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  1. Goals of the Neuro Nursing Assessment
    Gather data about functioning of the NS in an unbiased orderly manner and clearly record it

    Follow data over time, look for trends

    Analyze the data to develop a list of potential or actual dx

    Determine effects of dysfunction on daily living and ability to perform self-care
  2. Tests to evaluate LOC and arousal, orientation to environment and thought content
    Mental Status Assessment
  3. Most critical parameter of pts Mental Status assessment, evaluating function of the cerebral hemisphere
    LOC
  4. LOC evaluates the function of the ____ hemisphere in the brain
    Cerebral
  5. Categorized according to pts arousal to external stimuli
    Responsiveness
  6. Levels of Arousal
    • Awake
    • Lethargic
    • Obtunded
    • Stuporous
    • Semi-Comatose
    • Comatose
  7. Level of Arousal: pt may sleep more than usual or be confused when first awakening
    Awake
  8. Level of Arousal: Pt is drowsy but follows simple commands when stimulated
    Lethargic
  9. Level of Arousal: pt is arousable with stimuli... responds verbally with just one or two words. Follows simple commands but otherwise drowsy
    Obtunded
  10. Level of Arousal: pt is very hard to arouse, inconsistently may follow commands or speak a single word with much stimulation
    Stuporous
  11. Level of Arousal: pt movements are purposeful when stimulated; doesn't follow commands or speak coherently
    Semi-comatose
  12. Level of Arousal: pt may respond with reflexive posturing but limited spontaneous movement
    Comatose
  13. Ways to assess orientation to environment
    • What is your name?
    • Where are you now?
    • What month, year, date, time?

    *An increase in wrong answers indicates increasing confusion and possible deterioration

    *Increase in correct response indicates improvement
  14. Maximum score of an assessment of cognitive ability
    30
  15. A score of _____ on assessment of cognitive ability indicates neuro impairment
    20 or lower
  16. Image Upload 1
  17. An assessment of Motor Function includes:
    Tests of strength and coordination

    What elicits motor responses (words/pain)

    Evaluate ability to follow commands

    Ask pt to move extremity against gravity

    "noxious stimuli" = eliciting pain by pinching tranpezius muscle, pressure on supraorbital ridge, sternal rub, compressing nailbeds

    Localization and Withdrawal
  18. Eliciting pain by pinching trapezius muscle, pressure on supraorbital ridge, sternal rub, or compressing nailbeds
    Noxious stimuli
  19. Pt tries to remove stimulus in an organized way (part of motor assessment)
    Localization
  20. Pt tries to pull away from the noxious stimuli (part of motor assessment)
    Withdrawal
  21. Extension, adduction, and hyperpronation of upper extremities...extension of lower extremities with plantar flexion of the feet (may clench teeth)
    Decerebrate Rigidity
  22. Decerebrate Rigidity denotes:
    midbrain or pons injury
  23. Flexion of the arms, wrists, fingers....adduction of upper extremitites and extension of legs
    Decorticate Rigidity
  24. Decorticate Rigidity indicates:
    Cerebral hemisphere injury
  25. Way to assess strength and coordination by asking pt to lift legs one at a time straight off bed against resistance
    • "Pronator drift"
    • (weakness indicates damage to motor neuron pathways)
  26. Ways to assess motor strength and coordination
    • "Pronator Drift"
    • Hemiparesis (weakness)
    • Hemiplegia (paralysis)
  27. The _____ is responsible for smooth synchronization, balance, and ordering of movement
    Cerebellum
  28. "Paresis"
    Weakness
  29. "Plegia"
    Paralysis
  30. Assessment of v/s in neuro pt
    Temp, HR, BP are late findings 

    Respiratory may be seen early

    CNS fevers can be very high and resistant to antipyretic therapy

    Hypotension must be avoided in post-injury bc it leads to decreased cerebral perfusion
  31. CNS fevers can be very:
    High and Resistant to antipyretic therapy
  32. ____ must be avoided in a post-injury neuro patient
    • Hypotension
    • (because it decreases cerebral perfusion)
  33. Assessment of Bad Respirations in neuro pt
    Shallow, rapid respirations indicate problem with maintenance of airway/need for suctioning

