NRNP Finals 6560 QUESTION AND ANSWER WITH COMPLETE SOLUTION

NRNP Finals 6560 QUESTION AND ANSWER WITH COMPLETE SOLUTIONcoup-contrecoup injury Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. Scalp laceration: what, effect, management Primary head injury profuse bleeding - signs of hypovolemia Apply direct pressure Suture/ staple laceration Lidocaine 1% with epi to control bleeding, not close to nose/ ears Skull fracture: types, effect, management Primary head injury Simple: no displacement of bone. Observe and protect spine Depressed: bone fragment depressing thickness of scull Surgery for debridement. Give tetanus and seizure precautions Basilar: fracture at floor of skull Raccoon eye - periorbital bruising battle's sign: mastoid bruising otorrhea/ rhinorrhea - halo sign: do not obstruct flow Give Ab's Oral intubation and oral gastric instead of nasal Brain injury: types, effect, management Primary head injury Concussion: reversible change in brain functioning loss of consciousness, amnesia Do not give opioids, admit for unconsciousness greater than 2min Contusion: bruising to surface of brain with edema Frontal and temporal region Brainstem contusion: posturing, variable temp, variable vital signs N/V, dizziness, visual changes seizure precautions Hematoma - neuro: types, effect, management Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into epidural space Loss of consciousness Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation CT scan (non contrast) Treatment based on Brain trauma foundation. Surgical if greater than 30cm Subdural hematoma most common type of intracranial bleed Acute (hours): drowsy, agitated, confused, headache, pupil dilation, CT scan (noncontrast) surgery for 10mm thickness or 5mm midline shift or for worsening GCS Chronic (days): headache, memory loss, incontinence CT scan (noncontrast) Surgery: burr holes/ crani Cerebral edema/ ICP elevated/ herniation: symptoms, management decreased level of consciousness Blown pupil Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure) Neuro exam components AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive GCS: 8 or below is comatose Posturing: decorticate = arms, legs in decerebrate = arms, legs out Electrolyte imbalances in brain injury Hyponatremia: SIADH and cerebral salt wasting Hypernatremia: DI (give mannitol) Management of traumatic brain injury - Consult neurosurgery - Limit secondary injury - Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion. - Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during first 24hrs. - sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to help oxygenate/ ventilate - steroids: avoid - Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium, and bp. - Seizure precautions: give phenytoin or keppra - DVT prophylaxis: stockings, LMWH - head injury means spine injury until proven otherwise - hypothermia: can control ICP (89 - 91F) - decompressive crani: ICP refractory to tx - brain O2 monitoring (jugular vein O2 sats) ICP monitoring For: GCS 3-8 with abnormal CT and comatose pt's with normal CT and older than 40, posturing, hypotension. Normal value: 5-10 mmHg Recommend initiating treatment if ICP > 20 mmHG. Can calculate CPP (CPP = MAP - ICP). Should be 60 Brain death criteria Must have all: No spontaneous movement Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll's eyes, absent gag, absent vestibular response) Absence breathing drive/ apnea can't be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base imbalance EEG, CTA of brain, Cerebral angiography, transcranial doppler Spinal cord trauma: cause and who - MVA, falls, acts of violence, sports, wounds - Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then shattering from falls/ dive lands on butt, at C1 from diving), whiplash - Distraction injury: from hanging - penetrating trauma: from wound - pathologic fractures (osteoporosis/ cancer) mainly cervical spine. High mortality. More common in men more common in young than old Fractures and vertebrae Cervical: C1-C7. Flexible and small diameter so many fractures Thoracic (T1-T12): connected to ribs. Not common in fractures Lumbar: L1-L5: Very mobile, requires great force to fracture Sacral Spinal cord trauma assessment - History: mechanism of injury, pt's complaints, pre-hospital tx - Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 - C6 spares diaphragm so breathing exists. - grade strengthening (0= no muscle contraction, 5 = full strength) - complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis. - incomplete lesion: parts of spinal cord intact - sensory function: start at no feeling then go to feeling - evaluate back (log-roll) Motor assessment in spinal cord trauma If unable to do, # above: Deltoids (C4): shrug shoulder Biceps (C5): flex arm and push arms away Wrist (C6): try to straighten wrist while pt tries to flex Triceps (C7): extend arm and try to bend while pt prevents that Intrinsic (C8): fan fingers and push together Hip flexion (L2 - L4): bend knee and apply pressure Knee extension (L2-L4): extend knee with hip/ knee flexed key signs of spinal cord injury - various levels C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss C5-C6: diaphragmatic brething, paralysis of intercostal muscles, quadriplegia, anaesthesie below clavicle, areflexia, fecal/ urinary retention, priaprism T12-L1: paraplegia, anesthesia legs, areflexia legs, fecal/ urinary retention, priaprism L1-L5: flaccid paralysis, ankle/ plantar areflexia Multisystem impact of spinal cord injury Cardiovascular: - hypotension/ spinal shock. Fluid resuscitation (LR) - bradycardia; oxygenate well, normothermia, atropine - vasovagal reflex: limit suctioning length - Poikilothermy - venous thrombosis: dvt prophylaxis - orthostatic hypotension GI: - abdominal injuries: assess for abd distention - curling's ulcer: stress ulcer. Give ranitidine - gastric atony and ileus: NG to LIS - loss of bowel function: initiate bowel program GU: - autonomic dysreflexia: HTN crisis from distended bladder or other noxious stimulu. Decompress bladder. - UTI Musculoskeletal: - paralysis - wounds Psychological: - ineffective coping, powerlessness, denial/ anger/ depression. Be honest with positivity, include pt, interdisciplinary approach Spinal cord lesions/ syndrome Anterior cord syndrome: weakness/ paralysis with loss of sense of pain and temp Posterior cord syndrome: can't feel touch and vibration Central cord syndrome: greater loss in upper extremities than lower Brown sequard syndrome: one side of spinal cord is damaghed by stab/ gun wound. Ipsilateral motor loss and contralateral loss of pain and temp sense. Extremities that can move have no feeling and that have feeling can not move. Spinal cord injury: diagnostics Cervical vertrebrea: lateral xr, then AP (swimmer view) Thoracic vertebrae: lateral and AP xr, view all 12 Lumbar: lateral and AP, view all 5 CT to check for bony fragments Films in flexion. extension to check for fractures Myelogram: detects compression of cord by herniated disks, bone or foreign matter MRI: cord impingement, hematoma, infarct, contusion, hemorrhage. Spinal cord management - Consult neuro - Airway maintenance (do not hyperextend neck when intubating) - immobilization (cervical collar/ spine board) - intravascular fluid (neurogenic shock: warm, dry, brady) - monitor bp (avoid hypotension: keep MAP 85) - Foley - NG - AB for penetrating injury - room temp - good skin care - fixation of spine - fusion: attaching injured vertebrae Key features of dementia - General decrease in level of cognition - thinking, memory, reasoning - Behavioral disturbance - Interference with daily function and independence Not a disease, but group of symptoms by various diseases Alzheimer's disease most common form of dementia Neuritic plaques, neurofibrillary tangles, degeneration of cholinergic neurons causing irreversible neuronal damage. B-amyloid present in high levels. Effect: cerebral atrophy. Causes of brain degeneration Alzheimer's Parkinson's Huntington's Vascular: stroke, arteritis Infectious: HIV, Syphilis, Meningitis, Encephalitis CNS/ toxic: drug overdose Nutritional deficiency: Vit B12, folate deficiency Chronic seizures Lewy body dementia symptoms of dementia - Slow onset - memory loss and confusion - problems with language - impaired abstract reasoning - aphasia, apraxia, agnosia - disorientation - poor judgement - emotional problems - sleeplessness Dementia labs/ diagnostics - History: family/ spouse report - Physical: neuro, cognitive examz: Mini mental State exam (score 23 or less is cognitive impairment), document