around site 

Apply ice pack to site

Keep the extremity straight and immobilized 

Maintain pressure dressing for 2 hours

Term
After a Cerebral angiography what assessment needs to be done on the affected extremity?
Definition
Check the extremity for adequate circulation to include skin color and temperature, pulses distal to the injection site, and capillary refill.
Term

Your pt had a Cerebral angiography. When you check the bandage sight there is bleeding.

What is your best action?

Definition
If bleeding is present, maintain manual pressure on the site and notify the physician immediately.
Term
After a Cerebral angiography what should the nurse continually be assessing
Definition
Assess vital signs and "neuro"
Term
What education should you give your pt about the proceure, that is to have a Lumbar puncture?
Definition
Explain the procedure, noting that some discom¬ fort may be felt when the local anesthetic is injected or that pain may occur in the leg(s) when the spinal needle is inserted.
Term
Hoe should you position a pt for a Lumbar puncture
Definition
Place the patient in the fetal position, and remind him or her to remain still. If needed, keep the patient from moving.
Term

after a Lumbar puncture the nurse does not need to do neuro checks because the procedure does not affect ICP

 

True or False?

Definition

False

complications, especially increased intracranial pressure (severe headache, nausea, vomiting, photophobia, change in level of consciousness).

Obtain vital signs and complete neurologic checks.

 

Term
What should the nurse know about leakage from a Lumbar puncture sight.
Definition

This is not a normal finding

Notify the physician if it occurs.

Term

After a Lumbar puncture your pt has a HA.

What is your best action?

Definition
Provide drug for headache. Notify the physician if drug does not relieve pain.
Term
What is tonic-clonic seizure
Definition

lasting 2 to 5 minutes

begins with a tonic phase- rigidity of the muscles,  immediate loss of consciousness.

Clonic- or rhythmic jerking of all extremities follows.

Term
What is an absence seizure
Definition

more common in children

brief periods of loss of consciousness and blank staring as though the person is daydreaming.

 

Term
What is an atonic (akinetic) seizure?
Definition
a sudden loss of muscle tone, lasting for seconds, followed by postictal (after the seizure) confusion.
Term
What are the risks for primary or idiopathic epilepsy
Definition

Metabolic disorders • Acute alcohol withdrawal • Electrolyte disturbances (e.g., hyperkalemia, water in¬ toxication, hypoglycemia) 

• High fever • Stroke • Head injury • Substance abuse • Heart disease

Term
What are the factors that can trigger a seizure?
Definition
increased physical activity, emotional stress, excessive fatigue, alcohol or caffeine consumption, or certain foods or chemicals.
Term
What drug is used for Status epilepticus
Definition

Diazepam (Valium)

 

Monitor airway, breathing, circulation (ABCs)

 

Term
What is the therapeutic drug level of Phenytoin (Dilantin)?
Definition
(10-20 mcg/mL) and toxic levels (>30 mcg/mL).
Term
What Care should you give a Patient During a Seizure
Definition

Protect the patient from injury. 

• Do not force anything into the patient's mouth. 

• Turn the patient to the side to keep the airway clear. 

• Loosen any restrictive clothing the patient is wearing. 

• Maintain the patient's airway and suction as needed. 

• Do not restrain or try to stop the patient's movement; guide movements if necessary. 

• Record the time the seizure began and ended.

Term

What Care should you give a Patient after a Seizure

Definition

Take the patient's vital signs. 

• Perform neurologic checks. 

• Keep the patient on his or her side. 

• Allow the patient to rest. 

• Document the seizure

Term
What is Meningitis
Definition

an inflammation of the meninges that surround the brain and spinal cord.

Bacterial and viral organisms are most common cause

Term
What are S/S of meningitis?
Definition

possible nuchal rigidity

Photophobia • Nystagmus • Abnormal eye movements 

Hemiparesis, hemiplegia, and decreased muscle tone possible later 

• Cranial nerve dysfunction, especially CN III, IV, VI, VII, VIII 

• Severe, unrelenting headaches

• Generalized muscle aches and pain

• Nausea and vomiting • Fever and chills • Tachycardia • Red macular rash (meningococcal meningitis)

Term
Your pt has Meningitis what is your first concern for this pt?
Definition

ABCs (airway, breathing, circulation).

Take vital signs and perform neurologic checks every 2 to 4 hours, as required.

