med surge 2 mod 3 study guide

7/29/2019 Med Surge 2 Mod 3 Study Guide

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1Module 3 Blueprint

Increased ICP

Glasgow coma scale

EYES Spontaneous 4

To voice 3

To pain 2None 1

VERBAL Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

MOTOR Obeys command 6

Localized pain 5

Withdraws from pain 4

Flexion (decorticate) 3

Extension (decerabrate) 2

None 1

Glasgow Coma Scale pointers

15 is fully alert

7 or less is comatose book says 8 or less is generally

accepted as indicating a severe head injury

Score of 0 does not exist a dead person will score 3

MOTOR ~ be able to distinguish btw 4 & 5

MOTOR ~ 3 flexion is corticated posturing is where they bringto core; 2 extension is cerebrate posturing which is opposite of

corticated

HESI HINT

Use of the Glasgow coma scale eliminates ambiguous terms to

describe neurologic status such as lethargic, stuporous, or obtunded.

Dolls phenomenon

Tests occulocephalic reflex ~ Dr performs, not nurse; think of

eyes of baby dolls

fixed to look straight; pt will be told tofocus on something

Intact occulocephalic eyes deviate to opposite direction in

which head is turned

Abnormal eyes remain midline & move with the head

Abnormal indicates brain stem injury

If pt has cervical spine injury or even just a suspected, do not

attemptPathophysicology

3 components of brain brain tissue, blood, CSFMonroe-Kellie hypothesis - volume of any one of the 3 contents of

the skull changes the volume of the other 2 contentsCushings response is seen when cerebral blood flow significantly.

When eschemic, the vasomotor center triggers and in arterial

pressure in an effort to overcome the ICP.S/S:

Early sign is change in LOC

HA d/t pressure

N/V

Changes in VS drastic changes or significantly ICP

Cushings triad

Cushings triad systolic BP with widening of pulse

pressure, bradypnea, bradycardia,

NURSING ALERT

The earliest sign of ICP is a change in LOC. Slowing of speech and

delay in response to verbal suggestions are the other early indicators.

HESI HINT

Even subtle behavior changes, such as restlessness, irritability, or

confusion, may indicate ICP

HESI HINT

CSF leakage carries the risk of meningitis and indicates a deteriorating

condition. Because of CSF leakage, the usual signs of ICP may notoccur.

Management


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blood volume

cerebral edema

volume CSF

Done by

Restricting fluids

Controlling fever cellular metabolic demands

Administration of osmotic diuretics & corticosteroids

Draining CSF

Hyperventilating pt

HESI HINT

If temperature elevates, take quick measures to it since fever cerebral metabolism and can cerebral edema.

HESI HINT

Safety features for immobilized client:

Prevent skin breakdown with frequent turning

Maintain adequate nutrition

Prevent aspiration with slow, small feedings or NG feedings

Monitor neurological signs to detect the first signs that intracranial

pressure may be

Provide ROM exercises to prevent deformities

Prevent respiratory complications frequent turning andpositioning for optimal drainage.

HESI HINT

Restlessness may indicate a return to consciousness but can also

indicate anoxia, distended bladder, convert bleeding, or cerebralanoxia. Do notover-sedate, and report any symptoms of restlessness.

Medical management

Surgical removal of cause

clot, tumor, etc...

Osmotic diuretics ~ Manitol which removes fluid from normal

brain tissue with little effect on edematous tissue because ofblood/brain barrier (this allows more space & Lasix may be

used in conjunction), glycerol, urea cerebral edema

Steroids ~ Ex Decadron edema with tumors in areas that

are edematous around tumors complications areimmunosuppression, BS (pt on sliding scale insulin), GI

bleeding (tagment, protonix, nexium), risk of infection

CSF drainage ~ catheter in ventrical to remove CSF bur

hole in scull

Mechanical ventilation ~ controlled hyperventilation to induce

respiratory alkalosis which then causes cerebral

vasoconstriction reduces volume of blood and volume ofCSF

Temperature control ~ fever cerebral metabolism & rate that

edema occurs High dose barbiturate therapy ~ if not resolved by other

measures; cerebral resistance therefore cerebral blood flow

basically allowing less blood flow to get to head means lessvolume in head

NI

Use of narcotics are contraindicated; NEVER give morphine

to pt with ICP narcotics can ICP, Morphine affects

pupil size and accurate size cant be obtained on assessment;Codeine be prescribed for HA r/t ICP

Maintain patent airway with suctioning hyperoxygenate

prior; airway obstruction will ICP

Position ~ HOB elevated & keep head in neutral alignment

gravity enhances venous return & turned head impedes venousreturn

No straining ~ BM ICP so pt on stool softeners; NO valsalva

maneuver; Do not allow them to help repostition bc it will

cause them to push and facilitate valsalva maneuver have pt

exhale while turning or moving them up in bed to prevent

Monitor IVs to prevent fluid overload


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Passive ROM active ROM will cause I CP

HESI HINT

TRY NOT to use restraints; they only restlessness. AVOID

narcotics since they mask level of responsiveness.