    Snoring/Stridor

    Cheyne-Stokes Respirations

    Hypoventilation
  34. If your neuro pt is breathing shallow and rapidly, it may indicate a need to:
    suction (problem with resp maintenance)
  35. Snoring/Stridor can indicate _____
    Obstructed Airway
  36. Breathing: Crescendo-decrescendo alternating with periods of apnea
    Cheyne-Stokes Respirations
  37. ____ must be avoided to prevent respiratory acidosis
    Hypoventilation
  38. Group of assessments needed in neuro patient:
    Pupil changes (size/shape)

    Cranial nerve function

    Sensation (perception of being touched)

    Proprioception (which way am i moving your finger)

    Stereognosis (ability to recognize objects by touch)

    Graphestesia (ability to recognize numbers or letters traced lightly on skin)
  39. Perception of being touched
    Sensation
  40. "which way am I moving your finger"
    Proprioception
  41. Ability to recognize objects by touch
    Stereognosis
  42. Ability to recognize numbers or letters traced lightly on skin
    Graphestesia
  43. S/S of increased intercranial pressure
    (manifested by deterioration in all aspects of neuro functioning)

    Decrease in LOC (may begin with restlessness, confusion, combativeness)

    Pupil reactions diminish (pupil ipsilateral to injury will dilate first)

    Motor function declines

    Changes in V/S are late
  44. As a decrease in LOC occurs, you may start to see:
    • Restlessness
    • Confusion
    • Combativeness

    (will decompensate quickly)
  45. Pupil reactions to increased ICP
    The pupil ipsilateral to the injury will dilate first
  46. Cluster of changes that indicate very high ICP and impending herniation
    Cushing's Triad

    (Increased SBP, Bradycardia, Decreased Resp)
  47. Cushing's triad includes what changes: (indicating high ICP and impending herniation)
    Increased SBP (widening pulse pressure)

    Bradycardia (into 30s)

    Decreased, Irregular respirations
  48. Dx study done to measure density of tissues, blood and bone...used quickly in trauma settings for seizure, h/a, LOC, and strokes
    Computer Tomography (CT)
  49. _____ appears less dense in a CT and therefore is lighter in color than normal tissue
    Cerebral Edema
  50. CT dx and shows:
    • Seizures
    • H/A
    • LOC
    • Suspected Strokes
    • Skull Fractures
    • Tissue Swelling (edema)
    • Hematomas 
    • Tumors
  51. Pt education regarding CT scan
    • Lie Still
    • *Claustrophobia
  52. Dx test that provides more detailed images (like anatomy) but does not show bony anomalies
    MRI
  53. An MRI can interfere with:
    Pacemakers, Surgical Clips/Prosthetic Implants, Ventilators
  54. It a pts prosthetic implant is made of _____ it can't be scanned
    Ferrous materials
  55. Gold standard dx test for evaluating vascular problems in neuro patients...can reveal aneurysms and AV malformations
    Cerebral Angiography
  56. Process of Cerebral Angiography
    Riodgraphic cath is passed through femoral artery to each of the arterial vessels bringing blood to brain and spinal cord

