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Scott Gardner N211 Q4F05 Unit 4


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What is a Craniotomy?
An incision through the cranium.
What is a Ventriculostomy.
Plastic surgery to establish communication between the floor of the third ventricle of the brain and the cisterna interpeduncularis.
What are the preoperative interventions for craniotomy?
Ventriculostomy, Assess neurological status, remove hair at the surgical site.
What are intraoperative craniotomy interventions?
What are some potitions that a craniotomy can take place in?
Sitting up in surgical chair, head down, depends on where problem is.
What kind of problems can the supporting head frames cause with a craniotomy?
Skin pressure on the head, edmea on the face, muscle soreness, especially in the neck.
What happens to the eyes after craniotomy?
Ecchymosis and periorbital edema may be present, but is temporary.
Describe coughing /p a craniotomy.
Coughing should not be encouraged simply for coughing sake such as in TCDB, but if the client needs to cough to clear the airway they should do so.
Is ICP a problem after craniotomy?
Yes, and stroke or trauma are a concern. Notify the neurosurgeon of any changes in the assessment.
Name six complications of craniotomy.
Increased ICP * Motor Sensory Deficits * Seizures * CSF Leak * Wound Infection * CNS Infection
What is an example of a CNS Infection?
Where might you see a CSF leak?
From the wound or incision, but also from the nose or the ears.
What is a hypophysectomy?
Excision of the hypophysis cerebri.
What are two approaches of Transphenoidal Hypophysectomy?
Traditional and Endoscopic
Describe the traditional approach of Transphenoidal Hypophysecotmy.
Incision made behind the upper lip. Fat or muscle grafts might be implanted to help healing. Nasal packing may be used.
Describe the new endoscopic incision transphenoidal hypophysectomy.
The tumor tissue is removed with microsurgical instruments inside the nostril.
What are some interventions postoperaively for a tradional approach hypophysectomy craniotomy?
No Drinking straws. Provide frequent oral care. Use cool vaporizor to keep mucous membrains moist. Provide care to the donor site if tissue or muscle was used. Provide a Nasal drip pad or mustache dressing which should be assess for CSF and or Blood.
When might you see Diabetes insipidus?
After a craniotomy.
What is Diabetes insipidus?
Excessive urination caused either by inadequate amounts of antidiuretic hormone in the body (hypothalamic DI) or by failure of the kidney to respond to antidiuretic hormone (nephrogenic DI).
Is DI permenant after a craniotomy?
No, it is usually temporary.
How much urine might one see per day with a post craniotomy patient?
Between 2 and 15 liters of urine each day.
When a client has DI, what are the properties of the urine?
It has a very low specific gravity, very dilute (less than 1.005 SG).
What lab tests might need to be tested after a craniotomy?
Sodium and serum osmolality, due to DI complications.
What is hypertonic encephalopathy?
Generalized (i.e., not localized) brain dysfunction marked by varying degrees of impairment of speech, cognition, orientation, and arousal.
What are two medications that might be given for DI?
IV Vasopressin or Inhaled Desmopressin.
What is what is polydipsia?
Excessive Thirst.
How do vasopressin and desmopressin help DI?
They help replace the ADH.
What is an SAH?
Subarachnoid Hemorrhage
What is an AVM?
Atteriovenous Malformation
Name six causes of SAH.
Brain Trauma (Most)
Intracranial aneurysms
Blood Dyscrasias
Anticoag Therapy
What is a Blood Dyscrasia?
An old term meaning abnormal mixture of the four humors.
What is them most common type of aneurysm?
Saccualr or Berry Aneurysm.
Do men or women have more berry aneurysms?
What is the pathology of berry aneurysm?
Congenital, but weaken over time from HTN, Atherosclerosis, aging, and stress.
Where are aneurysms most common?
Anterior and middle cerebral areas, especially in circle of Willis, and at bifurcations.
What happens with vasospasm in an aneurysm?
