65trf Exam 376 Questions with Verified Answers
What are the three main constituents in the brain? - CORRECT ANSWER CSF, Brain Tissue (mostly water),
... [Show More] Blood
The brain makes up approximately _____% of the volume of the skull and is _____% water. - CORRECT ANSWER 80%
75%
CSF makes up about _____% of the volume of the skull. - CORRECT ANSWER 10%
There is approximately _____ mL of CSF. - CORRECT ANSWER 125-150 mL
Blood makes up about _____% of the volume of the skull and _____% of the blood is venous. - CORRECT ANSWER 10%
80%
The pressure of water, CSF and blood against the skull is known as _____. - CORRECT ANSWER ICP - Intracranial pressure
What are the normal ICPs for children and adults? - CORRECT ANSWER Child - 0-5 mmHg
Adult - 5-12 mmHg
ICP pressures above _____ mmHg in any age group is considered elevated. - CORRECT ANSWER 20 mmHg
ICP pressures above 20 mmHg do what? - CORRECT ANSWER Compromise blood flow into the skull and contribute to cerebral hypoxia and hypoglycemia.
What can happen if ICP pressures climb too high? - CORRECT ANSWER The brain may be forced out of the skull through any opening (such as skull fractures, tentorial plate or foramen magnum).
ICP above _____ mmHg is severe and life-threatening. - CORRECT ANSWER 40 mmHg
ICP between _____ and _____ mmHg is termed "moderate intracranial hypertension". - CORRECT ANSWER 20 and 40 mmHg
ICP above 20 mmHg is abnormally high and is known as _____. - CORRECT ANSWER Early increased ICP
What should resting ICP be? - CORRECT ANSWER Less than 10 mmHg
When ICP increases, pressure is exerted downwards on brain tissue, affecting the cerebral cortices _____ and _____. - CORRECT ANSWER Reticular Activating System (RAS) and Cranial Nerves
List 6 things caused by pressure on the RAS (Reticular Activating System). - CORRECT ANSWER 1. Progressive restlessness
2. Confusion
3. Disorientation
4. Lethargy or combativeness
5. Changes in speech
6. Loss of judgement
List 4 motor functions caused by increased ICP. - CORRECT ANSWER 1. Monoplegia
2. Hemiplegia
3. Over-pronation or supination of the wrists
4. Pronator drift
List 5 eye changes caused by increased ICP. - CORRECT ANSWER Diplopia
Blurred Vision
Visual field defects (loss of sight in part of one visual field)
Conjugate deviation of eyes or gaze palsies
Oval pupils with hippus
Increased ICP causes _____ losses. - CORRECT ANSWER Sensory
List 3 things caused by pressure on the hypothalamus. - CORRECT ANSWER Nuchal rigidity
Temperature changes
Vomiting (usually without nausea)
Describe how to test for pronator drift. - CORRECT ANSWER Ask the patient to hold both arms straight forward with the palms up for at least 30 seconds. Have the patient close his or her eyes. Monitor for unilateral downward drift of one hand (known as pronator drift).
Describe "conjugate deviation of the eyes". - CORRECT ANSWER Both eyes move in the same direction.
What is a gaze palsy? - CORRECT ANSWER Inability to move both eyes in one direction.
What is a hippus? - CORRECT ANSWER Pupil rapidly dilates and constricts when stimulated with light so it looks as though it is jiggling up and down.
