66- Managment
In order to maintain CCP and decrease ICP what postion should the nurse maintain?
*HOB = 30-45 degrees- promotes venous drainage *maintain the head in midline/neutral position-Possible cervical collar AVOID *neck flexion, head rotation, hip flexion *coughing, sneezing, bending fwd, suctioning
increased intracranial pressure
5-15 mmHg normal pressure. Anything that causes swelling, bleeding, space occupying will increase this pressure. Results from an increase in intracranial content that occurs with tumor growth, edema, excess cerebrospinal fluid (CSF) or hemorrhage.
3
A nurse assesses the patients LOC using the Glasgow coma scale. What score indicates severe impairment of neurologic function?
Bradycardia, Bradypnea, hypertension
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's Triad what will the nurse recognized as the symptoms associated with Cushing's Triad?
More than 200 ml/hr
A nurse is assessing a patients urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly out part of what volume over two hours maybe a positive indicator?
Locked in syndrom
A patient has a lesion affecting the pons, resulting in paralysis And the inability to speak, but has vertical I movements and lid elevation this patient is suffering from
Notify the physician of a possible cerebral spinal fluid leak
A patient three days postoperative from a craniotomy informs the nurse, I feel something trickling down the back of my throat and I taste something salty. What priority intervention does the nurse initiate?
Foot drop and paralyzed extremity
Assist with daily active or passive range of motion
Loosen clothing, position oon side with head flexed forward, provide for privacy
Care provided for a patient experiencing a convulsive seizure- SATA
Impaired cough reflex, paralyzed diaphragm
Elevate the head of the bed 30°
Before and after suctioning the patient is adequately ventilated to prevent hypoxia
If a patient with an altered LOC requires suctioning what intervention is a priority for the nurse to provide?
Incontinence
Institute of bowel training program
Respiratory distress, pneumonia, aspiration, pressure ulcer, deep vein thrombosis, and contractures
List five potential collaborative problems for a patient with an altered LOC
Foot drop
Maintain dorsiflexion to affected area
high protein, low carbs
Nurse is educationg patient with seizure disorder. What diet would be best?
Cerebral Adema, pain, seizures, increased ICP and neurologic status
Nursing postoperative management includes detecting and reducing_______ relieving______ preventing______ and monitoring______ and ______
Notify Physician of possible CSF leak.
Patient 3 days post op from craniotomy informs nurse " I feel something trickiling down my throat that tastes salty" what priority intervention does the nurse initiate?
Vasopressin
Patient had a small pituitary adonoma Removed by the transphenoidal approach and has developed diabetes insipidus. What pharmacological therapy will the nurse be administering to this patient to control symptoms?
Impaired cough reflex
Place the patient in a lateral position
A change in the LOC
The earliest sign of increased ICP
ICP Assessment/ Causes
The most important nursing assessment is that of the level of consciousness. If there is an alteration, the patient might exhibit a decrease in orientation to person, time, or place; may not follow commands appropriately; and may not be alert. This can be a sign of an increase in intracranial pressure. There are many factors that can influence an altered level of consciousness, including trauma, tumors, seizures, or stroke.
0-10mmhg
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient?
Increased ICP
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a sub dural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases the lungs. What does the nurse suspect is occurring?
Maintenance of a patent airway
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?
Mannitol
The nurse is caring for a patient with increased ICP. As a pressure rises what asthmatic diuretic does the nurse prepare to administer?
70
The patient is admitted to the hospital with an ICP reading of 20 MMHG and a mean arterial pressure of 90 MMHG. What would the nurse calculate the CPP to be?
Brain herniation resulting in death
The primary lethal complication of ICP is
Pneumonia, aspiration, respiratory failure
Three major potential complications in a patient with a depressed level of consciousness are
Brainstem herniation, diabetes insipidus, Syndrome of inappropriate antidiuretic hormone SIADH
Three primary complications of increased ICP are
Lethargy and stupor
What does the nurse recognized as the earliest sign of serious impairment of brain circulation related to increased ICP?
Stool softeners may be prescribed. When Alex is awake and alert, a high-fiber diet may be indicated. Abdominal distention, which increases intra-a domino and intrathoracic pressure and I CP, should be noted. Enemas and cathartics our avoided if possible. When moving or being turned in bed ask Alex to exhale which opens the quad us to avoid the Valsalva maneuver.
What intervention can the nurse provide to avoid having Alex perform the Valsalva maneuver?
An altered level of consciousness is present when the patient is not orientated does not follow commands, or needs persisted stimuli to achieve a state of alertness. LOC is guaged on a continuum, with a normal state of alertness and full cognition on one end and coma on the other end.
What is meant by an altered level of consciousness?
Alertness is measured by the patient's ability to open the eyes spontaneously or in response to a vocal or noxious stimulus which is pressure or pain.
What is the optimal way to determine the level of a patient's alertness?
Osteoporosis
When educating patients about long-term use of anticonvulsant medication, what should the nurse inform the patient is a result of long-term use in women?
A neurologic examination should include evaluation of mental status, cranial nerve function, cerebellar function, reflexes, and motor and sensory function, as well as the score of the Glasgow coma scale.
When the nurse performs a neurologic examination, what should be included?
Space activities to avoid stress and strain. Maintain a calm atmosphere and decrease environmental stimuli.
When the nurse plans Alixis care, how can his needs be met in order to prevent a rise in ICP and a decrease in CPP?
epidural hematoma tx
emergency craniotomy
epidermal hematoma
is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull.