    Radiopaque contrast is injected and rapid images are taken
  57. Dx test that can determine cerebral vasospasms and brain death (no blood flow) by using radioisotope IV and scanning the brain
    Cerebral Blood Flow Studies
  58. Most serious Head Injury
    Closed Head Injury with traumatic brain injury
  59. Most common causes of head injuries
    MVC and Falls
  60. Head injuries have high potential for _____
    poor outcomes
  61. A ____ on arrival after head injury is a strong predictor of survival
    GCS (glasgow coma score)
  62. A GCS score of ____ indicates only a 30-70% chance of survival
    Below 8
  63. Skull Fracture when the base of the skull is injured
    Basilar Skull Fracture
  64. ____ and ____ may be seen, indicative of a tear in the dura with leakage of CSF
    Battle's Sign and Racoon Eyes
  65. Post auricular ecchymosis
    Battle's Sign
  66. Periorbital Ecchymosis
    Racoon Eyes
  67. CSF leaking from nose
    Rhinorrhea
  68. CSF leaking from the ear
    Otorrhea
  69. What two things confirm a torn dura?
    Rhinorrhea and Otorrhea
  70. The pt with a torn dura is a great risk for ____
    Meningitis
  71. A glucose test strip will be ____ if the fluid is CSF
    Positive
  72. If pt presents with bloody drainage from nose or ear, perform:
    Halo Test
  73. Letting bloody drainage drip on a 4x4...Blood will coalesce in the center and a yellow-ish ring encircles the blood
    Halo Test (CSF testing)
  74. A diffuse injury to the head, pt may or may not lose consciousness...oten brief disruption of LOC and amnesia...H/A and lethargy
    Concussion
  75. H/A and Lethargy can persist _____ after concussion
    up to 2 months
  76. Brusing of the brain tissue within a focal area...may contain an area of hemorrhage, infarction, necrosis, and edema
    Cerebral contusion
  77. Brain moves inside skull due to high energy or high impact...2 sources of injury
    Coup-Contrecoup Injury

    • Croup= front
    • Contrecoup= back
  78. Bleeding between dura and inner surface of the brain
    Epidural hematoma
  79. An epidural hematoma is _____
    A Neuro Emergency!!!
  80. Epidural hematoma is usually from:
    linear fracture crossing a major artery in the dura, causing a tear
  81. Venous epidural bleeds develop ____ whereas arterial bleeds happen _____
    Slowly; Quickly
  82. Hemorrhage in epidural space ____ ICP
    Raises
  83. Classic sign of ____: Initial period of unconsciousnes at scene with brief lucid interval followed by decreased LOC
    Epidural Hematoma
  84. Bleeding between dura mater and arachnoid layer of meninges
    Subdural Hematoma
  85. Source of most subdural hematomas:
    Veins that drain from surface of the brain into the sagittal sinus
  86. Acute subdural hematomas develop with _____ hours of injury
    24-48 hours
  87. Acute subdural hematomas ____ LOC and cause h/a
    Decrease
  88. The ____ of a subdural hematoma determines the clinical presentation of the pt (drowsy, confused, unconscious)
    Size
  89. During subdural hematoma, the ipsilateral pupil ____ and becomes fixed if the ICP is significantly elevated
    Dilates
  90. Chronic Subdural hematomas can occur ____ after injury and are common in older adults because of brain atrophy...they have more space in the skull
    2-14 days
  91. Assess a drunk person very carefully for subdural hematomas because:
    Their sx could be from ETOH or it could be due to ICP and subdural hematoma injury
  92. Emergency Nursing Care for Head Injuries
    Assure pt airway

    Assume cervical spine injury always 

    Immediate CT

    Oxygen via non-rebreather or intubation

    IV access with 2 large bore cath

    Employ all measures to reduce ICP (elevate HOB 30)

    Control external bleeding with pressure dressing but NO firm pressure until skull fracture is ruled out

    NO NG TUBE AND NO NT SUCTION (in case dura is torn or sinuses are fractured)

    Explain need for frequent V/S and neuro checks

    V/S every few min, oxygen sats, monitor, GCS, pupil assessment

    Treat N&V

    Determine CSF leak (place loose pad under nose/ear)

    Be calm, gentle, firm if pt is combative

    Protect self

    Prepare for surgery (craniotomy)
  93. What must you never do to a pt that comes in ER with head injury
    NG tube or NT suctioning!
  94. Nursing dx for head injuries:
    Risk for ineffective cerebral tissue perfusion r/t interruption of cerebral blood flow

    Hyperthermia r/t increased metabolism, infection, loss of cerebral integrative function due to hypothalamic injury

    Acute pain
  95. Nursing goals for head injury
    Maintain adequate cerebral oxygenation

    Remain normothermic

    Acheive pain control

    Be free of infection

    Attain maximal cognitive, motor, sensory function
  96. Health Promotion to prevent head injuries
    Seat Belts (backseat too!)