List 6 late signs of increased ICP. - CORRECT ANSWER 1. Further reduction in LOC and responsiveness
2. Wide fluctuations in core body temperature
3. Seizures
4. Pressure on the brainstem
5. Pupillary changes
6. Flexor/extensor posturing
What two things are caused by pressure on the brainstem? - CORRECT ANSWER Cushing's Triad
Decreased or absent brainstem reflexes
What is Cushing's Triad? - CORRECT ANSWER Systolic hypertension with a widened pulse pressure
Bradypnea or irregular respirations
Bradycardia
What are some examples of absent brainstem reflexes? - CORRECT ANSWER Cough, gag, corneal, Doll's eye, cold calorics
What 2 types of pupillary changes are caused by pressure on the brainstem? - CORRECT ANSWER Unilateral or bilateral dilation
Decreased reactivity to light
What are the 7 indications of brainstem herniation? - CORRECT ANSWER GCS decreases by 2 or more points
BP and ICP significantly increase
Heart rate drops by 30-40 BPM
Respiratory pattern changes
Unilateral or bilateral dilation of the pupils
Pupils fail to react to light
Posturing
What are the indications for ICP monitoring? - CORRECT ANSWER Salvageable patients with severe injury
GCS score of 3-8 after resuscitation
Abnormal findings on the CT scan (hematomas, contusions, swelling, herniation, compressed basal cisterns)
What are the contraindications to ICP monitoring? - CORRECT ANSWER Wake patient
Coagulopathies
What are the risk factors with ICP monitoring? (2) - CORRECT ANSWER Infection (8% of patients)
Hemorrhage (2-10% of patients)
What are the risk factors for infection related to ICP monitoring? - CORRECT ANSWER Concurrent systemic infections
Longer duration of monitoring (highest risk factor after 10 days of use)
Presence of intraventricular hemorrhage or subarachnoid hemorrhage
Open skull fracture
Trauma
Cerebrospinal fluid leakage at the site
What are the signs of infection associated with ICP monitoring? - CORRECT ANSWER Headache (if patient has headache from the injury, look for changes in the headache)
Neck stiffness
Fever
AMS
New-onset seizures
Which patients are most likely to have hemorrhage related to ICP monitoring? - CORRECT ANSWER More likely in patients who develop coagulopathies
Discuss hemorrhages related to ICP monitoring? - CORRECT ANSWER Most hemorrhages are small (less than 15 mL) and clinically insignificant. Clinically significant hemorrhage occurs in 1% of cases.
What two things are perfusion to cerebral tissue dependent upon? - CORRECT ANSWER An adequate MAP that is able to propel blood from the body into the skull
A normal ICP
Describe the relationship between MAP and ICP. - CORRECT ANSWER ICP acts against MAP to reduce blood flow from the body into the skull.
How do you determine CPP? - CORRECT ANSWER CPP = MAP-ICP
What is the average CPP (cerebral perfusion pressure)? - CORRECT ANSWER 80-100 mmHg
A CPP above _____ mmHg is ideal. - CORRECT ANSWER 70
A CPP above _____ mmHg is required for consciousness. - CORRECT ANSWER 60
A CPP less than _____ mmHg causes critical reduction in brain tissue oxygenation. - CORRECT ANSWER 50
A CPP below _____ mmHg reduces cerebral blood flow to 25% of normal - CORRECT ANSWER 40
A CPP below _____ mmHg equates to irreversible brain ischemia - CORRECT ANSWER 30
If the MAP is lower than the CPP, the patient is _____. - CORRECT ANSWER Dead
What is the first step in performing a neurological assessment? - CORRECT ANSWER Determine LOC
What is the LOC of a patient who responds immediately to minimal external stimuli? - CORRECT ANSWER Alert
What is the LOC of a patient in a state of drowsiness or inactivity, in which the patient needs increased stimulus to be awakened, but is still easily arousable. - CORRECT ANSWER Lethargic
What is the LOC of a patient who is very drowsy when not stimulated, follows simple commands when stimulated, a duller indifference to external stimuli still exists, and response is minimally obtained? - CORRECT ANSWER Obtunded
What is the LOC of a patient who has minimal spontaneous movement, arousable only with vigorous and continuous external stimuli, motor responses to tactile stimuli are appropriate, verbal responses are minimal and incomprehensible? - CORRECT ANSWER Stupurous
What is the LOC of a patient in which vigorous stimulation fails to produce any voluntary neural response; both arousal and awareness are absent, no verbal responses, motor responses may be purposeful withdrawal to pain in light coma, non-purposeful or absent movement in deep coma? - CORRECT ANSWER Comatose
If the patient is awake enough to respond, determine the patient's degree of orientation based off of which 4 questions? - CORRECT ANSWER What happened to you? (Event)
What month and year is it? (Time)
Can you tell me your home address? (Place)
What is your name? (Person)
What are usually the first signs of neurological deterioration? - CORRECT ANSWER Changes in orientation
Changes of orientation tend to occur in order. What is the order? - CORRECT ANSWER The first sphere of orientation to decline is event, then time, then place. Person is almost always the last sphere to be lost.