It can cause additional bleeding, which might be worse than the original bleed, leading to death.
What are some premonitory Sx of an aneurysm?
Premonitory symptoms might be mild H/A, Fainting/Vertigo, and is often found during a H/A workup.
What might the client complaining of the most sudden, severe headach they have ever experienced be experiencing?
The onset of a bleed in an aneurysm.
What is nuchal rigidity?
Inflexibility of the neck movement, esp. forward flexion of the neck.
What is Kernig's Sign?
A sign of meningeal irritation evidenced by reflex contraction and pain in the hamstring muscles, when attempting to extend the leg after flexing the hip.
What is Brudzinski's Sign?
Flexion of the hips when the neck is flexed from a supine position.
Name three Dx methods for SAH, and which is the most definitive.
Transcranial Doppler.
Angiography is the most definitive.
What are some interventions or medications that might be given to treat vasospasm?
Increase Volume
Maintain pressue
Hemodilute (HCT Low)
Might use CCB Nimodinine
When is clipping performed?
Within 3 days if alert, later if not alert. If Vasospasm is still present might delay further.
What is an AVM, according to John?
Congenital lack of bapillaries causing a tangled array of veins and arteries to form. They can be small or large.
Where are AVM found?
Brain or spinal cord.
What age are AVM usually found?
Usually before 40.
A Surgical frame to support the head during surgery can cause what kind of skin problems?
What medication might be given for Dibeates insipidus?
What is the most common intervention used for aneurysms?
What is the main nursing intervention that should be focused upon in neurosurgery?
Increased Intracranial Pressure.
Is there a specific cause for epilepsy?
It can be Genetic, Acquired, or Idopathic.
What is the pathyphysiology of Epilepsy?
The impulses are not controlled.
What two elements are rapidly used up during an epilepsy seizure?
Oxygen and Glucose, which cause Hypoxemia and Lactic Acidosis.
Other than epilepsy, what are some other reasons for seizures?
Intracranial Tumor
Head Injury
ETOH or Barbituate ingestion/Withdrawl
What is a Pseudoseizure.
A psychiatric problem in which the patient does not exhibit the same activity each time.
What are four types of Seizures?
Partial /s Loss of Consiousness
Complex Partial which may incluse LOC
Status Elipepticus.
Name the four subtypes of partial seizure, without LOC.
What happens in a partial motor seizure?
Starts in upper arm with involuntary movement spreads to same side face and lower extremety. AKA Jacksonian March.
What is a Jacksonian March?
A localized form of epilepsy with spasms confined to one part or one group of muscles
What happens in a Partial Sensory Seizure?
Numbness or tingling in affeected area, bright or flashing lights and problems with aphasia.
What is aphasia?
Absence or impairment of the ability to communicate through speech, writing, or signs because of brain dysfunction.
If a client has numbness or tingling with a sensory partial seizure, where will that probably be originated from?
Parietal Lobe
If a client has bright or flashing lights with a sensory partial seizure, where will that probably be originated from?
Occipital Lobe.
If a client has aphasia with a sensory partial seizure, where will that probably be originated from?
Temporal lobe.
What is seen in an autonomic partial seizure?
GI Sensations, pallor, sweating, flushing, piloerection, pupil dilation, tachycardia, tachypena
What is seen in a Psychic Partial Seizure?
The client will usually have an Aura.
What is an Aura?
A localization of a seizure which can be a smell, noise, sensation, feeling of rising up or welling up in the epigastric area. Visual or deja vu.
Where do psychic seizures usually originate?
What is automatism?
Lip smacking, chewing, patting part of the body, picking at clothing while in a dreamlike state.
When is an automatism seen?
Partial complex seizure.
What is postictally?
After a seizure.
Is the client aware of the automatimic behaviour during a complex partial seizure?
No, they will be unaware during, and may be drowsy or confused after.
List four types of Genarlized Seizures.
Tonic Clonic
What is differentiates a Generalized Seizure from others?
