S&S
Nursing Care
ICP
Medications
100
Sense of hearing
What is the last sense affected by brain injury
100
Application of an Aspen collar and immobilization of limbs.
What is an appropriate technique for C-spine stability?
100
Elevate HOB at least 30 degrees
What is a simple necessary intervention to help avoid increase in ICP?
100
A medication used to manage ICP that can only be administered by RN's with critical care/ER specific training
What is Pentobarbital (Nembutal Sodium)
200
Decorticate or decerebrate posturing (decreased LOC); headache; and dilated pupils
What are signs and symptoms of increased ICP
200
To ensure adequate tissue perfusion
What is administering oxygen to keep SaO2 above 92%?
200
Calm and gentle speech/tone of voice
What is an appropriate relational practice to prevent anxiety and increased ICP?
200
Phenytoin (Dilantin)
What is client specific and based on therapeutic blood levels?
300
Bruising around the ear
What is the Battle sign?
300
The "golden window"
What is the hour in which emergency treatment should be provided to decrease morbidity and mortality rates?
300
Hypersensitivity to light
What is a sign of pupillary changes secondary to increased ICP?
300
A last resort treatment used when ICP is above: 25 mmHg for 30 min 30mmHg for 15min 40mmHg for 1 min
Pentobarbital (Nembutal Sodium)
400
Cheyne-Stokes respirations
What is a response to cerebral injury?
400
Left ipsilateral pupil dilation
What is a manifestation of injury (or mass or lesion) to the left side of the brain?
400
The Monroe Kelly hypothesis
What is the relationship between ICP, cerebral perfusion pressure (CPP), mean arterial pressure (MAP), CSF and brain tissue?
400
Recommended for management of headaches secondary to mild TBI/concussion
What is acetaminophen or ibuprofen? (stronger analgesics can be sedating and mask signs of worsening injury)
500
An anticipated outcome (observed in the blood) following trauma, especially if dexamethasone or other steroids are used for inflammation.
What is increased BGL or hyperglycemia?
500
The yellow ring you may see around the blot of blood (from ear or nose) on a paper towel?
What is the halo sign?
500
Intraventricular catheter
What is a method (gold standard) of monitoring ICP?
500
Requiring serum electrolyte and osmolality monitoring Q6H
Mannitol (Osmitrol)
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