in 3-6mo intervals - Labs: glucose, electrolytes, magnesium, calcium, liver tests, BUN/ creat, thyroid, Vit B12, HIV, CBC, ABG, cultures, drug screen - CT head/ MRI: for tumor/ infarction - PET scan: differentiate dementia type - EEG - Lumbar: rule out meningitis, neurosyphilis - XR chest: rule out CHF, COPD - ECG - Identify treatable cause DSM-V criteria for dementia 1. Memory impaired 2. At least two of these: aphasia, apraxia, agnosia, disturbance in executive functioning 3. Disturbance of one or two of these disrupts functioning 4. Disturbance not only during delirium Dementia management - supportive: living situation - treat underlying illness - stop nonessential meds - maintain nutrition - avoid restraints, except for safety - address safety issues - cholinesterase inhibitors can improve symptoms mildly (because of cholinergic deficiency) - Alzheimer's related: meds very mild and temporary effect Medication for dementia Mild to moderate Alzheimer's: - Donezepil 5mg, then 10mg after 4-6 wks. Can cause syncope, brady, AV-block, N/V, weightloss - Rivastigmine. With food, can cause hypotension, syncope - Galantimine, 4mg for 4 wks, then 8mg 4 wks, then 12mg. Avoid in renal and liver failure Moderate to severe dementia: - Memantine (N-methyl-d-aspartate rec anatgonist), prevents progression. May be paired with donezepil. May cause Stevens-Johnson's For aggression: - Olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone, Ziprasidone. Short term. May cause tardive dyskinesia - Haldol may help too for unmanageable aggression. - Benzo's: Clonazepam. May cause paradoxical aggression. Lorazepam For emotional lability: - Imipramine - Setraline - Zoloft - Citalopram multiple sclerosis Disease with myelin sheath destruction causing disruptions in nerve impulse conduction. Acquired, immune-mediated. Relapses/ attacks/ exacerbations and remissions Etiology of MS More women than men Caucasians, more northern European Early onset, 20-40ies Measles, Herpes, Chlamydia, Epstein-Barr Classification of MS Relapsing - Remitting: Clear/ defined episodes of relapse and recovery. No progression between episodes and return to baseline. Most often initial presentation. Secondary progressive: As Relapsing- Remitting, but then progression between episodes. No return to baseline. Primary progressive: Continued disease progression. Minor improvements. Usually after 40yrs. Progressive relapsing. Progressive disease with relapses, and progression in between. Malignant MS: rapid onset, rapid deterioration Benign MS: No deterioration after 10 yrs MS symptoms Subjective: - Motor weakness, stiffness - Numbness, tingling, burning, pain - double vision, dysarthria, dysphasia, vertigo (brain stem) - visual deficits - gait ataxia, tremor, uncoordinated movements (cerebellum) - cognitive dysfunction: memory, processing - fatigue (common!) - sleep disorder - bladder, bowel dysfunction - seizures Objective: - decreased sensation of pinprick, vibratory, temp - Reflex changes: abnormal deep tendon, pos babinski, pos hoffman's - brain stem changes: nystagmus, hearing loss, tinnitus - Cerebellar: ataxia, tremor, poor coordination - visual field changes - frontal lobe: cognitive dysfunction, emotional changes MS diagnostics - neuro exam - MRI (white matter lesions, lesions spinal cord, T1 and T2 lesions) (diagnostic!) - CSF analysis: elevated igG and oligoclonal bands in CSF but not serum MS management - consult neuro - no intervention for mild attack - Acute intervention for relapse with Glucocorticoid (po or iv) - symptom management meds - disease modifying meds: to reduce relapse, delay disability, and decrease MRI lesions: - Fingolimod. For relapsing. May cause brady, AV-block, HTN, diarrhea - Betaseron. For relapsing. May cause depression/ suicidality - Avonex. For relapsing. May cause flu-like symptoms - Rebof. For relapsing. May cause flu like symptoms - Glatiramer acetate. For Relapsing/ remitting. - Mitoxantrone. For sec progressive, progressive, or worsening relapsing/ remitting. Parkinson's disease: what, etiology Neurodegenerative disorder caused by depletion of dopamine-producing cells causing resting tremor, rigidity, slowness of movement. Age onset: 60 more men than women caucasians Environmental (metals such as copper) and genetic factors. Gene: PARK1