Term
Your pt has Meningitis and needs cranial nerve assessment. What cranial nerves are you most interested in testing?
Definition
cranial nerves III, IV, VI, VII, and VIII, and monitor for changes.
Term

Your pt with Meningitis needs stict I/O's

Why?

Definition
Record intake and output carefully to maintain fluid balance and prevent fluid overload.Pt at risk for increased ICP.
Term
Your pt has Meningitis. How would you identify fluid retention early.
Definition
Monitor body weight to identify fluid retention early.
Term
Your pt has Meningitis. How should you controll the environment
Definition

Decrease environmental stimuli: 

• Provide a quiet environment. 

• Minimize exposure to bright lights from windows and overhead lights.

Term
Your pt has Meningitis. How should you position the pt?
Definition

Maintain bedrest with head of bed elevated 30 degrees.

Position carefully to prevent pressure ulcers.

Term
Your pt has Meningitis. What percations are needed to enter this room?
Definition

Maintain Transmission Precautions per hospital policy (for bacterial meningitis). 

 

Term
What complications should the nurse Monitor for a pt with Meningitis? 
Definition

Increased intracranial pressure

 Vascular dysfunction

 Fluid and electrolyte imbalance

 Seizures

 Shock

Term
What is Encephalitis
Definition
an inflammation of the brain tissue and often the surrounding meninges.It affects the cerebrum, the brainstem, and the cerebellum.
Term
What sre the S/S of Encephalitis
Definition

nausea, vomiting, a stiff neck

High fever, Changes in mental status (e.g., agitation)

Photophobia, Fatigue

 

Term
Definition

nuro dysfunction (e.g., dysphagia [difficulty swallowing])  Focal (specific) neurologic deficits

increased ICP (e.g., decreased LOC)

Term

Your pt has increased ICP and respiratory status is compromised.

What is your best action?

Definition
Perform deep tracheal suctioning even in the presence of increased ICP if respiratory status is compromised.
Term
What is Parkinson disease (PD),
Definition
a progressive neurodegenerative disease, affecting motor ability
Term

What are the four cardinal symptoms

of Parkinson disease (PD)

Definition

tremor

rigidity

bradykinesia/akinesia (slow movement/no movement) postural instability

Term
The nurse is interviewing a patient with Parkinson Disease. What is the nurses best action in this situation.
Definition
Allow the patient extra time to respond to questions.
Term
What should the nurse know about administering medications to a pt with Parkinson Disease
Definition
Administer medications promptly on schedule to maintain continuous therapeutic drug levels.
Term
You have a pt with Parkinson Disease. What should you do if they complain of pain, tingling in limbs
Definition
Provide medication for pain, tingling in limbs as needed.
Term
You have a pt with Parkinson Disease. What side effects of medications should you assess for 
Definition
orthostatic hypotension, hallucinations, and acute confusional state (delirium).
Term
You have a pt with Parkinson Disease. What collaborative care should be considered?
Definition
Collaborate with physical and occupational therapists to keep the patient as mobile and as independent as possible in ADLs.
Term
You have a pt with Parkinson Disease. What interventions are needed to prevent complications of immobility?
Definition

constipation- bowl regiment, stool softners, hydration

pressure ulcers- reposition Q2Hr, hydration

contractures- PT, ROM

Term
You have a pt with Parkinson Disease. What should you keep in mind when Scheduling a fallow up appointment.
Definition
Schedule appointments and activities late in the morning to prevent rushing the patient, or schedule them at the time of the patient's optimal level of functioning.
Term
You have a pt with Parkinson Disease. What intervention could you provide concerning communication.
Definition

Teach the patient to speak slowly and clearly. Use alternative communication methods, such as a communication board.

Refer to speech-language pathologist.

Term
Why is a nurse concerned for the pt that has Parkinson disease at meal tiem?
Definition

Pt at risk for aspiration

Monitor the patient's ability to eat and swallow. Monitor actual food and fluid intake. Collaborate with the nutritionist.

Term

Pts with Parkinson disease offtin have insomnia, depression and anxiety.

 

True or False?

Definition

True

Assess for depression and anxiety. 

Assess for insomnia or sleeplessness.