HESI HINT

Almost every diagnosis in the NANDA format is applicable, as

severely neurologically impaired persons require total care.

HESI HINT

Pts with an altered state of consciousness are fed by enteral routes

since the likelihood of aspiration with oral feedings is great. Residualfeeding is the amount of previous feeding still in the stomach. The

presence of 100 mL residual in adults usually indicates poor gastric

emptying and the feeding should be held.

HESI HINT

Paralytic ileus is common in comatose clients. Gastric tube aids ingastric decompression.

HESI HINT

Any client or bedrest/immobilization must have ROM exercises oftenand very frequent position changes. Do no leave the client in any one

position for longer than 2 hours. Any positions that venous return isdangerous, i.e., sitting with dependent extremities for long periods.

NURSING ALERT

If the pt begins to emerge from unconsciousness, every measure that isavailable and appropriate for calming and quieting the pt should be

used. Any form of restraint is likely to be countered with resistance,

leading to self-injury or to a dangerous in ICP. Therefore, physicalrestraints should be avoided if possible; a written prescription must be

obtained if their use is essential for the pts well-being.

NURSING ALERT

The body temperature of an unconscious pt is never taken by mouth.

Rectal or tympanic (if not contraindicated) temperature measurementis preferred to the less accurate axillary temperature.

Posturing

Decorticate ~ abnormal flexion; arms, wrist, fingers flexed &

arms abducted; legs fully extended & internally rotated with

plantar comes to the core

Decerebrate posturing ~ stiff arms extended & adducted, hands

hyperpronated, wrist & fingers flexed, plantar flexion of feet

outward rotation from the body

Headaches

Symptom not a disease

Temporomandibular Joint Pain (TMJ) unilateral facial pain

pain can be referred to upper part of face as well as down into

neck

usually caused by malocclusion, trauma, arthritis, bruxism

(teeth grinding)

Temporal Arteritis (Cranial arteritis)

inflammation of the walls of the temporal (cranial) arteries

S/S: pain, fatigue, wt los, fever & malaise; heat, redness, &

tenderness over involved artery

specific S/S of this kind ofHA d/t the inflammation

visual disturbances or blindness may result from ischemia of

involved structures

Tx analgesics for comfort & steroids for inflammation

Migraine

Complex S/S, characterized by periodic and recurrent attacks of severHA

Caused by VASCULAR disturbance that occurs more

commonly in women and has strong familial tendency


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Onset: childhood, adolescence, puberty occurs more often

when major change in pace or schedule such as holidays,

stress, first job can have one from having time off fromwork from the let down/change in pace

Pain is unilateral

Causative factors: vasoconstriction of arteries followed by

vasodilation stretches nerve ending in vessel walls causing

pain

S/S: aura something signals the attack is coming on, lasts

about 30 min visual disturbances (light flashes, commonly

not verbalized though), N/V, photophobia, numbness &tingling in face & hands

Lasts for hours or days; until very intense

Recovery: sleep, photophobia, wet cloth on face, be alone

Precipitating factors:

o Foods tyramine, monosodium glutamate, milk

products or nitrates

Tyramine ~ cheese, chocolate, coffee, sausages,hot dogs, canned meats

Tyramine in foods with vasoactive monamine

BP ~ pickles foods, wineso Sun glare, weather changes causing sun to seem

brighter, noise, bright lights

o Birth control, Nitro vasodilator

o Mental & emotional excitement can not do welllwith certain changes in life; dont give surprise b-dayparty to

o Fatigue, hunger, smoking, alcohol

TX:

o Prevent relaxation techniques, diet (avoid foods that

cause it), quiet & dark roomso Ergotamine preps:

effective is taken early on must be taken 30-60 min prior to full blown HA (during aura)

