NGN Neurologic EAQ Case Study Questions and Answers

NGN Neurologic EAQ Case Study Questions and Answers Complete the diagram from the choices below to specify what one potential condition the client is most likely experiencing, two scoring tools the nurse should use to document the condition, and two primary pharmacologic treatments that should be prescribed for the condition. Scoring Tool Glasgow Coma Scale (GCS) 15 Hunt and Hess classification grade II National Institutes of Health Stroke Scale (NIHSS) score of 12 Visual Aura Rating Scale (VARS) score of 3 undefined Potential Condition subarachnoid hemorrhage (SAH) bacterial meningitis thrombotic stroke migraine headache Pharmacologic Treatment intravenous antihypertensive medication intravenous antibiotic therapy triptan therapy parenteral opioids intravenous recombinant tissue plasminogen activator (rtPA) Potential Condition - Subarachnoid Hemorrhage (SAH) Scoring Tool - Hunt and Hess classification grade II Glasgow Coma Scale (GCS) 15 Pharmacologic Treatment - Intravenous antihypertensive medication Parenteral opioids Rationale: An SAH is intracerebral bleeding in the subarachnoid space. One of the most common causes of SAH is a cerebral aneurysm. As an individual with a congenital cerebral aneurysm gets older, blood pressure increases, and more stress is placed on the poorly developed thin vessel wall. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space. A client with an SAH characteristically has an abrupt onset of pain, described as the "worst headache of my life." A brief loss of consciousness, nausea, vomiting, focal neurologic deficits, photophobia, and a stiff neck may accompany the headache. The presence of blood is an irritant to the meninges, particularly the arachnoid membrane, and the irritation causes headache, stiff neck, and photophobia. Clients with meningitis also experience an acute onset of symptoms (e.g., headache, stiff neck, vomiting, photophobia), but the symptoms develop over 1 to 2 days. There also may be a recent history of infection, foreign travel, or illicit drug use. The client reported feeling well until the morning of admission. Clinical presentation of meningitis often reveals signs of systemic infection, including fever (temperature as high as 101.3°F [39.5°C]), tachycardia, chills, and petechial rash. The client did not have an elevated temperature or tachycardia. With meningitis, left shift is typically present; there is no evidence of abnormal white blood cell (WBC) count findings with this client. The client did not have hemiparesis, aphasia, and hemianopia Neurologic - Patient 2 H&P 1700 (admission): A 29-year-old client transferred to the ED after bystanders found client lying in a ditch after apparently losing control of motorcycle and going off the road. The physical examination revealed mild facial abrasions, a Glasgow Coma Scale (GCS) of 11, and cerebral spinal fluid (CSF) otorrhea on the left. Computed tomography (CT) of the head shows a subarachnoid hemorrhage. Previous medical records indicate a history of smoking, clinical depression, and hyperlipidemia. NURSES' NOTES 1700 (admission): Client admitted to emergency department (ED). Drowsy. Does not open eyes spontaneously but will open them slowly upon command. Flexes upper and lower extremities to withdraw when applying mild pain. Able to state name. Unable to state date of birth, location, or the day of the week. Client remembers leaving apartment on motorcycle but does not remember an accident. Cardiac tel Review assessment findings. Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The assessment findings related to an increased intracranial pressure (ICP) include ____1____, ____2____, and ____3____. 1. confused flexes to withdraw from pain Cheyne-Stokes respirations 2. Glasgow Coma Scale (GCS) of 11 eyes open to verbal command Cushing triad 3. blood pressure (BP) 170/114 mmHg temperature 100F (37.78C) 2+ deep tendon reflexes (DTRs) 1. Cheyne-Stokes respirations 2. Cushing triad 3. blood pressure (BP) 170/114 mmHg Rationale: Cushing triad is a late sign of increased ICP and consists of systolic hypertension with a widening pulse pressure, bradycardia, and irregular respirations. An example of irregular respirations is Cheyne-Stokes breathing, which is characterized by cyclical episodes of apnea and hyperventilation. Widening pulse pressure is the difference between the systolic BP and the diastolic BP. Upon admission, the pulse pressure was 56 (170 minus 114); at 1715, the pulse pressure was 66 (174 minus 108). The increase from 56 to 66 is a widening pulse pressure. Hypertension (170/114 mmHg) is common early with increased ICP and represents a compensatory mechanism to augment cerebral perfusion pressure. It often signifies irreversible damage. The GCS is a commonly used standardized tool assessing consciousness and cognition. The best response in each of the three categories of eye opening, verbal response, and motor response is scored, and the three scores are added together to get a total score. GCS scores