    Child Safety seats

    Helmets for motocycles and bikes

    Protective headwear for lumberjacks, construction workers, miners, horseback riders, and snowboarders

    Talk to groups of teenagers
  97. Normal ICP
    5-15mmHg
  98. Increased ICP is life threatening and results from:
    an increase in any of the three components within the skull (brain, blood, CSF)
  99. Increased ICP will _____ cerebral perfusion pressure and can cause brain ischemia or infarction
    DECREASE
  100. Distorts brain tissue, further increasing ICP
    Edema
  101. Goal of ICP
    To maintain cerebral blood flow

    (sustained increases in ICP result in brain stem compression and herniation of the brain from the skull into the spinal canal...FATAL!!!)
  102. Clinical Manifestations of Increased ICP:
    Change in LOC

    Change in vital signs (cushing's triad)

    Cranial Nerve III compression (ipsilateral pupil change)

    Decreased motor function (contralateral to injury)

    Headache

    Vomiting
  103. Gold Standard for monitoring ICP
    Ventriculostomy
  104. Process of ventriculostomy (to monitor ICP)
    Catheter is placed in lateral ventricle and attached to an external transducer

    Measures pressure inside ventricle and facilitates removal of CSF if the ICP gets too high (normally 20-30ml of CSF produced every hour)

    Transducer is leveled at the TRAGUS of the ear...must rezero transduced any time patient's position is changed

    Three-way stop cock opens to allow CSF to drain once pressure reaches a certain level

    ICP should not exceed 15 mmHG
  105. Normally _____ml of CSF is made every hour
    20-30ml
  106. ICP should not exceed ____
    15 mmHg
  107. Cerebral Perfusion Pressure Calculation can only be done if the patient has an ____ monitor
    ICP
  108. Formula for Cerebral Perfusion Pressure Calc (CPP)
    CPP = MAP - ICP
  109. Normal CPP (cerebral perfusion pressure)
    60-100
  110. A CPP less than ____ is associated with ischemia and tissue death
    50
  111. A CPP of less than ____ is incompatible with life
    30
  112. Formula for MAP
    (SBP - DBP) / (3+ DBP)
  113. A _____ Oxygen Cath is placed in healthy, viable white matter of the brain to monitor brain oxygen levels
    LICOX brain tissue oxygen cath
  114. Normal brain oxygen level (PbtO2)
    20-40
  115. A brain ox level less than ____ indicates ischemia
    20
  116. The LICOX brain tissue oxygen cath also measures ____
    Brain Temp (cooler brain temps produce healthier outcomes)
  117. ICP Management
    Maintain adequate cerebral perfusion (keep BP up!!!)

    Maintain oxygen (keep pO2 = 100, pCO2 = 30-35)

    Mannitol (Osmitrol)

    Barbiturates (pentobarb)

    Nutrition within 3 days

    Elevate HOB 30 degrees but be sure there is no neck flexion

    Suction only if necessary, then only 2 passes with hyperoxygenation between the suctioning

    Quickly treat pain and anxiety

    Keep room dark and quiet (noise increases rate of metabolism and raises ICP)

    Monitor combinations of sedatives, paralytics, analgesics

    I&O, Electrolytes

    Turn slowly and gently

    Avoid hip flexion (increases intraabdominal pressure which increases ICP)

    Protect from self-injury

    Pad side rails

    Talk, touch even if in coma
  118. In a pt with ICP, keep O2 at ____
    100
  119. In a pt with ICP, keep CO2 at
    30-35
  120. Medications used for ICP management
    Mannitol (osmitrol)-- expands blood volume, dilutes hematocrit and blood 

