Hinkle Chapter 66: Management of Patients With Neurologic Dysfunction
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered
Low Normal = 70-100
The most common cause of status epilepticus
Sudden withdrawal of medication
In a client with a contusion to the forehead, what reaction of the pupils would confirm increasing intracranial pressure?
Unequal response
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as
decerebrate
Which phase of a migraine headache usually lasts less than an hour?
Aura
What may the symptom papilledema indicate in this client?
Brain Tumor
These may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.
Burr Holes
An abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities
Decerebrate
What would be the expected outcome of Baclofen for a patient diagnosed with MS?
Decreased muscle spasms in the lower extremities
What nutritional approach for seizure management would be beneficial for a patient with a seizure disorder
High in protein and low in carbohydrate
What diuretic is given to dehydrate the brain and reduce cerebral edema.
Mannitol
During the postictal phase of a seizure, the client is yelling and swings a closed fist at the nurse. What is an appropriate action by the nurse?
Reorient the client while gently holding their arms
Which cardiovascular findings are late indicators of increased ICP?
Rising blood pressure and bradycardia
After supratentorial intracranial surgery the nurse should place the patient in what position?
Supine position with the head slightly elevated
What pharmacologic therapy will the nurse administer to a patient with diabetes insipidus to control symptoms?
Vasopressin or Desmopressin
the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet. What posture would the nurse record this as?
decorticate
A client is being treated for intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because
shivering in hypothermia can increase ICP
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
Of the two choices of posturing (decorticate or decerebrate), which one demonstrates a deeper and more severe dysfunction?
Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing.
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate
This is the initial sign if elevated intracranial pressure
Decreased level of consciousness
What is one of the earliest signs of increased ICP?
Decreased level of consciousness (LOC)
What adverse effects can be associated with long-term phenytoin (Dilantin) use?
Gingival hyperplasia (swollen and tender gums) - Perform thorough oral care
A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. An ICP of what would demonstrate effectiveness?
ICP of 0 to 15 mm Hg
What does the Cushing's triad indicate?
Increased ICP
An hourly output of what volume over 2 hours may be a positive indicator of diabetes insipidus
More than 200 mL/h
What drug may be used after a seizure to maintain a seizure-free state?
Phenytoin or phenobarbital
What is the most appropriate intervention for a patient experiencing papilledema?
Place a patch over one eye
A client with neurologic infection develops cerebral edema from SIADH. Which is an important nursing action for this client?
Restricting fluid intake and hydration
In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?
Vasodilation
Neurologic sequelae include damage to the cranial nerves that facilitate
Vision (II Optic) and hearing (VIII Acoustic)
The underlying cause of a seizure is:
An electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain
The causes of acquired seizures include:
Cerebrovascular disease Hypoxemia of any cause, including vascular insufficiency Fever (childhood) Head injury Hypertension CNS infections Metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure) Brain tumor Drug and alcohol withdrawal Allergies
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:
52 mm Hg. CPP = MAP - ICP MAP = 2(DBP)+SBP 3 MAP = 2(60)+90 = 52 3
These seizures are characterized by a brief loss of consciousness, during which physical activity ceases
Absence
Which nursing intervention following a subdural hematoma reduces the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as ordered
What will the nurse recognize as the symptoms associated with Cushing's triad?
Bradypnea (respiratory irregularity) Hypertension Bradycardia
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. What is the first action the nurse should take?
Check the equipment - A reading of 0 mm Hg indicates equipment malfunction
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). What would be considered some late signs of increasing ICP?
Decreasing level of consciousness until client is comatose Decreased or erratic pulse and respiratory rate Increased blood pressure and temperature Widened pulse pressure Cheyne-Stokes breathing Projectile vomiting Hemiplegia or decorticate or decerebrate posturing Loss of brain stem reflexes (pupillary, corneal, gag, and swallowing)
What would the nurse expect when assessing a patient with dibetes insipidus secondary to a TBI?
Excessive urine output and decreased urine osmolality, and serum hyperosmolarity
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Generalized
What medications are administered slowly in an attempt to halt seizures immediately?
IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx)
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). What is your priority nursing diagnosis?
Ineffective airway clearance related to altered LOC (ABCs)
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?
Maintains a patent airway
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol
