Unit V: Advanced understanding of intracranial regulation
A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client states that he has been achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? "It's important to drink plenty of fluids while you're taking laxatives." "Make sure that you supplement your laxatives with a nutritious diet." "Let's explore other options, because laxatives can have side effects and create dependency." "You should ideally be using herbal remedies rather than medications to promote bowel function."
"Let's explore other options, because laxatives can have side effects and create dependency."
The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." "The sudden, severe headache increases muscle tone and can cause further nerve damage."
"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."
A nurse is collecting data from a client who has increased intracranial pressure (ICP) which of the flowing expected (select all apply) a disoriented to time and place b restlessness and irritability c unequal pupils d ICP 15 mmHG E Headache
A B C E
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? An epidural hematoma An extradural hematoma An intracerebral hematoma A subdural hematoma
An intracerebral hematoma
A halo sign is indicative of which of the following complication of brain injury? Cerebrospinal fluid (CSF) leak Seizure Cerebral edema Ischemia
Cerebrospinal fluid (CSF) leak
one of the earliest signs of increased ICP
Decreasing level of consciousness (LOC)-Clients may slip from alert and oriented to lethargic, stuporous, semicomatose, and, finally, comatose
A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache? Initiating a patient-controlled analgesia (PCA) of morphine sulfate Administering hydromorphone IV as needed Dimming the lights and reducing stimulation Distracting the client with activity
Dimming the lights and reducing stimulation
A client with a herniated lumbar disc has asked about nonsurgical strategies to help with mobility. What strategies will the nurse teach the client? Select all that apply. Muscle relaxants Weight reduction Physical therapy Hydrotherapy Nonsteroidal anti-inflammatory medications Positive feedback and attitude
Muscle relaxants Weight reduction Physical therapy Nonsteroidal anti-inflammatory medications
A skull fracture is a break in the continuity of the cranium. The most common types are simple, depressed, or comminuted fractures
Simple- Linear crack without any displacement of the pieces Depressed-Broken bone pushed inward toward the brain Comminuted-Bone splintered into fragments
¡Assess for CSF leakage from nose and ears ÷How do you assess for CSF?
Teens lose CSF if they get hit ine the nose- nosebleed (clear fluids with pink streaks) and nose swell up ÷Check the ears using the halo test obtain the fluid the blood will separate the ring
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? The effects of brain tumors are often attributed to the cognitive effects of aging. Brain tumors in older adults do not normally produce focal effects. Older adults typically have numerous benign brain tumors by the eighth decade of life. Brain tumors cannot normally be treated in clients over age 75.
The effects of brain tumors are often attributed to the cognitive effects of aging.
Inside the cranium, there are 3
are (1) brain tissue, (2) blood, and (3) cerebrospinal fluid (CSF).
A client receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for: chronic traumatic encephalopathy. a blood clot. ALS. stroke.
chronic traumatic encephalopathy.
The goals are to ICP
to maintain BP, prevent hypoxia, and ensure cerebral perfusion. To maintain cerebral tissue perfusion and BP, the physician administers isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions. Hypotonic solutions and solutions containing glucose are avoided because they increase ICP.
cerebral angiography
which detects distortion of cerebral arteries and veins, indicating an aneurysm, a tumor, or other vascular abnormality
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Irrigates the wound to remove debris Administers an oral analgesic for pain Administers acetaminophen (Tylenol) for headache Shaves the hair around the wound
Irrigates the wound to remove debris
A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? Loss of hearing, tinnitus, and vertigo Loss of vision, change in mental status, and hyperthermia Loss of hearing, increased sodium retention, and hypertension Loss of vision, headache, and tachycardia
Loss of hearing, tinnitus, and vertigo
Lumbar puncture diagnostic 3
This goes between L4 and L5 in the subarachnoid space in the lateral recumbent position They need to lie flat 6-8 hours after procedure If have cerebral spinal leak they usually have a headache
Intracerebral hematoma s/s 5
-Blood collects within the brain. -Client shows classic signs of increased ICP: headache, vomiting, seizures, posturing, hyperthermia, irregular breathing.