If the patient has deteriorated to the point where they cannot cooperate with determination of orientation, assess for arousal looking for what signs? - CORRECT ANSWER Spontaneous eye opening
Verbalization attempts
Moaning
Tossing
Reaching
Leg crossing
Yawning
Coughing
Swallowing
What do you do if there are no signs of arousal? - CORRECT ANSWER Call the patient's name loudly watching for a response
What do you do if the patient does not respond to the calling of his name? - CORRECT ANSWER gently shake him or her
If the patient does not respond to being shaken, what do you do? - CORRECT ANSWER Apply noxious stimuli (nail bed pressure, trapezius pinch)
What is the second step in a neurological assessment? - CORRECT ANSWER Assess motor function
What should NOT be used to test noxious stimuli? - CORRECT ANSWER Sternal Rub
Supraorbital Pressure
Nipple or Testicular pinching
What does ipsilateral mean? - CORRECT ANSWER The same side
What does the suffix "paresis" mean? - CORRECT ANSWER Weakness
What does the suffix "plegia" mean? - CORRECT ANSWER Paralysis
Motor deficits above the neck (such as facial weakness) will be _____ to the injury or lesion. Motor deficits below the neck (such as hemiparesis or hemiplegia) will be _____ to the lesion. - CORRECT ANSWER Ipsilateral
Contralateral
What are some abnormal or spontaneous movements to observe for when assessing motor function? - CORRECT ANSWER Twitching or jerking of the face or limbs (even subtle) may indicate seizure activity.
Asymmetry of the resting limb (like external rotation of the leg) may indicate weakness
If the patient has spontaneous movements, assess the ability to follow what motor commands? - CORRECT ANSWER Hold up your thumb
Stick out your tongue
Ask the patient to perform a task such as making a smile, performing a pronator drift, pushing against resistance on the thighs, performing plantar or dorsiflexion. Look for lateralization which could indicate a contralateral lesion.
What is the definition of lateralization? - CORRECT ANSWER Defecit affecting only one side of the body
When assessing the ability to follow motor commands, which command should be avoided and why? - CORRECT ANSWER "squeeze my fingers" because it may be a pathological response rather than a purposeful motor response
If the patient does not exhibit spontaneous motor movements, what is tested? - CORRECT ANSWER Reflexes
List the relex tests. - CORRECT ANSWER Deep tendon reflexes (achilles, quadriceps, biceps, triceps)
Superficial reflexes (corneal reflex, gag reflex, swallowing reflex)
Pathological reflexes (grasp reflex, babinski reflex)
What is the third step in a neurological assessment? - CORRECT ANSWER Assess pupillary function and eye movement
What is anisocoria? - CORRECT ANSWER A difference in the diameter of the pupils of more than 1mm.
What are some signs of abnormal pupillary function or eye movement? - CORRECT ANSWER Irregular or oval shaped pupils
Anisocoria
_____, along with _____ is a strong indicator of neurological dysfunction. - CORRECT ANSWER Anisocoria
Diminished or absent pupillary response and/or lack of consensual movement
Pupils are usually equal in size and reactive to light in ICP of less than _____. - CORRECT ANSWER 30 mmHg
When ICP exceeds _____ mmHg, pupils tend to become pinpoint and less reactive to light. - CORRECT ANSWER 30 mmHg
With _____, one pupil tends to become fixed and dilated. - CORRECT ANSWER Unilateral herniation
With _____, both pupils tend to become fixed and dilated. - CORRECT ANSWER Bilateral herniation
What is the 4th step in a neurological assessment? - CORRECT ANSWER Assess Vital Signs
What is a eupnea respiratory pattern? - CORRECT ANSWER moderately fast symmetrical breaths
What is Cheyne-Stokes breathing? - CORRECT ANSWER quick deep breaths with intermittent pauses
What is central neurogenic hyperventilation? - CORRECT ANSWER Very Rapid deep breaths
What is Apneusis - CORRECT ANSWER Virtually apneic breathing
What is ataxic breathing? - CORRECT ANSWER Very abnormal breathing with no specific pattern
Discuss blood pressure in relation to the neurological assessment - CORRECT ANSWER Hypotension is rare but detrimental
Pulse pressure widens
Pulse: bradycardia often develops, followed by dysrhythmias
What are the BP and HR when the ICP is 10mmHg or less? - CORRECT ANSWER BP is normal
Pulse pressure is normal
Pulse rate and rhythm is normal
What are the BP, Pulse Pressure and Pulse when the ICP is 20 mmHg? - CORRECT ANSWER BP, Pulse Pressure, Rate and Rhythm are all normal.