range from 3 (deep coma) to 15 (normal functioning). A score of 11 does not indicate increased ICP. A GCS of 8 or less is consistent with coma. Confusion, flexing to withdraw from pain, and eyes opening to verbal command are three of the criteria on the GCS. GCS findings are abnormal but do not necessarily indicate increased ICP. An elevated temperature may cause increased ICP, but it is not an assessment finding associated with increased ICP. Additionally, a body temperature of 100° F (37.78° C) is not considered to be significant. DTRs are graded according to the response elicited: 0, no reflex; 1+, hypoactive; 2+, normal; 3+, increased but normal; 4+, very brisk, hyperreflexive, clonus. Alterations in DTRs may indicate damage of the For each body system, chose the most likely option for diagnostic test and treatment goal. Body System-Neurologic Diagnostic Test CT scan with contrast MRI Treatment Goal intracranial pressure (ICP) 20 mmHg cerebral perfusion pressure (CPP) 80 mmHg Body System-Respiratory Diagnostic Test arterial blood gas (ABG) pulmonary function tests Treatment Goal PaO290 mmHg PaCO2 35 to 45 mmHg Body System-Cardiac Diagnostic Test echocardiogram electrocardiogram (ECG) Treatment Goal mean arterial pressure (MAP) 70 to 90 mmHg slight bradycardia (55 to 60 bpm) Body System-Neurologic Diagnostic Test MRI Treatment Goal intracranial pressure (ICP) 20 mmHg Body System-Respiratory Diagnostic Test arterial blood gas (ABG) Treatment Goal PaCO2 35 to 45 mmHg Body System-Cardiac Diagnostic Test electrocardiogram (ECG) Treatment Goal mean arterial pressure (MAP) 70 to 90 mmHg Rationale: Neurologic: Radiologic studies and other diagnostic tests that maybe performed on a client with increased ICP include CT scan (usually without contrast) to assess the potential for a worsening intracranial mass effect and MRI to provide anatomical detail of pathology contributing to increased ICP. The goal of management is to maintain an ICP of less than 20 mmHg while maintaining the CPP at greater than 70 mmHg. Respiratory: ABG exerts a profound effect on cerebral blood flow. There is no indication that pulmonary function tests should be performed; excessive stimulation should be avoided in clients with increased ICP. The goal is to maintain a PaO2 above 80 mmHg and to ensure that oxygen delivery to the brain exceeds oxygen consumption. Carbon dioxide, which affects the pH of the blood, is a potent vasoactive substance. It is recommended that the PaCO2 be kept within a normal range (35 to 45 mmHg). Cardiac: Side effects of the medications used in nervous system alterations include ventricular dysrhythmias, bradycardia, tachycardia, and ECG changes; the client should be placed on continuous cardiac monitoring. There is no indication that an ECG is needed. The MAP is usually kept between 70 and 90 mmHg; however, it is critical to monitor the ICP and MAP collectively to sustain an adequate CPP of at least 70 mmHg. A normal heart rate should be maintained to ensure adequate perfusion. The nurse reviewed the assessment findings and anticipates which action is included in the client's plan of care? Select all that apply. Assess neurologic status hourly. Notify healthcare provider if intracranial pressure (ICP) is 20 mmHg for 15 minutes. Suction every 4 hours and as needed. Maintain head in a neutral position. Weigh daily. Cough and deep breathe every 2 hours. Maintain hourly intake and output (I & O). Administer osmotic diuretics as prescribed. Assess neurologic status hourly. Maintain head in a neutral position. Weigh daily. Maintain hourly intake and output (I & O). Administer osmotic diuretics as prescribed. Rationale: To detect changes indicative of increased ICP, assess neurologic status hourly, including level of consciousness, pupillary function (other cranial nerve functions as indicated), strength and equality in bilateral extremity movements, superficial and deep tendon reflex activity, and sensory function where appropriate. To facilitate cerebral venous drainage and prevent increased ICP, maintain the client's head in a neutral position and maintain head-of-bed elevation that keeps ICP and CPP within normal ranges. To monitor fluid volume status, weigh the client daily and monitor I&O hourly. An osmotic diuretic is often prescribed to treat increased ICP. The medication pulls water from the brain interstitium into the plasma. Monitor ICP and CPP; notify the healthcare provider if ICP 20 mmHg is sustained for more than 5 minutes. Sustained increases in ICP lasting longer than 5 minutes should be prevented. Because endotracheal suctioning is associated with hypoxemia, suction the client only when necessary. Obstruction of venous outflow results in increased cerebral blood volume and increases ICP. Mechanisms that increase intrathoracic or intraabdominal pressure also impair venous return (e.g., coughing, vomiting, posturing, isometric exercise, Valsalva maneuver, positive end-expiratory pressure, hip flexion); these activities should be avoided. For each medication, click to