vasoconstrictor

not used for HTN bc it is vasoconstrictor

Ergotamine tartate: acts on smooth muscle,

causing prolonged vasoconstriction of cranialblood vessels

SE:parasthesias of fingers & toes d/t

vasoconstriction; N/V, weakness in legs

d/t vasoconstriction, muscle pain in

extremities, bradycardia

contraindicated: cardiac pts, HTN, PVD,

impaired renal function, pregnancy

Cafergot: combo of ergotamine and caffeine

Imitrex: abords HA before it gets fullblown

Zomigo Meds to prevent

Inderal 40 mg tid-qid: beta blocker

remember not to abruptly dc Sansert 2 mg BID or TID: rarely used d/t SE

(blood dyscrasias) and the drug holidays that the

pt has to take q6 months for 1-2 months

prevents retroperitoneal fibrosis andpleuropulmonary and cardiac fibrosis

Cluster HA

Vascualr HA seen more during spring or fall

More frequent in men

No warning symptoms

Come in clusters one to eight per day each attack last 15

min - 3 hrs

Unilateral pain

Sudden onest & subsides abruptly

Usually localized around eye

Eyes & nose might run

Occurs mainly at night & wakes person up

This person will be up pacing floor vs migraine who wants to

be left alone

TX: eliminate the factors that cause it same as migraine


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Cluster VS Migraine

No aura Has aura

No vomiting Vomiting

Rarely nausea Nausea

Affect more men Affects more women

No menstrual relationship Menstrual cycles can trigger

Only neurological deficit is ocularsympathetic paralysis

Neurological deficits

Pt up pacing floor Dark, quiet room, alone, asleep

Frequency is greater Frequency not as often

Nocturnal attacks more frequent Waking hours normally

Serotonin does not at the onset serotonin occurs during HA

Tension HA

Muscle contraction HA

Caused by: result of sustained contraction of the mujscles ofthe neck and scalp, face & upper back

Prolonged state of contraction causes blood supply to the

muscle to become diminished and metabolic wastes begin to

accumulate

S/S: steady constant feeling of pressure in back of neck,

forehead, & temple; pt c/o feeling like a brick/wt is on head

TX: remove souce of stimuli; analgesics, Tylenol, muscle

relaxants, moist heat, massage

CVAAny functional abnormality of the CNS caused by a pathologiccondition of the individual cerebral vessels or of the cerebrovascular

system; includes any of the vessels which furnish blood to the brain

if any portion of brain has disturbed blood flow

Onset: any age; usually elderly; children with sickle cell

Risk factors: modifiable and non-modifiable

Pathological causes of CVAs

o Cerbral thrombosis

o Cerebral embolism

o Cerebral ischemia

o Cerebral hemorrhage

Epidural

Subdural

Subarachnorid

IntracerebralAnatomy of skull form outside to inside

Skin skull epidural (above dura) dura mater

subdura (below dura) arachnoid subarachnoid (below

arachnoid) pia mater brain (grey matter & white matter)

Meninges ~ fibrous connective tissue that cover the brain and

spinal cord; provide protection, support, and nourishment

Meningeal layers: dura mater arachnoid pia mater

Cerebral thrombosis

Blood clot occluding vessel that is supplying that area of the

brain with blood Slowly developing pathological process

Can occur over mins, hrs, days, or months not usually

abrupt though

May be preceded by prodromal warning such as

parasthesias Mary mentioned that migraine is preceded byprodromal warning also and also parasthesias

S/S: paresis ( strength & mobility of extremity), aphasia

(language function);

Can occur at rest or 1 hr after arising or after unusual fatigue Usually does not develop abruptly

Associated with TIA

Major causes: atherosclerosis

S/S: conciousness may or may not be lost; HA uncommon at

onset; may c/o dizziness, possible seizures

The ischemia from the clot leads to edema in that area of the

brain; since it is slowly occurring; symptoms may not be

initially d/t the thrombosis in that particular area it occurs

over time; as time goes the area of brain that is deprived of

oxygenation will start to swell edeam occurs


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Area of brain effected will give you the symptoms

HESI HINT

Atrial flutter/fibrillation has a high incidence of thrombus formation

following arrhythmia d/t turbulence of blood flow through allvalves/heart chambers.

Cerebral embolism

Can be fat or blood

Can occlude vessel totally or partially

Usually lodges in the middle cerebral artery branches of the

carotid carotid is larger so clot does not occlude and it keepsgoing until it reaches smaller vessels

Can orriginate from heart A-fib pts (from stagnant blood in

heart) or pulmonary (from infection or bedrest)

Occurs rapidly Not related to activity

Usually no prodromal signs maay have HA, but basically

have no warning sign that this is occuring

S/S & prognosis: Depends on area & how much tissue

Cerebral ischemia (TIA)