The client will lose consiousness.
What is an Absense Seizure?
Usually seen in childhood. Brief LOC, may progress to tonic-clonic.
What is a myoclonic seizure?
Single or multiple muscle groups. Will cause client to fall.
What is an atonic seizure?
Loss of Muscle tone.
What was the former name of a Tonic Clonic seizure?
Tonic Clonic.
Do Tonic Clonic seizures have an aura before they begin?
They can have an aura.
What is the Tonic Phase of Seizure?
Stiffening of all muscles.
Cry out and Fall. Respirations cease. May become cyanotic, pupils become fixed and dialated. A deep sigh or breath signals the end of the tonic phase.
What is the Clonic Phase of a Seizure?
Rhythmic jerking. Contraction and relaxation of all body muscles. May beocome incontinent, biting the tongue and mouth.
How long does an entire Tonic Clonic Seizure last?
Two to Five Minutes.
Will a client be tired after a Tonic Clonic?
Yes, several minutes to several hours.
Will the client remember the Tonic Clonic Seizure?
No, will have amnesia.
What are some other after care issues for a Tonic Clonic Seizure?
Client may be stiff, nauseated, sore, with fatigure, depression, confusion, headache or other injuries from the fall or jerking.
What tests might be used for diagnosing Epilepisy?
Often EEG.
Occassionally, CT, MRI, PET, SPECT
Why would an EEG be used in the OR?
The client can not answer questions or participate in a Neuro Assessment, but the EEG will show what the brain is doing.
What is the preparation for an EEG?
Wash Hair
Not Stimulints, sedatives, antidepressants, or anticonfulsants for 1-2 days before test.
May want client sleep deprived before test.
Anxiety might interfere with results.
What are post care issues with EEG?
Resume normal diet, shampoo and acetone to remove gel from electrodes.
What is the EEG used for?
Finds the Focus and identifies the specific type of seizure.
What are nursing interventions during a seizure?
Put in side lying.
Provide Oxygen
Pad the head and arms to prevent injury.
Is suctioning used during a seizure?
Yes, but don't force in an airway.
When should help be called for with a seizure?
If lasts longer than ten minutes, or a second seizure rapidly follows, or if having respiratory trouble, or the client is pregnant.
What are some observations that need to be made about a seizure?
Length of time.
Where it started, what body part.
Eye or head deviation
Respirations labored or frothy
Loss of Consciousness.
What is another name for Phenytoin?
What is the brand name for Carbamazepine?
What is the brand name for valproic acid?
How does Anti-Seizure drugs work?
They block the initiation or spread of sizures.
What are the three first line anti-seizure drugs?
Valproic Acid
Name three second line anti-seizure drugs.
Valium, Phenobarbitol, Gabapentin.
What are some side effects of anti-seizure medications?
Fatigue, Weighloss, dizziness.
What are some General Adverse Affects of Anti-Seizure medications?
Allergies, extreme fatigue, staggering, slurring of speach.
Depression, Psychosis
What two metabolic issues must be watched when taking anti-seizure medications?
Serium levels of the drug, and liver functions.
How long should someone be seizure free before discontiuing medications?
Two Years.
Phenytoin is only compatible with which colloid?
NS Only.
What happens when Phenytoin is mixed with D5 and Water?
A precipitant forms.
What are the tube issues when giving Phenytoin?
A filter must be used, even with NS so that in case a precipitant forms, it will be filtereed out.
What is the fastest period that Phenytoion can be given?
No more than 50mg per minute, so a syringe pump should be used.
How can enteral feedings interfere with Phenytoin absorbtion?
Must be turned off two hours before and after administration.
What oral care is necessary when receiving phenytoin?
Can develop Gingival Hyperplasia (Swollen tender gums). Reduced with brusing bid/tid.
What is the target serum level for phenytoin?
What are the adverse effects of Tegratol?
Slowed Cardiac Conduction
Heart Failure
What are some adverse effects of Valproic Acid?