Describe the BP and Pulse when the ICP is 30 mmHg. - CORRECT ANSWER Widening pulse pressure
Bradycardia palpated as a full and bounding pulse
Describe the BP and Pulse with herniation. - CORRECT ANSWER Wide pulse pressure
Bradycardia with irregularities
Mild temperature _____ are common with increased ICP - CORRECT ANSWER elevations
Temperature elevations due to brainstem lesions will lack _____. - CORRECT ANSWER Sweating and Gooseflesh
Rule out _____ rather than assuming temperature elevations are related to increases in ICP. - CORRECT ANSWER infection
Describe best eye opening in a Glasgow Coma Score. - CORRECT ANSWER Spontaneous = 4
To verbal command = 3
To pain = 2
No response = 1
Describe best motor response in a GCS. - CORRECT ANSWER Obeys commands = 6
Localizes pain = 5
Withdraws from pain = 4
Abnormal flexion = 3
Abnormal extension = 2
No response = 1
Describe best verbal response in a GCS. - CORRECT ANSWER Oriented = 5
Confused = 4
Inappropriate words = 3
Incomprehensible sounds = 2
No response = 1
A GCS of 13-15 indicates _____. - CORRECT ANSWER Normal function, or a mild brain injury
A GCS of 9-12 indicates _____. - CORRECT ANSWER A moderate brain injury
A GCS of 3-8 indicates _____. - CORRECT ANSWER Profound brain injury
The goal of neurological treatment is to _____. - CORRECT ANSWER Reduce the volume of the skull constituents in order to reduce the ICP. (reducing the volume of the brain)
How quickly does Mannitol lower ICP? - CORRECT ANSWER Within 1-5 minutes.
What is the peak effect of Mannitol? - CORRECT ANSWER 20-60 minutes
How long does Mannitol last? - CORRECT ANSWER 1.5-6 hours
How is Mannitol given? - CORRECT ANSWER As a bolus of 0.25g to 1g/kg
(0.25g-0.5g/kg for long term reduction, 1 g/kg for urgent reduction)
Is Mannitol preferred as a bolus or as a continuous infusion? - CORRECT ANSWER bolus
What should be done with mannitol in order to prevent rebound cerebral edema? - CORRECT ANSWER Tapered down
Mannitol should be tapered down in order to prevent _____. - CORRECT ANSWER Rebound cerebral edema
What are the advantages of Mannitol? - CORRECT ANSWER Rapid reduction in ICP
Expands plasma volume, causing a reduction in hematocrit and blood viscosity
Makes the RBC membrane more pliable, and able to flow through cerebral vessels easily
What are the disadvantages of Mannitol? - CORRECT ANSWER Heart failure
Pulmonary Edema
Hyperosmolar hypotension
Electrolyte Imbalances
Renal failure (if serum osmolality exceeds 320 mOsm)
What are the goals of treatment with Mannitol? - CORRECT ANSWER CVP or PAOP at or near 10-15 mmHg
Serum osmolality between 300 & 320 mOsm
What two things should be carefully monitored when administering Mannitol? - CORRECT ANSWER intake and output
monitor and correct electrolyte imbalances
What is another medication that can help decrease the blood volume in the skull? - CORRECT ANSWER Hypertonic saline
What availability is hypertonic saline in? - CORRECT ANSWER 3-23.4% available
How is hypertonic saline given? - CORRECT ANSWER 30 mL boluses given over 15 minutes
What are the advantages of hypertonic saline over Mannitol? - CORRECT ANSWER Does not have diuretic effects (more effective with hypovolemia)
Does not accumulate in the neural tissue like Mannitol
What are the risk factors with hypertonic saline? (4) - CORRECT ANSWER 1. Bleeding
2. Prolonged coagulation times
3. Hypokalemia
4. Hyperchloremic acidosis
What are three non-pharmalogical ways to reduce the volume of the blood? - CORRECT ANSWER 1. Patient Positioning
2. Avoid venous compression in the neck rlated to tight tracheostomy ties or tight cervical collars
3. Reduce intrathoracic pressure through careful ventilator management
What ways can patient positioning reduce the volume of the blood? - CORRECT ANSWER Elevate the head of bed (30-45 degrees recommended)
Monitor BP. (If HOB decreases BP, supine positioning may be required)
Keep the head midline
Avoid hip flexion
Minimize time in Trendelenburg position during central line placement
Prevent elicitation of Valsalva maneuver, cough, gag, vomiting or sneezing
How can the volume of CSF be reduced to decrease ICP? - CORRECT ANSWER CSF can be removed through a ventriculostomy catheter. Removal of 1-2 mL of CSF can temporarily reduce ICP by 1-2 mmHg.