specify whether it is indicated (appropriate or necessary) or contraindicated (could be harmful) if included in the client's plan of care at this time. Labetalol Benzodiazepine Phenytoin Nitroprusside Morphine INDICATED Labetalol Benzodiazepine Phenytoin Morphine CONTRAINDICATED Nitroprusside Rationale: Hypertension (160 mmHg systolic) can worsen cerebral edema by increasing microvascular pressure. However, hypertension may be necessary for adequate cerebral perfusion. If necessary, systolic blood pressure is lowered with antihypertensive medications (e.g., beta blockers such as labetalol). Beta blockers decrease the sympathetic response and catecholamine release associated with neurologic injury. Administer analgesia and sedation for the client with an elevated intracranial pressure (ICP) to reduce pain, agitation, restlessness, or resistance to mechanical ventilation. Analgesics (e.g., morphine, fentanyl) can be administered in a low-dose continuous infusion or in small, frequent intravenous boluses for analgesia and sedation or analgosedation. Common sedatives administered are benzodiazepines and propofol. Benzodiazepines do not affect cerebral blood flow (CBF) or ICP. Phenytoin (Dilantin) depresses seizure activity by altering ion transport in the motor cortex. Some antihypertensive medications (nitroprusside, nitroglycerin) and some calcium channel blockers (verapamil, nifedipine) cause cerebral vasodilation, which increases CBF and causes increased ICP. Review the findings to anticipate the course of treatment for the new symptoms that began on hospital day 5. Drag from Word Choices to complete the sentence. The nurse identifies that inclusion criteria for the administration of recombinant tissue plasminogen activator (rtPA) include __________ and_________. Word Choices the administration of medication before 1130 (and possible consideration of extending the administration to 1300) the absence of anticoagulant therapy administration in the past 24 hours the National Institutes of Health Stroke Scale (NIHSS) score of 10 the Glasgow Coma Scale (GCS) score of 10 that the CT scan results are consistent with an ischemic stroke the administration of medication before 1130 (and possible consideration of extending the administration to 1300) that the CT scan results are consistent with an ischemic stroke Rationale: Inclusion criteria for the administration of rtPA include: onset of stroke symptoms less than 3 hours (the time frame for rtPA can be extended to 4.5 hours, with some additional exclusions); clinical diagnosis of ischemic stroke with a measurable deficit using the NIHSS; age greater than 18 years; and CT scan consistent with ischemic stroke. A NIHSS score 10 is not an inclusion (or exclusion) criterion. There is no GCS score that determines the client's eligibility. The client may still be eligible even if the client received anticoagulation therapy. The client's coagulation profile results will be evaluated to determine eligibility; this would include international normalized ratio (INR), platelets, and the partial thromboplastin time (PTT; also known as activated partial thromboplastin time (aPTT). For each client care criteria, click to specify the evaluation finding that reflects successful prevention of increased intracranial pressure. Each client care criteria may support more than one evaluation finding. Each category must have at least one response option selected. Client Care Criteria-Laboratory results Evaluation Finding serum osmolality 305 mOsm/kg water (H2O) potassium 3.1 mEq/L Client Care Criteria-Blood pressure management Evaluation Finding cerebral perfusion pressure (CPP) 75 mmHg mean arterial pressure (MAP) 75 mmHg Client Care Criteria-Client activities Evaluation Finding client performs coughing and deep breathing exercises every 2 hours client medicated with antiemetics as needed Laboratory Results -serum osmolality 305 mOsm/kg water (H2O) Blood pressure management -cerebral perfusion pressure (CPP) 75 mmHg -mean arterial pressure (MAP) 75 mmHg Client activities -client medicated with antiemetics as needed Rationale: Strict measurement of intake and output while monitoring serum sodium, potassium, and osmolarity is required. The goal is to keep serum osmolality at less than 320 mOsm/L. The MAP is usually kept between 70 and 90 mmHg; however, it is critical to monitor the ICP and MAP collectively to sustain an adequate CPP of at least 70 mmHg. Along with MAP, the ICP determines CPP, which is the pressure required to perfuse the brain. CPP is calculated as the difference between MAP and ICP (CPP = MAP - ICP). The normal CPP in an adult is between 60 and 100 mmHg; it must be maintained at 70 mmHg or greater in those with brain pathology. Mechanisms that increase intrathoracic or intraabdominal pressure impair venous return (e.g., coughing, vomiting, posturing, isometric exercise, Valsalva maneuver, positive end-expiratory pressure, hip flexion). These activities should be avoided. Preventing vomiting through the use of antiemetics is appropriate.