Increased Amonia Levels.
What do increased amonia levels cause?
Decreased Level of Consiousness
Hepatic dysfunction
Decreased platelets.
What is the Generic Name for Depakene?
Valproic Acid
What is the Generic name for Valproate?
Valproic Acid
What is the generic name for dilantin?
What is the generic name for Tegretol?
What is a getogenic diet?
High fat, low carb diet which mimics fasting, probably through ketosis.
Is a Ketagonic diet firstline intervention for seizures?
No, only after medications fail.
What surgical interventions are available for seizures?
Removal of corpus collosum, Temporal Lobe, or Parietal Lobe. Or the cortex of a hemisphere.
What is a vagal nerve stimulator?
Pacemaker like device implanted in neck and attached to vagus nerve. Causes interference with the seizure electircal activity.
How long does a driver have to be seizure free in Washington? Other states?
WA is 6 months. Others up to two years.
Why should ETOH be avoided when a client has seizures?
ETOH reduces the threshold and might allow seiure to begin. Seizure medications are metabolized by liver, and might cause problems.
What are some personal safety issues for those with seizure disorders?
Avoid dangerous things like smiming, horeback riding.
Other than ETOH, what can decrease the seizure threshold?
Poor diet, and sleeping habits.
What is Status Epilepticus?
A medical emergency consisting of seizure that lasts 30 minutes, or seizures that come in rapid succession.
What are firstline drugs for treatment of Satus Epilepticus?
IV Diazepam or Lorazepam q15m.
Might also use IV Phenytoin.
If seizure just will not stop, what intervention might be used?
Might induce a barbituate coma, or put client under general anesthesia.
What equipment should be ready when a client is in Status Epilepticus?
Ambu Bag, ET, Ventialtor. An NG should be ready for respiratory depression.
A seizure where there is a stiffening of all muscles followed by alternating flexion and extension is called what?
Tonic Clonic
A seizure which is localized to one part of the body is called what?
Partial Seizure.
What is the classification of a Tonic Clonic Seizure?
It is Generalized.
What are some stimulents that can interfere with an EEG?
Coffee, Tea, ETOH, Cola, Cigarettes.
What is the most common type of Stroke?
Ischimic which is about 83% of all storkes.
What are the two major types of strokes?
Ischemic and Hemorrhagic.
What causes an ischemic stroke?
When the blood supply to a part of the brain is interrupted or tatoally occluded.
What is the most common type of stroke in DM patients?
What is a Lacunar stroke?
A pathological change in the brain caused by diminished or lack of blood flow through one of the brain's small penetrating arteries.
What is one of the disease processes that is assoicated with a high incidence of embolic stroke?
Atrial Fibriliation.
When are most people affected by an Intracerrebral Hemorrhage?
After age 50.
What is the most important modifiable risk factor for both ischemia and hemorrhagic stroke?
Other than HTN what are some other modifiable risk factors for stroke?
Hyperlipidemia, smoking, heavy ETOH, cocaine, obesity.
When can cell death from cerebral ischemia happen?
Between 3-10 minutes.
What is the area in the center of the stroke called?
Primary neuronal injury.
What is the zone around the infarcted zone (Primary Neuroal Injury) called?
The Penumbra.
What are some general findings in stroke?
H/A, Vomiting, seizures, changes in mental status, fever and ECG changes with t waves. PVC, Sinus Brady, ventricular and superventricular techycardias.
What is a TIA?
A focal neurologic deficit lasting less than 24 hours.
What is hemiparesis?
Weakenss on one side of the body.
What is hemiplegia?
Paralysis on one side of the body.
If someone has an infarction on the left side of the brain, how will this affect paralysis?
The right side will be paralized.
When do trhombosis usually occur?
During sleep or within 1 hour of waking.
When do embolism occur?
Not related to time or activity.
When do brain hemorrhages usually occur?
During active, waking hours.
What other Sx might be seen with stroke?