Which of the following is the order of change in motor response that coincides with declining neurologic function? Purposeful, flaccid, withdraw Withdraw, flaccid, decorticate Withdraw, flaccid, decerebrate Decorticate, decerebrate, flaccid
Decorticate, decerebrate, flaccid -Decorticate posturing (decorticate rigidity) is a position in which the arms are flexed, fists are clenched, and the legs are extended -Decerebrate posturing(decerebrate rigidity) is when the extremities are stiff and rigid -flaccidity, when the client makes no motor response
A client with neurologic disorder is at risk for disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. Which nursing intervention facilitates the functional use of the limbs? Keep extremities at neutral position. Remove and reapply elastic stockings. Change client's position. Use a flotation mattress.
Keep extremities at neutral position.
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Falls Sports-related injuries Motor vehicle crashes Acts of violence
Motor vehicle crashes
Monro-Kellie hypothesis,
if one or more of these increases significantly without a decrease in either or both of the other two, intracranial pressure (ICP) becomes elevated.
Anisocoria:
not the same size one is dilated and one is constricted-neurological comprise
Examples of disorders that may lead to increased ICP include: 6
· brain tumors, traumatic brain injuries from concussions, ruptured cerebral aneurysms, stroke, obstructions in the circulation of CSF, and infectious disorders of the nervous system such as meningitis and encephalitis
Nursing Interventions of IICP4
-Elevate the HOB to 30 to 40 degrees. -Avoid Trendelenburg position.(feet higher than head) increase the pressure in the head -Prevent flexion of the neck and hips. (cut off the blood flow) -Lumbar Puncture contraindicated in clients with IICP because this procedure will cause a rapid decrease in pressure in the CSF around the spinal cord, leading to brain herniation.
Increased Intracranial Pressure (IICP) 2
-Inside the cranium, there are (1) brain tissue, (2) blood, and (3) cerebrospinal fluid (CSF). - If one or more of these increases significantly without a decrease in either or both of the other two, intracranial pressure (ICP) becomes elevated.
Head Injuries minor injuries 5 traumatic brain injuries 3
Cause minor damage (closely monitor at home with observation every 2 hours for first 8hrs) ¡May be able to see scalp lacerations ¡Major damage to skull or brain ¡Make sure they aroused-do not go deeply asleep and not wake up ¡Do not want to see change LOC (don't know what day it is and change of personality) or vomiting, visual changes signs of pressure is increasing and the central nervous becomes overwhelm ¡Need to have them quite and calm Traumatic brain injury (TBI) ¡Leading cause of death and disability in US ¡High risk factors : Males 15 to 24 yrs old, children 5 and younger, and elderly 75 yrs or older ¡Motor vehicle accident (MVA) and falls are major causes
CSF leakage from the nose and ears indicate halo sign test
-basiliar skull fracture -a test clear or yellow tinted ring
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? Grade 1 concussion Grade 2 concussion Grade 3 concussion Grade 4 concussion
Grade 3 concussion
A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches? Increased intracranial pressure Dehydration Migraines The tumor is shrinking.
Increased intracranial pressure
One of the nurse's foremost priorities for providing care to the client who has sustained a concussion is to: Provide a safe environment so that the client does not sustain additional injury Monitor the client's ability to swallow and avoid any situation which can lead to aspiration Monitor for any signs of change in level of consciousness or increased intracranial pressure Monitor for erratic breathing patterns which would indicate a deterioration in neurological status
Monitor for any signs of change in level of consciousness or increased intracranial pressure
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? Temperature increase from 98.0°F to 99.6°F Urinary output increase from 40 to 55 mL/hr Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air
Temperature increase from 98.0°F to 99.6°F
cerebral hematoma is high risk 2
bleeding within the skull. The accumulation of blood forms an expanding lesion. People at high risk for cerebral hematomas are those receiving anticoagulant therapy or those with an underlying bleeding disorder, such as hemophilia, thrombocytopenia, leukemia, and aplastic anemia
A gymnast sustained a blow to the head after falling off the balance beam. The client has had surgery to repair an epidural hematoma. On regaining consciousness, the client asks for something to drink. The nurse advises that the client is under fluid restriction to: increase cerebral perfusion. decrease cerebral perfusion. prevent vomiting. prevent hyperhydration.
increase cerebral perfusion.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: raccoon's eyes and Battle sign. nuchal rigidity and Kernig's sign. motor loss in the legs that exceeds that in the arms. pupillary changes.
raccoon's eyes and Battle sign.
A craniotomy is a
surgical opening of the skull to gain access to structures beneath the cranial bones. It is performed to remove a blood clot or tumor, stop intracranial bleeding, or repair damaged brain tissues or blood vessels
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.
vomits.