Insufficiency of blood supply to the brain

Mainly d/t [atheromatous] constriction of the arteries supplying

the brain

Most common manifestation is TIA TIA: transient impairment of blood flow comes and goes

o Temporary

o Symptoms usually resolve completely without

permanent damageo Commonly a sudden loss of motor, sensory, or visual

funciono Lasting few seconds or min or hrs, but no longer than

24 hrs

o Red flag: warning sign for impending stroke, advanced

atherosclerosis something is going on & can become

severeo TX: antiplatelet aggregation (presantine, aspirine) &

possibly anticoagulants

Cerebral hemorrhage

General info Bleed in brain

Rapid development

Occurs during activity valsalva, straining, anything that

the intrathoracic pressure that can raise the arterial pressure

S/S: result from the compression of cranial nerves or brain

tissueo Blood escaping compresses & displaces brain tissue

o Frequently asymptomatic until vessel breaks and then

o C/O severe HAo As blood escapes into brain tissue the pt will experience

nuchal rigidity (neck stiffness) the blood on thenerves or affecting the meninges is very irritating

o Dizziness; visual disturbances diplopia or loss of

vision; hemoplegia or hemoparesis; seizureso Clot will form just like in cut and blood left in tissues

will reabsorb clot will be reabsorbed/dissolved

rebleed even up to a week aftero The pt may not experience many S/S until the rebleed

then they will get severe S/S

Preceding events:

o Severe occipital HA with nuchal rigidity HA in back

of neck Mary discussed pt coming in with severe

HA and ruling out migraine d/t location and then saidthat if BP was then you know it is not good

o BP, vertigo, syncope, parasthesias in extremities,

epistaxis usually d/t BP, retinal hemorrhage

Types of cerebral hemorrhages

Epidural (extradural) hemorrhage


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o d/t head injury (usually)

o middle meningeal artery has ruptured

o if not tx with in a few hours of incident they have little

chance of survival d/t rapid pressure on brain tissue

from the bleeding

Subdural hemmorrage

o Involves small vessels

o Acute, subacute, and chronic

o Chronic seen a lot in elderly takes a longer period of

time for a hematoma to form in this area of brain to

cause pressure on the braino Pts with chronic subdural hemorrhages may have them

for months without showing any S/So Mary gave an example of elderly pt falling a couple of

months prior Intracerebral hemorrhage

o Usually arterial BP (usually)

o S/S: depends upon the area of the brain that is involved

as well as the amount of bleeding; Rapid onset, severe

HA, nuchal rigidity, N, vertigo, loss of conciousness

o NI: Keep pt quiet and inactive it can occur with

activity

Subarachnoid hemorrhage

o Causes: trauma, hypertension, malformation of

arterial/venous system (AVM congenital)o The rupture is usually preceded by some degree of

physical straino S/S: sudden shooting pain in back of eye & sudden

shooting HA, N, nuchal rigidity, loss of conciousnesso HA is explosive

o If LP was done on this pt they would find blood in the

CSF

Diagnostic studies for CVA

Performed to differentiate btw the types/causes of the CVA

Pt hx when did it start, do they have any other problems

Neuro exam baseline to check for further deterioration;

continuously done, can predict affected areas of brain, andprognosis

Skull series (X-ray of skull/brain scan) see if there is

fx/trauma

EKG cardiac vs cerebral

LP usually not done bc can not be done if evidence of ICP

brain stem herniation or rebleeding can occur d/t the rapid

release of pressure from the ICP

MRI

CT initial diagnostic test, should be done emergently for

prompt tx (esp if candidate for tpa); differentiates type

ischemic vs hemorrhagic tx based on the typeo shows location and size of lesion; affected and/or

possibly affected areteries, veins, adjoining vessels, and

vascular branches predicts deficits pt will exhibit

PET

EEG ~ brain wave test; done with the things that stick on head

Interventions of CVA

Diuretics to edema & ICP

o Manitol osmotic diuretic; Lasix can be used as

adjunctive therapyo NI to check effectiveness of diuretics

Urinary output ~ at least 30 mL/hr should bemore

Possitive effects to neuro exam

Antiplatelet aggregates

o ASA

o Presantine 50-75 mg TID

o Ticlid

o Plavix

NURSING ALERT

Wrong pg # given but mary said When you get your pts hx duringassessment make sure you ask about herbal remedies. GINKO &


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GARLIC potentiate bleeding time. So if you give an ASA or anything

of that nature, your anticoagulants; you need to know what else the pt

is taking, like herbal remedies as well. Basically they will bleedingtime.