    Barbiturates (pentobarb) -- reduces cerebral metabolism causing decrease in ICP and reduction in cerebral edema "Drug Induced Coma"

    Propofol (Diprivan) -- often used due to short half-life

    Norcuron (paralytic) -- allows complete respiratory control
  121. Occurs when there is ischemia to part of the brain OR hemorrhage into the brain
    Stroke
  122. Strokes result in the _____ of brain cells
    Death
  123. About ____% of people with strokes are younger than 65
    25
  124. 3rd leading cause of death behind heart disease and cancer
    Stroke
  125. Partial or complete occlusion of an artery...accounts for 80% of strokes
    Ischemic Strokes
  126. Strokes result from a build up of plaque in ___
    cerebral blood vessels
  127. Bleeding within the brain caused by rupture of a vessel
    Hemorrhagic Stroke (intracerebral hemorrhage)
  128. People with hemorrhagic strokes (intracerebral hemorrhages) have a ____ prognosis
    poor

    50% of people died in first 48 hours
  129. Most important cause of intracerebral hemorrhage
    Hypertension
  130. Hemorrhagic strokes can occur from other causes other than high BP such as:
    • Vascular Malformations (congenital)
    • Coagulation disorders
    • Anti-coagulation disorders
    • Thrombolytic therapy
    • Trauma
    • Ruptured Cerebral Aneurysm
  131. Hemorrhagic Strokes commonly occur during
    Activity

    (sudden onset of sx with rapid progression over minutes)
  132. S/S of Hemorrhagic Stroke:
    "Worst H/A I've ever had"

    N/V

    Decreased LOC

    Weakness

    Deviation of Eyes

    Dilated Pupils

    Posturing
  133. Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes
    Subarachnoid Hemorrhage
  134. Subarachnoid Hemorrhages are usually caused by
    Rupture of Aneurysm
  135. ___% of people with subarachnoid hemorrages die immediately with no warning
    40%
  136. Subarrachnoid Hemorrhages affect the
    Contralateral Side of the body....

    (can happen at any age...cocaine causes sharp increase in BP)

    Can cause bleeding into the ventricles...Hydrocephalus
  137. Dx of Cerebral Bleeding:
    Non-Contrast CT done STAT for any sign of stroke

    tPA (Streotokinase) for ischemic stroke

    MRI will later show the extent of brain injury

    Angiogram shows malformations of vessels and can show the exact site of the subarachnoid hemorrhage

    Lumbar puncture shows blood in CSF
  138. Nursing Care for patients with cerebral bleeding
    Anticoagulants of any kind CONTRAINDICATED

    Manage HTN

    Seizure precautions

    Prepare for immediate surgery if there is aneurysm

    Manage elevated ICP

    Calcium Channel Blocker (Nimodipine - decreases vasospasm of cerebral arteries...restricts influx of calcium ions into cells by reducing the number of open calcium channels...Hold if HR < 60 or BP <90 )
  139. Most common surgical repair of aneurysm
    Coiling

    (insert metal coil into lumen of aneurysm via interventional neuroradiology...Coils prevent blood pulsation within the aneurysm and eventually a thrombus forms within the aneurysm and it becomes sealed off)
  140. Ways to surgically repair aneurysm
    Clipping

    Coiling
  141. "This is the Worst headache I've ever had!"
    Red Flag for aneurysm!!!!
  142. Person at greatest risk for Spinal Cord Injury
    Young Adult Men (16-30)
  143. Causes of SCI (Spinal Cord Injury)
    • MVC- 42%
    • Falls- 27%
    • Violence- 15%
    • Sports (diving into water too shallow)- 7%
  144. Most common cord compression cause:
    Bone Displacement
  145. Mechanisms of Spinal Cord Injury
    Felxion/Hyperextension