Hemisensory loss
What is hemianopia?
Blindness in one-half of the visual field.
What is apraxia?
Inability to perform purposive movements although there is no sensory or motor impairment. 2. Inability to use objects properly.
What is Wernicke's Aphasia?
An injury to the Wernicke's area in the temporal lobe of the dominant hemisphere of the brain, resulting in an inability to comprehend the spoken or written word.
What is Brocas Aphasia?
Expressive or Motor
Aphasia in which patients know what they want to say but cannot say it; inability to coordinate the muscles controlling speech.
What is Global Aphasia?
Affects both speech comprehension and speech production.
Total aphasia involving failure of all forms of communication.
What is unilateral neglect?
The state in which an individual is perceptually unaware of and inattentive to one side of the body and the immediate unilateral area that the patient visualizes.
What is homonymous hemianopia?
Blindness of nasal half of the visual field of one eye and temporal half of the other, or right-sided or left-sided hemianopsia of corresponding sides in both eyes. (X )(X )
What is horners syndrome?
A syndrome characterized by contraction of the pupil, partial ptosis of the eyelid, enophthalmos, and sometimes loss of sweating over one side of the face.
What is agnosia?
Inability to recognize or comprehend sights, sounds, words, or other sensory information.
A person sees the fork, shirt, or toilet tissue and does not know what they are used for. Dangerous becuase client can not distinguis dangerous things.
If someone had a stroke in the left cerebral hemisphere, how might their attitude be?
Slow, cautions, disorganized.
If someone has stroke damage in the Right side how will their personality change?
Impulsive, overestimate ability, short attention span.
When the stroke affects the frontal lobe, what might be seen in personality.
flat affect, lack of spontaneity, distractability and forgetfullness.
Does stoke cause incontinence?
Yes, Bowell and Bladder.
What do stroke patients have contractures?
The stronger flexors overbalance the extensors when volunary muscle control is lost.
Name three manifistations of increased ICP.
Change in LOC, refelx HTN, worsening neurologic status.
What are HOB issues for clients with Increased ICP?
Not below 30 degrees
How is mannitol used to treat Increased ICP?
An osmotic diuretic helps lower increased ICP.
What is an effective aPTT for a stroke client?
1.5 - 2.5
What is an appropritae INR for a stroke patient?
2.3 - 3.0
When does death from stroke usually happen?
Can happen in 3-12 hours, but usually in 1-14 days.
What member of the interdisclipinary team would assess clients swallow ability?
Speech Therapy
By defination, how does a TIA differ from a stroke?
TIA is less than 24 hours, and the client has complete recovery.
How long does a TIA usually last?
Most are 5-20 minutes.
What is a carotid endarterectomy?
A surgical technique for removing intra-arterial obstructions of the proximal cervical portion of the internal carotid artery.
List six manifistations of stroke that should be warning signs to get help fast.
=Sudden Numbness or weakness of the face, arm or leg, especially on one side of the body.
=Sudden confusion, trouble speaking or understanding
=Sudden trouble seeing in one or both eyes
=Sudden trouble walking, diziness, loss of balance or coordination.
=Suddden, severe headache with no known cause.
Why would a physician order a non-contrast CT scan of the head prior to beginning thrombolytic therapy?
To rule out hemorragic stroke as the reason of the stroke. This would contra-indicate the use of thrombolitics.
What is the cause of an Ischemic Stroke?
Thrombotic or Embolic blockage of blood to the brain.
What is the cause of an Hemorrhagic Stroke?
Bleeding into the brain tissue, may be due to an aneurysm.
Which type of stroke has a higher incidence?
Clients with this metabolic disorder are at a higher risk of developing hemorrhagic stroke.
The brain requires a MAP of how many mm Hg to maintain adequare blood flow?
Why is it important to keep a client with stroke afebrile?
Elevated temperatures require increased metabolic need, which in turn will cause cerebral edema and increased risk of ischema.
