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This is how to open the airway in patients with suspected head and neck trauma.
What is the jaw-thrust maneuver?
This is often the first sign of increased intracranial pressure (ICP).
What is restlessness?
Other signs of increased intracranial pressure are irritability and confusion along with a change in level of consciousness, or a change in the speech pattern; pupillary changes.
These are important nursing interventions to help not increase ICP.
What is positioning the patient in a neutral position and avoiding flexion of the neck and hips?
In order to avoid hip flexion, the patient should be log rolled when repositioned.
The normal range of this is 10 to 15 mmHg.
What is intracranial pressure?
With a traumatic brain injury, it is extremely important to reduce this when caring or establishing a plan of care for the patient.
What is reduce stimuli?
This includes decreasing the number of visitors, speaking calmly, and creating a quiet environment.
This is characterized by a change in cognition over a short amount of time, and manifests as alterations in memory, agitation, restlessness, illusions, or hallucinations.
What is delirium?
A patient who becomes acutely confused an agitated may be showing manifestations of delirium. When it frequently progresses in the evening hours it is sometimes called "sundown syndrome."
This will helpful in quickly replacing cerebral spinal fluid which is removed during a lumbar puncture and will facilitate resolution of a headache created by the procedure.
What is increase fluid intake?
A patient should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.
Besides positioning, these other things can increase intracranial pressures.
What are suctioning, coughing, sneezing, and straining?
This breathing pattern is characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration; common respiratory alterations in patients who are unconscious, comatose, or moribund (approaching death).
What is Cheyne-Stokes respirations?
A PHARM 1 Flashback!!! This is the main adverse effect which should be instructed to a patient taking phenytoin to prevent seizures.
What is developing a rash?
Phenytoin can case a rash which can progress to Stevens-Johnson syndrome or toxic epidermal necrosis. If a rash develops, the patient should notify the provider immediately and stop the use of phenytoin.
This should be done as part of the admission assessment if a patient has a suspected cognitive disorder.
What is a mental status examination (MSE) or a mini-mental exam (MME)?
This is similar to delirium, but the onset occurs slowly over months or years and is a progressive and irreversible disorder.
What is dementia?
Dementia can be caused by such disorders as Alzheimer's disease, long-term alcohol use disorder, and Parkinson's disease.
This is the possible source of clear fluid found in the ear canal in patients with head trauma.
What is cerebral spinal fluid?
Cerebral spinal fluid (CSF) in the ear indicates a basilar skull fracture, and CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.
This is an intervention a patient could be taught to help prevent increasing ICP when having a bowel movement.
What is encouraging exhaling through the mouth during defecation?
This occurs when stimulation of the lateral planter aspect of the foot leads to extension (dorsiflexion or upward movement) of the big toe (hallux). Also there may be fanning of the other toes.
What is Babinski sign?
Positive Babinski sign suggest that there is a CNS pathology. In older children and adults without neurological problems, the foot will remain still, or the toes may curl downward during the Babinski test.
This is the position a patient should be in for a lumbar puncture.
What is being placed in a lateral (side-lying) position with the knees drawn to the abdomen and chin touching the chest?
This position separates the lumbar vertebrae and allows for easier needle insertion.
This is a reflex pose that's a symptom of damage to or disruptions in brain activity which causes the legs to become rigid and straight with planter flexion, while the arms flex upward and hold tensely to the chest.
What is decorticate posturing?
It's usually a sign of brain damage or disrupted brain activity.
This is a test a nurse can perform to see if a patient can safely ambulate if there is a concern about balance.
What is a Romberg's test?
The nurse should perform a Romberg's test to check the ability of the patient to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the patient from falling.
These labs must be checked prior to a lumbar puncture.
What are anticoagulation studies?
Systemic inflammation caused by meningitis can cause coagulopathy to occur. To decrease the risk of bleeding during the procedure, the nurse should obtain coagulation studies prior to the procedure.
This is an appropriate nursing intervention when a client displays sudden confusion and vital signs have been checked.
What is complete a focused neurological assessment?
The normal for this is 70-80 mmHg, and goal is to to keep greater than 70 mmHg.
What is cerebral perfusion pressure (CPP)
As CPP is a calculated measure, MAP and ICP must be measured simultaneously, most commonly by invasive means. Easiest way to help increase CPP is adjusting the patient's head of bed to keep CPP greater than 70 mmHg.
Pushing away or withdrawing from pain is what type of reaction to a painful stimulus?
What is a normal reaction or normal response?
This medication needs to be held for 48 hours prior to receiving an IV contrast containing iodine, like the contrast used in a head CT or contrast for a cardiac catheterization, due to interaction which can alter renal function and cause renal failure.
What is metformin?
What is 30 to 45 degrees?
There are a several questions regarding these, and students should make sure they are familiar with these for this test.
What are the Glasgow Coma scale (GCS) and how to assess the cranial nerves?