Neuro 1
What is the difference between a hemorrhagic and ischemic stroke and what is a common cause of each?
Hemorrhagic: bleeding, most often caused by HTN, also aneurysm or AVM
Ischemic: vascular obstruction, thrombi, emboli (vascular disease)
What are 5 abnormal neurologic findings that would be expected with neurologic decline:
1: First sign *Decreased LOC
2:Pupillary changes (sluggish, fixed, downward gaze, dilated, pinpoint, nonreactive, unable to follow 6 cardinal gazes)
3:Posturing (decorticate, decerebrate/extension, lack of reaction to noxious stimuli).
4:Changes in respiratory status (irregular, resp depression, c02 retention)
5:Lack of response to cold caloric (oculobestibular reflex)
6) Changes in vital signs (Cushing Triad *late finding), increased/decreased temp, sudden hypotension, sudden increase or decrease in ICP
7) Coma (dysfunction of reticular activating system/sleep-wake system)
Discuss priority care for patients with suspected cerebral or intracerebral hemorrhage:
-Baseline severity score from American Stroke association
-Rapid neuroimaging (CT without contrst vs MRI)
-Coag panel and reversal
-POC blood glucose
-Critical care admission
-Mental status monitoring/EEG
Box 17.4
fever
Discuss two treatments for Thyroid storm:
address dysrhythmias and prevent cardiovascular arrest
cooling
antipyretics (Tylenol not aspirin (why?)
Beta Blockers to reduce catecholamines
Antithyroid medication
Plasmapheresis
Antidiuretic hormone (ADH,vasopressin)- vasoconstriction-increased volume and BP as a protective measure to stress response
Epinephrine-vasoconstrictive, increased HR/BP, slowed GI motility
Glucagon (triggers release of insulin)- released to prevent hypoglycemia due to times of stress
Insulin:
List three facts pertaining to nursing care for a patient with a ventriculostomy drain:
1) Limit movment/stimulus
2) Dressing change only when ordered
3) Monitor LOC and changes in drainage (amt/color)
4) Monitor for infection
5) Monitor ICP trends related to output from drain
6) Closed system
7) External auditory meatus landmark for zeroing (generally 15 cm above)
Name 3 abnormal findings of lumbar puncture CSF sample and nursing care points:
1) Blood/rust tinged = blood
2) Cloudy or tubid= microorganism or WBC
3) Positive serology for Syphillis
4) Elevated Glucose = bac meningitis, TB,
5) Protein elevated = bac meningitis, tumor, ALS, Guillain Barre
Nursing Care: s/s of pain, anxiety, hemorrhage, vital signs, education, awareness of contraindications
What is the priority nursing interventions (including education) would you provide for a patient in a coma?
ABC, secretion, aspiration precautions, support of underlying cause, nutrition, skin care/repositioning, family education related to cause, prognosis, support
Discuss two treatments for patient in Myxedema coma:
Ventilator support r/t CNS depression
fluid/electrolyte imbalance
corticosteroid supplementation
Thyroid hormone replacement therapy
Gradual rewarming to prevent vasodilation
improve circulation with skin care/repositioning
Discuss IV two treatments for SIADH along with two nursing assessments.
hypertonic solutions (3%) and furosimide
500-600 ml over 3-4 hours
*not too fast
Conivaptan (Vaprisol)-inhibits ADH, may also be indicated
Nursing assessment: Intake/output, serum/urine osmolality, daily weights, neuro status, serum electrolytes
Risk factors: traumatic, infectious, atherosclerosis, neoplasm, prior hx of, family hx, ETOH abuse, HTN, elicit substance/stimulant use.
Assessment: Sudden onset seer pain, headache, n/v/ photophobia, increased ICP/decreased perfusion, syncope, progression to coma/death.
