Traumatic Brain Injury (TBI)
This posturing may occur in severe TBI's; indicating severe damage to the brainstem
decerebrate posturing
Client and family teaching for new diagnosis of epilepsy
Put nothing in their mouth, time the seizure, stay with them, clear the area, turn on their side
Priority assessment for a patient with suspected TBI
Patent airway, breathing, and circulation
1st line medication used to treat ICP
Mannitol
2 Methods of Diagnostic Imaging used for TBI's
CT and MRI
Seizure precautions consist of
Bag, mask, and suction at bedside, padding on bedrails, bed in the lowest position with side rails up
This scale is used by nurses to monitor a patient's level of consciousness after a TBI
What is the Glasgow Coma Scale (GCS)?
Nonpharmacological action to decrease ICP
reduce stimulation
3 Clinical Signs of Cushing's Triad
Hypertension
Bradycardia
Irregular Respirations
Acute seizure medications
IV-push lorazepam or diazepam, or diazepam rectal gel
Client and family teaching for seizure medications
The client will remain on seizure medication until they are seizure-free for a period of time and EEG and provider evaluation indicate it may be safe to taper off
Manifestations of increased ICP
Headache, Altered LOC, Nausea, Vomiting, Vision changes
Concerning manifestations of increased ICP
Altered mental status, headache, dilated pupils, posturing
Nursing interventions for a client with hypoglycemia experiencing a seizure
seizure precautions, check blood glucose, call provider, administer Glucagon
This medication class may be given to prevent secondary brain injury caused by seizures after TBI
What are antiepileptic drugs (AEDs)?
Normal ICP range
5-15
This medication is often used as adjunctive therapy to reduce the incidence of rebound from mannitol
Furosemide
- enhances the therapeutic action of mannitol, reduces edema and blood volume, decreases sodium uptake by the brain, and decreases the production of CSF
Nurse knows that it is important to ensure that this is done for all patients with seizure precautions
establish IV access
Interventions to prevent an increase in ICP
pain management, prevent straining, low stimulation environment, elevated HOB to 30 degrees, neutral head and neck alignment, adequate oxygenation and ventilation, cluster care, sedation meds
1st nursing action to decrease ICP
elevate HOB 30-45 degrees