Hypotension _____ head injury. - CORRECT ANSWER Exacerbates
What are the optimal hemodynamic levels? - CORRECT ANSWER MAP >90 mmHg
CPP >70 mmHg
Pulmonary artery occlusive pressures between 10 and 15 mmHg
List 3 ways adequate blood pressure is accomplished. - CORRECT ANSWER Administration of fluids
Vasopressors (dopamine or phenylephrine)
Inotropic agents
Discuss early RSI to help reduce ICP. - CORRECT ANSWER Pre-oxygenate with 100% oxygen for at least 5 minutes prior to intubation.
Consider providing lidocaine 1.5 mg/kg bolus to reduce spikes in ICP associated with intubation.
Administer a sedative/hypnotic agent and a rapid-acting neuro-blocking agent
Titrate mechanical ventilation to establish a pCO2 of between 30-49 mmHg. End tidal capnography is strongly recommended.
Suctioning can _____ ICP. - CORRECT ANSWER Increase
Discuss ways to manage suctioning in ICP. - CORRECT ANSWER Consider medicating with lidocaine, opiates, or neuromuscular blocking agents prior to suctioning.
Hyperoxygenate prior to suctioning
Limit suctioning to two passes of the suction catheter, not to exceed 10-15 seconds duration per pass.
What are some ways to ensure adequate oxygenation? - CORRECT ANSWER Maintain adequate hemoglobin
Ensure adequate arterial PO2
How can you maintain adequate hemoglobin? - CORRECT ANSWER Ensure Hgb is at least 10 g/dL (may require transfusions)
How could a Hgb too high be bad related to ICP? - CORRECT ANSWER A Hgb too high is bad because increased blood viscosity can reduce tissue oxygenation
How do you ensure adequate arterial PO2? - CORRECT ANSWER Increased FiO2 on the ventilator
Cautious use of PEEP (positive-end-expiratory-pressure)
List 6 ways to reduce cerebral metabolism. - CORRECT ANSWER 1. Maintain a darkened, quiet room
2. Limit visitors appropriately
3. Speak softly
4. Cluster nursing activities
5. Limit dialogue, keep topics light-hearted
6. Regular sedation/analgesia
Describe the effect of Diazepam, Lorazepam and Midazolam on BP, ICP and CBP. - CORRECT ANSWER BP decreases
No effect on ICP
CBP decreases
Describe the effect of Morphine, Fentanyl, Alfentanil and Sufentanil on BP, ICP and CBF. - CORRECT ANSWER BP decreases
ICP increases
No effect on CBF
Describe the effect of Propofol and Etomidate on BP, ICP and CBF. - CORRECT ANSWER BP decreases
ICP decreases
CBF decreases
Describe glycemic maintenance to decrease ICF. - CORRECT ANSWER Serum glucose should be maintained between 80-120 using titrated insulin drips.
Avoid IV fluids and medications mixed with D5W
Seizures are more likely in patients with: (5) - CORRECT ANSWER GCS less than 10
Depressed skull fracture
Subdural hematoma
Epidural hematoma
Intracranial hematoma
Prophylactic _____ may prevent early-onset seizures but will have little effect on late-onset seizures. - CORRECT ANSWER Dilantin
What is the difference in early-onset seizures and late-onset seizures? - CORRECT ANSWER Early onset seizures are within 7 days of injury
Late onset seizures are more than 7 days after the injury
What is the loading dose of prophylactic Dilantin? - CORRECT ANSWER 20 mg/kg
How fast is dilantin administered? Why? - CORRECT ANSWER No faster than 50 mg/minute
Faster administration may result in hypotension and circulatory collapse
Dilantin can only be mixed with _____. - CORRECT ANSWER Normal Saline
What is the preferred route of dilantin? - CORRECT ANSWER Central line
Plasma levels should be maintained between _____&_____ while giving dilantin. - CORRECT ANSWER 40-80 umol/L
When administering dilantin, you should monitor closely for _____. - CORRECT ANSWER Rashes
Rashes during administration of dilantin may indicate _____. - CORRECT ANSWER Steven Johnson Syndrome
How is normothermia maintained in relation to ICP? - CORRECT ANSWER Treat fevers with antipyretics
Sponge baths
Cooling blankets
Avoid shivering
In regard to normothermia, consider _____. - CORRECT ANSWER Indomethecin
How is indomethecin beneficial? - CORRECT ANSWER Reduces temperature, CBF and ICP
Vasoconstricts blood vessels
Which skull bones are the strongest? - CORRECT ANSWER Frontal & Occipital
Which skull bone is the weakest? - CORRECT ANSWER Temporal [Show Less]