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Alert
awake and responsive
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Lethargic
drowsy or sleepy but easily awakened
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Stuporous
arousable only with vigorous or painful stimulation
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Babinskis sign
Dorsiflexion of the great toe and fanning of the other toes is positive Babinskis-neuro problems
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Positive Brudinskis
if lift head then knees go up; meningitis
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Positive Kernigs
when knee gets brought up, pain in back occurs-meningitis
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The leading cause of death from head trauma in patients who reach the hospital alive
Increased ICP
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As ICP increases, what happens
cerebral perfusion decreases leading to tissue hypoxia, a decrease in serum pH level and increase in CO; these cause cerebral vasodilation, edema and increased ICP
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Barbituate coma
pentobarbital sodium or thiopentone is drug; decrease the metabolic demands of the brain and cerebral blood flow, stabilize cell membranes, decrease the formation of vasogenic edema and produce more uniform blood supply
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Complications of barbiturate coma
decreased GI motility, cardiac dysrhythmias and fluctuations in temp
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What med is given for ICP
Mannitol (bolus) and Lasix to prevent rebound from mannitol; need to draw it up with filter needle because it can crystallize
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ICP increases
cerebral perfusion decreases
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How to calculate CPP
MAP-ICP
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S/S of ICP
early: restlessness and irritability; late-decorticate/decerb; cushings triad, severe HA, N/V, seizures, papilledema
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Cushings triad
increased systolic (widening pulse pressure), decreased HR, decreased RR
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MGMT of ICP
meds, neuro check, monitor for fever (cooling blankets to protect hypothalamus), hyperventilate before suctioning if on vent
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Intraventricular catheter
allows accurate measurement of ICP
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Complications with IVC
invasive, infection, CSF leakage around insertion site
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Cerebral angiography
show circulation to detect blockages in the arteries or veins in the brain, head or neck; NPO 4-6 before, do not move; post op check for bleeding and swelling, keep extremity straight and immobilized, maintain pressure for 2 hours
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PET
provides function of the brain, 2-3 hour procedure, may be blindfolded or have earplugs
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Transcranial Doppler
uses sound waves to measure blood flow through the arteries; evaluates vasospasm or narrowing of the arteries; safe and can be used repeatedly for the same pt and inexpensive related to angiography.
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EEG
electrical activity of cerebral hemispheres; must be sleep deprived (wave up at like 2 or 3 a.m.) before procedure and anticonvulsants may be withheld
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EMG
electromyography that identifies nerve and muscle disorders as well as spinal cord disease
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CSF norms
pressure of 20 or less, clear, 0-5 lymphocytes, 15-45 protein, 3-12% of protein, 50-75 glucose, 10-15 lactic acid, 6-15 glutamine, 10% of serum lactate dehydrogenase
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Because of the danger of sudden release of CSF pressure
a LP is not done for patients with symptoms of severely increased ICP
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Position of pt for LP
fetal side-lying to separate vertebrae and move spinal nerve roots away from area to be accessed
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Opening and closing pressures
are taken and 3-5 test tubes of CSF are usually collected and numbered sequentially
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Complications of LP
brainstem herniation, infection, CSF leakage and hematoma, headache
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Nursing considerations for LP
may give sedation, assist with cleaning area, hold person still; apply light dressing or bandaid
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TIAs resolve
within 30-60 minutes
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Features of TIA
blurred vision, blindness, diplopia, tunnel vision, weakness, gait disturbance, numbness, vertigo, aphasia, dysarthria
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Modifiable risks for stroke
smoking, booze, drugs, obesity, sedentary lifestyle, oral contraceptive, PPA (in antihistamines)
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Embolic stroke
sudden development
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Aneurysm rupture causes
bleeding into subarachnoid space, the ventricles and intracerebral tissue; vasospasm results; blood flow to distal parts of brain is markedly diminished
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AVM
tangled malformation of veins and arteries during embryonic development; no capillary network; vessels rupture; thin veins cant handle pressures arteries can
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Left sided stroke
right sided weakness, aphasia, alexia, dyslexia, agraphia, acaculia
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Right sided stroke
left sided weakness, spatial perceptual deficits; unilateral neglect
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Post-op endarterectomy
2 nite stay, monitor VS, neuro, peripheral pulses, incisional bleeding, cerebraral hyperperfusion
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To assess function of frontal lobe
give math problem
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Patients with embolic strokes
may have afib
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Stroke is AKA
brain attack
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Which is more serious? Open or closed head injuries?
Closed
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Open head injury
when the skull is fractured or when it is pierced by a penetrating object; integrity of the brain and dura are violated, exposure to environmental contaminants
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Closed head injury
blunt trauma
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Linear fracture
simple, clean break, most common
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Depressed fracture
bone is pressed inward into the brain tissue to at least the thickness of the skull
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Two distinct features of basilar skull fracture
raccoon eyes and battle signs behind ears
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Patient with penetrating injury
at high risk for infection
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Acceleration injury
external force contacting the head
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Deceleration injury
occurs when moving head is suddenly stopped or hits a stationary object
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Epidural hematoma
arterial bleed, have lucid intervals
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Subdural hematoma
venous bleeding
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Subarachnoid hematoma
aneurysm (worst headache ever)
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CSF halo sign
yellowish stain surrounded by bloody drainage
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Contusion
bruising of brain tissue at site of impact (coup) or opposite (contracoup)
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Concussion
shaky movement of the brain and may be mild or more severe
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Mgmt/treatment of head injuries
c-spine precautions, ABCs, VS, LOC, fluids and electrolytes, nutrition, meds, be ready for surgical intervention
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What causes subarachnoid hemorrhage?
AVM or aneurysm
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Migraine
chronic, episodic disorder with multiple subtypes; intense pain on one side of the head and occurs with photo or phonophobia
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Topamax
common antiepileptic drug used for migraines (low doses)
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Migraine triggers
caffeine, red wine, stress, MSG
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Cluster headaches
30 minutes to 2 hours, intense unilateral pain in spring or fall
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Treatment for cluster headaches
percutaneous stereotactic rhizotomy and deep brain stimulation
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Ct may be needed
for pt with headaches over 50 years old
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Primary brain tumor
originates within CNS and rarely metastasize
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Secondary brain tumor
results from metastisis from other areas of body
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Supratentorial tumors
located within cerebral hemisphere
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Infratentorial tumors
area of brainstem structures and cerebellum
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Transphenodial surgery
to remove pituitary tumors (go through nose)
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Crainotomy preop care
check that pt has not had alcohol, tobacco, anticoagulants or NSAIDS for at least 5 days pre surgery; NPO for at least 8
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Symptoms of a brain tumor
early morning headaches, N/V, visual symptoms, seizures, changes in mentation or personality, papilledema
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Decadron
control cerebral edema; check BS with glucocorticoids
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Periorbital edema and ecchymosis
are not ususual and cold compresses are used
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Supranatorial surgery
bed at 30 degrees
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Infratentorial surgery
flat and on either side for 24-48 hours
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Complications of trigeminal neuralgia surgery
h/A, cranial nerve dysfunction and bleeding
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Acute maximum paralysis is
within 48 hours in half of patients and 5 days in almost all (bells palsy)
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Trigeminal neuralgia patients present
bursts of pain (excruciating, sharp, shooting, piercing); bouts of pain for weeks or months and then spontaneous remission
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Trigeminal intervention
balloon microcompression-compresses the trigeminal nerve root; surgical is crainiotomy with microvascular decompression (surgical relocation of artery which compresses the trigeminal nerve)
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