What is decorticate posturing? what is it caused by? What is decerebrate posturing? what is it caused by? Which is worse, why?
decorticate: arms flexed, legs straight; caused by hemorrhage, brain tumor, cerebral infarction (stroke), TBI
Decerebrate: extension of arms and legs; caused by hemorrhage, brain stem injury, stroke, TBI; indicates significant spinal or neuro trauma
Decerebrate is worse; deeper in the brain with less chance to recover
What is a lumbar puncture? What is the nurse's role? What are 3 nursing diagnoses? What is a treatment for LP spinal headache?
If the pt complains of tingling in legs/toes what does it indicate?
insertion of a spinal needle into the lumbar space (L3, 4, 5, 6) to withdraw spinal fluid for lab testing. Looking for bacterial, proteins, pressure reading or used to insert spinal anesthesia
Nurse: position pt in fetal position, lying on one side; instruct pt not to move during procedure, send collected tubes to lab-label with pt info; instruct pt to lay flat after LP to keep lumbar spine closed and to prevent spinal fluid leakage
Risk For: infection at site, hematoma, spinal leak wish leads to spinal headache;
Spinal Patch: draws blood from arm and put it into spine to promote a clot which leads to a leak plug
indicates that the anesthetist should pull back the needle (to far in)
What is a Migraine? Signs and symptoms? What 2 things can induce them?
Severe throbbing headache; usually unilateral
lasts 4-72 hours
Sometimes present upon awakening
can be stress induced
can be hormonally induced
What causes the severe pain of a migraine?
The skull is an enclosed box that contains what?
What is the normal intracranial pressure level?
0-15 mmHg (any higher and it can lead to herniation out the foramen magnum
What are the priority problems for patients with spinal cord injury?
1: difficulty breathing related to upper motor neuron injury
2: potential for neurogenic shock (face is red, lift the head, face is pale lift the tail) ( hypotension and bradycardia, poikilothermia) R/T loss or interruption of sympathetic innervation patients with SCIs above T6
3: Potential for further spinal cord injury R/T swelling and or fractures
4: impaired physical mobility and or self care R/T to decreased muscle control
5: Spastic or flaccid bladder and bowel R/T direct neurologic damage or disruption in nerve impulses
6: impaired adjustments R/T disability requiring need for life change
What are halo fixation devices?
It is 4 screws inserted into the skull using sedation or gen anes.
Check jacket for pressure points
Halo keeps cervical spin still
Pin care- antibiotics, check for lose pins
What is autonomic dysreflexia? S&S? Causes? Treatment?
S/E: dizziness; ortho hypotension(Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position) ;
What is a stroke? the different types? causes? S&s?
Episode that causes the brain to not receive oxygen
Ischemic: occlusive; thrombus or embolism
PE: sudden onset, large clot, complication of a DVT
FES: fat embolism, gradual onset, multiple small fat droplets, complication of surgical intervention to long bones and multiple fractures