· Signs of Increased Intracranial Pressure · Early Signs 5
· Drowsiness; difficult to awaken · Restlessness · Confusion · Glasgow Coma Scale ≥13 · Personality changes
· Signs of Increased Intracranial Pressure · Late Signs 6
· Unresponsive · Glasgow Coma Scale ≤12 · Decreased response to painful stimuli -Decorticate or decerebrate posturing · Dilated pupil(s) · Cushing's triad: bradycardia, elevated systolic blood pressure with wide pulse pressure, irregular breathing
electroencephalogram (EEG)
· records the electrical impulses generated by the brain. Up to 25 electrodes are attached to the scalp with a type of skin adhesive, and electrical activity is recorded on a graph. Techniques such as rapid breathing or looking at a flashing light, known as photic stimulation, can induce a seizure during the EEG.
subdural hematoma s/s 6
-Venous blood collects between the dura and subarachnoid layers. -Deterioration in LOC is progressive -There are ipsilateral pupil changes, decreased extraocular muscle movement, and contralateral hemiparesis, with periodic episodes of memory lapse, confusion, drowsiness, and personality changes.
There three types of subdural hematomas
-acute: rapid deterioration from drowsiness and confusion; ipsilateral pupil dilation and contralateral hemiparesis -subacute: appears 48 hours to 2 weeks later; followed by slow progression to coma -chronic: slowed thinking , confusion, and drowsiness; develop weeks to months after initial injury
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure Look for a halo sign
Look for signs of increased intracranial pressure
A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? Preparation for emergency craniotomy Watchful waiting and close monitoring Administration of inotropic drugs Fluid resuscitation
Watchful waiting and close monitoring
A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? When the client is resting When the client is ambulating When the client is preparing his or her meal tray to eat When the client is participating in occupational therapy
When the client is resting
Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? Increased pulse Decreased respirations Widened pulse pressure Decreased body temperature
Widened pulse pressure
contusion s/s 4
- is more serious than a concussion and leads to gross structural injury to the brain. -vary depending on the severity of the blow and the degree of head velocity. Clients exhibit hypotension, rapid and weak pulse, shallow respirations, loss of consciousness, and pale, clammy skin
IICP causes 4
-Brain tumors, -traumatic brain injuries from concussions, ruptured - stroke, -obstructions in the circulation of CSF,
Late IICP manifestation LOC pupils vision motor function speech
-decreasing LOC progress to coma and no response to painful stimuli -sluggish response to light progressing to fixed(no response to light). Pupils may dilate on one side (ipsilateral) progress bilateral -cannot assess due to decreasing LOC -decoritate or decerebrate posturing --cannot assess due to decreasing LOC
Early IICP BP Pulse Respiration Temp other symptoms
-elevated BP -slightly elevated pulse -rate may increase -maybe increased or decreased -headache worse on rising in the morning and with position changes
Early IICP manifestation LOC 3 pupils vision motor function speech
-Irritability, restlessness, personality change; disorientation to time then place then person -pupils equal round and reactive to light -decreased visual acuity; blurred vision -weakness in one extremity or side progressing to hemiplegia opposite to brain injury side -difficulty speaking
The most important nursing priority of treatment for a patient with an altered LOC is to: Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. Maintain a clear airway to ensure adequate ventilation. Position the patient to prevent injury and ensure dignity.
Maintain a clear airway to ensure adequate ventilation.
A client is status post-CVA with significant residual effects. When did this client begin the recovery phase of the neurologic deficit? upon stabilization at the time of the CVA one day after the CVA upon receiving diagnostic results
upon stabilization
Cushing's triad is characterized by 3
· (1) a pulse rate that increases initially but then decreases, (2) systolic BP that rises with a widening pulse pressure (the difference between the systolic and diastolic measurements), and (3) a respiratory rate that is irregular. -Cushing's triad occurs late in increased ICP.
The nurse regards a head injury, no matter how mild it appears, as an emergency. 5
-He or she obtains a history of the injury and performs a neurologic examination, -paying particular attention to vital signs; LOC; -presence or absence of movement in the arms and legs; and -pupil size, equality, and reaction to light. -the nurse examines the head for bleeding, abrasions, and lacerations
Nursing consideration of IICP 3
-Keep head of bed slightly elevated and the head in midline (straight). -Limit movement, space essential nursing tasks, and reduce or eliminate environmental stimuli (e.g., loud noise, bright lights). -Avoid extreme hip flexion.