Purpose of comparing MAP and ICP and clinical indications that affect this comparison:
MAP-ICP= CPP
-Autoregulation: vessels constrict/dilate to regulate Cerebral perfusion
-Oxygenation or lack of
-Head trauma-cerebral edema
-Changes in brain matter (masses), CSF, or blood (intracranial hem/stroke/infection) within cranial cavity
-Cushing Triad (bradycardia, syst hypertension, bradypnea
-Intracranial Hypertension
-Chiari Malformation, Atrioventricular Malformation
-Hydrocephalus
Describe two causes of intracranial hypertension and two nursing interventions:
Abscess, tumor, TBI, anoxic injury, encephalopathy, edema r/t tumors or trauma, hemorrhage, vasospasm, vasodilation
Nursing interventions: Monitor for changes in ICP and herniation (Cushing triad), monitor brainstem reflexes, positioning, hyperventilation (decreased PCO2 to vasoconstrict), decrease metobolic rate to decrease blood flow, medication to manage hypertension
Describe the Thyroid gland, related hormones, and associated disorders:
1)TSH
2) Free T3 and Free T4
1) Myxedema- severe deficiency of thyroid hormone producing hypothyroidism, increased TSH
2)Thyroid Storm/Thyrotoxicosis: Graves disease-hyperthyroidism, low TSH
Alterations from medications ASA (increase Free T3/T4, Amiodorone)
List differences between the following
1) Thyroid Storm
2)Myxedema Coma
Thyroid- Extremely low TSH, increased FT4 and FT3 (severe hyperthyroidism), FEver, AFIB/SVT, Acute HF, agitation, restless, N/V, diarrhea,
Myxedema- Increased TSH and decreased FT4 and FT3 (severe hypothyroidism), CNS depression, decreased CO, bradycardia, decreased temp, anemia *opposite of thyroid storm
What is the initial top priority for a person with a traumatic brain injury, stroke, subarachnoid hemorrhage?
Airway/respiratory/breathing
What is a top inpatient nursing assessment related to the nervous system? (once airway is managed)
Change in LOC
List 2 surgical procedures related to the neurologic system (brain specifically) and nursing care:
1)Aneurysm clipping or coiling
2) Burr hole/craniotomy/ventriculostomy for drainage, resection or decompression
3) Resection of AVM (arteriovenous malformation)
Nursing care: ABC, control hypertension and ICP, environment/stress manangment, monitor for rebleeding and vasospasm, nutrition, skin eye care, positioning, seizure control, temp control, monitor CSF drainage, DVT prophylaxis,fluid management, early rehab, education, med administration, infection monitoring,
Discuss 2 causes of coma:
Structural or surgical-ischemic stroke, intracerebral hemorrhage, trauma, hemorrhage, surgical
Metabolic/medical-medication induced, drug overdose, infectious disease, endocrine disorder, poisonings, anoxia, poisoning
** affect reticular activating system/sleep/wake ability
What is the syndrome that results from deficit in ADH related to pituitary disfunction (or small cell carcinoma) and what would you expect to see regarding urine output?
Diabetes Insipidus
high urine output that are dilute, signs of dehydration
Explain the difference between DKA and HHS and why this difference likely occurs.
DKA cause acidosis because of increased ketone production, HHS is not a state of acidosis.
HHS; Type 2 DM, have some insulin production
HHS generally has significantly higher serum blood glucose levels when compared to DM
Describe ways to decrease intracranial pressure in a intubated patient (give 4 ways).
1. Manage CO2 levels: high is a vasodilator, low is a vasoconstrictor
2. Administer Mannitol: increases serum osmolality and decreases cerebral blood volume and edema
3. Analgesics: often times opioids such as fentanyl and morphine
4. Anesthetics/Induced Coma: Propofol and neuromuscular blockers
5. Blood pressure management: beta-blockers, Ace inhibitors ( if elevated)
6. seizure prophylaxis, craniotomy, HOB elevated and head neutral, minimize environmental stimuli
Discuss three medications related to neurologic function as well as any special indications:
1) tPA (fibrinolytic)- contraindicated with hemorrhagic stroke, bleeding our outside window of 4.5 hours
2) Nimodipine-targets cerebral tissue, treat vasospasm, may cause hypotension
3) Phenytoin (Dilantin)-administer with NS only, no more than 50 mg/min, monitor serum levels
4) Mannitol (osmotic diuretic)- cerebral edema treatment
5) Phenobarbitol-CNS depression (barbituate)
Explain Autonomic Dysreflexia after a spinal cord injury and immediate interventions.
stimulation below level of injury caused by bladder or intestinal distention, spasticity, ulcer, or other stimulation: causes vasoconstriction and extreme HTN, bradycardia, headache, flushing, vision changes
Treatment: check urinary catheter for kinks, elevate HOB, check for bowel impaction, give sublingual nifedipine.
Describe the adrenal gland, related hormones, and associated disorders:
1) glucocorticoid/cortisol
2)epinephrine/norepinephrine
3) aldosterone
Cushing Syndrone -excess cortisol
Primary Aldosteronism-excess aldosterone
Addison disease/crisis-hyposecretion of cortisol and/or aldosterone
Pheochromocytoma-neuroendocrine tumor-release of epinephrine or norepinephrine
Explain the difference between diabetes mellitus and diabetes insipidus and what is similar.
DI: lack of ADH
DM: glucose/insulin related (r/t hormone insulin)
Similar: both may cause massive diuresis.