Term
What is Alzheimer's disease (AD)?
Definition
a chronic, progressive, degenerative disease, manifested by loss of memory, judgment, and visuospatial perception and by a change in personality.
Term
What are the aries of the brain that are particularly affected by Alzheimer's disease
Definition
Precentral gyrus of the frontal lobe • Superior temporal gyrus • Hippocampus • Substantia nigra
Term
What changes in neurotransmitters may you expect to find with a pt with Alzheimer's disease
Definition

High levels of beta amyloid are associated

with reduced acetylcholine

Term
What education would you give at pt that asks you how they can prevent Alzheimer's disease
Definition
There are no proven ways to prevent AD.
Term
When colecting info on a pt suspected of having Alzheimer's disease what is the most important information to be obtained?
Definition

the onset, duration, progression, and course of the symptoms.

 

Ask about changes in memory or increasing forgetfulness and about the ability to perform ADLs.

Term
What Changes in Cognition may you see in your pt with Alzheimer's disease? 
Definition

Attention and concentration

Judgment and perception

Learning and memory

Communication and language

Speed of information processing

Term
What are some S/S of EARLY (MILD)Alzheimer's disease
Definition
Independent in ADLs • No social or employment problems initially • Denies presence of symptoms ¦ Forgets names; misplaces household items • Short-term memory loss; difficulty recalling new information • Subtle changes in personality and behavior • Loss of initiative; less engaged in social relationships • Mild cognitive impairment, problems with judgment • Decreased performance, especially when stressed • Unable to travel alone to new destinations • Decreased sense of smell
Term

What are some S/S of MIDDLE (MODERATE)

Alzheimer's disease

Definition

Impairment of all cognitive functions • Problems with handling or unable to handle money and finances

Disorientation to time, place, and event • Possible depression, agitated • Increasingly dependent in ADLs • Visuospatial deficits: difficulty driving, gets lost • Speech and language deficits: less talkative, decrease in use of vocabulary, increasingly non-fluent, and eventually aphasic • Incontinent • Wandering; trouble sleeping

Term

 

What are some S/S of LATE (SEVERE)

Alzheimer's disease

 

Definition
Completely incapacitated; bedridden • Totally dependent in ADLs • Motor and verbal skills lost • General and focal neurologic deficits • Agnosia (loss of facial recognition)
Term
What is Multiple sclerosis (MS)?
Definition
a chronic autoimmune disease that affects the myelin sheath and conduction pathway of the central nervous system (CNS). characterized by periods of remission and exacerbation
Term
What areas of the brain are most commonly affected with Multiple sclerosis?
Definition
optic nerves, pyramidal tracts, posterior columns, brainstem nuclei, and the periventricular region of the brain.
Term
What are early sings of Multiple sclerosis
Definition

increased fatigue and stiffness of the extremities

change in vision

Alterations in sexual function

decreased ability to solve problems

hyperactive deep tendon reflexes, clonus, positive Babinski's reflex,

 

 

Term
What factors can aggravate the symptoms of MS
Definition
fatigue, stress, overexertion, temperature extremes.
Term

Pts with MS may exibit dysdiadochokinesia.

What does this mean?

Definition
an inability to stop one motor impulse and substitute another
Term
How is MS managed?
Definition
The purpose of management is to modify the disease's effects on the immune system, prevent exacerbations, manage symptoms, and improve function.
Term
What druge used to treat MS is an immunomodulator that modifies the course of the disease and has antiviral effects
Definition
Interferon beta (Avonex, Betaseron, or Rebif)
Term
What drug is the first monoclonal antibody approved for MS that binds to WBCs to prevent further damage to the myelin
Definition
Natalizumab (Tysabri)
Term

What drug is a chemotherapy drug, has also been shown to be effective in reducing neurologic disability.

 

It also decreases the frequency of clinical relapses in patients with secondary progressive, progressive-relapsing, or worsening relapsing-remitting MS.