Concussion path manifestation 3
-brain injury is caused by violent shaking of the brain -immediate loss of consciousness for less than 5 mins -drowsiness, confusion, dizziness -headache or double vision
Nursing interventions IICP 2
-The client's head is maintained in midline at 30° of elevation to promote venous drainage of blood and CSF. -Persistent hyperthermia caused by altered functioning of the hypothalamus may require measures such as administering acetaminophen (Tylenol) or applying a cooling blanket to maintain normothermia. Care must be taken to avoid hypothermia because shivering can increase ICP
· Prevention of health problems is a major component of nursing care. To reduce the potential for both minor and life-threatening head injuries, the nurse stresses the importance of the following: 5
-Using seatbelts for all passengers in automobiles -Restraining infants in approved car seats located in the rear seats of automobiles -Wearing protective headgear while riding bicycles or motorcycles, skiing, and when participating in contact sports such as hockey, baseball, football, or softball -Raising neck restraints on the back of car seats -Not driving under the influence of alcohol or drugs
Contusion patho 3 manifestation
-bruising of brain tissue when brain strikes inner skull like coup-countercoup(brain hits the front of the skull and then hits the back of the skull); can cause cerebral edema and increased intracranial -Varies from injury initial loss of consciousness the client may be combatitive -full consciousness is regained very slowly
A concussion results 2
-from a blow to the head that jars the brain. -It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence
What types of IV fluids can you give a patient with IICP? What types of IV fluids should not be given (or given with extreme caution)? other med 3
-hypertonic or isontonic -Hypotonic -D5 increase intracranial Mannitol (osmotic diuretic) Furosemide (loop diuretic) Dexamethasone (corticosteroid)
Epidural hematoma patho 2 manifestation 3
-severe blow to brain causes arterial bleeding collects between the skull and dura mater -common site is temporal area -brief loss of consciousness followed by short period of alertness -rapid detoriation to a coma -contralateral (opposiste side)/ ipsilateral (same side) fixed pupil dilation
A client with a history of a brain tumor is undergoing diagnostic testing to evaluate whether current symptoms are the result of the tumor or scar tissue. The nurse would prepare the client for which test? Positron emission tomography (PET) Magnetic resonance imaging (MRI) Three-dimensional biopsy Cerebral angiography
Positron emission tomography (PET)
A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client? The client reports a headache. The client reports pain at the site where the ball hits his head. The client is visibly fatigued. The client's speech is slightly slurred.
The client's speech is slightly slurred.
What are the immediate complications of spinal cord injury? Select all that apply. respiratory arrest spinal shock tetraplegia paraplegia
respiratory arrest spinal shock
concussion occurs 4
· the client may experience a brief lapse of consciousness, with temporary disorientation, headache, blurred or double vision, emotional irritability, and dizziness.
The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan? Body image disturbance Anxiety Impaired cognition Knowledge deficit
Knowledge deficit
Lumbar Puncture (spinal tap) purpose 2 preparation 4
Purpose: to withdraw cerebro-spinal fluid 1. Color of normal CSF is clear 2. Normal CSF contains glucose or sugar B. Preparation of patient 1. Encourage fluids 2. Empty bladder 3. Position in side lying position knees pulled up to chest or sitting on side of bed and leaning forward 4. Care of patient after procedure: Flat for 6-8 hours
Glascow Coma Scale (GCS) Head Injury Classification:
Based on motor responsiveness, verbal performance, and eye opening to appropriate stimuli, the Glascow Coma Scale was designed to assess the depth and duration coma and impaired consciousness. ¡Severe Head Injury----GCS score of 8 or less ¡Moderate Head Injury----GCS score of 9 to 12 ¡Mild Head Injury----GCS score of 13 to 15
subdural hematoma patho 3
- closed head injury causes venous blood to collect between dura mater and subarachnoid layer -subacute: less severe head injury -chronic: most often in elderly, alcoholics, and those taking anticoagulants
Lumbar puncture 3
-(spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure -Strict aseptic technique is required during the procedure -CSF is normally clear and colorless, with a pressure of 80 to 180 mm H2O; a pressure over 200 mm H2O is considered abnormal
intracranial hematoma patho manifestation 3
-bleeding into the brain tissue; caused by gunshot or depressed skull fx -decreasing LOC to coma; pupil changes and motor deficits
Conditions Having Increased Intracranial Pressure A. Subdural hematoma 5
1. Slow bleed beneath the dura 2. Normal x-rays and findings on day of injury 3. Symptoms appear after significant blood accumulates; often 4-12weeks after the injury 4. Treatment usually evacuation of hematoma by surgeon 5. Nursing care: care of person with increased intracranial pressure
A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? Cerebral angiography ABG analysis CT EEG
EEG
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Ecchymosis over the mastoid Bruising under the eyes Drainage of cerebrospinal fluid from the nose Drainage of cerebrospinal fluid from the ears
Ecchymosis over the mastoid
Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? Complete the pin site care to decrease risk of infection. Notify the neurosurgeon of the occurrence. Stabilize the head in a lateral position. Reattach the pin to prevent further head trauma.
