Cognition
Monroe-Kellie
- What 3 substances make up the contents of the skull?
-Following Monroe-Kellie, what is the extreme result of an increase in volume of any of the 3 components of intracranial composition?
CSF, Intravascular blood, Brain tissue
The risk is Brainstem Herniation
Most common injuries that cause SCI, and the populations at risk
•Motor vehicle accidents
•Falls
•Violence (Gunshots)
•Sports injuries (Diving, Gymnastics)
Adolescents and older adults
Which cranial nerves are assessed by following a pen with the eyes?
3 of them: CN III oculomotor, CN IV trochlear, CN VI abducens
A client is brought to the ED following motor vehicle collision. Initial assessment reveals that the client is unconscious with BP of 165/73, HR 50 bpm, Respiratory rate of 8 and irregular, with a temperature of 103 F. The client is intubated and measures to decrease ICP are implemented. Which nursing action is priority at this time?
A. Clean and stitch lacerations on patient's face
B. Administer acetaminophen as prescribed
C. Obtain order for portable X-ray to evaluate the swollen right ankle
D. Contact the family
Administer acetaminophen as prescribed
Temperature may increase ICP and should be treated.
Other ICP interventions:
-HOB at 30 degrees
-Neck at neutral position
-Maintaining oxygen and Co2 levels
The nurse arrives to assist the triage of victims from building collapse. One person who has fallen from the building is unconscious, bleeding from several areas, and has one leg in an awkward position. Which action is priority at this time?
A. Immobilize neck and spine
B. Inspect for symmetrical chest movements
C. Assess pupil reactions
D. Insert intravenous access
Immobilize neck and spine
Signs of brain death
-Apnea
-Coma
-Absence of brain stem reflexes (Gag, cough, sneeze)
What is Primary and Secondary Injury following SCI?
Primary
The damage itself from the impact
-Direct trauma, cord compression, interruption of blood supply, and tension on the cord
Secondary
(Ongoing) the progressive insult after the primary injury
The inflammatory reaction and increasing edema that continues compression of the spinal cord
If you touch a cotton swab to a patient’s face, what cranial nerve are you assessing?
CN V: Trigeminal
While caring for a patient with traumatic facial injuries, the nurse notices bloody drainage surrounded by a clear ring on the pillow behind the client's right ear. What action should the nurse take?
A. Assist client to sitting position and provide new pillowcase
B. Mark the area of drainage with pen
C. Pack the ear with gauze
D. Test the fluid for glucose and notify the physician
D. Test the fluid for glucose and notify the physician
Indicative of halo sign
A client with C5 cervical injury following a motor vehicle crash is conscious when arriving at the emergency department. Over the course of several minutes, the nurse notes that the client becoming increasingly agitated. What nursing action is priority at this time?
A. Measure pulse and blood pressure
B. Assess pulse oximetry readings
C. Palpate for distended bladder
D. Assess pupil response and Glascow coma scale
Assess Pulse Oximetry readings
Clients with C5 cervical injury are at risk of respiratory failure. The Diaphragm is innervated at level of C4.
Early signs of ICP and interventions
***Change in LOC
-Vomiting not proceeded by nausea
-Extreme headache
-Sluggish pupillary changes, Dilation on same side as injury
Nursing interventions for brain injury/increased ICP
- Monitor resp status and lung sounds (maintain patent airway): any lvl of hypoxia or hypercapnia can effect CPP
- Position head in neutral position w/ HOB 30º
- Avoid stimuli & activities that may increase ICP (Ex: valsalva maneuver, hip flexion, abdominal distention)
- Protect Pt from stress (Ex: calm & quiet environment)
- Monitor fluid status carefully (I/Os hourly)
- Strict aseptic technique
What is the term for incomplete SCI that results in loss of motor function on the side of the injury, and loss of sensation on the opposite side?
Brown-Sequard Syndrome
How would you test CN XI: Accessory?
-shrug shoulders and look for symmetry
-turn head side to side
A patient with a closed head injury has a respiratory rate of 30 and irregular, a blood pressure of 198/110mmHg, and a pulse rate of 48. The nurse is reporting these vitals to the PCP because they indicate:
A. Neurogenic shock
B. Cushing's triad
C. A pending seizure
D. Stroke
-Widening pulse pressure
-Bradycardia
-Irregular respirations
During an assessment, the nurse determines that the spinal shock in a patient being treated for C6 spinal cord injury has resolved. What did the nurse assess?