Anticoagulants

o Heparin & coumadin

TPA

o Criterial protocolsmust rule out active bleed

Surgical intervention for ischemic strokes

Carotid endarterectomy remove plaque/atherosclerosis/thrombus toprevent ischemia from the occlusion

Post op care from endarterectomy

Important, especially during first 24 hours

Keep head in neutral position

o Keep incision intact

o Do not want to prevent venous return HOB

Neuro assessment VS & hand grips

o VS

o Hand grips contraleteral weakness weakness on

opposite side

Monitor operative side for edema or hematoma

Nursing assessment after a sever cerebral hemorrhage

Classic picture of what you will see if somebody is having/just had a

cerebral hemorrhage Pt unconscious

Face is brick red

Difficulty in breathing

Contralateral paralysis

Cheek will blow out on paralyzed side during expiration d/t

forcefulness from the difficult respirations

BP

Slow, full, bounding pulse

The longer they are comatose the poorer the prognosisAcute care of CVA d/t cerebral hemorrhage

Complete bedrest to keep pt as quiet and inactive as

possible

Head in neutral position venous return

Prevent valsalva maneuver (straining) intrathoracic

pressure BP arterial pressure

3 main causes of death d/t hemorrhagic stroke Pneumonia

Rerupture of aneurism

Brain herniation ICP

Clinical manifestations of CVA

Baseline data: VS & neuro (Glasgow)

Perceptual Disturbances: parietal & temporal lobe (optic tract)

visual disturbanceso Homonymous hemianopsia: loss of half of visual field

(not entire eye, only half of each eye) temporary orpermanent; Loss of vision will be on SAME side of

paralysis

Neglect to one side of body

Difficulty judging distances

Eat only half of food if they only eat 50%

will be unusual looking food on the side of

visual loss will not be seen and thus ignored

turn plate around

Seizure activity: can cause seizures prophylactic

anticonvulsants Emotional lability: unpredictable; exaggerated use

distraction (change subject) when behavior becomes

exaggerated

Agnosia: incapable of importing information in various senses

o Visual identify colors

o Auditory problems identifying auditory stimuli

they can hear it, but cant identify where it is comingfrom and what it is

o

Olfactory

identifying smells


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o Tactile cant identify what they are touching hard

time identifying textures, shapes, etc

o

CRANIAL NERVE ASSESSMENT

1 Olfactory Identify smells with eyes closed

2 Optic Snellen chart; visual fields

3 Oculomotor 3,4,6 ocular rotation, conjugate

movements, nystagmus. Papillaryreflexes, inspect eyelids for ptosis

4 Trochlear

5 Trigeminal Cotton to forehead, cheeks, jaw. Rotate

btw sharp & dull in same places sensitivity to superficial pain. If

incorrect responses, test temperaturesensation.

6 Abducens

7 Facial Symmetry while smiling, whistles,

eyebrows, frowns, tightly closes eyelids

8 Acoustic Whisper or watch-tick test. Weber,

rinne

9 Glossopharyngeal Swallow, differentiate sugar vs salt

10 Vagus Gag reflex, hoarseness in voice,

swallow, AH uvula

11 Spinal accessory Shrug shoulders, head side-to-side

12 hypoglossal Stick tongue out, move it side-to-side

Type of Agnosia Affected Area

Visual Occipital

Auditory Temporal

Tactile Parietal

HESI HINTType of

Aphasia

inability to perform purposeful movements in the

absence of motor problems

Dysarthria: Difficulty articulatin

Dyshpasia: Impairment of speech and verbal comprehension

Aphasia: Loss of the ability to speak

Agraphia: Loss of the ability to write

Alexia: Loss of the ability to read

Dysphagia: Dysfunctional swallowing

Use short sentences when communicating with pt who has had a stroke dont give too many options (keep instructions & questions verysimple)

Prevention of longterm complications

Assess movement relieve pressure

Prevent external rotation of hip

Prevent clawlike contracture deformity

Prevent footdrop

Bladder control

Assess sensations Maintain Skin integrity

Speech therapy to regain communication

Brain Tumor

Biphasic age distribution peak 5-8 & 55-60

Males slightly higher risk

Children more likely to develop tumors of the cerebellum

cerebellum s/s imbalance & ataxia

90% of all tumors in adults are about tentorium

Type of Aphasia Affected Area

Auditory-Receptive Temporal

Visual-Receptive Parietal-Occipital

Expressive Speaking Frontal

Expressive writing Frontal


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Classified based on tissue origin, location, & relation to the

brain

TISSUE ORIGIN TERMINOLOGY

Neural Neuroma

Connective Glioma

Meninges MeningioBlood vessels Angio

Glands Adenoma

SUPRATENTORIAL INFRATENTORIAL

Cerebrum Cerebellum

Adults Children

HOB Supine

INTRINSIC EXTRINSIC

Originated inside brain Originated outside brain

Rapid growing Slow growing

Malignant (most) Benign (most)