Definition
Mitoxantrone (Novantrone)
Term
What three drugs are the most common Immunosuppressive therapy agents used in the treatment of MS?
Definition

cyclophosphamide (Cytoxan) 

methylprednisolone (SoluMedrol)

 Methotrexate (MTX)

Term

Why wouls your pt with MS be taking:

(Lioresal), diazepam (Valium, Apo-Diazepam), or dantrolene sodium (Dantrium)

Definition
to lessen muscle spasticity.
Term

Why might your pt with MS be taking:

carbamazepine (Tegretol) or tricyclic antidepressants. Propranolol hydrochloride (Inderal) and clonazepam (Klonopin)

Definition
used to treat cerebellar ataxia (decreased motor coordination).
Term
Why might your pt with MS be taking anticholinergic agents.
Definition
Bladder dysfunction (detrusor hyperreflexia)
Term
What is Amyotrophic lateral sclerosis (ALS)
Definition

an adult-onset deterioration of motor neurons found in the spinal cord and brainstem

 

characterized by progressive weakness, muscle wasting, and spasticity eventually leading to paralysis.

Term
How would you expect a pt with Amyotrophic lateral sclerosis (ALS) to progress with the disorder?
Definition

Rapid progression 


Beginning in one area of the body, motor weakness and deterioration spread until the entire body is involved, including the ability to talk, swallow, and breathe.


Death typically occurs within 3 years of diagnosis

Term

Pts with Amyotrophic lateral sclerosis (ALS) need mental stimulation because they are still mentaly intact.

 

True or False?

Definition
True 
Term

What is the only drug approved for treatment of ALS patients.

 

What is its affect?

Definition

Riluzole (Rilutek)

 

It is not a cure, but it does extend survival time.

Term
What are the common complications of ALS?
Definition

pain, fatigue, spasticity, excessive secretions, sleep disturbances, immobility, loss of speech/swallow

 loss of respiratory control

Term
What is Guillain-Barre syndrome (GBS)
Definition

demyelination

of the peripheral nerves, progressive motor weakness and sensory abnormalities occur.

Term
How does Guillain-Barre syndrome (GBS) progress in a pt 
Definition
Symptoms typically begin in the legs and spread to the arms and upper body.  ascending paralysis.
Term
What typically proceeds Guillain-Barre syndrome (GBS) 
Definition
Most patients report an acute illness before the develop¬ ment of GBS symptoms
Term
What three stages make up the acute course of GBS:
Definition

1. The acute or initial period (1 to 4 weeks), which begins with the onset of the first symptoms and ends when no further deterioration occurs 

2. The plateau period (several days to 2 weeks)

3. The recovery phase (usually 4 to 6 months, maybe up to 2 years), which is thought to coincide with remyelination and axonal regeneration (Some patients do not completely recover and have permanent neurologic deficits, referred to as chronic GBS.)

Term
A pt has rapid worsening GBS what treatment may be ordered?
Definition
Plasmapheresis- removes the circulating antibodies thought to be responsible for the disease.
Term
What is the priority nursing intervention for the patient with GBS
Definition
to maintain adequate respiratory function
Term
how will the nurse promote airway patency in a pt with GBS?
Definition

Elevate the head of the bed to at least 45 degrees

provide suctioning at bedside

incentive spirometer if able

Oxygen by NC

 

 

Term
What is Myasthenia gravis (MG)
Definition
An autoimmune disease of the neuromuscular junction. an autoantibody attack on the acetylcholine receptors (AChR) in the muscle end plate membranes. As a result, nerve impulses are not transmitted to the skeletal muscle
Term
How will Myasthenia gravis (MG) typically progress in a pt
Definition

usually insidious (slow), some instances of fairly rapid 

remissions and exacerbations

characterized by fatigue and weakness primarily in muscles innervated by the cranial nerves, as well as in skeletal and respiratory muscles.

 

Term

What are the MOTOR MANIFESTATIONS

of Myasthenia Gravis

Definition

• Progressive muscle weakness (proximal) that usually improves with rest 

• Poor posture • Ocular palsies • Ptosis "drooping eyelid."        • Weak or incomplete eye closure • Diplopia • Respiratory compromise • Loss of bowel and bladder control • Fatigue

Term

What are the SENSORY MANIFESTATIONS

Myasthenia Gravis

Definition

Muscle achiness

 Paresthesias

 Decreased smell and taste

Term
How is Myasthenia Gravis treated?
Definition

immunosuppressive drugs or corticosteroids, plasmapheresis, and thymectomy

 

symptoms: anticholinesterases or cholinergic drugs

Term
What are the S/S of a Myasthenic Crisis
Definition

Increased pulse and respiration

Rise in blood pressure

Anoxia (decrease in the level of oxygen)

 Cyanosis

Bowel and bladder incontinence

Decreased urine output

Absence of cough and swallow reflex

Term

What are the S/S of a Cholinergic Crisis

Definition

Nausea Vomiting Diarrhea

Abdominal cramps

Blurred vision

Pallor

Facial muscle twitching

Pupillary miosis (pin point)

Hypotension

Term
How should anticholinesterase be administered in relation to meals?
Definition
Administer anticholinesterase drugs, as prescribed: 45 to 60 minutes before meals.
Term

Your pt with Myasthenia Gravis has morphine 2 mg ordered for pain PRN Q4hr. 