How long after an infusion of thrombolytic should a nurse wait before beginning administration of anticoagulant and antiplatlet medications?
Twenty Four
If the client has hemiparesis, Hemisensory loss, loss of speech and slow onset, what type of stroke?
If a client has severe occipital and nuchal headache, what type of stroke?
Vertigo, Syncopye show what kind of stroke
What is a RIND?
Reversable Ischemic Neurologic Deficit? It is like a TIA, but lasts up to a week.
Define Dysarthria.
Articulation and enunciation problems from paralysis of muscles in the face, mouth, and neck. Speech and writing are understood. Able to construct the sentence, just difficult getting it out.
What is paresthesia?
An abnormal or unpleasant sensation that results from injury to one or more nerves, often described by patients as numbness or as a prickly, stinging, or burning feeling.
What is proprioception?
The awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body.
What is emotional lability?
Bursts into tears or laugh without cause. Distracting them will usually stop this. Not sadness.
What is the newer name for a Storke?
Brain Attack.
What is the window for brain thrombolitics?
Three Hours
What is a level that HTN needs to be treated?
BP 185/105
Talk about Hyperthermia.
May use a hypothermia blanket. Oil or lotion the client to keep skin moist. May use muscle relaxant to prevent shivvering, which will only bring temperature back up.
Who leads the team of people that work to rehab a client after a stroke?
Case Manager facilitates the rehabilitation.
What is nimodipine?
Given for vasospasm in cerebral hemorrhage.
Can you turn a stroke client to their affected side?
Other than skin integrity issues, why is it important to turn a client (even onto their affected side)?
Helps increase ventillation and perfusion.
What is the consistancy of food for someone with a swallowing disorder?
It should be thickened.
What are some issues about feeding for a stroke client?
Food should be softenend, but thick.
Watch for pocketing
Put food on unaffected side.
What is visual filed scanning?
Moving head position to scan areas when eyes don't do it for them.
This type of stroke with a rapid onset and may proceed rapidly to coma is called...
An abnormal sensation that may occur in a stroke patient is called ....
How soon must a thrombolitic be given in a stroke?
Three HOurs
What is a lack of awareness on one side of the body?
Unilateral Neglect
What can happen to the shoulder and hip if they are not supported properly in a stroke client?
They can become dislocated.
Paralysis of one side of the body is...
Facial Palsy.
To stimulate mouth closing, apply what to the lips?
What is done to prevent cornial abrasian in stroke patient?
Apply eye drop/moisturizer and then cover with a patch.
This is the inability to carry out a skilled act.
This type of aphasia is sensory or receptive.
The client bursts into tears or laughter without provocation with....
Emotional Lability
What is the inability to recognize familiar objects through the senses?
How often should passive ROM be performed for a stroke client?
Understanding Language, but has difficulty speaking clearly.
This test is performed to assess the nutritional status for a CVA.
In helping a Right-sided hemiplegic client to transfer to a wheelchair, the chair should be placed on the ....
Left side of the bed.
What is the leading cause of SAH?
What does SAH stand for?
Sub Arachnoid Hemorrhage.
What is the Munroe-Kellie Hypothesis?
Because the skull is fixed, when one of the three components of brain (blood, CSF, Brain Tissue) expand, one of the other two must compensate, or an outlet will form.
What is normal brain ICP?
5-15 mm
What is CPP?
Cerebral Profusion Pressure and is the MAP-ICP.
How is MAP calculated?
What is the CPP Calculation?
Define Compliance
Compensation by the brain to adapt to increasing pressure, using the Munroe-Kellie Mechanaism.
What are the steps of compliance?
First: CSF Moves out of the brain.
Second:Blood flow reduction to brain.
Last:Herniation or Displacement across the tentorium or through the foramen magnum.
What is autoregulation?
Blood vessels change diamater to maintain comstant blood flow. This is lost with ICP.
What are some causes of ICP?
Brain swelling.
Cerbtral Edema.

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