Usually encapsulated

May or may not be

removed

Can be removed if too

much pressure

Most common tumor to metastasize to the brain is lung CA

followed by breast CA


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RIGHT-SIDED VS LEFT-SIDED

Left-sided paralysis Right-sided paralysis

VISIONSpatial perceptual deficits: Inability to judge distance, size, position

Inside from outside of clothing

Wheelchair running into frame of door

Buttoning clothes wrong

Lipstick crooked

One sided neglect hemianopsia

Reading left side of words can be dropped women might

be seen as men

Unable to discriminate words and lettersReading problems

Deficits in right visual field

BEHAVIORImpulsive behavior they will go too fast: teach small segments &

get them to demonstrate or repeat it back to you

If pt is getting up they might try to walk before they have theirbalance and then end up falling

When learning something new they might rush to the next stepand not learn it

Unaware of neurologic deficitsEuphoric; Distractable

Slow, cautious, & disorganized

These pts need frequent feedback

Dont give too many options (keep instructions & questions verysimple)

AnxiousQuick anger and frustration

LANGUAGEMay be alert & oriented Dysarthria: articulation muscles impaired

Aphasia may not be hard of hearing just can communicate

information; they hear, process it, but cant respond you do not have

to raise your voice

Receptive aphasia receiving

Expressive aphasia speaking

Global aphasia receptive & expressiveAgraphia

MEMORYDisoriented

Cannot recognize facesNo deficit

H

EARINGLoses ability to hear tonal variations No deficit


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Assessment

Take complete hx

o From pt

o From family they may have seen something pt cant

see personality or behavioral changes

S:S: common to all

o ICP: HA, nausea, Projectile vomiting, cushings

triad (bradycardia, BP with widening pulse pressure(systolic hypertension), braypnea)

o Focal disturbances: slight change in LOC seizure

activity

HESI info Mary pointed out as 2 classic differentiate from

Migraineo HA more severe upon awakening

o Vomiting not associated with nausea

Tumors based on tissue origination Neuroma (Acoustic)

o Involve cranial nerves

o Benign

o Intrinsic

o S/S: involves # VIII hearing & balance vertigo,

staggering, loss of coordination; as tumor grows it

compresses # V pain on same side of faceo Prognosis: can be completely removed, but because # V

is involved they can have facial paralysis; they can alsohave deafness on the side with lesion

Glioma

o Neoplasm of connective tissue

o Common brain CA

o Always intrinsic

o Infiltrating filtrates throughout brain tissue

o Can not be completely removed because it is not

ncapsulatedo Bulk can only be removed, but brain tissue comes with

o TX: surgery, chemo, radiation

o Not curable, Reoccurring

o Two main types

Astrocytomas

Graded 1-4; 4 more malignant & faster

growing 1 less malignant & slow

grawing

Medullablastomas

Rapidly growing

Children in brainstem (age 6-10)

Seeds through CSF

Most commonly in cerebellum

Meningioma

o Tumors that cover lining of brain

o Extrinsic usually encapsulated cant spread & can

be removedo Slow growing

o S/S: HA; depending on pressure put on tissue they may

have other symptoms like seizureo Prognosis: this is one you would rather have;

completely removed if needed; cured after removalo Not reoccurring

Angioma ~ Hemangioma ~ Hemangioblastoma ~

angioblasomao

Tumor of immature blood vesselso S/S: ICP HA, vertigo, nystagmus, + Rhomberg

where they tilt toward side of lesiono Prognosis is good; they can remove entire lesion

Adenoma ~ pituitary

o Can or pituitary function

o Anterior lobe GH, TSH, LSH, ACTH

o Posterior lobe ADH

o Hyperpituitarism


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Accelerates growth when GH secretion d/t

tumor children will have giantism & adults

will have acromegally

Cushings syndrome from ACTH d/t tumor

moon face, buffalo hump, BS, obesityo Hypopituitarism

Adiposity & loss of sexual function

Loss of libido, sterility, impotence, amenorrhea

Loss of vision pressure on optic nerve

Primary symptom that these pt have is when

they talk about HA they will describe it as

bifrontal HA not on one side; across entirefront of head

o TX: transphenoid hypophysectomy

Incision into maxillary gingival

Go up nasal cavity to remove tumor Postop

Mustache dressing

Mouth breathing (not nose)

No blowing nose, coughing, sneezing

ICP d/t tissue manipulation & edema

Diabetes insipidus transient

(temporary) post-op Foley, urine

looks like H20 & 3-10 L/day tx with

ADH VasopressinSymptoms according to site/location

LOBE Function S/S

Frontal Personality, mood,

language center

Impaired judgement, slowness

of thought, obscene language(never used before),

expressive aphasia

Temporal Short-term memory Hemianopsia

Parietal Sensory Parasthesias, hypoasthesias,

hyperesthesia or

sensitivity to touch

Occipital Visual Impairment, homonymous

hemianopsia

Cerebellar Balance Unstady gait, fall toward side

of lesion, intentional tremor(have tremor when reaching

for object), + Rhomberg, neg

finger to nose, nystagmus, HAin suboccipital area

Prognosis of Brain tumor

If untreated leads to death from either ICP or brain damage.