    Flexion-Rotation

    Extension-Rotation

    Compression (landing on feet or top of their head very hard)
  146. Edema occurs after SCI about ___ hrs after initial injury
    24 hours
  147. Why is edema after SCI so harmful?
    Lack of space for tissue expansion...more cord compression results
  148. The extent of a SCI and prognosis cannot be determined for at least _____
    72 hours
  149. Corticosteroids cause more harm to pts than good by:
    Messing up glucose levels in pts
  150. Neurogenic Shock is characterized by:
    Loss of vasomotor tone (below injury) caused by the injury

    Hypotension 

    Bradycardia (not tachycardia because that would be hypovelmic shock)

    Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling and decreased cardiac output

    Warm, dry skin below the level of injury (cold/clammy above the injury)
  151. Loss of sympathetic nervous system innervation causes:
    peripheral vasodilation, venous pooling and decreased cardiac output
  152. Neurogenic Shock most often occurs with ___ or ___
    Cervical or High Throacic Injury (T-6 or higher)
  153. What is the best way to treat neurogenic shock
    Hydrate the patient!!! Do not give dopamine or levafed because they are uneffective below the injury!
  154. 3 levels of SCI
    Cervical

    Thoracic

    Lumbar
  155. Most common levels of SCI (becasue levels of spine have greatest flexibility and movement)
    Cervical and Lumbar
  156. ____ spine injury will cause paralysis of all 4 extremities (tetraplegia)
    Cervical Spine injury

    (if low cervical injury, pt may be able to move arms slightly)
  157. Thoracic or Lumbar injuries cause ____
    Paraplegia (loss of sensation and paralysis of the legs)
  158. Degrees of SCI
    • Complete
    • Incomplete
    • Brown-Sequard Syndrome
  159. Degree of SCI where cord involvement results in total loss of sensory and motor function below the level of injury
    Complete
  160. Degree of SCI where cord involvement results in a mixed loss of voluntary motor activity and sensation (some tracts are intact)
    Incomplete
  161. Degree of SCI where damage is to 1/2 of the cord...(anterior to posterior)... Loss of motor function and vasomotor paralysis on the ipsilateral side...Contralateral side has loss of pain and temp sensation ... most common with penetrating trauma
    Brown-Sequard Syndrome
  162. S/S of Brown-Sequard Syndrome
    Loss of motor function and vasomotor paralysis on the ipsilateral side

    Loss of pain and temperature sensation on the contralateral side
  163. Degree of respiratory care in a SCI pt corresponds:
    To Level of Injury
  164. C-4 of SCI causes ___ loss of respiratory muscle function
    TOTAL

    (mechanical ventilation required!!!)
  165. Lower cervical and thoracic injuries paralyze ___ muscles, leading to poor cough, atelectasis and pneumonia
    Abdominal and Intercostal
  166. ___ is always first priority in SCI patient!!!
    AIRWAY!
  167. It patient comes in with helmet on after injury:
    Leave it on UNLESS there is a total loss of airway that you cannot manage without it being removed!
  168. Cardio Care: an injury above the T-6 influences the ____ regulation
    SNS..sympathetic nervous system
  169. Cardio care of SCI pt:
    Bradycardia and Peripheral Vasodilation

    Cardiac monitoring

    Atropine (new spinal cord injuries) to increase heart rate if symptomatic; stimulates the actual pacemaker of the heart

    IV fluids

    Vasopressors (Dopamine) to support BP...won't help very much (ineffective to area beaneath SCI)
  170. Urinary care for SCI pts
    Neurogenic bladder and Urinary Retention are common

    Foley-- indwelling and intermittent (people will not know their bladder is full)

    Strict I&O
  171. GI system care for SCI patients
    (hypomotility, paralytic ileus, and gastric distention of the GI)

    NG placed early to relieve distention

    Reglan -- GI emptying

    Prevent stress ulcers (H2 Blockers, PPIs)

    "ABCs" first,....then "D, E" = Disability, expose... if the anal sphincter doesn't respond it is positive proof that there is paralysis and SCI 

    Bowel Program- high fiber diet, adequate fluids, dulcolax suppository followed by digital rectal stimulation to cause bowel elimination

    Stool Softeners every day
  172. Bowel Program:
    High Fiber

    Adequate Fluids

    Dulcolax suppository followed by digital rectal stimulation to cause bowel elimination
  173. Skin care for SCI pts
    Prevent skin breakdown with frequent position change (LOGROLL!)

