6-headaches

neurologic infection

A patient with _________should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratory distress

surgery

After______, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg position, and the prone position can increase intracranial pressure

barbiturates

Although mannitol is a type of diuretic, it is not used to increase urine output. Medications such as________ are given to the patient with IICP to reduce cellular metabolic demands

To dehydrate the brain and reduce cerebral edema

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects?

Assess for a patent airway.

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?

______

Controlling a fever is an important intervention for a patient with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate for control of fevers. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection.

patient's head

Enemas should be avoided in patients with increased ICP. The Valsalva maneuver causes increased ICP. Suctioning should not last longer than 15 seconds. Environmental stimuli should be minimal. If monitoring reveals that turning the patient raises ICP, rotating beds, turning sheets, and holding the________ during turning may minimize the stimuli that cause increased ICP

Rational

Some patients during the postictal phase will become confused and agitated. This reaction is not intentional and most patients do not remember becoming agitated. The nurse should attempt to calm and reorient the patient, but also should gently hold the arms to prevent the patient from hitting. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the patient before applying wrist restraints. Lorazepam (Ativan) is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this patient.

ICP

The eartiest sign of increasing______ is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

Monro-kellie hypothesis

The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.

Decorticate

Which of the following types of posturing is exhibited by abnormal flexion of the extremities and plantar flexion of the feet?

Aura

Which phase of the migraine headache lasts less than an hour? This phase occurs in 20% of patients who have migraines and may be characterized by focal neurological symptoms.

Herniation

_______refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure.

Cranial arteritis

______is caused by inflammation. The inflammation can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The patient should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Documentation of signs and symptoms of inflammation should be done by the nurse after measures have been taken to decrease complications.

Cushing's response

______is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP.

Shivering

female patient is receiving hypothermic treatment for uncontrolled fevers related to increased ntracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?

headache phase

lasts from 4-72 hours. During the post headache phase, patients may sleep for extended periods

prodrome phase

occurs hours to days before a migraine headache.

ventriculostomy

A________ is used to continuously measure ICP and allows cerebral spinal fluid (CSF) to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so an ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system.

ICP early signs and aymptoms

Headache is an early sign of increased ICP. Irritability and any change in LOC are early signs of increased ICP. Speech changes, such as slowing or slurring, are early signs of increased ICP.

The dynamic equilibrium of cranial contents

The Monro-Kellie hypothesis refers to which of the following statements?

70 to 100 mm Hg

The normal CPP is________. A CPP of 40 mm Hg is low.

Place patient in supine position with head slightly elevated.

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate?

Administer acetaminophen (Tylenol) per orders.

The nurse is caring for a patient involved in a motorcycle accident 7 days ago. Since admission the patient has been unresponsive to painful stimuli. The patient had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92 , respirations per ventilator , temperature 102.7 ° F rectal , urine output 320 mL in 4 hours , pupils pinpoint and briskly reactive, and hot, dry skin. Which of the following is the priority nursing action?

IICP is 12 mm Hg.

The nurse is caring for a patient with a ventriculostomy. Which assessment finding documented demonstrates effectiveness of the ventriculostomy?

Administer corticosteroids as ordered.

The nurse is caring for an 82-year-old patient diagnosed with cranial arteritis. What is the priority nursing intervention?

Altered resp. Patterns

What is a late sign of ICP? This may indicate pressure or damage to the brainstem.

Decerebrate posturing

_________, the result of lesions at the midbrain, is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Anticonvulsants

__________are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the patient with increased ICP

24-36hrs

Cerebral edema peaks at which time frame after intracranial surgery?

_____

Oral care should be provided frequently because the patient is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a patient with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated at 30 to 45 degrees and in a neutral position to allow for venous drainage.

Migraine

This type of headache is caused by vascular changes. It is generally more common in women than men and can last up to 72 hours. There are four phases: • The first phase is prodromal. This occurs for a few days or hours prior to the start of a migraine. • An aura may be present prior to the start of the headache pain and is described as seeing spots or light flashes. Half of the visual field is affected so the disturbance is seen on one side, rather than both. • The headache phase begins with the onset of unilateral throbbing pain. It can be severe and can render the patient incapable of normal daily functioning. • The recovery phase occurs when the pain is subsiding and the patient can return to normal functioning. Rest and sleep are imperative and muscle aching is common.

increases, intrathoracic pressure

Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins________ ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and__________, which can produce a rise in ICIP

seizure

When a patient is in a________, the nurse should turn the patient to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway should not be inserted while the patient is actively seizing. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the patient is actively seizing could cause harm to the patient and is not indicated for seizure activity.

Cerebral circulation

__________ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading of less than 50 is consistent with irreversible neurologic damage

Osmotic diuretics

__________draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

Shivering

_________can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

Autoregulation

_______is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure.

Akinetic mutism

_______is the phrase used to refer to unresponsiveness to the environment.

Restricting fluid intake and hydration

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?

Migraines

The patients should be encouraged to keep a food and headache diary to identify triggers, and to track frequency and characteristics of the migraines. The patients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but the exercise may worsen the headache and associated symptoms. Patients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.

Anticonvulsants

Which of the following medication classifications is utilized preoperatively to decrease the risk of postoperative seizures?

Enemas

Which of the following should be avoided in patients with increased ICP?

Herniation

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Decorticate posturing

_________is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet.

Cushing's response

_________is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.

Flaccidity

_________occurs when the patient has no motor function, is limp, and lacks motor tone.

Antipyretics

________and a cooling blanket are used to control fever in the patient with lICP.

Fluid restriction

________may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients.

Decerebrate

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records patient's posturing which of the following?

b) Administering prescribed antipyretics, d) Maintaining aseptic technique with the intraventricular catheter, a) Frequent oral care

Which interventions are appropriate for a patient with increased ICP?

Ineffective cerebral tissue perfusion

Which is the priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter?

Using a cervical collar

Which of the following are used to help reduce ICP?

Change in level of consciousness (LOC)

Which of the following is the earliest sign of increasing ICP?

Decerebration

_________is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper extremities and plantar flexion of the feet.

Persistent vegetative state

_________is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.

Turn the patient to the side

A female patient with meningitis has a history of seizures. Which of the following actions by the nurse is appropriate while the patient is actively seizing?

• Migraine • Tension • Cluster

A headache is a common condition that is categorized as a symptom rather than as a disease. Many different factors can cause a headache and there may not be an organic cause. This is referred to as a primary headache, and there are three types:

Reorient the patient while gently holding the arms.

A patient experiences a seizure while hospitalized for appendicitis. During the postictal phase, the patient is yelling and swings with a closed fist at the nurse. Which of the following is the appropriate action for the nurse to take?

LOC

A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.

The CPP is low.

A patient with increased ICP has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP?

______

The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The patient is at risk for injury, but this is not first priority. The patient is at risk for fluid volume deficit due to a possible fluid restriction to maintain normovolemia, but this is not first priority. The patient is at risk for infection due to the placement of the intraventricular catheter, but again this is not first priority.

Keep a food diary., c) Maintain a headache diary.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session?

Rational

The nurse needs to control the fever by administering the ordered acetaminophen (Tylenol) as the priority action. An increase in the patient's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the patient has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.