Intracranial surgery

Pre-op intracranial surgery

Tell pt what to expect post-op

o O2

o Suction

o IV

o Art lines

o Frqnt neuro check & VS

o Cranial dressing and drain

o Foley

o Transfusions

o Periorbitol edema & ecchymosis looks like they

were punched in eyes

o Leg exerciseso Deep breathing

Baseline neuro assessment to determine conditions needing

intervention post-op

Steroids brain edema

Prophylactic dilantin

Surgeries

Craniectomy

o Portion of skull removed to accomadate cerebral edema

by allowing expansions for inoperable tumor


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o Do NOT position pt on operative side no skull to

protect brain

Cranioplasty

o Repair of cranial defect d/t cosmetic defect or done to

protect braino NI

Observe dressing for bleeding & CSF leakage

Observe dressing for tightness, indicatingedema

Do NOT allow pt to lie on portion of headwhere skull has been removed

Take precausions to not accidently hit the head

Do NOT remove dressing without an orderstrict aseptic technique

Craniotomy

o Surgical opening of skull to gain access to intracranialstructures (monitors for ICP bur hole)

o Supratentorium adults, cerebrum

o Infratentorium children, cerebellum

HESI HINT

Craniotomy preoperative medications:

Corticosteroids to reduce swelling

Agents and osmotic diuretics to reduce secretions (atropine,

robinul)

Agents to reduce seizures (Dilantin)

Prophylactic antibiotics

Transphenoidal hypophysectomy approach

o Monitor for ICP d/t edema

o Pituatary surgery

o Incision in maxillary gingival upper lip btw gums

and lip; go up through the nasal passage

o Tumor is packed with muscle or fat from thigh/lower

abdomen

o Nasal cavities packed with Vaseline gauze and

ointmento Upper gums sutured

o Moustache dressing under nose to hold the packing in

placeo NI:

High fowlers

Vasopressin & steroids

No nasopharyngeal suctioning

Mouth breathing

No nose blowing, sneezing, or coughing

No tooth brusho Post-op complications

Diabetes insipidus

Hypothyroidism

Hypoglycemia CSF leak

Post-op intracranial surgery

Monitor for signs of ICP

Establish & maintain adequate airway and ventilation

Maintain body alignment after supratentorial

o HOB 30 (45)

o Position pt on side or back

o

If tumor was large do not turn on the side it was on

displacement from gravity

o Neutral head positon; no neck flexion venous

return ICP

o Pillow under head & shoulders not just neck

o When repositioning do not let pt help to prevent

valsalva have pt exhale

Maintain body alignment after infratentorial

o Supine HOB flat

o Position from side to side

o Head in neutral position esp when turning


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15o When repositioning do not let pt help to prevent

valsalva have pt exhale

Assess surgical dressing

o CSF leakage if clear use dextrose strip it will be +

for glucose; if bloody look for halo sign (clear/yellow)

HOB, Diamox formation of CSFo Excessive bleeding

o Do not change dressing until ordered

o Ventricular drainage

Monitor elimination avoid circulatory overload

Provide pt comfort

o HA for 24-48 d/t stretching/irritation of nerve of the

scalp

Activites to avoid bending over, coughing, sneezing;

valsalva, vomitting

Surgery complications Meningitis

o D/T

Infection

Blood in the subarachnoid space

Prolonged use of intracranial monitoring

devices 2/3d post surgeryo S/S

Headache, chills, fever, irritability, nuchal

rigidity, soreness of skin & muscles, cells inCSF, + Kernigs, + Brudzinski, delirium,

convulsiono PI

Strict aseptic technique

Prophylactic antibiotics

Seizures

o Greater risk with supratentorial

o NI: padded side rails, side rails up, dilantin prophylactic

Stress ulcers pepcid, protonix Diabetes insipidus

o Hypothalamus and pituitary gland area surgery

edema interferes with production of ADH excessiveoutput

o TX: fluid and vasopressin

Seizures

Divided into 2 major classes

Generalized

Person loses conciousness for a few sec to a min, no warning

or aura associated

Tonic-clonic (Grand Mal)