 

Should the nurse question this order?

Why/Why not?

Definition

Yes

Opioids may cause MG to worssen 

 

Term
What drugs should pts with Myasthenia Gravis not be on?
Definition
Strong cathartics • Antidysrhythmics • Beta-blocking agents • Antibiotics • Antirheumatic drugs • Antispasmodics • Antihistamines • Opioids • Phenytoin (Dilantin) • Antidepressants (tricyclics)
Term
What is the difference between a transient ischemic attack (TIA) and an a reversible ischemic neurologic deficit (RIND)
Definition

TIA lasts a few minutes to fewer than 24 hours

RIND symptoms last longer than 24 hours but less than a week.

 

Both TIAs and RINDs may damage the brain tissue with repeated insults

Term

What is a CEREBRAL VASCULAR ACCIDENT (CVA) [STROKE]

Definition

INTERRUPTION OF THE BLOOD FLOW TO THE BRAIN RESULTING IN DYSFUNCTION IN MOTOR, SENSORY, PERCEPTUAL, EMOTIONAL OR COGNITIVE ABILITIES

Term

ALL strokes are unaviodable.

 

T/F?

Definition

False

SOME MAY BE PREVENTABLE


Term

Why might the S/S of a stroke 

vary from person to person 

Definition

S/S VARY DEPENDING ON AREA OF THE BRAIN AFFECTED  

Term
What atr the 4 types of strokes?
Definition

HEMORRHAGIC

ISCHEMICn  EMBOLUSn THROMBUS 

Term
What is a HEMORRHAGIC CVA
Definition
occur when a cerebral blood vessel ruptures and blood is released in brain tissue
Term
What is an ISCHEMIC CVA
Definition

occur when a thrombus or embolus obstructs an artery carrying blood to the brain;

about 80% of strokes are the ischemic variety.

Term

What risks are you worried about for a pt with a

HEMORRHAGIC CVA

Definition

 VERY HIGH MORTALITY RATE

n   CAN REBLEED IN TWO WEEKS

Term

What factors predisose a preson to a HEMORRHAGIC CVA

Definition

HTN, AV MALFORMATION, CEREBRAL ANEURYSM, DISEASES THAT CAUSE COAGULOPATHIES, OVER USE OF ANTICOAGULANTS

  INTRACEREBRAL BLEED

Term
What is the classic symptome of a hemorrhagic CVA
Definition

"THIS IS THE WORST HA OF MY LIFE”

Term
What are common S/S of a hemorrhagic CVA
Definition

LOC CHANGES, NUCHAL RIGIDITY, PHOTOPHOBIA, RESTLESSNESS, IRRITABLE, N/V, FOCAL S/S IE HEMIPARESIS, PUPIL 

Term
How is a hemorrhagic CVA diagnosed
Definition

CT, MRI, LP (BLOODY FLUID), MAYBE ANGIOGRAM

Term

What are the s/s of a L CVA 

DAMAGE ON L SIDE OF BRAIN

Definition

 

R HEMIPARESIS

   DYSFUNCTION OF SPEECH & LANGUAGE IN 95% PT.

SLOW & CAUTIOUS

MEMORY DEFICITS

Swallow DYSFUNCTION 

 

Term

What are  the s/s of a R CVA

Definition

  L HEMIPARESIS, L SIDED NEGLECT

FALL RISK R/T QUICK, IMPULSIVE BEHAVIOR, POOR JUDGMENT

  MEMORY DEFICIT

Term
What is a TRAUMATIC BRAIN INJURY
Definition
the result of a blow or jolt to the head or as a result of penetration of the head by a bullet or other foreign object.
Term
What are the consequences of a TBI
Definition
short-term or long-term physical, cognitive, financial, and emotional consequences.
Term
Wht is a Primary Brain Injury
Definition
occurs at the time of injury and re¬ sults from the physical stress (force) within the tissue caused by open or closed trauma.
Term
What are the S/S of a Traumatic Brain Injury
Definition

