TBI / Increased ICP
This is the most sensitive indicator of a change in neurologic status.
What is level of consciousness?
A patient with a head injury becomes increasingly drowsy and difficult to arouse. What is the nurse most concerned about?
What is worsening neurologic status / increased ICP?
Facial droop, arm weakness, and speech difficulty should prompt the nurse to determine this information immediately.
What is the time symptoms began/last known well?
An SCI involving these cervical levels places the patient at greatest risk for impaired breathing because of diaphragm involvement.
What are C3–C5?
Patients with spinal cord injuries at or above this level are at greatest risk for autonomic dysreflexia.
What is T6?
This late triad includes hypertension with widened pulse pressure, bradycardia, and irregular respirations.
What is Cushing’s triad?
A patient with a head injury develops a worsening headache, vomiting, and new confusion. What should the nurse do?
What is perform an immediate neurologic reassessment and notify the provider of deterioration?
Before giving a patient with an acute stroke anything to eat, drink, or take by mouth, the nurse must assess this.
What is swallowing ability?
A patient with a suspected cervical SCI needs their airway opened. The nurse uses this maneuver to protect spinal alignment.
What is the jaw-thrust maneuver?
These are common triggers the nurse should look for when a patient develops autonomic dysreflexia.
What are bladder distention, bowel impaction, and other irritating stimuli?
This is the first-line imaging test used after TBI to rapidly assess for hemorrhage, fracture, or cerebral edema.
What is a CT scan?
Which assessment findings should the nurse trend closely in a patient with an intracranial hematoma?
What are LOC/GCS, pupils, motor strength, and changes from baseline?
A stroke patient is impulsive, has poor judgment, and ignores one side of the body. Which side of the brain is most likely affected?
What is the right hemisphere?
After an acute SCI, the patient has flaccid paralysis and absent reflexes below the injury. What complication is occurring?
What is spinal shock?
A patient with a T5 SCI develops BP 210/110 and a pounding headache. What is the nurse's FIRST action?
What is sit the patient upright/raise the HOB?
To help lower ICP, the nurse should place the patient in this position.
What is HOB about 30° with the head and neck midline/neutral?
The nurse caring for a patient with a suspected intracranial bleed should position the patient this way to promote venous drainage and help reduce ICP.
What is HOB about 30° with the head and neck midline/neutral?
After treatment for an acute stroke, the patient develops a sudden severe headache, nausea/vomiting, and worsening neurologic status. What complication should the nurse suspect?
What is intracranial bleeding/increased ICP?
A patient with a cervical SCI has a BP of 78/40, HR 42, and warm, dry skin. What complication should the nurse recognize?
What is neurogenic shock?
After sitting a patient with AD upright, what should the nurse assess first for the cause of the episode?
What is bladder distention/urinary obstruction?
A patient with increased ICP receives this osmotic diuretic, which requires monitoring of serum osmolality, electrolytes, and urine output.
What is mannitol?
A patient with an intracranial hematoma suddenly develops a unilateral dilated nonreactive pupil and a rapid decline in LOC. What should the nurse recognize?
What is impending brain herniation requiring immediate intervention?
A stroke patient suddenly has a worsening LOC and new neurologic deficits. What is more important for the nurse than simply documenting the change and continuing routine assessments?
What is recognize acute neurologic deterioration and intervene/notify the provider immediately?
A patient with a C4 SCI has weak respirations and difficulty clearing secretions. Which nursing intervention can assist with secretion clearance?
What is an assisted/quad cough?
A patient with a T4 spinal cord injury suddenly reports a severe pounding headache. Which additional vital-sign change would be most concerning?
What is sudden severe hypertension?