o Most common

o Loss of conciousness

o Tonic phase stiffening of body

o Clonic phase Jerking of extremities

o Excessive salivationo Bite tongue or cheeks

o Incontinence

o After seizure muscle soreness, tired, sleep for hours

o May not for normal for several hours to days after

o No memory of seizure

Petit Mal (Absent)

o Usually only children

o Rarely continues beyond adolesecence

o Brief staring spell that lasts only a few sec can gounnoticed

o Can have 100 or more episodes in a day

o May experience twitching in facial muscles

o Typical of kids that come home from school with note

from teacher saying that they are staring out into space,

they are not paying attention, and their grades areslipping

Partial

Begin in a specific region of cortex


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16

Confined to one side of brain and remain partial or focal in

nature or may spread to involve entire brain

Simple motor Jacksonian simple partial seizures

o Only a finger or hand may shake or mouth may jerk

uncontrollablyo May talk unintelligibly

o May be dizzy

o May experience unusual or unpleasant sights, sounds,

odors, or tasteso No loss of conciousness

o Rarely last longer than minute

Complex symptom psychomotor Complex partial

o Involves temporal lobe

o Person either remains motionless or moves

automatically (automatisms) either way it is

inappropriate movement for the time and placeo May experience emotions of fear, anger, elation, or

irritability.o Person does not remember the episode with it is over

o Lipsmacking

o Automatisms are picking at clothes, fumbling with

objects, walking away (during conversations)

Status epilepticus

Most serious

Continous

No conciousness between seizures

Problem is lack of O2 to brain brain damage can result

Severe injury or death can happen d/t trauma head injury

from falling, drowning in tub, sever burn

TX: IV Valium, Ativan, Cerebyx administered slowly to stop

seizures Dilantin, phenobarbital are administered later to

maintain seizure free state

Diagnostic Studies

Aimed at determining type, frequency, and severity, and

factors that precipitate them.

o Labs, EEG, CT, etc to determine cause of seizure

Management

Look at 2192 and picture pt on side with O2 and suctionsetup. Pads, o2, suction when pt has hx of seizures

Maintain privacy of pt

Ease pt to floor if possible

Protect head with pad

Loosen constrictive clothing

Push furniture out of way

If pt in bed, remove pillows and raise side rails

If aura precedes, insert oral airway to reduce the possibility of

pt biting tongue or cheek do not put anything in their mouth

during the seizure; can only be done prior or after Do not restrain pt

Put pt on side with head flexed forward allows tongue to fall

forward and facilitates drainage of saliva and mucua.

Use suction to clear secretion

O2

After keep pt on side

Make sure airway is patent

After grand-mal, usually a period of confusion

Short apneic period may occur during or immediately after ageneralized seizure

Pharmacological management

Maintain seizure free statemust be at a therapeutic level Periodic serum therapeutic levels taken usually every 6

months

Dilantin side effects gingival hyperplasia, drowsiness


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18

Meningioma Neuroma

(Acoustic)Gliomas Hemangioma

(hemangioblasoma

angioblastoma)

Adenoma

Astrocytomas Meduloblas

tomas

Location Covering of

brain

Crainial VIII

(hearing &balance)

Grows &compresses V

(Acoustic &

Facial)

Connective tissue Immature blood vessels Pitutitary

Tumor of ductless glandAdultscerebrum

Childrencerebellum

Mostcommonly

incerebellum

Originated Extrinsic Intrinsic Always intrinsic Forms a cyst

The tumor itself remains alittle nodule in the cyst wall

Benign VS

malignant

Benign Benign Usually malignant

Malignant

Grade 4 mostmalignant

Highly

malignant

Growth Slow ------------ Gades 1&2 ~slow

Grades 3&4 ~rapid

Rapid

Age 30-60 ------------ Any Frqntly inchildren

Any

Sex Femalesgreater

------------- Female to male 2:1

Prognosis Can becompletely

removed

Not recurringAfter removal

they are cured

Not curable; can neverremove all of tumor;

When removed brain tissue

comes with it d/t beinginfiltrating

Good; they can remove entirelesion

S/S Depends on

location

Vertigo,

staggering loss of

ICP HA, vetigo,

mystagmus, + rhomberg

function function


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19

HA usually coordination

Pain on side offace

Facial paralysis &

deafness

tilt toward side of lesion

of GHHyperpituittar

ism

Children:

gigantismAdultsacromegaly

Cushing;s

syndrome

ACTH:moon face,

buffalo hump,

BS

Encapsulated

VSInfiltrating

Encapsulated Infiltrating

med surge 2 mod 3 study guide

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