A. Urine output of 45ml over the last hour
B. Blood pressure of 110/66mmHg
C. Positive perianal reflex
D. Areflexia of the ankle reflexes
C: Positive perianal reflex
The return of this reflex indicates resolution of spinal shock
A patient's blood pressure is 152/96 and ICP is 20. What is the patient's cerebral perfusion pressure?
95mmHg
CPP (Normal is 60-100mmHg)
Formula
- (CPP = MAP - ICP)
MAP formula
- (MAP = (SBP + 2[DBP]) / 3)
What is the term for incomplete SCI that results in impaired motor function in the upper extremities and impaired sensation and positioning in lower extremities?
Central Cord Syndrome
Which should be part of the patient's plan of care for impaired function of CN IX: glossopharyngeal, CN X: Vagus, And CN XII: hypoglossal
NPO/Speech Consult
A 35 year old woman is snowboarding when she falls and crashes down the slope. She briefly looses consciousness and then returns acting normal. She states she feels "fine" and doesn't need medical attention. What should the nurse infere from the scenario? and what is the treatment?
A. Subdural Hematoma
B. Epidural Hematoma
C.Concussion
D. Everything's fine
B: Epidural Hematoma and emergency craniotomy
**This is a arterial bleed
Patient may have a brief loss of consciousness with return of lucid state; then as hematoma expands, increased ICP will often suddenly reduce LOC.
An emergency situation!
The nurse is caring for a patient with a T4 spinal cord injury. Which assessment finding should the nurse address immediately?
A. Reflexes are absent in lower extremities
B. Patient is incontinent for feces
C. Patient's bladder is distended
D. Patient has warm, blanching erythema on the sacrum
C: Patient's bladder is distended
Spinal injuries above T6 are at risk for autonomous dysreflexia. The most common triggers are distended bladder or bowel.
Other interventions:
HOB raised atleast 45 degrees to reduce BP
You patient is supine on the bed with feet platter flexed and pronated, arms extended, and hands flexed and pronated. What is this position called?
Decerebrate
Whereas "Decorticate" hands are adducted to the "Core"
Key difference between Spinal Shock and Neurogenic Shock
Spinal shock shows no reflexes below LOI —> no signals complete the reflex arc even in the intact portion of the spinal cord; flaccid paralysis —> loss of motor function
-Flaccid paralysis, Loss of sensation, Absent sphincter reflexes below injury level
Neurogenic Shock
-Bradycardia, Low BP, Irregular temperature, Poikilothermia
You walk into a patient’s room and greet them, they turn facing you and say ‘hello’ and smile as they look at you. How many cranial nerves have you just assessed?
7 CN: II optic [vision]; CN III oculomotor, CN IV trochlear, CN VI abducens [eye movement]; CN VII facial [symetrical smile]; CN VIII vestibulocochlear [hearing]; CN XI Accessory [Head turns]
The nurse is caring for a client admitted to the ICU following a traumatic brain injury (TBI). The client's intracranial pressure (ICP) has been trending greater than 20mmHg over the last four hours, and mannitol (Osmitrol) 20% IV is being administered. Which findings should the nurse expect following the administration of mannitol? SATA
A. Increased serum osmolality
B. Decreased Glasgow Coma Scale
C. Increased mean arterial pressure (MAP)
D. Decreased cerebral perfusion pressure (CPP)
E. Increased Urine Output
A, D, E
-Increased serum osmolality
-Decreased CPP
-Increased Urine Output
A client with C8 spinal injury is monitored for signs of neurogenic shock. What should the nurse expect to assess?
A. HR 48, BP 70/45, warm extremities
B. HR 120, BP 70/45, cold and clammy
C. HR 48, BP 165/95, warm and flushed skin with diaphoresis
D. HR 120, BP 70/45, and distended neck veins
A is the correct answer: HR 48, BP 70/45, and warm extremities
Distributive type of shock with massive vasodilation and bradycardia.
B=Hypovolemic shock
B. HR 120, BP 70/45, cold and clammy
C=Autonomic Dysreflexia
HR 48, BP 165/95, warm and flushed skin with diaphoresis
D=Cardiogenic shock
HR 120, BP 70/45, and distended neck veins