    Weight gain or loss can contribute to breakdown

    Visual and tactile exam of skin every 12 hours
  174. Ability to maintain normal body temperature
    Poikilothermism
  175. Why do pts with SCI have problems with thermoregulation
    Interruption of the sympathetic nervous system prevents peripheral temperature...

    Inability to shiver or sweat below the level of injury

    Maintain heat/cool with warming or cooling blankets, appropriate clothing
  176. Leading cause of death after initial SCI
    Pulmonary Embolus
  177. Common complication within the first 3 months in SCI patients (but they will have no pain or tenderness in their legs!!!)
    Deep Venous Thrombosis
  178. DVT prevention for SCI pts
    • Lovenox
    • Sequential compression devices
    • Position changes
    • ROM
  179. We must know the level and completeness of the injury is needed to understand male patient's potential for _____
    orgasm, erection, and fertility
  180. Women with SCI remain fertile and have ____ pregnancies
    Successful
  181. What standard protocol for SCI pts has been recently called into question
    High Dose Steroids
  182. Originally, High Dose Steroids in SCI pts were thought to:
    Decrease edema in the cord and improve function
  183. Autonomic Dysreflexia occurs in pts with ___ SCIs
    T-6 or higher
  184. Massive uncompensated CV reaction mediated by the sympathetic nervous system
    Autonomic Dysreflexia
  185. Autonomic Dysreflexia occurs in response to _________
    Visceral Stimulation
  186. Receptors ____ the level of injury are still stimulated with Autonomic Dysreflexia
    Below
  187. Autonomic Dysreflexia: Baro-receptors in the carotid  sinus and aorta sense hypertension and stimulate the PNS to ____
    decrease HR
  188. Autonomic Dysreflexia BP/HR
    • critically high BP
    • critically low HR
  189. Sx of autonomic dysreflexia
    • BP >300
    • Throbbing h/a
    • Marked diaphoresis ABOVE level of lesion
    • Bradycardia (30-40)
    • Piloerection (body hair)
    • Flushed skin above the level of injury
    • Blurred vision, nasal congestion, anxiety, nausea

    ***can lead to status epilepticus, stroke, MI, death

    Most common precipitating cause is a distended bladder or rectum
  190. Nursing Care for autonomic dysreflexia
    Always measure BP immediately if pt has a h/a

    Elevate HOB 45 or sit pt up

    Notify MD

    Search for cause (bladder? rectum?)

    Insert cath (check for kinks or plugs) or do rectal stimulation with lidocaine jelly 

    Remove skin stimuli (constricted clothing or tight shoes)

    Vasodilators to lower BP
  191. Ways SCI pts may experience grief/depression
    Overwhelming loss

    Loss of control over everyday life activities and must depend on others for daily care

    May believe they are useless and burdens to their families

    Life-long process of grief

    Families will need grief care

    Support groups!!!
  192. Irreversible end of all brain activity including the brainstem...due to necrosis of cerebral neurons following loss of oxygenation
    • Brain Death
    • (legal dx and legal term for pt whos hearts continue to beat and are maintained on mechanical ventilation in the ICU...occurs when the cerebral cortex stops functioning or is irreversibly destroyed)
  193. "Brain Death" criteria:
    Coma and unresponsiveness

    Absence of brainstem reflexes

    Apnea

    NO response to anything including deep pain, cranial nerves, response to carbon dioxide levels

    Dx made by physician

    Cerebral perfusion studies and flat EEG may help families come to terms with brain death but not required
Author
NurseFaith
ID
288237
Card Set
Neuro
Description
Neuro
Updated
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