Amnesia (loss of memory)

Seizure

Loss of consciousness or sleepiness/drowsiness Restlessness or irritability

Disorientation or confusion

Scalp bruising and tenderness

Personality changes

Diplopia

Gait changes

Term
What are the S/S of a Severe head injury
Definition

Pupil changes

 Bradycardia

Papilledema 

High blood pressure/widened pulse pressure

 Hypotension and tachycardia (hypovolemic shock)

 Nuchal rigidity (cerebrospinal fluid [CSF] leak)

Term
What is a Secondary injury to the brain
Definition

any processes that occurs after the initial injury and worsen or negatively influence outcome.

 

hypotension, hypoxia, ischemia, and cerebral edema.

Term
What is the normal range for ICP?
Definition
10 to 15 mm
Term
What physiological changes occur due to increased ICP
Definition
cerebral perfusion decreases, leading to tissue hypoxia, a decrease in serum pH level, and an increase in the level of carbon dioxide → causes cerebral vasodilation, edema, and a further increase in ICP.
Term

What is the cerebral perfusion pressure (CPP)?

What is the normal range?

Definition

the pressure gradient over which the brain is perfusedand is determined by subtracting the mean ICP from the mean arterial pressure.

 

CPP above 70 mm Hg is generally accepted as an expected outcome of therapy.

 

 

Term
What factors can influences the cerebral perfusion pressure (CPP)
Definition
oxygenation, cerebral blood volume, blood pressure, cerebral edema, and ICP
Term
What age groups of people have a high insedence of TBI
Definition

children and elderly

 

Term

What is the first priority of a nurse who is admitting a pt to the ED with a TBI

 

Definition
assessment of the patient's ABCs—airway, breathing, and circulation.
Term
Why should you not sit your pt up who is newly admitted with TBI
Definition
TBI is associated with cervical spinal cord injuries, all patients with head trauma are treated as though they have cord injury until x-ray studies prove otherwise.
Term
Whatare the S/S of spinal cord injury ,that may ocmpany a TBI?
Definition

loss of motor and sensory function, tenderness along the spine, and abnormal head tilt.

respiratory problems and diaphragmatic breathing, diminished or absent reflexes.

Term
The mechanisms of autoregulation are often impaired as the result of a TBI. How will you assess your pt for this?
Definition
Monitor the patient's blood pressure and pulse to detect possible changes in cerebral blood flow.
Term
What is Cushing's triad?
Definition
a classic but late sign of increased ICP, is manifested by severe hypertension with a widened pulse pressure and bradycardia.
Term
What is typically the first sign of deterioration in neurologic status.
Definition
A de¬ crease or change in LOC
Term
How should the nurse treat a pt with Asymmetric pupils that comes to the ED?
Definition
They are treated as herniation of the brain from increased ICP until proven differently.
Term
When should you check for Nuchal rigidity in a pt who came to the ED with a TBI?
Definition
Nuchal rigidity is not checked until a spinal cord injury has been ruled out.
Term
What drug is given IV or endotracheally to suppress the cough reflex; coughing increases ICP.
Definition
Lidocaine
Term
How would you determin if it is safe to elivate the HOB to 30º
Definition

Head positioning should be based on both intracranial pressure (ICP) and systemic blood pressure.

 

If increasing head elevation lowers ICP but also significantly lowers systemic blood pressure, the patient does not benefit and may actually be harmed.

Term
What is the Criteria for brain death
Definition

• Glasgow Coma Scale <3 • Apnea • No pupillary response • No gag and cough reflexes • No oculovestibular reflex (no eye movement after ice water is placed in ears) 

• No corneal reflex • No oculocephalic reflex ("doll's eyes")

Term
The patient with a major head injury after the acute phase of management may have changes in these areas:
Definition

Sense of smell • Ability to taste, swallow, or feel the presence of food within the oral cavity 

• Vision, pain, and temperature sensation

Term
What would you need to teach the patient who has sustained a minor head injury about post-concussion syndrome
Definition

This syndrome is a group of clinical manifestations including, but not limited to: 

• Personality changes • Irritability • Headaches

• Dizziness • Restlessness • Nervousness • Insomnia

• Memory loss • Depression

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