ICP & LOC
What is one early sign of increased ICP?
What is:
Headache, disorientation/restlessness, confusion, changes in LOC, pupillary changes (sluggish response), and weakness in one extremity or side
What does ESI stand for?
Emergency Severity Index
In trauma assessment, what does “A” stand for?
Airway with cervical spine protection
DAILY DOUBLE!
A patient weighs 165 lbs and has an order for mannitol 0.5 g/kg IV every 6 hours. Mannitol is supplied as 20% solution (20 g/100 mL).
How many mL per dose should the nurse administer?
Convert weight: 165 ÷ 2.2 = 75 kg
Dose: 0.5 g × 75 = 37.5 g
Concentration: 20 g/100 mL = 0.2 g/mL
Volume: 37.5 ÷ 0.2 = 188 mL per dose
What seizure precaution should always be in place at the bedside?
Padded side rails, suction and oxygen equipment, bed in low position, call bell accessible
Which triad signals a late, life-threatening stage of increased ICP?
Cushing’s Triad — bradycardia, irregular/abnormal respirations (Cheyne-Stokes or ataxic), and widened pulse pressure
Which ESI level is assigned to a patient needing immediate intubation for respiratory failure?
Level 1 — requires immediate life-saving intervention
In the “D” of ABCDE, what is assessed?
Disability — neurologic status (AVPU scale, GCS, pupillary response)
Which condition presents as hypotension, bradycardia, and loss of sympathetic tone?
Neurogenic shock
During a generalized tonic-clonic seizure, what position should the nurse place the patient in?
Side-lying position to maintain airway, loosen clothing, clear environment of hazards
A patient with ICP 22 mmHg is restless and responds only to pain. What is the priority nursing action?
Elevate HOB to 30° with neutral alignment, maintain airway and oxygenation, avoid extreme neck flexion, and notify provider
Which ESI level applies to a stable patient needing one resource such as an x-ray?
Level 4 — stable, requires one diagnostic/therapeutic resource
A trauma patient with suspected internal bleeding and airway compromise arrives. Which interventions are priority?
Establish and secure airway with spinal immobilization, provide oxygen, control hemorrhage with direct pressure, and prepare for IV fluid resuscitation
A patient with T4 injury develops pounding headache, HTN, bradycardia, flushing above injury. What is the priority nursing action?
Elevate HOB, loosen tight clothing, check for bladder distention or bowel impaction, remove stimulus
Which IV medication is first-line treatment for status epilepticus?
IV benzodiazepine (diazepam or lorazepam)
Which hypothesis explains the fixed cranial volume and compensation among brain, blood, and CSF?
Monro-Kellie hypothesis — if one component increases, another must decrease to maintain normal ICP
Name examples of “non-resources” in ESI triage.
History & physical exam, point-of-care teaching, single-dose oral medication, prescription writing, simple wound care, tetanus shot
What step of trauma assessment involves full exposure and prevention of hypothermia?
“E” — fully expose patient for assessment, cover with warm blankets, prevent hypothermia
Which type of shock involves loss of reflexes below the level of injury?
Spinal shock
Why is phenytoin prescribed after diazepam in seizure management?
Diazepam stops seizure immediately but is short acting; phenytoin prevents recurrence by maintaining long-term seizure control
Which are terminal signs of uncontrolled ICP?
Hyperthermia due to brainstem compression, loss of brainstem reflexes (corneal, gag), fixed dilated pupils, coma, respiratory arrest, cardiac arrest
A febrile neonate, 26 days old, is automatically classified as which ESI level?
Level 2 — high risk even if vitals are stable
Which findings strongly suggest intra-abdominal hemorrhage?
Tachycardia, hypotension, delayed cap refill, abdominal distention, referred shoulder pain, absent bowel sounds
The most common trigger for autonomic dysreflexia is what?
Bladder distention (catheter kink, full bladder); bowel impaction is second most common
When documenting seizures, what detail is most critical for guiding treatment and identifying triggers?
Pre-ictal activity, aura, seizure onset, duration, type of movements, LOC changes, incontinence, post-ictal behavior