Notify the neurosurgeon of the occurrence.
A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? Restrain the client as ordered. Administer opioids PRN as prescribed. Arrange for friends and family members to sit with the client. Pad the side rails of the client's bed.
Pad the side rails of the client's bed.
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To decrease cerebral arterial pressure To avoid impeding venous outflow To prevent flexion contractures To prevent aspiration of stomach contents
To avoid impeding venous outflow
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (ICP) for which of the following actions? To dehydrate the brain and reduce cerebral edema To control fever To control shivering To reduce cellular metabolic demands
To dehydrate the brain and reduce cerebral edema
If findings are normal and the client does not require hospitalization, the nurse instructs the family to watch the client closely for signs of increased intracranial pressure (ICP). Common signs of increased ICP 5
· include behavioral alterations, sleepiness, personality changes, vomiting, and speech or gait disturbances
echoencephalography
· is an ultrasound examination of the structures of the brain. This procedure is performed to detect abnormalities in the ventricles and the location of intracranial bleeding.
A skull fracture results from 2
-a blow to the head. -It can be associated with an open head injury, in which the scalp, bony cranium, and dura mater (the outer meningeal layer) are exposed, -or it may be a closed head injury, in which an intact layer of scalp covers the fractured skull.
The earliest sign of serious impairment of brain circulation related to increased ICP is: A bounding pulse. Bradycardia. Hypertension. A change in consciousness.
A change in consciousness.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
Head injuries 2
Open - skull integrity is compromised, penetrating trauma (risk for infection)-damage to the tissue and can see inside; EX hit the corner of the table Closed- skull integrity is maintained; blunt trauma(hit with baseball bat or hit the dash)
When the intracranial volume (and therefore ICP) begins to increase 2
- Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels, leading to cerebral ischemia - · When increased ICP develops slowly, subtle changes can be overlooked.
Epidural hematoma 2 s/s 4
-Arterial blood collects between the skull and dura. -Client may be alert after initial unconsciousness but then becomes increasingly lethargic before lapsing into coma -Common symptoms are headache, ipsilateral (same side as injury) pupil changes, and contralateral (opposite side to injury) hemiparesis (weakness or paralysis).
Late IICP BP and pulse Respiration Temp other symptoms 3
-Cushing's triad: increased systolic BP, widening pulse pressure, bradycardia -decreased respiratory rate with altered respiaratory patterns (cheyne stokes) -significantly elevated -continual headache -projectile vomiting -loss of pupik, gag and swallowing reflexes
if suspected brain injury 2
-Do not move a patient with a suspected brain or spinal cord injury unless they are in immediate danger. -If fall in the floor first symptom your head is going to hurt and will have a knot or abrasion
Physiological Changes IICP 7
A. Pulsedecreases and Respirationsdecrease C. Pulse pressurewidens D. Projectile vomiting E. Decrease in level of consciousness F. Pupil changes G. Motor function loss on oppositeside of body from injury H. Normal ICP is 0-10 mm Hg; above 15 mm Hgis abnormal
Arteriogram 2
A. Visualization of arteries using a radioopaque dye B. Before procedure: Check for iodine allergy
The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? Help the family understand that the client could have died. Emphasize the importance of accepting the client's new limitations. Have the members of the family plan the client's inpatient care. Assist the family in setting appropriate short-term goals.
Assist the family in setting appropriate short-term goals.
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? Occipital skull fracture Temporal skull fracture Frontal skull fracture Basilar skull fracture
Basilar skull fracture
A male patient is brought to the emergency department by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be okay." Now the patient is complaining of a severe headache and states that he is "not feeling well." The care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention? Insertion of an intracranial (IC) monitoring device Treatment with antihypertensives Emergency craniotomy Administration of anticoagulant therapy
Emergency craniotomy
